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 www.german-practice-collection.org/en/discussions/gdcs-position-regarding-rbf-in-health and tweet via #HealthRBF.

1. Results Based Financing of
Maternal 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. 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. Why did RBF develop in health
Because:
• 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. 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. 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. 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. 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 clients
insurance entity to private (not-for- administrative and providers
agencies/facilities profit) facilities levels and public
“Contracting-out” “Contracting-in” health facilities

8. Difference in impact on behaviour
Influence on Influence on
Results Based Financing Approaches provider client
behaviour behaviour
Performance-Based
XX X
Contracting (PBC)
Supply-side, with a
Performance-Based
demand-side XX X
Financing (PBF)
component
Results-Based Budgeting
XX X
(RBB)
Health Equity Fund X XX
Demand-side with a
supply-side component
Vouchers X XXX
Demand-side, no Conditional Cash
-- XXXX
supply-side component Transfers (CCT)

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. 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. 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. 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. 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 effect
1. Studies with strenght of evidence being medium or high

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. 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. 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. 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. Findings from the 70 studies
PBC PBF Vouch RBB Total
Characteristics er
Countries with RBF 7 8 11 4 25
Programs studied: 7 8 18 4 37
Number of studies 11 18 33 8 70
Strength 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. PBC PBF Voucher RBB Total
Objectives, type of services, for whom
N=7 N=8 N=18 N=4 N=37
and where
Overarching 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 - - 2
Target groups:
Poor 7 7 12 3 29
Specific: sex workers, adolescents - - 2 - 2
All: poor and non-poor - 1 4 1 6
Scale:
Particular geographical area(s) 6 2 13 - 21
National scale (and state level in India) 1 6 5 4 16

20. Where implemented, who initiated
PBC PBF Voucher RBB Total
Context programs N=7 N=8 N=18 N=4 N=37
Region
Africa 1 6 3 2 12
Asia 4 2 12 2 20
Latin America and 2 - 3 - 5
Caribbean
Ownership
Donor-initiated 4 1 8 - 13
Gov.-initiated 2 - 6 4 10
Donor-initiated, scaled 1 7 4 - 14
by Gov.

21. PBC PBF Vouch RBB Total
List of MNCH
N=7 N=8 er N=4 N=37
interventions N=18
Adolescents & pre-pregnancy
Family planning 4 6 6 - 16
Prevent and manage STI - 5 4 - 9
Pregnancy
Appropriate ANC package and
other relevant interventions 7 7 13 - 27
Childbirth
Institutional or skilled normal
delivery, referral of complicated 7 7 13 4 31
deliveries
Postnatal
Postnatal check and care of
7 7 13 4 31
mother and child

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. 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. 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. 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. Number of individual RBF programs
addressing particular barriers
Barrier PBC PBF Vouch RBB Total
N=7 N=8 er N=4 N=37
N=18
Supply-side barriers addressed:
Availability 7 8 18 4 37
Acceptability 7 8 18 4 37
Affordability 3 2 18 4 27
Demand-side barriers addressed:
Availability 5 7 18 1 31
Acceptability 5 7 18 1 31
Affordability 1 1 9 1 12

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% 3
utilisation (6)
Quality / 2 2 100% 100% 50% 1
satisfaction (2)
Equity / targeting 2 3 100% 100% 67% 2
(3)

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% 1
utilisation (9)
Quality / 7 8 100% 100% 50% 4
satisfaction (8)
Equity / targeting 3 4 100% 75% 33% 1
(4)

29. Vouchers: 18 programs, 31 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=18 N=33 effect)
Quantity/ 15 22 100% 100% 45% 10
utilisation
Quality / 11 16 100% 100% 50% 8
satisfaction
Equity / 13 17 100% 100% 53% 9
targeting

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% 1
utilisation
Quality / 1 1 0% - 0% -
satisfaction
Equity / targeting 2 2 100% 50% 0% 0

31. Summary evidence on effect of RBF
Insufficient
Robust Modest # rigorous
evidence
Type of Effect evidence evidence
<2 studies or
studies positive
>3 studies 2-3 studies effect
no effect
PBC
Quantity/utilisation X 3
Quality / satisfaction X 1
Equity / targeting X 2
PBF
Quantity/utilisation X 1
Quality / satisfaction X 4
Equity / targeting X 1
Vouchers
Quantity/utilisation X 10
Quality / satisfaction X 8
Equity / targeting X 9
RBB
Quantity/utilisation X 1
Quality / satisfaction X -
Equity / targeting X 0

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. 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. Thank you