RBF in Afghanistan: Motivation, Design and Preliminary Results

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This presentation outlines the latest information about RBF's project in Afghanistan RBF, shared with attendees of Women Deliver 2013.

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RBF in Afghanistan: Motivation, Design and Preliminary Results

  1. 1. Results-Based Financing in Afghanistan Motivation, Design, and Preliminary Results Tekabe Belay Senior Economist, South Asia HD, World Bank Women Deliver Kuala Lumpur , Malaysia May 28, 2013
  2. 2. Motivation In 2002, the health system was in a very poor condition • Limited capacity in the Ministry of Public Health • 80% of services provided by NGOs • Lack of coordination among stakeholders • Inequitable distribution of health services, with many rural areas extremely under-served • Few functioning health facilities 2
  3. 3. Motivation… Reflected in health indicators that were among worst in the world • Life expectancy: women 45 years and men 47 years • Under-five child mortality: 257 deaths per 1,000 live births • Maternal mortality ratio: 1600 per 100,000 live births 3
  4. 4. • Focus on stewardship functions o Define the package of services: BPHS and EPHS o Define the beneficiaries: service areas defined for each provider o Define the standard of services: inputs requirements for BPHS and EPHS defined • Partner with the private sector o that has been serving 80% during the conflict • Use its purchasing power effectively to register results • The approach is largely along the lines of current thinking on service delivery in fragile states (e.g. Collier) Strategy: Afghanistan’s Approach to Health Service Delivery 4
  5. 5. This achieved impressive results… 5
  6. 6. Skilled Birth Attendance - 3 times 6 6.00% 8.40% 18.40% 24.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 2003 2005 2006 2008
  7. 7. 7 4.60% 12.60% 30.30% 36.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 2003 2005 2006 2008 Antenatal Care (>1 ANC) - almost 7 times
  8. 8. 8 5.10% 10.40% 15.40% 23.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 2003 2005 2006 2008 Contraceptive Prevalence Rate – 3.5 times
  9. 9. 9 DPT3 Coverage - doubled 21.20% 17.40% 34.60% 43.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% 50.00% 2003 2005 2006 2008
  10. 10. Infant Mortality - 32% reduction Under 5 Child Mortality – 35% reduction 10 165 257 129 191 111 166 0 50 100 150 200 250 300 Infant Mortality Rate Under 5 Mortality Rate 2001 2006 2008
  11. 11. ...but not enough 11 Coverage of important services remains low by global standards e.g. o CPR 15%, o ANC 36% o SBA 24 % Additional effort to increase coverage needed
  12. 12. Results-Based Financing (RBF) • Since 2010: o 14 provinces: gradually scaled up o Primary care and hospitals • RBF means: o Payment for additional services o Payments for improved quality o Payments for serving the poor • Rigorously assessed with a gold standard IE design 12
  13. 13. Results after 24 Months of Implementation 13
  14. 14. ANC: in RBF Facilities 0 15 30 45 60 75 90Numbermonth ANC1-4 Treatment 14
  15. 15. ANC 0 15 30 45 60 75 90Numbermonth ANC1-4 Treatment ANC1-4 Control 15
  16. 16. PNC: in RBF Facilities 0 15 30 45 60 75 90 Numbermonth PNC1-2 Treatment 16
  17. 17. PNC 0 15 30 45 60 75 90 Numbermonth PNC1-2 Treatment PNC1-2 Control 17
  18. 18. SBA: in RBF Facilities 0 2 4 6 8 10 12 14 16 18 20 Numbermonth SBA Treatment 18
  19. 19. SBA 0 2 4 6 8 10 12 14 16 18 20 Numbermonth SBA Treatment SBA Control 19
  20. 20. 0 10 20 30 40 50 60 Numbermoth DPT3 Treatment DPT3: in RBF Facilities 20
  21. 21. 0 10 20 30 40 50 60 Numbermoth DPT3 Treatment DPT3 Control DPT3 21
  22. 22. RBF Indicators: Changes Between 2010 Q3 and 2012 Q1 21.8 16.5 5.4 1.3 4.3 6 2.6 -0.1 -5 0 5 10 15 20 25 ANC1-4*** PNC1-2*** SBA** DPT3 Treatment Control 22
  23. 23. The longer RBF is in place, the better (ANC 1-4) (highest after 12 months ~ control for seasonality) 9.9 13.5 21.8 6.9 1.4 4.3 0 5 10 15 20 25 3months** 12 Months*** 19 months*** Treatment Control 23
  24. 24. The longer RBF is in place, the better (PNC 1-2) 3.9 7.7 16.5 3.1 1.5 6 0 2 4 6 8 10 12 14 16 18 3months** 12 Months*** 19 months*** Treatment Control 24
  25. 25. The longer RBF is in place, the better (SBA) -0.3 1.2 5.4 0.5 -0.2 2.6 -1 0 1 2 3 4 5 6 3mohths 12 Months 19 months** Treatment Control 25
  26. 26. Quality improved in most hospitals with RBF in place 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 1 2 3 4 5 6 7 8 9 10 11 12 13 Score Hospitals Overall Score Before After 26
  27. 27. Improved Quality 0.0 20.0 40.0 60.0 80.0 100.0 120.0 1 2 3 4 5 6 7 8 9 10 11 12 13 Score Hospitals Hospital Infection prevention Before After 27
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