Results-based Financing for Health
in Tanzania
Health Financing Technical Working
Group Meeting
28th August 2015
Ministry of Health and Social Welfare
1
Presentation outline
RBF definition
Purpose and goals of RBF in tanzania
Institutional set up
 Indicators and factors considered in pricing quality
indicators
Available financial resources for RBF implementation
Fund flow in RBF implementation
Invoicing and payment
Progress made
Quality results
Timeline and next steps
 Sustainability strategy
2
What is RBF for health?
Results-Based Financing (RBF) – Umbrella term
applicable to many sectors
RBF for Health – “a cash payment or nonmonetary transfer made to a national or
subnational government, manager, provider,
payer or consumer of health services after
predefined results have been attained and
verified” (www.rbfhealth.org)
3
Role of RBF in health
• RBF in the health sector is needed to:
• Help focus attention on outputs and outcomes
• Example: the number of women receiving antenatal care or
taking children for regular health and nutrition check ups to
reduce child mortality rather than inputs or processes (i.e.,
training, salaries, medicines).
• Balance resource allocations to elevate low performing
indicators and maintain existing achievements (like
immunizations) to accelerate progress toward national health
objectives.
4
• Increase use, quality and efficiency of services
Why RBF in Tanzania?
•
There has been slow progress in achieving some health
objectives despite a significant increase in inputs
•
RBF is an innovation which promotes efficiency in health care
delivery
•
It has observed effects in strengthening health systems
•
It can be harnessed to move along the road of Universal
Health Coverage
•
Efficient use of limited resources for more and quality output
•
Enhance D by D implementation up to the level of HFs
5
Goals of Tanzania’s RBF
Overall goals
•Strengthen the health system
•Accelerate Tanzania mainland’s move to UHC
•Help focus government and donor attention on outputs and outcomes
•Re-orient mindset of health service providers
Immediate goals
•Increase utilization of specified services in health facilities
•Increase quality of service provision
•Incentivise more focused health workers and management teams
6
INSTITUTIONAL SET UP
7
Institutional setup - Roles
RBF Functions
Regulation
Fund
Holding
Purchasing
Provision
Verification
Counter
verification
Facilitator
To lead the RBF system with strategic planning and policy
coordination among the various actors; provide guidelines,
norms and standards and overall support and supervision.
(MOHSW)
To hold the funding for RBF and distribute funds to service
providers as indicated by the Purchaser (MoF)
To enter into contracts with service providers, purchase
and pay for the health care services. (NHIF)
To provide health care services to the designated
population (HF&HMT)
To confirm the actual provision of health care services
(IAG)
Counter verify (CAG)
Facilitating the providers and verifier (PMORALG)
8
Quantity indicators for dispensaries & health Centers
Category
Indicator
Fee
OPD
Number of new Outpatient consultations
OPD
Number of TASAF beneficiaries seeking outpatient care
TZS 1,240
ANC
Number of first antenatal visits, with gestation age < 12 weeks
TZS 8,290
ANC
Number of pregnant women attending ANC at least 4 times during pregnancy
TZS 6,210
TREATMENT
TREATMENT
Number of pregnant mothers receiving Mebendazole for de-worming
Number of children receiving Mebendazole for de-worming
Number of pregnant women receiving two doses of intermittent presumptive Therapy of
Malaria (IPT2)
TZS 1,244
TZS 829
ANC; Malaria
TZS 415
TZS 1,240
PMTCT:HIV/AIDS Number of HIV positive (infected) pregnant women receiving ARVs
TZS 3,310
Labor/Delivery
Number of institutional deliveries
TZS 20,720
Postnatal Care
Number of mothers receiving Post Natal Services within 3-7 days after delivery
TZS 8,290
Immunization
Number of children under one year immunized against measles
TZS 1,650
Nutrition
Number of under five receiving Vit. A supplements
Family Planning
Number of new users on modern Family Planning methods
HIV/AIDS
Number of clients initiated by health care provider to counsel and Test for HIV (PITC)
HIV/AIDS
Number of HIV exposed infants receiving ARVs
TZS 4,970
TB
TZS 8,290
Community
Number of TB suspect referred (already screened)*
Number of non-institutional maternal and perinatal deaths reported within 24 hours by
TBA or CHW
Number of pregnant women escorted for delivery at a health facility by known or
registered TBA or CHW
Community
Number of household visits by CHW
TZS 1,240
Community
TZS 820
TZS 5,800
TZS 620
9
TZS 4,145
TZS 8,290
RBF QUANTITY INDICATORS PRICING FACTORS
• The index indicator was OPD and was
given 1 as basic Unit of weighing other
indicators,
• Priority by indicators,
• Coverage,
• Available funds for incentives.
