Literature review: Results-based Financing in Maternal and Neonatal Health Care


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This presentation was held in the context of a discussion, led by GIZ, on Results-based Health Financing in low- and middle-income countries.
To join the discussion go to and tweet via #HealthRBF.

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  • Narrow targets such as reduction of maternalmortalityBroadtransformation of health system, forexampleinclusion of private sector intoprovision of public services, increasingresponsiveness of the public health system
  • Taken from a recent review of the evidence by Anna Gorter, Ir Por and Bruno Meessen.
  • Literature review: Results-based Financing in Maternal and Neonatal Health Care

    1. 1. Results Based Financing ofMaternal and Neonatal Health Care in Low- and Lower-middle-Income Countries Presentation of the literature review Expert talk Eschborn – 12 december 2012 Anna Gorter, Por Ir, Bruno Meessen
    2. 2. Outline of the Presentation• General introduction• Methods• Findings of 14 reviews• Potential negative or unintended side-effects of RBF• Supply and demand side barriers to access of maternal and neonatal care• Findings of 70 individual studies• Summary of findings
    3. 3. Why did RBF develop in healthBecause:• current service provision does not meet public expectations, huge gaps, poor do not receive basic health services, catastrophic health costs..• Frustration with lack of results (among governments, donors, services providers, and clients alike)• One of the options developed: linking payments to results
    4. 4. A wide range of approaches• Different objectives and expected results (from narrow targets to broad transformation health system)• Different reward recipients (public, private providers, clients, district or provincial health offices)• Type and magnitude of rewards• Proportion of financing paid for results compared to rest of funding• Different ways of measuring (indicators)
    5. 5. Development RBF approaches• Vouchers (started early 60ties)• Conditional cash transfers – CCT (90ties)• Performance based contracting – PBC (late 90ties)• Health equity funds - HEF (since 2000)• Performance based financing – PBF (since 2000)• Results Based Budgeting – RBB (since 2000)• Combinations: – vouchers and CCTs (Cambodia, Bangladesh) – RBB and CCTs (Nepal)• Distinction can be rather artificial – E.g. between PBF and PBC
    6. 6. Demand-side and Supply-side RBF and their effect on providers• Demand-side  Money goes to the client (i.e. conditional cash transfers or vouchers)• Vouchers: “money follows the client” resulting in a strong effect on provider side• Supply-side  Money goes to the provider, but is often linked to number of clients, and hence has an effect on the demand side
    7. 7. Results-Based Financing (RBF) Supply-side with Demand-side Demand-side a demand-side component with a supply- with no supply- (focus on provider) side component side component (focus on (focus on client) provider and client) Performance- Performance- Results- Based Based Based Vouchers and Conditional Contracting Financing Budgeting Health Equity Cash Transfers (PBC) (PBF) (RBB) Funds (HEF) (CCT) 1 2 3 4 5 Government/ Government/ Government Government / Government / donor/health donor to public or to all MOH donor to clients donor to clientsinsurance entity to private (not-for- administrative and providers agencies/facilities profit) facilities levels and public “Contracting-out” “Contracting-in” health facilities
    8. 8. Difference in impact on behaviour Influence on Influence onResults Based Financing Approaches provider client behaviour behaviour Performance-Based XX X Contracting (PBC)Supply-side, with a Performance-Baseddemand-side XX X Financing (PBF)component Results-Based Budgeting XX X (RBB) Health Equity Fund X XXDemand-side with asupply-side component Vouchers X XXXDemand-side, no Conditional Cash -- XXXXsupply-side component Transfers (CCT)
    9. 9. Methods (1)• Objective: – compile evidence on RBF of MNH care in LLMICs that will help program managers and partners answer relevant questions for programming of GDC in health – Specifically look at RBF programs that focus on providers or have a strong supply-side component• Inclusion and exclusion criteria: – Relevant supply-side RBF approaches were included, such as PBF, PBC and RBB – Demand-side RBF approach with strong effect on the supply-side (vouchers, but not HEF) – Excluded CCTs, vouchers for bednets etc.• 14 review papers and 70 individual studies
