The RBF program in Zimbabwe was launched in July 2011, to provide performance-based subsidies to rural health clinics and hospitals based on their performance in delivering a package of free health services to pregnant women and children under five. Positive initial results have spurred the Government of Zimbabwe to commit $5 million per year of its own funds in addition to $35 million in funding from HRITF, to help scale up existing RBF programs around the country and to pilot the approach in select urban areas. Cordaid, a Dutch NGO, is the implementing agency under the guidance of the Ministry of Health and Child Care. Phaoroah Mlambo, a member of the Cordaid team in Gwanda District, works with health facilities to build their capacity to introduce and implement a performance-based financing (PBF) approach.
Today, World Bank Group President Jim Yong Kim announced US$700 million in new IDA funding for the scale-up of results-based financing (RBF) programs to help save more women and children’s lives, an endorsement of the idea that the RBF approach is an opportunity to accelerate progress towards the Millennium Development Goals (MDGs) 4 and 5—reducing child mortality and improving maternal health.
My experience as a doctor who practiced actively in this country did not prepare me for the shock I had during the preparation of the Nigeria State Health Investment Project. I had worked for three years in the public sector at the beginning of my career but then spent more than a decade in the private sector. I had not imagined the decay in public infrastructure – leaking roofs, heaps of garbage, broken down equipment, and stock-outs of drugs and disposables for months on end in public health centers. The general morale of frontline health workers was low and some ingenious workers were actually buying their stock of drugs to provide services for patients. Not surprisingly, the utilization of health services was low and the quality of service appalling.
This is a joint post with Peter Nicholas from Social Finance
In a recent RBF blog post Victoria Fan and Amanda Glassman noted that RBF represents a shift in global health and development aid from an‘auditing and accounting paradigm’ to a ‘performance and results paradigm’. A recently released consultation document suggests that this welcome paradigm shift can be taken a stage further through the use of Development Impact Bonds (DIBs), whereby private investors provide project financing up-front and take the risk that agreed results are not achieved. Outcome payments are financed by donors/Governments, but implementation modalities are determined by the investors in conjunction with a specialized convenor such as Social Finance, and carried out by specialized service providers. Donors/governments take no implementation or financial risk, since no disbursements are made until tangible results are verifiably achieved.
They came from all corners, men and women, to re-focus the world’s attention on investing in women’s health and rights as a key to a more sustainable world for all. Over 4,000 academics, advocates, global health practitioners, policymakers, and storytellers, descended on Kuala Lumpur (KL), Malaysia, May 28-30, to shine a collective spotlight on the importance of building a better world for women and girls.
Hailed by the organizers as “the largest global meeting of the decade to focus on the health and well-being of girls and women,”Malaysia was a fitting choice to host the Women Deliver 2013 conference (WD2013). This Southeast Asian constitutional monarchy has made impressive progress on Millennium Development Goals (MDG) 4—reducing child mortality—and 5—improving maternal health, which, along with MDG 1—eradicating extreme poverty and hunger, are at the core of the Health Results Innovation Trust Fund’s (HRITF) work.
These past weeks I’ve visited several southern African nations to assist on-going evaluations of health sector pay-for-performance reforms. It’s been a whirlwind of government meetings, field trips, and periods of data crunching. We’ve made good progress and also discovered roadblocks – in other words business as usual in this line of work. One qualitative data point has stayed with me throughout these weeks, the paraphrased words of one clinic worker: “I like this new program because it makes me feel that the people in charge of the system care about us.”
This expressed sentiment is in stark contrast with a prominent viewpoint that the introduction of an incentive program is ineffective at best and counter-productive at worst. A forceful summary of this view can be found in a 2012 editorial by Steffie Woolhandler and Dan Ariely, published in the Health Affairs journal blog. Woolhandler and Ariely conclude their editorial with the warning that “Few have countenanced the possibility that P4P (pay-for-performance) may simply not work in health care”. Why may P4P not work? Their answer:
The World Bank’s Africa Health Forum: Finance & Capacity for Results during its 2013 Spring Meetings brought together ministers of finance and of health from 30 African countries in a unique opportunity for mutual listening between countries and partners. One recurring theme in forum and in the first panel was that results-based financing (RBF) – where financing is conditioned on achievement of results in health – is a key approach to driving value for money. In short: RBF = more money for more health. (You can watch the recorded ministerial discussion here.)
The reasons for doing RBF are persuasive, not only for donor agencies but also for countries. Indeed, several ministers in the forum voiced with remarkable consistency their support of RBF – even in countries deemed as ranking low in ‘governance’ or ‘capacity’. By linking payments to specific outcomes, RBF makes a donor more accountable to its constituencies and also increases the mutual accountability between the donor and the country by focusing the contract terms on shared goals and verified results.
While the world is focusing on achieving the health Millennium Development Goals (MDGs), especially MDG 4 and 5, results-based financing (RBF) is gaining increasing attention as a strategy to scale up the provision of and demand for essential maternal and newborn health care services in low and lower-middle income countries (LLMICs) where coverage of such services remains low, and maternal and neonatal mortality remains unacceptably high. It is generally believed that by linking payments with results or performance targets, RBF stimulates health providers and users to achieve the results or targets, which in turn contributes to improved health system performance and health outcomes (more health for the money).
Can there be such a thing? Well, yes, and it’s what’s resonating in the Eastern Caribbean islands nations of Dominica and Saint Lucia, countries exploring the feasibility of piloting an RBF approach in their health sector. Both countries after all are facing tight budgets and ever increasing demands on their health systems from non-communicable diseases, an ageing population, and a shortage of health workers. So while securing additional funding to pilot an RBF approach may be unlikely, both countries are keen to apply such an approach to an existing area of their health sector budget. After all, Dominica is already implementing results-based performance budgeting and Saint Lucia is initiating performance based financing in their country-wide budgeting process providing an enabling environment in support of RBF.