ResultsBasedFinancingforPrimaryCareServices

withfocusonImmunization

EvidenceSummary

Clickheretoentertext.

February,2016

TableofContents

PurposeoftheDocument 1

Background 1

DifferentformsoftheRBF 1

EvidencefromRBFpiloting 2

Majorindicatorsevaluated 2

MainFindings 3

Performance-BasedContracting 5

Performance-BasedFinancing 6

Conclusionandrecommendation 8

References 10

1

PurposeoftheDocument

ThedocumentaimstopresentbriefsummaryofevidencesonapplicationandeffectofResults

BasedFinancing(RBF)schemesinprimarycareinLowandLower-MiddleIncomeCountries

(LLMIC)withfocusofimmunizationservices.Thesummaryisbasedonreviewoflatest

evidences.Itisintendedforoperationalreadership:forpolicymakers,healthcaremanagers

andotheractorsinterestedtolearnmoreonRBFschemes.Moredetailedinformationandfull

resourcescouldbeaccessedatwww.zotero.org-https://www.zotero.org/groups/rbf_for_mch/items

ThedocumentwasdevelopedintheframeofthePolicyInformationPlatformProjectinGeorgia

fundedbytheAllianceforHealthPolicyandSystemsResearch.

Background

Results-BasedFinancing(RBF)isahealth-financingmodeldesignedforimprovinghealth

systemperformance.ThemainareaofitsapplicationisaMaternalandChildHealth(MCH).It

hasbeenimplemented(asapilotornationwide)inmanycountriestoaccelerateprogress

towardsthemillenniumdevelopmentgoals(MDG)forwomen’sandchildren’shealth(MDGs4

andMDG5).MCHserviceshavebeenthemajorareaoftheRBFreasoning,possiblythemain

one.

DifferentformsoftheRBF

RBFforhealthisdefinedasacashpaymentornon-monetarytransfermadeafterpredefined

resultshavebeenattainedandverified.1Afteritsintroduction,therehasbeenshapedvarious

formsoftheRBF,thatworkatdifferentlevelsofthehealthsystem,mainlydifferentiatedas

supply-anddemand-sideapproaches:2

• Performance-BasedContracting(PBC)

• Performance-BasedFinancing(PBF)

• ResultsBasedBudgeting(RBB)

• Vouchersforhealth

• HealthEquityFund(HEF)

• ConditionalCashTransfer(CCT)

2

Table1:Incentivesandchiefsupply-anddemand-sideRBFapproaches

RBF Approaches Provider

Supply-side,withademand-sidecomponent

Performance-BasedContracting(PBC)

Contractdefinesexpectedperformance(inquantity/orquality)aswellaslevelofpayment,plusrewardsorsanctions

Performance-BasedFinancing(PBF)

Levelofpaymentisbasedonachievingperformancetargets,oftenquantityandqualityindicators

Results-BasedBudgeting(RBB)

Alladministrativelevelshaveanincentive:bonusorlargerbudgetonthebasisofpre-agreedperformancetargets

Demand-sidewithsupply-sidecomponent

HealthEquityFund(HEF)

Incentivesareequaltothefeepaidforeacheligiblepatienttreated.Sinceshortpilotwithqualityindicators

Vouchers Incentivesareequaltothefeepaidforeacheligiblevoucher.Qualityindicatorsusedforselection;qualityassurance

Demand-side

ConditionalCashTransfers(CCT)

Providerdoesnotreceiveincentives,butthereisproviderselectionwhichcanincludequalityindicators

(fromGorterAC,IrP,MeessenB:Results-BasedFinancingofMaternalandNewbornHealthCareinLow-

andLower-Middle-IncomeCountries.EvidenceReview,2013)

RBFschemes,designedconsideringthecontext-specificissues,aimtoincreaseautonomy,

strengthenaccountability,andempowerfrontlineprovidersandhealthfacilitymanagersto

makehealthservicedeliverydecisionsthatbestmeettheneedsofthewomenandchildrenin

thecommunitiestheyserve.

EvidencefromRBFpiloting

TheRBFhasbeenpilotedinmanyLowandLowerMiddleIncomeCountries(LLMICs).

Althoughsomeformsofitstilllacktheproperevaluations.Forexample,thereviewssuggest

thatVouchershavebeenappliedandevaluatedearlierinhealthsystems,comparedtoPBFand

haveshowedrobustevidencethattheycanimpactonhealthoutcomesinvestigated,whilethe

PBFimpactonhealthoutcomehasnotyetsufficientlystudied.2,3AsofJuly15,2015theWorld

Bank-managedHealthResultsInnovationTrustFund(HRITF)continuedtosupportongoing

workinitsportfolioof36RBFprojectsin30countries(mainlylocatedinAfrica).