    10. 10. Methods (2)• Not a Cochrane type of review• But extensive review using techniques of a systematic review such as – pre-defined evaluation criteria, – evaluation of studies` methodological quality• Less rigorous but this precisely allowed to consider a greater number of papers reflecting the actual state of research efforts implemented so far• However the rigorousness of evaluation technique was scored; and this was taken into account in the final analysis
    11. 11. 3 outcome categories• Quantity of services provided / number of services utilised• Quality of the services and satisfaction by clients• Targeting of the services / equity among clients
    12. 12. Scoring of strength of evidence• Very low: e.g. descriptive study using stakeholder interviews and no before and after comparison with or without a control.• Low: comparison of data obtained before and after the intervention, but no control• Medium: comparison before-after with control or other sophisticated design controlling for confounding factors• High: very good study design with rigorous control of confounding factors
    13. 13. Conclusion categories• Robust evidence: if 4 or more rigorous studies1 found a positive effect, and none a negative effect• Modest evidence: if 2 or 3 rigorous studies found a positive effect, and none a negative effect• Insufficient evidence: 0 or 1 rigorous study found positive effect or 1 or more studies a negative effect• Conflicting evidence: if 2 or more rigorous studies had findings in opposite directions• No effect: if more than half of the rigorous studies found no effect1. Studies with strenght of evidence being medium or high
    14. 14. Results of review of 14 review papers (1)• Strength of evidence: 6 low, 6 medium, 2 high• wide range of RBF approaches being piloted/scaled• few robust studies from LLMICs• RBF can make a difference in terms of utilisation and coverage of those health services which are incentivised• evidence on the effects on service quality and maternal health outcomes is limited• anecdotal evidence suggests potential undesirable effects, such as motivating unintended behaviours, gaming or fraud
    15. 15. Results review of 14 review papers (2)• If carefully designed and implemented, RBF can complement other interventions to address supply and demand barriers to effective MNH• However not well documented: – efficiency or cost/effectiveness – the long-term effect of RBF on providers’ behaviours and sustainability• research will be needed to disentangle positive and negative effects of RBF in order to analyse the overall impact on the health system
    16. 16. List of potential negative or unintended side-effects of RBF (1)• focus on ‘contracted’ indicators can lead to: – crowding out of other services, adverse selection of patients, focus on quantity rather than quality, over- servicing and moral hazard, cherry-picking / cream- skimming• fraud or abuse: – gaming, corruption: falsification of documents, counterfeiting of vouchers, collusion between providers and voucher bearers or voucher distributors, bribery and kickbacks to verification agencies or voucher management agencies, demoralisation
    17. 17. List of potential negative or unintended side-effects of RBF (2)• motivating unintended behaviours including distortions: – ignoring important tasks that are not rewarded, irrational behaviour to fulfil requirements, paper work instead of clinical work, bureaucratisation• undermining goals and motives – crowding-out intrinsic motivation, unsustainable improvement of services, dependency on financial incentives• creating inequity – increasing inequity by rewarding providers and facilities that are in better position to reach targets, widening the resource gap between rich and poor
    18. 18. Findings from the 70 studies PBC PBF Vouch RBB TotalCharacteristics erCountries with RBF 7 8 11 4 25Programs studied: 7 8 18 4 37Number of studies 11 18 33 8 70Strength of evidence Very low - 4 4 - 8 Low 5 10 13 7 35 Medium 5 3 14 1 23 High 1 1 2 - 4
    19. 19. PBC PBF Voucher RBB TotalObjectives, type of services, for whom N=7 N=8 N=18 N=4 N=37and whereOverarching objectives programs Reduce maternal/neonatal mortality (MNM) - - 13 4 17 No MNM, focus on other aspects SRH/child - - 5 - 5 Increase quality and use of essential service 6 7 - - 13 package with focus on MNCH Increase quality and use of essential service package with no particular focus MNCH 1 1 - - 2Target groups: Poor 7 7 12 3 29 Specific: sex workers, adolescents - - 2 - 2 All: poor and non-poor - 1 4 1 6Scale: Particular geographical area(s) 6 2 13 - 21 National scale (and state level in India) 1 6 5 4 16
    20. 20. Where implemented, who initiated PBC PBF Voucher RBB Total Context programs N=7 N=8 N=18 N=4 N=37Region Africa 1 6 3 2 12 Asia 4 2 12 2 20 Latin America and 2 - 3 - 5 CaribbeanOwnership Donor-initiated 4 1 8 - 13 Gov.-initiated 2 - 6 4 10 Donor-initiated, scaled 1 7 4 - 14 by Gov.
