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.
The trip from Nairobi to Oldoinyo takes about 2,5 hours on a very dusty road through dry wide Masai area. I am in a minibus together with three other participants of the Performance Based Financing training in Nairobi. We were told it was going to take an hour, but as usual it’s a lot longer. Just as I start worrying if I should have brought more water, because my throat is getting dry, the minibus takes a turn and Oldoinyo Dispensary appears.
We are welcomed by a very friendly group of people consisting of the clinical officer in charge, other staff and community members. Our first impression of the health center is good: it looks very clean, has sharps boxes everywhere, there seem to be enough drugs and buildings were recently renovated with funds from the Dutch government. As part of the training, we were assigned to do a quick assessment of the dispensary and discover where their bottle necks are, so we take out our lists and start asking them the questions we prepared.
We ring in 2013 with an explosion of RBF initiatives that reward service providers and overcome demand side challenges, many of them featured on this rbfhealth site. Yet- most of these schemes continue to confront interrupted supplies of medicines and health commodities. In most systems, even highly motivated service providers can’t solve this supply problem. Incentives appear to be dysfunctional along the entire supply system- from the central medical store to the service delivery point and back up the chain. Does RBF hold (part of) the key?
When I read World Bank Group president Jim Kim’s post last week, Three Global Priorities for Women and Girls, one line in particular attracted my attention: "Women in developing countries die in childbirth every 1.5 minutes."
In Zimbabwe, I have seen first-hand how RBF is helping to change that figure. The RBF project that began in 2011, covering two districts and 28 health facilities now operates in 18 districts and 387 health facilities, many of them in rural areas. The results coming in are encouraging – increased access to health services, more institutional deliveries in rural health centers and hospitals, and more children being immunized against common childhood diseases.
Worldwide, nearly 800 women die every day from preventable causes related to pregnancy and childbirth. Ninety-nine percent of all maternal deaths occur in the developing world, and within these countries, it’s the poor who suffer the greatest morbidity and mortality rates. Providing high-quality medical care before, during, and after childbirth is key to saving lives, and reproductive health vouchers are one way we might accomplish that. Today, the Population Council is leading a major research project to evaluate vouchers for their ability to expand poor women’s access to maternal healthcare.
Public health specialists in developing nations are urgently seeking innovative ways to stretch resources to provide more results. Performance-based financing (PBF) has gained prominence as a possible solution because of its emphasis on paying for results rather than inputs. The basis of PBF is that cash or non-monetary benefits are offered in return for measurable actions or the achievement of a defined target.
You may know about PBF in the health service delivery context. For instance, doctors and nurses may be rewarded, if fewer patients acquire infections during a hospital stay. However, PBF interventions can also be used to improve public health supply chains in developing countries. For instance, staff at a central medical store can be rewarded for using a computerized logistics system correctly and for increasing their productivity. By linking a supply chain worker’s performance with rewards, PBF may be able to reduce bottlenecks along the supply chain, reduce stockouts, and improve commodity availability.
The Institut de Formation et de Recherche Démographiques(IFORD) [Institute for Demographic Training and Research] was hired to conduct the impact evaluation baseline survey on the performance-based financing (PBF) program in Cameroon, carried out by the Ministry of Health in 14 health districts and covering a total population of close to 2.6 million. The survey preparation period (October 2011 to February 2012) was followed by the data collection period (March to June 2012). The data entry process, which took place in parallel with the collection exercise, was conducted between April and August 2012.
We, the members of the IFORD survey firm, had made sufficient progress with the baseline survey data analysis when we were invited to attend the Fourth Annual Impact Evaluation Workshop. This workshop is organized annually by the World Bank with the aim of providing technical support to teams whose results-based financing (RBF) programs and impact evaluations are funded by the Health Results Innovation Trust Fund (HRITF) and implemented through collaboration between the World Bank and the governments of the countries involved. Although the workshop was largely geared toward RBF teams working in the health field, it is our view that it offered the advantage of accommodating, in a broader sense, survey firms involved in impact evaluation processes.
My initial objectives prior to the workshop. As the representative of a survey firm associated with an African development population sciences training and research institution, participation in this important workshop was initially aimed at achieving several objectives. First, I wanted to share about IFORD’s positive and negative experiences with conducting the baseline survey. I also wanted to learn from others and build IFORD’s capacity to carry out impact evaluations of RBF projects, in particular in the technical and evaluation methodology areas. It was also my wish to assimilate enough information to allow me to better position the institution to do evaluation follow up work. Lastly, I also wanted to use this opportunity or forum to help enhance IFORD’s visibility. After these five days