Majorindicatorsevaluated

PositiveandnegativeeffectsofRBFonaccesstoandquantity/utilization/coverageofhealth

services:

• FamilyPlanning

3

• Antenatalcarepackage

• Skillednormaldelivery

• Referralofcomplicateddelivery

• NeonatalandPostnatalcare,includingImmunization

BesidesthequantityindicatorsresearcherstriedtoinvestigateRBFimpactonqualityofhealth

servicesprovidedandbeneficiariessatisfactionwiththoseservices,healthequityand

targetingissueshavealsobeenevaluatedinsomecases.

MainFindings

Beforemovingforward,inthissummarywewouldliketoconcentrateonsupply-sideRBF

interventionsthathadbeenintroducedforimprovingtheMCHservicesinmanydifferent

countries.WewillpresentthefindingsofPBCandPBFimpactsontheMCH.

ThelatestreviewofRBFinterventionforMCHservicesproducedbyGorteretal.emphasizes

thelackofrobustevidencefromLLMICsdespitethegrowingnumberofstudiesonthistopic

fromLLMICs.

Althoughitisoftendifficulttodisentangletheeffectsoftheincentivesfromotherinterventions,

thefindingsshowthatwhereRBFisintroduced,itcanmakeasubstantialdifferencein

termsofutilizationandcoverageofthosehealthserviceswhichareincentivised,

especiallyfortargetedindicators,includingmaternalhealthindicators.Thereisgrowing

evidenceonthepositiveeffectsofRBFonaccesstoandutilizationofmaternalhealthservices,

butevidenceontheeffectsonservicequalityandmaternalhealthoutcomesislimited.Also

therehasbeenlittleornoinvestigationonthelong-termandsystem-wideeffectsofRBFon

overallhealthserviceprovisioninacountry.

TheTable2summarizesRBFimpactonoutcomecategories.Forvouchersthereisrobust

evidenceforallthreeoutcomecategories,forPBFrobustevidencewasfoundforitsimpacton

quality/patientsatisfaction,butinsufficientevidenceforothercategories.Aswithvouchers,

whenmorestudiesbecomeavailableitwillbecomemoreclearifindeedPBFcanincrease

utilization.PBChaverobustevidenceforincreasedutilizationandinsufficientforquality.

Table2:SummarytableimpactofRBFapproachesonthethreeoutcomecategories

Typeofeffect Robustevidence(>3studies)

Modestevidence(2-3studies)

Insufficientevidence(<2studiesornoeffect)

#rigorousstudiespositiveeffect

PBC Quantity/utilisation/coverage

X 3

4

Typeofeffect Robustevidence(>3studies)

Modestevidence(2-3studies)

Insufficientevidence(<2studiesornoeffect)

#rigorousstudiespositiveeffect

Quality/satisfaction

X 1

Equity/Targeting

X 2

PBF Quantity/utilisation/coverage

X 1

Quality/satisfaction

X 4

Equity/Targeting

X 1

Vouchers Quantity/utilisation/coverage

X 10

Quality/satisfaction

X 8

Equity/Targeting

X 9

RBB Quantity/utilisation/coverage

X 1

Quality/satisfaction

X -

Equity/Targeting

X 0

AlthoughnostudyfocusesonnegativeeffectsofRBF,anecdotalevidencesuggeststhatsome

potentialundesirableeffectsofRBF,suchasmotivatingunintendedbehaviours,

distortions,gamingorfraud,dilutionofprofessionals’intrinsicmotivation,arepossible

andneedtobecarefullymonitoredandevaluated.TheauthorsorexpertsinvolvedinRBF

impactevaluationdocumentingrevealthattheevaluationtechniquesusedarerelativelyweak

(whichisinherenttothistypeofinvestigations,whereitisnotoriousdifficulttodesignand

applyafullycontrolledexperimentoveralongerperiodoftimetakingintoaccountall

confoundingfactors).

AllRBFschemesaddressoneormorebarriersrelatedtosupply-sideavailability,suchas

waitingtime,motivationofstaff,readinessofthefacilitytoprovideservices(availability

ofdrugs,supplies,equipment),andimprovedreferral.Thesamecountsforacceptability

suchasstaffinterpersonalskills.MostRBFschemesaddressbarriersrelatedtodemand-side

availability,mostlythroughtheprovisionofinformationonhealthcareservicesand

providers.

