Results-Based Financing (RBF) projects for health are currently being implemented in 31 countries—mostly in sub-Saharan Africa. The introduction of this new health system strengthening intervention in countries with limited resources and weakened health systems has completely changed the status quo: health service delivery is no longer business as usual. In countries where Performance-Based Financing (PBF- a type of RBF that works at the service delivery level) has been introduced, health workers are now more motivated because PBF explicitly ties payment to the volume and quality of services delivered. Workers, previously frustrated by low salaries, now know that if they work hard and improve health service delivery, a performance bonus will be paid to them in addition to their regular salaries. They also know that their ideas for improving service delivery and efforts to ensure the communities they serve know where to come are an important part of the solution that comes with the RBF approach.
As a result:
- Hospitals and health centers are much cleaner,
- Health workers’ attitudes are much better than before, and
- Clients are happy about the new wave of change.
More, however, needs to be done. As a number of projects look at scaling up, capacity building in PBF will need to intensify in order to ensure that well-trained and qualified hands are available where the work is most needed—at the frontline. Countries like Nigeria are at the fore of this effort, building a pool of qualified PBF verifiers to strengthen the monitoring and evaluation component on the ground and to ensure that PBF payments are based on results achieved.
The Nigerian Example
In February 2014, an intensive PBF internship program was implemented by the National Primary Health Care Development Agency (NPHCDA) with funding from the World Bank through the Nigeria State Health Investment Project (NSHIP) to increase the number of PBF Independent Verifiers to support the already stretched PBF teams working in the three PBF Pilot States: Adamawa, Ondo and Nasarawa. The verification of results achieved by health centers and general hospitals, and subsequently paid for by donors and/governments, is critical for the sustainability and integrity of PBF. Monthly and quarterly verification exercises performed by independent PBF verifiers and the local government primary health center department provide much needed checks and balances. Health centers and hospitals that underperform or over-report their results are immediately identified and appropriate steps taken to help providers get back on track. This is why building a strong base of verifiers is key.
A total of 59 PBF interns were selected to participate in the first ever PBF intensive training program in Nigeria. The internship lasted for four months and focused on PBF concepts, practice and IT training. The use of adult learning methodologies paved the way for interns to take a more active role in the PBF modules presented in class. Interactive sessions were facilitated by PBF experts, with regular field trips to help the interns gain necessary insight and practice. Interns in the three pilot states conducted quantity and quality assessments under the supervision of the state PBF consultant. They were also able to interact with health facility managers thus giving them hands-on experience. At the end of the training, 56 interns graduated from the program and were ready to provide field support to PBF Pilot State Teams. The three states now have a pool of qualified PBF Independent Verifiers who are providing much needed support to the PBF Implementation Team in Nigeria.
Building the PBF Knowledge Base
PBF is a relatively new approach to health system strengthening and capacity building is pivotal to its growth and sustainability. This is why programs such as the RBF e-Learning course and the annual results and impact evaluation workshop delivered by the Health Results Innovation Trust Fund, aim to raise awareness as well as build capacity on important foundational concepts of the program. In addition, PBF short courses are also being offered by SINA Health in conjunction with other partners to senior and mid-level health administrators from various countries; but more must be done to train and re-train capable health professionals. These learning avenues are critical for increasing the RBF knowledge base and building a pipeline of people with the necessary tools and skills required to successfully design and implement RBF projects. Health administrators implementing PBF need to know how to transfer PBF knowledge and skills to facility managers, the nurses, community health workers, and all cadres involved in the sphere of a health facility.
To support such trainings, a continuous training program will need to be created to establish an environment that fosters creativity as well as provides a platform for sharing PBF best practices within a given locale. Since every country has its own peculiarities, tapping into the local experience will go a long way to strengthen the foundation needed for a successful PBF program. Collaborating with health professionals on the field and equally, garnering feedback from the users of health care services will help improve the quality of subsequent trainings and effectively give communities ownership in ultimately improving the quality of health care they receive.
In summary, capacity building is pivotal in current and future PBF projects, particularly as more and more countries seek to pilot RBF or scale-up existing programs nationally. As a PBF Master Trainer, I have seen first-hand PBF novices become strong supporters and implementers of PBF principles—or what I call “PBF Rangers”—after a short intensive training program. The more trained hands are available, the higher the likelihood for improved quality and increase in successful outcomes. This is why building a PBF training pool is important. It is excellent to have government buy-in for PBF but it is equally important that resources are channeled to skills training and capacity building in order to generate the necessary support needed for successful project implementation and sustainability.