The RBF project in The Gambia is in the early stages of implementation. Learn more about it and what makes it unique in this Q&A with Rifat Hasan and Menno Mulder-Sibanda, who are leading the project.

Tell us a bit about the RBF project in The Gambia. What are the different components? Which indicators are incentivized?
The project has three components. Component 1 is a demand-side intervention and involves the implementation of community RBF and antenatal-care conditional cash transfers (CCTs). Component 2 is a supply-side intervention, which consists of the implementation of performance-based financing (PBF) at the health facility. Component 3 focuses on capacity building for service delivery and RBF mechanisms.

Women and children in Gambia

In Component 1, the community RBF mechanism uses incentivized indicators to increase the demand for and the utilization of priority health and nutrition services and behaviors. It works like this: the Ministry of Health and Social Welfare (MOHSW) signs a contract with the Village Development Community (VDC) and Village Support Group (VSG). The VDC is a formal body with a bank account that oversees development activities within the community. The VSG is a group of community volunteers, who are responsible for social mobilization and behavior change within the village. Quarterly contracts are signed and payments are made for achieved performance on predefined indicators. The community RBF indicators include:

  • Percentage of indicators in community registers that are accurately completed
  • Percentage of pregnant women and mothers with children under 6 months who have adequate knowledge of breastfeeding
  • Percentage of lactating mothers, who can correctly describe minimum acceptable diet
  • Percentage of deliveries referred, evacuated, and/or escorted by the TBAs/VSGs for institutional delivery
  • Percentage of households with latrines
  • Percentage of environmental-hygiene measures being practiced by the community

The payments received are divided into two parts: 30 percent is allocated for performance-based incentives to VSG members, while the remaining 70 percent is managed by the VDC. Following a business plan, the VDC uses these payments for activities that promote the achievement of results related to the wellbeing of women and children. The National Nutrition Agency (NaNA) verifies the achievement of results using a combination of health facility records and a community survey, called the LQAS.

In Component 2, the PBF mechanism incentivizes the provision of a package of primary care services that improve maternal and child health and nutrition. In addition, a few indicators are included for facilities that also provide secondary level of services to ensure continuum of care for maternal and newborn health. The MOHSW signs quarterly contracts with health facilities, and payments are made on achieved results. The indicators include

Primary Care Secondary Care
  • New outpatient visits
  • Deliveries with complications
  • Antenatal care 1st visit under 3 months
  • Caesarean section
  • Antenatal care 4th visit
  • Postpartum complications of mother
  • Skilled delivery
  • Neonates treated for complications
  • Postnatal care 3rd visit                               
  • Modern family planning: tubal ligation, vasectomy                                           
  • Referral of mothers with complications and/or at-risk cases
  • Referral of neonates for complications
  • Modern family planning: pills, Depo provera, IUD, implant
  • Vitiman A supplementation
  • Deworming
  • Successful management of severe acute malnutrition

The NaNA verifies results using health facility records, and there is a penalty for any misreporting. Community-Based Organizations (CBOs) then counter-verify a sample of these results through patient-tracing and client satisfaction surveys. Payments for health facilities are also divided into two parts: 40% of the payment is used to pay health center staff bonuses, and the remaining 60% is used to implement the activities in their quarterly business plan.

Two women in Gambia

The project in The Gambia is particularly interesting because it includes both supply- and demand-side interventions. Can you explain why the team decided to include both?
During preparation of the nutrition and health project in The Gambia, we carried out quantitative and qualitative assessments at household and facility levels to understand the barriers to better health and nutrition outcomes. We found a number of barriers on both the supply and demand sides. For example, on the supply-side, we learned that poor health outcomes result from insufficient funding for the health system, inconsistent infrastructure, equipment and supplies, and poor training and motivation among health providers.

With the exception of provider attitudes towards patients, most of the demand-side barriers occurred at the community level. Cultural obstacles, the cost of care, the inconvenience of going to a health facility, and little understanding about the benefits of seeking care or the risks of adopting a particular behavior were among the barriers we discovered on the demand-side.

Based on our findings, we realized that not all the barriers could be addressed through an intervention at the health facility because many of them were concentrated at the community level. While it was still necessary to strengthen the provision of services at the facility level, focusing only on the supply-side would not be enough to achieve better health and nutrition outcomes. A demand-side intervention that tackled the community-level barriers needed to be included in the project.

More projects are now incorporating demand-side or community-based interventions. Why do you think that this shift has occurred?
Good health outcomes start with individual and household practices, like good hygiene and sanitation, proper infant and child feeding, and adequate nutrition and rest. Based on this premise, demand-side and community-based interventions are relevant everywhere. Many projects that have been implementing supply-side RBF mechanisms have shown substantial progress in service utilization. However, some indicators have not done as well as others, and in some cases, results have plateaued. Such occurrences could be due in part to barriers that remain on the demand-side, like the ones we mentioned above. Moreover, certain indicators, which are critical for improved health and nutrition outcomes indicators, are actually not service utilization indicators. Rather, they are rooted at the community-level.

Directions for proper handwashing in Gambia

Apart from addressing the demand-side barriers to improved health and nutrition outcomes, how has this shift to include demand-side interventions been particularly relevant in The Gambia?
The shift to include demand-side RBF mechanisms was particularly relevant in the Gambia due to the community structures that already existed in the country. With the objective of complementing primary health care services and boosting rural and agricultural development, The Gambia started to build structures for functional community engagement in the mid-1990s. This network of community structures—which are linked to the formal, public sector— allows the RBF approach to engage directly with communities to improve health and nutrition outcomes at the household and community level. These existing community structures have provided a natural platform upon which to develop an RBF approach.

The project in The Gambia has a particular focus on nutrition. How are RBF mechanisms are being used to improve nutrition outcomes?
RBF mechanisms are being used to improve nutrition outcomes though both supply- and demand-side interventions, like the community RBF we described earlier. While the package of indicators in the demand-side intervention affect both health and nutrition outcomes, there are two indicators that more directly promote nutrition. They are: the percent of pregnant women and mothers with children under 6 months, who have adequate knowledge of breastfeeding and the percentage of lactating mothers, who can correctly describe a minimally acceptable diet.

On the supply-side, the project incentivizes three indicators that directly influence the nutrition outcomes of women and children. These indicators include vitamin A supplementation, antenatal care, and the diagnosis and treatment of severe and acute malnutrition.

To improve health and nutrition outcomes, a continuum of care is critical along the life course and from the community level to health facilities. The RBF project in The Gambia attempts to provide this continuum of care in a comprehensive and integrated manner through a combination of RBF mechanisms.

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