5

Performance-BasedContracting

TheCochranereviewoftheimpactcontractingoutinterventiononhealthservicesutilization(3

separatePBCinterventionslocatedin3countries:Bolivia,CambodiaandPakistan)provides

evidencethatPBCresultedinincreasedaccesstoandutilizationofhealthservices,mainly

fortargetedindicators.ThestudyinPakistanshowedanimmediateincreaseofmorethan

130%inconsultationvisitstothebasichealthunits(+144%ondailyvisitsand+135%for

monthlyvisits),butthisincreasedidnotsustainasbothoutcomesdeclinedconsiderablyinthe

18monthsfollowingthestartoftheintervention.InCambodia,thererevealedanincreaseinthe

useofpublicfacilitiesby29%.ButPBChadnothadasignificantimpactonimmunizationrates

(authorsconcludethattheincreasemaybeexplainedbythegeneralsecularincreaseofservice

provisioninCambodiaatthetime).4

Thereviewidentifiesanumberofdifferentcomponentsincontractoutservicestonon-public

providersthatmaybeinstrumentalintheobservedeffect.Theseincludethepossibleroleofa

newmanagementstyle,thepotentialroleoftheincentivesandobjectivesincludedinthecontract,

ortheimplementationofthoroughmonitoringsystemsandsanctions(whichareusuallyabsentin

thedeliveryofhealthserviceswithinthepublicsector).Severalelementsmightpotentially

altertheeffectsofcontractingoutstrategies.Firstly,Weakcapacitywithinthegovernment

mightthereforecompromisethesuccessfulimplementationofcontractingoutstrategies.The

broadertheservicescontracted,theharderitwillbetodefineacontractprecisely.The

feasibilityofadequatelymonitoringservicedeliveryinremoteareasisalsoakey

implementationissue.4

Thereviewrecommendsthatthegovernmentsshouldpayparticularattentiontotheelements

includedinthecontracttheydrawupwithprivateproviders,inparticularthetargetsonwhich

theirperformancewillbeassessed.Forexample,ifthecontractfocusesonadefinedsetof

outcomes,thereisariskthatcontracteesmightdiverttheireffortfromunmeasuredto

measuredoutcomes.4

PBCwasintroducedinHaitiwhereNGOs(3intotalforpilotstage)werecontractedtodeliver

healthcareservices.PilotingrevealedpositiveimpactofPBCtoanincreasedchildimmunization

coverage.HoweveritwasnotpossibletoisolateeffectofRBF,becauseRBFschemewas

confoundedbywithotherfactors(combinationwithfixedpricecontract,increasedfunding,

aggressivetechnicalassistance,datavalidation,sharedlearningactivities).5,6

6

Table3:PBCpilotingresultsinHaiti

NGO1 NGO2 NGO3 Indicator Baseline Target Results Baseline Target Results Baseline Target ResultsImmunizationcoverage

40 44 79 49 54 69 35 38 73

Performance-BasedFinancing

PBFexperienceshavebeendocumentedinBurundi,DRC,TanzaniaandZambia,where

considerabledifferenceofstaffandhealthserviceproductivitywasfoundbetweenbeforeand

aftertheintroductionofPBFinseveralprojects;withanincreaseinhealthserviceutilizationfor

almostalltargetedindicators,includingmaternalhealthindicatorsandinqualityofcareas

perceivedbytheclients;andnoperverseeffectsweredirectlyobservable.7

ForPBFrobustevidencewasfoundforitsimpactonquality/patientsatisfaction,but

insufficientevidencefortheotheroutcomecategories.Aswithvouchers,whenmore

studiesbecomeavailableitwillbecomemoreclearifindeedPBFcanincreaseservice

utilisation,andwhenitdoesifthisistheninfavourofthemorevulnerableandpoor.2

InRwanda,56%and132%increasewasobservedinthenumberofpreventivecarevisitsby

childrenagedbelow23monthsandagedbetween24-59monthsrespectivelyinthetreatment

facilities.PBFimprovedqualityofprenatalcare(anincreaseof0.157standarddeviations(95%

