Results-Based Financing, RBF, rewards health facilities and frontline health workers for outcomes produced. The money earned as an incentive for the delivery of specified maternal and child health services provided makes up about 2% of the program budget - yet provides motivation for better results.
It’s a question of “I’m going to give you a little incentive to use the other 98% of your budget more efficiently,” said Paul Gertler, a professor of economics at the University of California.
Gertler joined a day-long conversation on RBF, co-organized by the Health Results Innovation Trust Fund (HRITF) and the PBF Community of Practice in Africa, at the Third Global Symposium on Health Systems Research in September.
Paul Gertler, at podium (photo: Wilson Johwa)
According to Bruno Meessen, a professor of health economics at Belgium’s Institute of Tropical Medicine, the introduction of RBF can be traced to the push some 15 years ago for the privatization of the public sector.
“Here we are trying to work out a third way which is recognizing that we have to think of quasi-market arrangements within health systems and the public sector, aligned with the public mission but aware that incentives work, “ said Meessen.
While most RBF programmes are run through the public sector, there are more examples of sub-contracting of the private sector according to Dinesh Nair, a senior health specialist at the World Bank.
“The heart of RBF is what happens at the frontline, at the [health] facility itself – in terms of the indicators we are incentivizing and how they compare with the non-incentivized indicators,” he said.
Nair was also speaking at the Transforming Health Systems through Results-Based Financing event, where representatives of some of the 36 countries already implementing RBF projects, researchers and World Bank consultants and staff from around the world considered the early successes and debated the issues arising around scale-up.
Tim Evans, senior director, Health, Nutrition and Population at the World Bank emphasized the need for the Bank to “allow for those sober [research] questions that might address institutional bias. Since the next phase of RBF was more ambitious than the first, investing in the “knowledge agenda” was critical, he said.
Evans also praised the quality of research on the RBF portfolio managed by the Bank, saying: “The more I’ve looked at what our institution has done I’m impressed with the quality and integrity of the research.”
Evans referred to his arrival at the World Bank some 16 months ago during which there was an impression that the “Holy Grail had been found (and) all you had to do was something called RBF.” This, he explained, was because of the excitement at the growing evidence that implementation of RBF in participating countries was improving outcomes in the reduction of preventable infant deaths and improving maternal health.
“As I started to know a little bit more than I knew initially, which was not much, I started to appreciate some of the depth of insight which was inherent in the implementation of this approach in over 30 countries,” he added.
Just a week earlier on September 25, the establishment of a Global Financing Facility for reproductive, maternal, newborn, adolescent and child health was announced at the United Nations.
The new facility builds on the work of the HRITF, which since 2007 has supported programs to help developing countries make progress towards the Millennium Development Goals for women’s and children’s health.
Evans said the funding will allow teh World Bank to work with a much larger group of partners, and not all the money will flow through the Bank.
“This is just to begin the journey and we’re developing this global financing facility over the next 9 months. We’re hoping that as the concept matures and as more stakeholders come onboard that we’ll be looking at a much larger sum of money so we can support countries much more systematically,” said Evans.
Africa accounts for 75% of RBF health programs in, followed by Asia and Latin America, according to Nair, who noted that countries implementing RBF do so to strengthen the utilization of services but also to improve the quality of those services.
RBF presents an opportunity to address key service delivery bottlenecks, such as problems with supply chains. The result is that RBF programs tend to be country-specific and are meant to help address issues in ways that make sense for the context.
Evans is excited by the ability of RBF programmes to decentralize the provision of healthcare, allowing districts and sub-districts greater levels of autonomy. “Once you give a small space to relatively smart people to manage their services it’s pretty impressive what they can do,” he said.
Head of Cordaid Zimbabwe Arjanne Rietsema noticed a similar trend as the country’s RBF program shaped up, largely driven by the spirit in the Ministry of Health of wanting to rebuild a health system that had fallen on hard times. “In the beginning there was much skepticism about decentralization and a guided form of decision making power at the health facility level,” she observed.
“But we have seen that health workers know their priorities best and together with the community they are very motivated to solve their problems. It is frustrating to make requests to the higher authorities for everything you need to run and improve your clinic and very motivating when you are allowed to manage your resources yourself.”
Implementation of RBF in Zimbabwe was initially piloted in two districts in 2011. It now covers over 4 million people in 18 rural districts and two low-income urban districts. The program is funded by the UK’s DFID and the government of Norway through the World Bank, to the tune of US$35 million. In 2013 Zimbabwe’s finance ministry provided US$1 million and then made a commitment of US$5 million per year from 2014.
A recently-concluded impact evaluation study comparing the two years of exposure to the program – 2012 to 2014 – to the two preceding years, shows a strong uptake and availability of services in RBF districts compared to the rest of the country. The result has been a 13 percentage point improvement in the in-facility delivery rate within the participating districts, along with a 12 percentage point improvement in post natal care and significant improvements in the quality of ante natal care services. “The design was around a prioritized package of services directly linked to the prevention of disease for mothers and children under 5,” said Zimbabwe’s permanent secretary for health Gerald Gwinji. “We use RBF as an opportunity to operationalize our government’s integrated results management system,” he added.
