Building awareness for results-based financing (RBF) and on studies about its contextual feasibility and appropriateness is an important activity that can help policymakers to make informed decisions about the use of RBF and its possible design. Another critical— and related— activity is holding stakeholder consultations. These consultations can help to ensure that the design of the RBF program is tailored to local realities.
These activities have been supported through preparatory grants and pre-pilot funding in the more than 30 countries supported by the Health Results Innovation Trust Fund’s (HRITF) Country Pilot Grants (CPGs). Knowledge and Learning (K&L) grants, one of three HRITF funding streams, serve as an additional funding source for these activities. Indeed, K&L grants are designed to fund technical dialogue and learning about RBF design and implementation in the 82 countries that make up the Bank’s International Development Association (IDA), the Bank’s fund for the poorest countries. Currently, there are 23 country and seven regional K&L grants in the HRITF portfolio.
Raise Awareness and Inform Decision-Making on RBF
One of the primary functions of K&L grants is to raise awareness and inform decision-making about RBF. These grants provide policy makers with the opportunity to become more familiar with the concept of results-based financing and with the different principles that underpin it. They also help them determine if RBF is appropriate for their respective contexts, through study tours, knowledge exchanges, feasibility studies, and other awareness-raising and decision-making activities.
A K&L grant in Chad financed a national RBF workshop, study tours to Rwanda and Democratic Republic of Congo (DRC), and the participation of a high-level delegation to the performance-based funding (PBF)/RBF Community of Practice conference in Senegal. These activities enabled policy makers to learn more about RBF and to see firsthand how RBF worked in practice, while simultaneously learning from colleagues in Rwanda and DRC. The activities funded under the K&L grant were instrumental in informing the government’s decision-making process on RBF. A large IDA-funded PBF pilot, covering a population of 1.45 million across eight districts and four regions, was subsequently implemented in 2011. Encouraging results from this pilot led to the inclusion of a PBF component in the new Mother and Child Health Services Strengthening project, which should be implemented in late 2014. K&L grants have also funded study tours for policy makers in Djibouti, Sierra Leone, Uzbekistan, Dominica and St. Lucia.
A K&L-funded study conducted in Yemen reviewed previous RBF experiences in the country and examined the lessons learned. A stakeholder-consultation workshop was also held, and it yielded a recommendation to adopt a voucher approach to improve maternal health. This recommendation was primarily based on an assessment of the current state of maternal health in Yemen, where despite declines, maternal mortality remains high, and the proportion of women delivering with a skilled birth attendant continues to be low. The growing, global evidence-base on the use of vouchers to improve access to and utilization of maternal and child health (MCH) services also supported this recommendation. The K&L grant ultimately resulted in the use of a contextually appropriate RBF model in the Maternal and Newborn Voucher Project, which will be supported under the new IDA project.
In Haiti, a K&L grant financed a readiness assessment for RBF, as well as the first draft of the contracting model. Through activities financed by the grant, the Bank was able to work closely with other development partners in the sector and to effectively assist the Ministry of Public Health and Population (MSPP) to encourage key donors to agree on a common contracting model for service delivery based on PBF. This model was spearheaded by the MSPP. Similar readiness and feasibility studies have been supported with K&L grants in India, Niger and Djibouti.
Support for RBF Design and Implementation
When a country decides to adopt results-based financing for health-service delivery, HRITF offers different options to finance activities necessary to explore different RBF approaches and to then design and implement the approach most appropriate to the context. These options include preparatory grants, pre-pilot grants, and K&L grants. K&L grants can also finance technical assistance and analytical work to address specific design and implementation questions or even small-scale testing of a particular RBF approach.
A K&L grant in Kenya financed the technical assistance required for the design and implementation of a PBF pilot in Samburu, a rural and underserved county. The pilot’s design and implementation arrangements proved to be effective: immunization rates increased, as did the number of women receiving antenatal and family planning care. Based on this success, the Samburu pilot will be scaled-up across all counties in the northern arid and semi-arid regions.
In Tanzania, a K&L grant financed the Ministry of Health and Social Welfare’s (MOHSW) review of the implementation of the Pay for Performance (P4P) pilot in the Pwani region, which was funded by the Government of Norway. Based on the lessons that emerged during the review, policy makers decided to scale-up a revised version of the program. The program design is currently being refined using HRITF preparatory grant funds to support the country team, which includes representatives from the MOHSW and the Prime Minister’s Office for Regional and Local Government (PMO-RALG). An upcoming Bank project, with combined IDA and HRITF funding, is intended to support the scale-up of RBF in several regions. This process has involved close collaboration with other donors that have shown an interest in supporting RBF in Tanzania.
Beyond Design and Implementation
Technical dialogue and learning does not stop once an RBF approach has been selected, designed, and implemented. In fact, both are vital throughout the duration of a pilot or its scale-up. As such, K&L grants fund reviews of implementation processes and other RBF capacity building activities.
Two regional K&L grants supported in-person and virtual knowledge exchanges for RBF capacity building in sub-Saharan Africa. One of the grants funded the Accra Flagship course on using RBF to achieve universal health coverage and the development of the RBF e-learning course. The other financed the creation of the Harmonization for Health in Africa (HHA) portal, which supports communities of practice for each of the WHO’s healthy systems pillars.
Building Solid Foundations
HRITF K&L grants are a vital resource for policy makers involved in results-based financing, and they are especially useful for those just beginning their RBF journeys. By supporting activities that promote informed decision-making, a well-planned design and implementation process, and strong in-country capacity, K&L grants help build a solid foundation for locally owned RBF programs.