CI0·026–0·289)inprenatalqualityasmeasuredbycompliancewithRwandanprenatalcare

clinicalpracticeguidelines:7.6%morewomenreceivedatetanusvaccineduringpregnancy

thanatbaseline.),butnoimprovementswereseeninthenumberofwomencompletingfour

prenatalcarevisitsorofchildrenreceivingfullimmunizationschedules.8

AftertheintroductionofPBFinIndonesia,2programyears,8targetedMCHhealthindicators

(e.g.ANC,assisteddelivery,immunization,growthmonitoring)wereanaverageof0.03

standarddeviationshigherinincentivizedareasthaninnon-incentivizedareas.9

InEgyptPBFhadlittleimpactonchildvaccinations,whichmightbeexplainedinpartbythefact

thatbaselineimmunizationrateswerealreadyhigh:closeto65percent.ButPBIdidincrease

theprobabilitythatachild0-23monthsvisitedahealthcenterforpreventivecare(a64%

increaseoverbaseline)andtheprobabilitythatachild24-59monthshadapreventivevisit–by

awhopping133%overthebaselineprobabilityforthetreatmentgroup.Significant

improvementsinthequalityoffamilyplanning,antenatalcare,andchildhealthservices

reportedbywomenseeninclinicswheretheincentivepaymentschemewasinoperation.10,11

7

Canavanetal.reviewednotonlytheeffects,butalsoinstitutionalarrangements,including

factorsdeterminingsuccess,costsandsustainabilityofRBFinLLMICs.Theyfoundthatthe

introductionofRBFinvarioussettingsledtoremarkableimprovements,mainlyin

targetedoutputandoutcomesindicatorssuchasutilisation,coverageandemergency

referrals,withenhancedqualityofproviderperformance.WhileRBFachievedsome

positiveresultsonthelevelofmeetingqualitativehealthindicators,theextenttowhichit

contributestoimprovedqualityofcareremainsaquestion.AsforRBF,thereisariskof

compromisingqualityofcaretomeetutilisationtargets.ThepercapitacostofRBFvaries

fromUS$0.25inDRCtoUS$4.82inAfghanistan.

TrendsinoperationaldataindicatethatsincethePBFprogramwasimplementedinCameroon

2012,thecoverageofkeyhealthservicessuchasinstitutionaldelivery,antenatalcare,family

planning,andimmunizationshasincreased.Freeoutpatientcareforthepoorandvulnerable

hasalsoincreased.Thequalityofcare,asmeasuredbytheaveragetotalqualityofcarescore

increasedfrom43percentto64percentbetween2012and2015.12

PreliminaryresultsfromtheimpactevaluationinZambiaindicatethatRBF(introducedin

2008)significantlyincreasesutilizationofselectMCHservices,suchasearlyantenatalcare

(ANC)-seekingbehaviorandin-facilitydeliverywhenthe

RBFdistrictsarecomparedtothedistrictsoperatingas

“businessasusual”—womenfromhealthfacilitiesinthe

RBFdistrictssoughtANCaboutthreeweeksearlierthan

womenreceivingcareinnon-RBFdistricts.Performance

onsomepost-natalcare(PNC)measuresincreasedinRBF

districts.PNCcoverageandimmediatebreastfeeding

increasedbynearly10%and14%,respectively,andwere

statisticallysignificant.12

ThepreliminaryresultsofPBFinterventioninBenin,introducedin2012,showthatthereis

improvedsomeaspectsofhealthworkerperformance.Theyindicateapositiveimpacton

qualityofcareandresponsivenesstowardspatientsbutnosignificantimpactonclinical

productivity.Forexample,acomparisonbetweenPBFtreatmentandcontrolgroupshighlights:

ImprovementsinthequalityofANCinPBFfacilities,withincreasesinthequalityofphysical

examinationsconducted,historytakingandadvicegivenbyahealthworker(measuredthrough

DirectClinicalObservations),ascomparedtobothcontrolgroups.Increasedconsultation

timewithalmost4additionalminutesforANCinPBFfacilitiescomparedtofacilitieswithno

intervention.IncreasedresponsivenessofhealthworkerstowardspatientsinPBF

facilities,withpregnantwomenreceivingANCvisitsandpatientsgettingcurativecarebeing

8

respectivelymoresatisfiedwithstaffattitudeandstaffcompetence(asmeasuredthrough

DirectClinicalObservationsandexitpatientinterviews).AsignificantimpactofPBFonthe

politenessofstaffduringANCvisits.12

AfterNigerialaunchedaPBFpilotuptakeofserviceshasbeenveryencouraging,withutilization

ofcoreMCHserviceslikeimmunization,

deliveriesinfacilities,andfamilyplanning,

showingmuchimprovement.Figureshows

animmunizationcoverageincreaseinpre-

pilotfacilitiesfrom5percentto44percent;

anincreasefrom14percentto44percentin

thefirstphasescaleupfacilities;andshowing

promiseinthemostrecentscaleupfacilities.

