Results based financing a paradigm shift for health systems in low income countries


Published on

Bruno Meessen, Professor of Health Economics, Institute of Tropicale Medicine, Antwerp & Lead facilitator of the HHA PBF Community of Practice, gave this this presentation at the OECD Technical Workshop on Results-Based Funding (also known as Performance Based Funding or PBF) on 19-20 May 2014, given together with the German Development Institute (DIE).

The workshop was overseen by the DAC Network on Development Evaluation in conjunction with DIE.

The DAC Network on Development Evaluation (EVALNET) contributes to better development results using evaluation to build a strong evidence base for policy making and for learning.

More on DIE:
More on EVALNET:

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Decide which services to be includedSet unit price for each serviceMeasure the quantity of services provided by each facilityEstimate the quality index for each facility based on facility assessmentCalculate payment Payment=quantity x unit price x quality index Adjust payment for remoteness and other difficultiesRBF is:A dynamic process of continuous improvementA strategy focused on the result (Quantity and Quality)Approach to motivate innovation and change in mindsetA strategy for integration of other reforms including decentralization and strengthening the health system in general.Health facility operation costs (about 40%): Maintenance and repairConsumablesDrugsOutreach Other elements for quality improvementPerformance bonus to health workers (about 60%) - Criteria are defined (what criteria?)
  • Results based financing a paradigm shift for health systems in low income countries

    1. 1. Results Based Financing: a paradigm shift for health systems in low-income countries May 2014 Bruno Meessen, Professor of Health Economics, Institute of Tropicale Medicine, Antwerp & Lead facilitator of the HHA PBF Community of Practice
    2. 2. Observation 1: Health: outcome of a co-production process 2 Governments / agencies Providers Households / users Other stakeholders Good health
    3. 3. Observation 2: It is about behaviors – incentive matters 3 Source: Bertone & Meessen 2013
    4. 4. • Incentives – at country level: Cash On Delivery – At provider level: Performance Based Financing (PBF) – At household level: conditional cash transfer – At user level: family planning voucher for poor women 4 RBF: many options
    5. 5. • Cambodia • Rwanda • Central Africa • The Health Results Innovation Trust Fund 5 PBF – the story (1998-2013)
    6. 6. 6 PBF: a reality in Africa
    7. 7. • A virtual group of 1,200+ experts 7 PBF: an African community of experts
    8. 8. Countries will : • “Improve efficiency in health systems (…) including the introduction of measures such as results based financing (RBF) and incentives to enhance transparency and performance and reduce wastage” (Tunis Declaration, 2012) PBF: an African agenda
    9. 9. PBF = a reform of provider payment Number provided Unit price ($) Total earned ($) Child fully vaccinated 100 5 500 Skilled birth attendance 20 10 200 Curative care <5 years 1,000 0.5 500 Total before correction 1,200 Remoteness Bonus + 50% 1,800 Quality correction x 60% 1,080 $1,080 available for: • Health facility operation costs (supplies, maintenance, outreach etc) – about 40% of funds • Performance bonus to health workers – about 60% of funds 9
    10. 10. • Primary health care • Community participation • Key role for the State (incl. strategic purchasing) 10 … which secures key strengths of previous strategies
    11. 11. … but also dares to reform the health sector 11 Output payment & strategic purchasing Contract & enforcement Separation of functions ICT Direct transfer of funds Autonomy Performance is defined
    12. 12. • Real SWAp • Public finance reform • Public sector reform • New approach to decentralisation in the health sector • Integration of the private sector • New ecosystem enhancing effectiveness of other interventions 12 PBF – many spill-over effects
    13. 13. • Agencies: adapt your instruments, approaches & expertise. • All of us: work together to find the right mix of approaches. • Accompany countries – from pilot to long term sustainability. 13 Challenges
    14. 14. • Join existing schemes. • Inform experts of your agencies. • Support knowledge building. 14 How you can contribute?
    15. 15. • RBF: health system strengthening strategy focused on results. • Many ways to support the momentum. 15 Conclusion
    16. 16. PBF improves efficiency Efficiency : – Allocative efficiency: Funding is targeted on cost-effective interventions – Technical efficiency: strong incentive for greater effort, better management, innovation. – Transactional efficiency: concern for low transaction costs (eg. direct transfer to health facilities).
    17. 17. PBF improves equity & accountability But can also improve • equity: – formula to target specific groups (e.g. Burundi) or geographical areas. • transparency and accountability: – Stress on verification – Possible to benchmark performance – Transparency of funding flows
    18. 18. • The most structured proposition for health systems in LICs for 25 years. • It fits well with the new agenda for results (MDGs…). • It shares common points with New Public Management introduced in the nineties in several OECD countries. 18 A paradigm shift?
    19. 19. 19 A paradigm shift? Old paradigm New paradigm Primary health care YES with some of the same strengths and limits (e.g. lack of attention to non-medical determinants) Community participation * ** but could be stronger Attention to results * *** but could be even stronger Role of the state The ubiquitous State The strategic State Private-for-profit sector Excluded Can be included Public finance reform Not necessary Necessary Mechanisms Reliance on planning, leadership and public service ethos Recognition of the importance of incentives (incl. autonomy) – overreliance? Theoretical back up Public & development planning New Institutional Economics Values Trust in the civil service & relationship Individual responsibility & market
    20. 20. Diversity of RBF Interventions CCT/Vouchers/HEF Payment based on FFS Other monetary payments Non-monetary rewards Providers Beneficiaries Countries & Organizations Incentives primarily for: Type of Reward: PBC Afghanistan COD/P4R Nigeria, Ethiopia OBA Cambodia PBF Community Primary Secondary Rwanda , Burundi “PRP”* *Provider Recognition Programs