RBF - Something New?

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Add to this the promising results coming from evaluations of supply side schemes in Rwanda and pre-earthquake Haiti and demand side CCT schemes from the LAC region, and there is a growing body of evidence that suggests that thoughtfully designed and carefully implemented RBF schemes can provide the push needed to achieve better results.

If anything is new it is that RBF approaches are being systematically considered, for large scale implementation, by donors and national and state governments across the globe. We see this in the performance based aid principles being incorporated into many recent global and bilateral initiatives. Intense interest by countries to attend design workshops, visit other countries to learn, and the momentum to implement at home is building quickly. Some examples include: through support from AusAID to the Center for Global Development, teams from four Asian countries (Bangladesh, Cambodia, Pakistan, Philippines) have designed innovative RBF programs to improve maternal and child health results. Neighbors to Rwanda such as Burundi and the Democratic republic of Congo (DRC), inspired by Rwanda’s achievements, are adapting the RBF approach used in Rwanda to their contexts. The Meso-American Initiative, supported by the Bill and Melinda Gates Foundation, Fundacion Carlos Slim, and national governments will soon implement a regional RBF initiative in Mexico and Central America.

I just returned from India where national and state governments are committed to reducing child and maternal mortality and many are turning to RBF as part of the solution. I learned about a fascinating smorgasbord of RBF schemes, most implemented at scale (LARGE scale- this is India!) by national and state governments during the past few years, and most focus on maternal and child health. The World Bank, DFID and USAID funded an RBF workshop in January 2010 that brought together teams from 9 states to learn about international and home grown RBF experiences and what it takes to implement them successfully. Everyone recognized that details of implementation are critical.

It seems that the global appetite for learning about RBF in health is increasing at an exponential pace. To satisfy this hunger, a banquet is needed. There is no one dish that will fit all tastes. We see:

Transfers from national to state governments linked to results in Argentina and Brazil.

Multi-level performance incentives to facilities, district teams, regions and national levels linked to results in Zambia.

Province-wide NGO umbrella contracts that condition a part of payment on results in Afghanistan and the Democratic Republic of Congo.

Service delivery NGOs paid partly linked to results in Liberia and Haiti.

Governments or private payers pay service providers (public and/or private) when they deliver services to voucher recipients in Bangladesh, India, Kenya, Myanmar, Nepal, Pakistan and Uganda and many also pay the user to cover transportation costs and incite action.

Governments pay public, nonprofit and/or for profit service providers partly based on results in Burundi, Egypt, India, Rwanda and Tanzania.

Hospitals are rewarded to improve quality, through performance on clinical vignettes in the Philippines; reducing patient harm in the US; following clinical protocols and quality processes in Honduras and Rwanda.

Conditional Cash Transfer Programs that link income transfers to poor households to whether they obtain key health interventions and keep children in school in Mexico, Nicaragua, Honduras and others.

All approaches specify indicators and payment rules and strong schemes incorporate approaches to validate that what is reported truly occurred (strong information systems and checks to guard against false reporting are the backbones of all RBF approaches). All must perform the following functions (by the MOH or by a combination of entities): 1) select recipients; 2) establish performance agreements or contracts (and enter into contracts with recipients); 3) report, monitor and validate; 4) generate payment; and 5) assess and revise.

RBF is not the magic recipe that will solve all health systems ills. Some performance challenges can be addressed with changed incentives, while others require investments in inputs such as infrastructure and training. Strong leadership and management are also clearly critical. If well designed and implemented, however, RBF may be a key ingredient that spices up the sauce and catalyzes the system to achieve results.

Rena Eichler, Broad Branch Associates