Increaseinimmunizationcoveragehasbeenidentifiedsincecompletionofscale-upin

December2014(post-scaleupimmunizationcoverageincrease).Intwostatesimmunization

coverageincreasedfrom30%to50%andhigherlevels.Moreover,datashowthatqualityof

servicesalsoimproved,alongwiththeincreasesincoverage.Aqualitychecklistappliedona

quarterlybasisfoundthatstructuralandprocessqualitymeasuressawrapidandsustained

improvements.Finally,PBFfacilitiesachievedgoodpatientsatisfaction,withratingsof80and

95%inNasarawaandinOndoStates,respectively.Itisworthhighlightingthattheseresults

havebeenachievedatamarginaladditionalcostof$0.8percapitaperyear.12

TheRBFprograminZimbabwewaslaunchedin2011.Impactevaluationwasimplementedwith

controlledbeforeandaftermethod.Theresultsdescribedinthe2014AnnualReportindicate

thatthereweresubstantialimprovementsinthequantityandqualityofservicesdeliveredin

RBFdistricts,whencomparedtotheirnon-RBFcounterparts.Resultsfromthequalitative

componentoftheimpactevaluationindicatethatwhentheRBFprogramisimplementedas

intendedandplanned,ittriggersandfacilitateschangesinthefacilitystaff’sperformance;andit

influencestheperformanceofhealthfacilities,andthemotivationandsatisfactionofstaffat

thesefacilities.RBFfacilitieshavemoreeffectivemonitoringandreportingmechanisms,

andbetterstaffcoordinationthannon-RBFfacilities.ResultsfromthePMEindicatethat

improvingfeedbackmechanismsalongwithsupervisionimprovesthequalityofservices.12

Conclusionandrecommendation

TheevidencebaseofRBFisnotyetstabilizedandisstillgrowing.Thereisanemergingbodyof

evidenceshowingthatRBFisabletoimproverelevantparametersrelatedtoMCHservices.

Impactonutilizationofthoseincentivizedserviceshasbeenthemostinvestigatedissueand

9

findingsarerathersupportive,eveniftheevidenceisrarelyofarandomizedcontrolledtrial

standard.ThefactthatRBFincreasestheamountofservicesutilizedbythetargetpopulation

(orcoveragerates)istrueforspecificprioritygroups(withvouchers)andalsoforlarge

populations(withPBFforinstance).

ThereisalsosomeevidencethatRBFcanleadtoimprovementinqualityofservices,specifically

forPBFandvouchers.ThereisgoodevidenceforvouchersandemergingevidenceforPBCthat

theseapproachescanimpactonequityinhealthcareutilization.

TheefficiencyofRBFcomparedtothestatusquoorotherhealthfinancingapproacheshasbeen

under-documentedandobviouslyforotherdimensionsevenmorecomplextodocumentsuch

asthelong-termeffectofRBFonproviders’behaviorsandexpectations.Thereisnosubstantial

evidenceonthenegativeandunintendedside-effectsofRBF.mainlyhypothesesexist.Other

dimensions,suchassustainabilityisneitherwelldocumented.

AnotherareastillinsufficientlystudiedistheeffectofacombinationoftwoormoreRBF

approacheswhichmighthaveagreaterimpactthaneachonitsown.Forexampleanationally

implementedPBF,whichincreasesthequalitycombinedwithvoucherstoreachthemost

underservedpopulations.

Inordertoensureweatherthehealthsector–whatevertheaffiliationoftheirproviders–

deliversqualityhealthservicestoallinanefficientway,withoutpushinghouseholdsinto

poverty,itiscrucialtoacknowledgethestatusofthecountryshealthsector.Today,health

systemsofmanyLLMICsarecharacterizedbyi)apublichealthsystemwhichdoesnotperform

asexpectedandii)anunregulatedprivatehealthmarketwhosequalityisnotassuredand

pricesnotregulated.Onthesetwosegmentsofthemarket,therearebothsupplysideand

demandsidebarrierswhichpreventthepopulationtoaccesscriticalservices.RBFcreates

systemicopportunities(e.g.itisanopportunityfortheministryofhealthtobemoreacquainted

withstrategicpurchasing),butalsorisks(e.g.iftheRBFapproachleadstoimprovedMNCHcare

tothedetrimentoftheprovisionofotherpriorityservices).

AsageneralrecommendationRBFinterventionhavetobedesignedconsideringother

contextual,publichealth,healthsystemfactors.Itshouldbeapartofapackageofreformor

overallstrategyinthehealthsector.RBFshouldcovermorethanasub-groupofMNCH

problems.RBFapproachedmaybevaluablefortheirancillarybenefits(likeincreasing

competitionandengagingwithprivatesector),howevertheseeffectsneedtobecarefully

monitored.2

10

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