Is results-based financing (RBF) the missing link between health systems strengthening and maternal, newborn and child health?

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Let’s face it, if something doesn’t change in a hurry we will be hard pressed to reach the Millennium Development Goals, especially for maternal, newborn and child health.   What could the needed changes be, many of us ask ourselves?
 

Part of the answer is using money for health to better effect in improving the functioning of health systems in low-income countries.   How can that happen?   One imperative is focusing on how to increase the chances that "stronger health system" translates into "better health," particularly among mothers, babies and children. To be candid, even the most well intentioned efforts to train health workers, streamline supply chains and modernize information systems might well lead to disappointing results where it counts -- in the prevention and treatment of ill health. Many of us who support more donor and national government support for health systems strengthening (HSS) know that the broken link between systems and saved lives needs specific and creative solutions.
 

Think about it: Translating funds for HSS into health requires that workers have the reason and resources to use their training to good effect. It means that those in need of health care have the wherewithal to get it. For maternal, newborn and child health, it means, among other things, that:
 

- health workers undertake the outreach to identify and attract pregnant women for prenatal care and, importantly, facility-based delivery or other skilled attendance;
- that basic standards of newborn care are adhered to both within health care settings and at home;
- and that children receive a comprehensive set of well child care, including immunization and other basic services. 
 
Whether those actions are taken is partly about the available skills and resources, but mostly about the behaviors of health workers, those who supervise them, and mothers and others in the home.
 

So if it's about behaviors, it's about incentives -- first the intrinsic incentives, such as the professionalism of health workers and conformity to social norms around seeking care.  And second, the extrinsic ones that determine whether giving (or receiving) care is a net plus or a negative in terms of money in pockets.   Here the evidence now emerging on results-based financing has much to offer: a share of the new resources for health system strengthening (or, for that matter, for "vertical programs") could be used as rewards for better performance of health services that have a clear and consistent connection to better health. 
 

Many examples are piling up of real-world application of the concept of using performance-based incentives to reward health workers for delivering more and better care, and/or using vouchers, stipends, food and other demand-side incentives to bring mothers and children in for services. Some of these have been documented in the book that Rena Eichler and I edited, Performance Incentives for Global Health: Potential and Pitfalls; and others are being linked or posted on this site. From those cases, it's clear that results-based financing has particular promise in addressing some of the supply- and demand-side challenges that most bedevil maternal and child health, including attracting women for facility-based deliveries and bumping up immunization coverage.
 

Performance incentives are in no way substitutes for the needed inputs. Who cares about a bonus for increasing immunization by 20 percent if the vaccines and injection supplies are stuck at the port, or there are no health workers in the community? But inputs in the absence of the motivation to use them well are similarly an incomplete and failure-prone approach. 
 

In my view, results-based financing is one of the most promising ways to make that all-important link between HSS and maternal, newborn and child health.
 
[This blog post was prepared by Ruth Levine when she was at the Center for Global Development. She has since moved to a position at USAID.]