    21. 21. PBC PBF Vouch RBB Total List of MNCH N=7 N=8 er N=4 N=37 interventions N=18Adolescents & pre-pregnancyFamily planning 4 6 6 - 16Prevent and manage STI - 5 4 - 9PregnancyAppropriate ANC package andother relevant interventions 7 7 13 - 27ChildbirthInstitutional or skilled normaldelivery, referral of complicated 7 7 13 4 31deliveriesPostnatalPostnatal check and care of 7 7 13 4 31mother and child
    22. 22. Supply side barriers to access of maternal and neonatal care• Availability/geographical accessibility: – Location, unqualified health workers, no 24/7, waiting times, equipment, drugs, late/no referral• Acceptability – Staff interpersonal skills, including trust, inability for patients to know prices beforehand• Affordability – Costs services, informal payments
    23. 23. Demand side barriers to access of maternal and neonatal care• Availability/geographical accessibility: – Distance, availability of transport, information on health care services/providers, awareness of services, demand for services• Acceptability – Households’ expectations, low self-esteem and little assertiveness, community and cultural preferences, stigma, lack of health awareness• Affordability – Household resources and willingness to pay, opportunity costs, cash flow within society
    24. 24. How does RBF address supply barriers (1)• Supply side availability (all schemes): – e.g. waiting time, readiness of the facility to provide services (availability of drugs, supplies, equipment), and improved referral• Supply side acceptability (all schemes): – e.g. staff interpersonal skills• Supply side affordability: – subsidizing fees (vouchers, RBB), – indirectly incentivising providers, regulating service prices, controlling informal payments (some PBF and PBC schemes) – Several PBF accompanied by abolishment of user fees
    25. 25. How does RBF address demand barriers (2)• Demand side availability (most PBC,PBF, vouchers): – e.g. mostly through the provision of information on health care services and providers (voucher distribution, outreach)• Demand side acceptability (most PBC,PBF, vouchers): – e.g. outreach activities increase health awareness, help overcome cultural barriers. Vouchers empower the holder improving self-esteem;• Demand side affordability (only 12 schemes): – 1 RBB through a CCT, 1 PBC through community work, 1 PBF through organisation of services such that opportunity costs were reduced, 9 vouchers paid for transport and food costs and 1 of these also provided a CCT
    26. 26. Number of individual RBF programs addressing particular barriersBarrier PBC PBF Vouch RBB Total N=7 N=8 er N=4 N=37 N=18Supply-side barriers addressed:Availability 7 8 18 4 37Acceptability 7 8 18 4 37Affordability 3 2 18 4 27Demand-side barriers addressed:Availability 5 7 18 1 31Acceptability 5 7 18 1 31Affordability 1 1 9 1 12
    27. 27. PBC: 7 programs, 11 research papers # of # of % with % with % with # of Type of Effect programs studies effect positive rigorous studies (of number effect study with of studies (of those investigated design (of rigorous with effect) those which the issue) design and investigated issue and had positive positive N=7 N=11 effect)Quantity/ 7 8 75% 100% 50% 3utilisation (6)Quality / 2 2 100% 100% 50% 1satisfaction (2)Equity / targeting 2 3 100% 100% 67% 2 (3)
    28. 28. PBF: 8 programs, 18 research papers # of # of % with % with % with # of Type of Effect programs studies effect positive rigorous studies (of number effect study with of studies (of those investigated design (of rigorous with those which the issue) design and effect) investigated issue and had positive positive N=8 N=18 effect)Quantity/ 6 14 64% 100% 11% 1utilisation (9)Quality / 7 8 100% 100% 50% 4satisfaction (8)Equity / targeting 3 4 100% 75% 33% 1 (4)
    29. 29. Vouchers: 18 programs, 31 research papers # of # of % with % with % with # ofType of Effect programs studies effect positive rigorous studies (of number effect study with of studies (of those investigated design (of rigorous with effect) those which the issue) design and investigated issue and had positive positive N=18 N=33 effect)Quantity/ 15 22 100% 100% 45% 10utilisationQuality / 11 16 100% 100% 50% 8satisfactionEquity / 13 17 100% 100% 53% 9targeting
    30. 30. RBB, 4 programs, 8 research papers # of # of % with % with % with # of Type of Effect programs studies effect positive rigorous studies (of number effect study with of studies (of those investigated design (of rigorous with effect) those which the issue) design investigated issue and had and positive positive N=4 N=8 effect)Quantity/ 4 7 100% 100% 14% 1utilisationQuality / 1 1 0% - 0% -satisfactionEquity / targeting 2 2 100% 50% 0% 0
    31. 31. Summary evidence on effect of RBF Insufficient Robust Modest # rigorous evidenceType of Effect evidence evidence <2 studies or studies positive >3 studies 2-3 studies effect no effectPBCQuantity/utilisation X 3Quality / satisfaction X 1Equity / targeting X 2PBFQuantity/utilisation X 1Quality / satisfaction X 4Equity / targeting X 1VouchersQuantity/utilisation X 10Quality / satisfaction X 8Equity / targeting X 9RBBQuantity/utilisation X 1Quality / satisfaction X -Equity / targeting X 0
    32. 32. Summary findings: our assessment (1)• Maternal and neonatal health services have been a major area of application of the RBF logic• High creativity in addressing barriers, implementers adapt the RBF strategy to local bottlenecks and priorities• Effectiveness: • there is more evidence for some RBF strategies than others, e.g. for vouchers • a lot of research being implemented, esp. on PBF• Not well investigated: negative and unintended side-effects of RBF, sustainability
    33. 33. Summary findings: our assessment (2)• Little attention to efficiency (cost/effectiveness)• Efficiency of a RBF scheme depends on the design, the funding, the implementation…• and heterogeneity across schemes (objectives, experiences, contexts, combinations of RBF strategies) will not ease the synthesis of the evidence• also schemes are improved while implemented• RBF is not a goal per se – the evidence should be put in the broader context of road to UHC
    34. 34. Thank you