In 2003, the Government of Uganda launched a pilot performance-based contracting scheme designed to improve the quality of and access to health services at private not-for-profit (PNFP) health
facilities. In addition to performance incentives, facilities were given freedom to decide how to allocate resources. The latter innovation had a discernible positive impact on health facility performance, but
the former—the incentives—did not. This brief explores the design and implementation issues behind the failure of the incentives and shows that while incentives matter, the success of RBF programs is
not inevitable. They require significant investment (of time AND money) and careful design and implementation. The good news, though, is that enormous improvements can be had for free—by
granting facilities the ability to choose how to spend their money.
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?
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?
For many people who keep up with world events, the news from Afghanistan has long appeared to consist mainly of terror attacks, counter-insurgency campaigns and the opium trade. Behind the sensational reporting, however, another major story is unfolding: how one of the world’s poorest countries, after decades of brutal conflict that claimed more than a million lives and made millions more people into refugees, is working to
build a modern health system. In a rugged land of mountain and desert that would present major obstacles even without the effects of war and widespread poverty, Afghanistan has made significant progress.
Central to this achievement has been the collaboration of the Afghan government with international donors including the World Bank in fashioning a system suited to the nation’s values, culture, priorities and geographic setting. Each of three major donors—the World Bank, the European Commission (EC), and the United States Agency for International Development (USAID)—has taken a different approach to funding and managing its contribution to the effort. The one chosen by the World Bank uses results-based financing (RBF), a system that provides rewards—in this case monetary ones--for improved performance. RBF has, some health experts believe, features well suited to the opportunities often present in countries with histories of conflict.
