Authors: Benjamin Loevinsohn, Dinesh Nair
This blog derives from a consultation with RBF Implementing Countries in Zimbabwe.
Results-Based Financing (RBF) has been defined by the World Bank as “any program that rewards the delivery of one or more outputs or outcomes by one or more incentives, financial or otherwise, after the results have been verified.” After more than 8 years of implementing RBF in the health sector, this narrow focus on incentives as the sole driving force for results seems too narrow. Although RBF provides a common approach to thinking about improving the quality, delivery, and coverage of essential services, it is not “one size-fits-all” by any means. RBF helped shine a light on the black box of service delivery. Through de facto decentralization, RBF allowed managers at district and facility level to gain autonomy and make their own decisions on how to organize services in a way that they are more accessible, better quality, and more accountable to the population. Finally, RBF has facilitated the move towards health systems to results, recognizing the achievements of those results.
With support from the governments of Norway and the United Kingdom through the Health Results Innovation Trust Fund (HRITF), the Bank has helped more than 30 countries implement large-scale pilot efforts in RBF. Completed rigorous impact evaluations (IEs) in Rwanda, Argentina, Afghanistan, Zimbabwe, and Zambia have shown some good results but these have not been uniform, and there remains much room for legitimate skepticism. Although a further meta-analysis may provide a clearer picture, now is clearly not the time for complacency. Given the broad array of interventions engendered by RBF, emerging results from IEs, and considerable experience on the ground, this may be a good time to re-imagine RBF. As program planners look to gearing up to the future, below is a deliberately provocative list of some of RBF successes that can be built on as well as some of its challenges that will require additional effort and attention.
1. Psst,….Creativity is Contagious - pass it on! Part of the attraction of RBF has always been the bold innovation in health systems that are reluctant to try new things. At the health facility level, RBF’s success may be due to encouragement of innovations by staff. Given the centrality of innovation to RBF, it is important to maintain and strengthen the culture of intrepid reform at all levels.
2. Keeping Our Eye on the Bottom Line! Another aspect of RBF that provides a crucial foundation on which to build has been its emphasis on robust measurement of results. If you are going to pay for results, you cannot be naïve about the sources of data you use. There are opportunities to use information and communication technologies to further strengthen data collection.
3. Peering Inside the Black Box: One of the critical advantages of RBF, and what has separated it from broader health sector reforms, is its focus on the processes in health facilities. In this way RBF has relied on short causal chains whereby facility staff themselves can address issues with their own resources. Protecting this autonomy and better understanding the “production function” inside health facilities is a compelling area of research and development.
4. Health Worker Motivation – Denial is Unlikely to Work: RBF deserves credit for taking on a very sensitive and political issue: understanding and addressing health worker motivation. This may be the aspect of health system strengthening that few people want to talk about openly because it is fraught; but denial has rarely been a successful strategy in public health. We should use the latest findings from behavioral economics and psychology to design even better motivation and incentive structures. The stakes are too high to be squeamish.
5. Going the Extra Mile: Initial data from the IEs suggests that RBF has only been mildly pro-poor. RBF pilots have usually involved extra support for remote and under-served health facilities, and it would be valuable to better understand how well this approach has worked. In addition, greater attention to addressing social, cultural and financial barriers to access for the poor is critical. Specifically, considerable work has to be done on how to use RBF to strengthen outreach activities to reach the under-served.
6. Management Matters: Most RBF practitioners have come to realize that issues of management can seriously impede improvements at health facility and district levels. Besides increased attention to coaching for the officers-in-charge (OICs) of facilities, other management-strengthening techniques deserve to be tested. Many innovations are possible here but could include: more emphasis on team work, increased transparency, greater involvement of the community, out-sourcing coaching activities to people outside the public sector, contracting-in managers, or entrepreneurial behavior training for OICs.
7. So Much Data, So Little Analysis: RBF generates a great amount of verified data that can be better harnessed. There is a real opportunity to mine the data using “big data” techniques and “crowd sourcing” of data analysis. The latter could take advantage of the large community of practice that has grown up around RBF.
8. What about Hospitals? The results achieved by RBF in hospitals have, generally, been disappointing. Improving the management of hospitals is tough and our understanding of the impediments remains modest. It would be useful to examine the reasons why hospital RBF has been disappointing and test different approaches that may address the issues. With hospitals both the public face of the health system and the fact that it is a resource guzzler, this is a worthy area for bold experimentation.
9. Where’s the private sector? Much of the work on RBF has focused on the public sector with only limited use of private providers. This seems like a missed opportunity. The private sector often provides the majority of primary care and in many countries there is already a broad network of private pharmacies that could help improve the supply chain.
10. Doing Better with Less: Given the current fiscal challenges that many governments face, there is a pressing need for innovations that achieve better results with current levels of resources or the same results at lower cost. Efficiency gains should be possible in many areas such as more rigorous purchasing of services and risk-based verification.
11. A Stake in the Outcome: Sustaining and expanding successful RBF arrangements will require strong Government ownership and buy-in. This commitment must be visible in terms of investments, policies, and attention from top management. It will require earlier, more frequent, and more in-depth dialogue with other parts of government, especially ministries of finance. The more diverse the people who understand RBF the more likely it is that RBF will be sustained if it proves to represent greater value for money.
12. More Diverse Outcomes of Interest: RBF has generally focused on out-patient visits, child immunization, and skilled birth attendance. In many countries these are still important outcomes, however, it will be valuable to test other kinds of outcomes such as: nutritional status, household behaviors, household knowledge, health worker knowledge, and quality of care.
To a person with a hammer, everything looks like a nail. There are health systems issues that RBF will not be able to resolve. However, RBF may end up being a powerful tool for gaining deeper insights into how health systems can achieve much better outcomes. Using that tool requires understanding what aspects of RBF have worked well and which still need greater attention.