Using Results Based
Financing to Strengthen
Health Systems
RBF Team, World Bank Group
Content
• Overview of Results-Based Financing (RBF)
– About RBF: definition, diversity, intervention
• Supply Side RBF
– Inter Governmental
– PBF at Facilities
– Performance Based Contracting
• Demand Side Financing
– CCT/ Vouchers
• Design & Implementation Tips
2
Definition
• Results-Based Financing (RBF) is a cash payment or
nonmonetary transfer made to a national or sub-national
government, manager, provider, payer or consumer of
health services after predefined results have been attained
and verified.
• RBF is an umbrella term that encompasses various types
of interventions that target beneficiaries (for example,
conditional cash transfers), providers (for example,
performance-based financing), and country governments
(for example, cash on delivery, program for results).
3
Different Types of RBF
Incentives primarily for:
COD/P4R
Countries &
Organizations
Nigeria, Ethiopia
Community Primary
Secondary
PBF
Rwanda , Burundi
PBC
Afghanistan
CCT/Vouchers
Type of Reward:
Payment
based on FFS
“PRP”*
Providers
OBA
BurkinaFaso,
Gambia, Nigeria
Other monetary
payments
Non-monetary
rewards
Beneficiaries
*Provider
Recognition
Programs
4
What is Results-Based Financing (RBF)?
• Demand-side incentive payments to individuals,
households or communities, conditional on
engaging in pre-agreed healthy behaviors or
utilization of health services
• Supply-side incentive payments to facilities, teams
of health workers conditional on increasing
processes, health outputs or outcomes
• ‘Results-Based Financing (RBF) encompass the
entire gamut of supply and demand side
approaches
Why so much interest in RBF?
 Disenchantment with traditional supply-side financing of inputs
w/o accountability for outputs (a ‘sinkhole’ issue)
 A way of motivating behavior change at household level by
providing incentives conditional on households attending health
education, clinics, or adopting preventive behaviors
 Redirect attention of providers to making greater headway on
priority diseases and health problems of the poor
 Promising instrument(s) to more effectively target socially
excluded and/or poorest households in remote areas,
 Urgent scaling up of national performance to attain
MDG 4 + 5 targets
Rapid Expansion of RBF
7
RBF & Inter Government
Transfers
Plan Nacer in Argentina
8
Plan Nacer
• Health Insurance plan for:
– Uninsured pregnant women (up to 45 days after birth)
– Uninsured Children under 6
– Target coverage of 2M women and children
• New strategy for health services provision:
– Payments tied to performance
– About 6% of health expenditures (2006 - NOA/NEA)
• Objectives:
– Strengthen primary healthcare network
– Increase accessibility and improve quality of health
services
– Reduce maternal and child mortality & morbidity
Argentina: Plan Nacer Intervention
Two Levels of Payments
1. Nation to Province
– Enrollment of eligible population
– Targets for eligible population
• Outcomes: Birth weight & APGAR
• Utilization: Prenatal care, well baby care, etc
• Process and management
2. Province to public clinics
– Enroll public
– Fee-for-service for 80 priority MCH services
– Provider autonomy over use of funds
10
Plan Nacer’s Payment Mechanism
60% Enrollment
National Level
Result Based-Financing
(RBF)
40% Health
Outcomes
(Tracers)
Provincial Level
Fee for Service
Providers
Additional Budget: Staff
incentives, equipment, etc
Target Population
Change in
health outcomes
Health in Argentina
• Spike in Maternal and Infant mortality and morbidity following
2001 crisis, mostly amongst poor/uninsured
Evolution of infant mortality rates in Argentina
Expressed as a rate per 1,000 live births
30
25.6
25
Infant Mortality rate
22.2
20
16.6
16.3
16.8
16.5
14.4
15
13.3
12.9
2005
2006
10
5
1990
•
1995
2000
2001
2002
Health coverage (2008)
– Social Security (52%)
– Private (10%)
– Public Sector Budget (38%): uninsured
2003
2004
Argentina: Plan Nacer Results
• Provided 4.7 million pregnant women and children with
health coverage
• Delivered 37 million maternal and child health services
– Reduced the probability of low birth weight by 23%
– Reduced the probability of in-hospital neonatal death
by 74 %
• Based on Plan Nacer’s success, the Government of
Argentina has launched Program SUMAR
– SUMAR uses RBF mechanisms to expand health
coverage to uninsured children and adolescents under
19 and to uninsured women between the ages of 20
and 64
13
Performance Based
Financing
Community/ Health Facilities/ Hospitals
Rwanda, Burundi , Zambia, Zimbabwe
14
Traditional
Financing
Inputs
Results Based
Financing
Activities
Outputs
Rwanda: Increasing
Coverage and Quality
17
Improving Efficiency in Zambia & Zimbabwe
18
Performance Based
Contracting
Afghanistan
19
Performance based contracting
• A method of contracting where the results are
defined rather than the process.
o Includes measurements
o Incentives
• Benefits
o Better performance
• Results oriented
o Better price
• Best and commercial practices and less mandated “how to’s” reduces costs
o Contractor has flexibility and incentive to be innovative
• Contractor motivated to save money
The standards & measurement are results
oriented
o quality of work or
product
o quantity of work or
product
o accessibility
o timeliness
o accuracy
o customer satisfaction
o not unduly
burdensome.
Performance indicators and
standards
o
o
o
o
Collect, track, and share data
Conduct surveillance systemically
Document results
Review periodically and jointly with
the contractor
• “Are we measuring the right
things
Demand Side Financing
Vouchers in Bangladesh & Pakistan
22
Bangladesh DSF program overview:
incentives for both demand and supply side
• Aims to rapidly increase utilization of maternal
health (MH) services via:
– Vouchers for free antenatal (ANC), delivery, emergency
referral, and postnatal care (PNC), and laboratory tests.
– Cash transfers Tk. 2000 [$25] and gift bags if women
deliver with skilled birth attendant at home or in facility,
and transport stipend Tk. 500 [$ 6.25]. Emergency referral
transport is also available.
– Cash incentives for providers/field workers for registering
women and providing MH services
– “Seed fund” for facilities
23
Token for free consultation
24
ANC1 (%) of DSF vs National (BDHS)
ANC (DSF)
Achievement Percentage (%)
100
90
80
70
60
50
40
30
20
10
0
ANC (BDH)
87
88
89
91
76
49
52
49
59
55
0
2004 2007 2008 2009 2010 2011 2012
2013 (upto july)
Year
Source: DSF project office
25
Assessing the Effects of RBF Approach
Zimbabwe: acute respiratory infection cases per
10,000 in RBF and non-RBF districts
350
RBF districts
non RBF districts Program start
per 10,000 population
300
250
200
150
100
The trend in nonincentivized indicator
appears similar between
RBF and non-RBF
districts, indicating no
negative spill over
50
0
26
ANC in DSF Upazila vs Control Upazila
Control
100
90
80
Intervention
92
76
70
%
55
60
50
40
34
30
20
10
0
Had any ANC visit
Source: Economic evaluation, 2010
Had at least 3 ANC check-ups
27
Safe delivery (%) of DSF vs National (BDHS)
Safe delivery(DSF)
Safe delivery(BDHS)
100
90
87
80
84
79
85
82
Percentage
70
60
59
50
40
32
30
25
18
20
10
13
0
2004
Source: DSF project office
2007
2008
2009
Year
2010
2011
20122013 (upto july)
28