RBF in the DRC: The Final Countdown

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10 – 9 – 8 – 7 – 7 -7 – 6 – 5 – 4 – 5 – 4 – 3 – 2 - 1 ----Yesterday, Soeur Hélène, head of the Saint-Jean health center in Kasenga, DRC, learnt that her center would soon move to a performance-based financing system. In a lucky draw, presided over by the provincial Minister of Health, Centre de Santé Saint-Jean and 141 other health facilities in Haut-Katanga district were randomly allocated into treatment and control groups - one of the final steps in the countdown to the launch of the DRC RBF pilot. Mwaba

When it comes to RBF design, it is often said that the “devil is in the details”. Through helping to design the DRC pilot, we have learnt, first hand, the truth of this statement. It has been more than 2 years since the design work started and the design which is now on the table is light years away from that which was first laid out in the initial funding proposal.  

So, why has it taken so long to get to this point?

1 - it is impossible to design an RBF mechanism with only a toolkit of RBF theory and a helicopter view of health system functioning. One needs to dig very deeply into understanding how the different elements of the system function.

2 - even when one digs deeply, there inevitably remain tremendous gaps in our knowledge , which requires undertaking simulations, sensitivity analysis, pre-pilots and more.

3 -  the fact that the RBF pilot is being linked to an existing Bank project, and must operate within its framework, creates many opportunities (such as political support, visibility, and an existing infrastructure), but it also introduces a whole new set of constraints, design limitations and additional stakeholders that need to be taken into consideration.DRC Map

4 - a non-negotiable was that this RBF pilot should contribute to the national policy dialogue on health financing reform. This necessitated the development of a design that could feasibly be scaled up and replicated elsewhere in the country, takes the experiences of other RBF schemes in the country into consideration, and also required extensive engagement at national and provincial level.

5 - it takes a very, very long time to build consensus around a model that , in addition to being technically sound, satisfies (even partially) the interests of key stakeholders who naturally wish to minimize their losses, and maximize their gains, from any change to the status quo.  

When in doubt, though, we always returned to two guiding principles. First, keep it SIMPLE. The final design may not be the technical ideal, but it is a design that can feasibly be implemented. Second, keep it FLEXIBLE. We may have made some design mistakes, but the inclusion of mechanisms that allow for the regular review and adjustment of design helps to mitigate that risk.

The DRC Pilot in a Nutshell

This pilot is being implemented in Haut-Katanga, a district of 1.26 million people in the province of Katanga in the south-eastern corner of the Democratic Republic of Congo. It involves the payment of performance-related subsidies to public, private and faith-based health centers and referral centers using a fee-for-service mechanism in the “treatment” group and a predictable monthly transfer in the “comparison” group. Both groups of facilities are treated exactly the same way in all other respects, such as the training provided to health workers, the quantity of drugs provided, the level of supervision, verification etc. The purchaser is an international NGO which also provides general support to district health facilities under the Bank-supported Health Sector Rehabilitation and Support project (HSRSP/ PARSS). Facilities will have autonomy in the allocation of the payment received, both across expenditure categories (staff bonuses and operating expenses) and among staff. Contracts will be signed with health centers, not individuals. Hospitals and health zone teams are excluded from the pilot, but receive performance incentives and support through the HSRSP. The pilot is partially funded by the Health Results Innovation Trust Fund (administered by the World Bank) and partially funded by the World Bank supported HSRSP.