10
18 AREAS FOR DIPENSARY QUALITY ASSESSMENT
#
SERVICE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Hygiene and sanitation
Privacy
Water supply
Waste management
ANC
Labour ward
Post-natal care
Maternal death audits
Perinatal death audits
Family planning
Immunization
Nutrition for under-five children
Pharmacy
Community
Community health fund
Facility profile reports (inc. rbf)
Transparency
Client Satisfaction
TOTAL
WEIGHT
9
4
4
6
13
13
9
10
10
17
7
4
22
5
10
6
5
20
174
11
26 AREAS FOR D.HOSP & COMPREHENSIVE HC Q. ASSESSMENT
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
SERVICE
Social Accountability
Facility Profile Reports (Inc. RBF)
Medical Records
Privacy
Hygiene and sanitation
Water supply
Labour Ward
Waste management
Obstetric emergencies
Partogram
Complicated deliveries including c/s
Post-natal care
Kangaroo mother care
Family planning
Maternal death audits
Perinatal death audits
Immunization
Sterilization
IPD
Laboratory
TB Services
Pharmacy
Nutrition for Under-Five Children
Community
Community Health Fund
Client Satisfaction
TOTAL
WEIGHT
5
4
4
4
7
11
14
6
35
18
10
9
15
24
15
15
7
3
10
4
2
13
4
5
10
20
274
12
12 AREAS FOR CHMT ASSESSMENT
#
SERVICE
1
100% of facilities Monthly HMIS reports timely and completely entered
into DHIS-2
Average (mean) number of tracer medicines available in RBF facilities
10
Council Progress Reports for all HFs produced submitted to PMORALG
and MOHSW on time
Health Facilities with qualified staff
5
2
3
4
WEIGHT
20
10
10
6
100% of HFs have received comprehensive supportive supervision visit
at least once per quarter
CHF enrolment rate increase in the council
7
Compiled quarterly financial report of all HFs enrolled in RBF
10
8
Planned preventive maintenance conducted quarterly as budgeted in
CCHP [For facilities enrolled in RBF]
Health Facilities Maternal deaths Audit by CHMT
15
5
9
10
10
10 Health Facilities perinatal deaths Audit by CHMT
10
11 Council Health Service Board [CHSB] quarterly meeting conducted
5
12 Management of motivation Agreements
10
TOTAL
125
13
10 AREAS FOR RHMT ASSESSMENT
# SERVICE
WEIGHT
1 Spearhead the verification process of the RBF in the region
10
2 RBF data management and Quarterly HFs RBF data timely
entered in the database
3 Participation in R-RBFC quarterly meetings
20
4 Management of motivation Agreements
10
5 Timely submission of regional quarterly report,
15
5
6 Quarterly report assessment results,
10
7 Regional Management Supportive Supervision for CHMT (RMSS-C)
implementation rate
8 Regional Management Supportive Supervision for Regional Referral
Hospital Management Team (RMSS-H) implementation rate
9 Comprehensive Hospital Operational Plan (CHOP) quarterly
report submission
10 Human Resource for Health (HRH) Data collection monthly
report
10
TOTAL
10
5
15
110
14
3 AREAS FOR IAG ASSESSMENT
# SERVICE
WEIGHT
1 Timely and Completeness of data
entry
50
2 Timely R-RBF Verification
Committee Quarterly meeting
25
3 Timely transmission of approved
quarterly consolidated invoice to the
NHIF
25
TOTAL
15
100
ALLOCATION OF BUDGET
Total RBF funds
USAID
POWER OF NUTRITION
US$
106.16M
$46M
$10M
IDA
GFF
SDC (TA)
$30M
$ 20M
$ 161,861
Fund flow for RBF system
Funds Flow
18
Flow Charts-Invoicing & Payments
19
CURRENT SCOPE OF PILOT & TIMELINE
SHINYANGA-KISHAPU DISTRICT HAS STARTED PILOT:
• 41 Dispensaries, 4 Health Centres of Kishapu and 1 District
Hospital of Kahama are now piloting RBF system since April
2015.