Contributing to the improvements was a team-based approach resulting from regular and structured supervision and in turn allowing for feedback and community participation. “More women are receiving a full package of ante-natal care services including during tests, blood tests and tetanus shots in the RBF districts,” said Tafadzwa Goverwa-Sibanda, a Provincial Maternal and Child Health Officer in one of Zimbabwe’s eight rural provinces that were part of the study.
RBF in Zimbabwe is aligned with and supports the national health strategy whose thrust includes equity in health services through the removal of user fees, rebuilding the quality of care standards, increasing priority and access to maternal, family planning and child health services as well as strengthening the country’s referral system.
However, the impact evaluation also revealed that more work still needs to be done around facilities in remote areas or with small populations. Just as important is breaking through religious, economic and socioeconomic factors that stand in the way of beneficiaries accessing services. The study showed little change in antenatal care coverage and contraceptive use – a result Goverwa-Sibanda interprets as showing that these indicators were probably already high at the onset of implementation.
“From the patient exit interviews, the ANC (antenatal care) interviews indicate that there were significant improvements in care processes such as measured abdomen and urines samples. Child health interviews also indicated an improvement in measurement and growth monitoring,” said Goverwa-Sibanda. In terms of the facilities themselves, there was an eight percentage point improvement in biomedical waste disposal. There was also an increase in supervision and community involvement after the introduction of RBF, along with a 34 percentage point increase in the presence of a community work plan in the RBF districts.
Outcomes were not the same across all districts, however. Some district indicators were better than others. “Because of this we went on to implement a process and monitoring evaluation to capture experiences and lessons from the frontline specifically looking at community engagement and support, along with looking at the state of mentorship and clinical supervision by the districts and provinces,” Goverwa-Sibanda said. Providers at high performing health facilities were highly motivated. There was regular supportive supervision which improved the capacity to earn more subsidies. For example, one high performing facility had an increase in subsidies of 53% to 94% between the first quarter and the second quarter. Teamwork was also noted to have improved communication, allowing greater community participation in monitoring the delivery of health services.
In the words of one of the beneficiaries cited by Goverwa-Sibanda, “We are now working as a team to ensure that the T5 (national data compilation form) is correct and accurate and we are able to send it to the district on time. We are motivated to work as we get paid for our effort.”
Argentina’s RBF program – known as Plan Nacer or ‘Birth Plan’ in Spanish – also came after a period of declining results when a national financial crisis resulted in 30% of Argentines losing their jobs, leaving large numbers of women and children without health insurance. The public health care system became overwhelmed yet, explained Gertler who worked on the Plan Nacer impact evaluation, the government did not want to give money to the provinces, which run the hospitals and clinics, to manage the situation. “They wanted to make sure that money followed people,” said Gertler. “So they said we’re going to put together an insurance scheme and we want you to enroll uninsured women and children and we’ll verify that they are uninsured, and those women and children will be attached to a clinic and the clinic that provides them with services we’ll give them more money.”
In Argentina, as in many countries, most of the in-hospital neonatal mortality comes from low birth weight babies – those who often end up in the intensive care unit. So preventing low birth weight through better prenatal care lowers neo natal mortality. “About half of the reduction in neonatal mortality comes from better prenatal care, preventing low birth weight and the other half comes from better in-hospital services,” said Gertler.
The resulting insurance in the country meant that for every woman and child that was enrolled into the scheme the provinces and healthcare facilities got a certain amount of money on a per capita basis. More money can also be earned if a set of healthcare indicators is met. “All of this is subject to external audit,” Gertler said. “When we come to look at cost effectiveness at the end we’re going to find that it’s probably one of the most cost effective things you could have ever done in Argentina to reduce low birth weight and in-hospital neonatal mortality.” Since its launch in northern Argentina in 2004, Plan Nacer now covers all of the country’s 23 provinces.
The results in both Zimbabwe and Argentina are consistent with the observation by Meessen that RBF is attracting the interest of other development agencies, such as UNICEF, the Global Fund and Germany’s GIZ. Describing RBF as a “paradigm shift”, Meessen says it is a new way to think about health systems. “If you want to change behaviors, the entry point is institutional arrangements... where you can negotiate and create incentives for people to take specific actions.”
Implementation of RBF has spawned a plethora of research over how and why it works. Various studies on the impact of RBF are at different stages of completion in implementing countries around the world. Among those seeking to better understand this funding model is the World Health Organisation which, supported by Norad and the Institute of Tropical Medicine, is engaged in a multi-country study aimed at drawing lessons on the scale-up of RBF, including the institutional arrangements adopted for system integration. “We don’t want any primary data, we don’t want any prospective data. We want people to go back and look at what has happened in the process of scaling up,” said Maryam Bigdeli, from the Alliance for Health Policy and Systems Research at the WHO. Such continuing enquiries are set to open new avenues for the growth and refinement of RBF.