Lindsay Morgan

Excitement is growing about results-based financing (RBF) for health, a financing mechanism that turns the traditional donor approach of paying for inputs on its head. RBF for health is a cash payment or non-monetary transfer made to a national or sub-national government, provider, payer, or consumer of health services after predefined results have been attained and verified. Payment is conditional on measureable actions being taken. Where RBF has been tried, experience suggests it can improve health outcomes and strengthen health systems. But there is little rigorous evidence on its impact and many questions remain: Does focusing on some health interventions lead to the neglect of others? Will the approach encourage people to cheat to receive the incentive? Is it cost-effective? Will it diminish workers’ intrinsic motivation? What about unintended consequences?

I was walking through a park one afternoon when I happened upon two boys careening wildly through the air on a seesaw. Theirs was a world of alternating motion, of two poles vying for ascendancy. Which makes it very much like our own world, the world of global health and development. With each new idea and plan and power point presentation for how to make people less sick and less poor, up we go, brimming with hope and anticipation—perhaps this will work! And with each setback and disappointment, down again we come, disenchanted and skeptical—we’ve seen so many failures. So it is with results-based financing for health (RBF), a concept designed to help people in poor countries live healthier lives by linking incentives with results. RBF is being supported by the World Bank through the Health Results Innovation Trust Fund, which is financing the implementation and evaluation of six RBF pilot programs in Africa. Benin, the Democratic Republic of Congo, Eritrea, Ghana, Rwanda, and Zambia each will receive between $10-14 million to implement and rigorously evaluate RBF schemes between 2008-2010, targeting child and maternal health mainly through incentives to service providers. Many are hopeful that these pilots will improve health and strengthen capacity in places where, despite huge investments, health status remains extremely poor. There is also a significant amount of skepticism. But let’s start with the term itself—what is RBF?