• The performance agreements have been signed by the
Providers side and Purchaser
• Verification of 1st quarter of implementation (April June) 2015
was recently done for the above Health Facilities
• The RBF Invoicing and data analysis component is now
integrated into the MOHSW DHIS2 by the contracted University
of Dar es salaam,
• Data entry is concluded and the approval process by the
Regional RBF Committee is about to take place.
20
READINESS ASSESSMENT RESULTS BY BRN STAR RATING
N NAME OF HF
1 KAHAMA D. HOSPITAL
2 KISHAPU HEALTH CENTRE
3 BAKWATA
4 NDOLELEJI RC
5 BUNAMBIYU HEALTH CENTRE
6 SONGWA HEALTH CENTRE
7 MAGANZO
8 MIPA FB
9 MWAJIDALALA
10 MASUSANTE
11 MIPA
12 BULEKELA
13 BULIMA
14 ITILIMA
15 NYENZE
16 MAGALATA
17 KINAMPANDA
18 NHOBOLA HEALTH CENTRE
19 MWAMANOTA
20 HINDAWASHI
21 MIHAMA AICT
22 SOMAGEDI
23 NEGEZI
24 BUBIKI
25 ITONGOITALE
26 IDUKILO
27 NYASAMBA
STARS
2 Stars
2 Stars
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
N NAME OF HF
28 LAGANA
29 NGOFILA
30 MWAMASHELE
31 MONDO
32 BUSANGWA
33 BELEDI
34 MASANGA
35 SEKEBUGORO
36 LUBAGA
37 KISESA
38 SHAGIHILU
39 BUGANIKA
40 KILOLELI
41 IKONDA A
42 BUPIGI
43 MIGUNGA
44 MWADUI LUHUMBO
45 ISUNGANG’HOLO
46 IGAGA B
47 BADI
48 BUBINZA
49 MALWILO
50 NGEME
51 UCHUNGA
52 ILEBELEBE
53 MUGUDA
54 SESEKO
STARS
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
1 Star
0-Star
0-Star
0-Star
0-Star
0-Star
0-Star
0-Star
0-Star
21
Trainings & Orientations Attendance
22
ATTENDANCE BY GENDER
23
KISHAPU QUALITY ASSESSMENT RESULTS 1st Q2015
KAHAMA DH GOT 46.4% AND KISHAPU CHMT GOT 59.1%
TIMELINE & NEXT STEP
25
Sustainability of RBF as envisioned by Health Care
Financing Strategy
AIDS Trust
Fund
Employer
Contribution
Portion of OC
Budget
Employee
Contribution
Remainder of
general
revenue
budget & HBF
Other vertical
or parallel
programs or
funding
GOT subsidy
for poor and
vulnerable
SNHI
Community
Contribution
(CHF)
Reimbursement to Facilities Matching Payment to MBP
Based on Core Output-Based Payment Systems,
Performance (RBF) and Star Rating (BRN)
27