Operational
Lessons from RBF
H E A LT H R E S U LT S I N N OVAT I O N T R U S T F U N D
Learning from Implementation
Petra...
The Why and How of
Operational Lessons
•  Review of ongoing PBF operations suggests
some useful lessons
•  Focusing on the...
Lesson
“Math-Phobes of the World Unite!”
– Use your data
•  Data is vital but under-utilized, despite a lot of effort
inve...
Coverage of full vaccination among children under 1
0
10
20
30
40
50
60
70
80
90
100
4 1 2 3 4 1 2 3
Benin
Burkina Faso
Ca...
Total quality score in health facilities
0
20
40
60
80
100
Burkina
Faso
Benin Cameroon Kenya Nigeria Zambia Zimbabwe
%
Sco...
Internet applications with public front-end
displaying performance & financial information
18
Burundi
Benin
Nigeria
3 services absorbing largest share of payment
7
OP >5
11%
OP
<=5
15%
Inst.
Delive
ries
17%
Other
s
57%
Burundi
Zambia
Came...
Strengthening work on administrative data
1.  Regularly monitoring program progress to identify candidates for
adjustment ...
Lesson
“Keep moving the goalposts!”
Continuous Quality Improvement
(CQI) implies Changing the Quality
Indicators
•  Many f...
At different levels:
•  Facility Staff (managers, providers, staff -hospitals and clinics):
Need quality measures to asses...
Consider phasing improvement priorities: “impossible to improve everything at once”
Involve local and international expert...
Illustrative quality measure: Quality of Partogram
Completion (not so simple!)
Quality	
  Measure	
   Opera/onal	
  Defini/...
Lesson
No commodities : No program
Worry about supply chains and drug
availability !!!!!!
6
Improving Medicine supply chains to
debottleneck RBF Programs
•  A useful first step is to diagnose the root causes of poo...
Lesson
Seeing is Believing !!!!!
Verify and Counter Verify to Ensure You
pay for real outputs !!!!
6
Factors influencing verification: A Conceptual
Framework
Context	
  
Verifica/on	
  Characteris/cs	
  
Impact	
  on	
  
accur...
Key Recommendations Verification
1.  Consider context to determine whether merging
functions is appropriate (be mindful of ...
Lesson
Capable People Matter !!!!!
Invest in Your RBF Institutions & Teams
6
Scaling up capacity building and human
resources for RBF and its sustainability
•  South-South TA with appropriate backsto...
Lesson
Let RBF Leave its Mark !!!
Think beyond tomorrow
6
RBF Institutional Set up and
Ensuring Buy in
•  There are 3 main stages in the integration of RBF into a
national health s...
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Annual Results and Impact Evaluation Workshop for RBF - Day Eight - Learning from Experience - Operational Lessons from RBF

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A presentation from the 2014 Annual Results and Impact Evaluation Workshop for RBF, held in Buenos Aires, Argentina.

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Annual Results and Impact Evaluation Workshop for RBF - Day Eight - Learning from Experience - Operational Lessons from RBF

  1. 1. Operational Lessons from RBF H E A LT H R E S U LT S I N N OVAT I O N T R U S T F U N D Learning from Implementation Petra Vergeer & Hadia Samaha
  2. 2. The Why and How of Operational Lessons •  Review of ongoing PBF operations suggests some useful lessons •  Focusing on the most important lessons will facilitate enhanced design and implementation 2
  3. 3. Lesson “Math-Phobes of the World Unite!” – Use your data •  Data is vital but under-utilized, despite a lot of effort invested into collecting, verifying and putting payment data on the web 17
  4. 4. Coverage of full vaccination among children under 1 0 10 20 30 40 50 60 70 80 90 100 4 1 2 3 4 1 2 3 Benin Burkina Faso Cameroon Kenya Nigeria Zambia Zimbabwe %
  5. 5. Total quality score in health facilities 0 20 40 60 80 100 Burkina Faso Benin Cameroon Kenya Nigeria Zambia Zimbabwe % Scores are averages of health centers and hospitals, technical and subjective where applicable Each bar represents a quarter of implementation
  6. 6. Internet applications with public front-end displaying performance & financial information 18 Burundi Benin Nigeria
  7. 7. 3 services absorbing largest share of payment 7 OP >5 11% OP <=5 15% Inst. Delive ries 17% Other s 57% Burundi Zambia Cameroon Zimbabwe OP contac t 6%Inst. Delive ries 35%FP 40% Others 19% OP contact 35% Inst. Deliveri es 15% FP 21% Others 29% OPC 21% Hosp. days 15% VCT 12% Others 52% Figures reported are averages of all quarters to date
  8. 8. Strengthening work on administrative data 1.  Regularly monitoring program progress to identify candidates for adjustment (indicators and tools) 2.  Taking advantage of HMIS data to compare with control facilities and assess performance on non-incentivized services 3.  Developing online dashboard to facilitate use of data and promote transparency 4.  Developing automated data analysis software to lessen burden of data analysis for teams and encourage focus on results (ADEPT RBF) 8
  9. 9. Lesson “Keep moving the goalposts!” Continuous Quality Improvement (CQI) implies Changing the Quality Indicators •  Many facilities make rapid improvements in quality and then plateau 6
  10. 10. At different levels: •  Facility Staff (managers, providers, staff -hospitals and clinics): Need quality measures to assess and continuously improve services. Is care improving? •  Regional/District & Program Managers: Need measures to assess and continuously strengthen essential system functions (e.g. competent workforce). Are essential system functions performing to standard? -------- Understanding what different stakeholders want:   Clients (users of care)   National Policy-makers (value, policy)   Global Stakeholders (leadership, advocacy, accountability) Integrating Quality into RBF Projects: Prioritizing Health Conditions/Services for Improvement
  11. 11. Consider phasing improvement priorities: “impossible to improve everything at once” Involve local and international experts to: •  Review country standards against global evidence: evidence is constantly changing •  Distill standards into minimum “intervention bundles”: focus attention on essential high-impact interventions •  Illustrative quality of care process measures based on minimum standards: o  % cases adherent with standards – “all or nothing adherence” (e.g. % PPH cases managed per minimum standard; % cases pediatric pneumonia treated per standard) o  Average % adherence with minimum standards (e.g. average % adherence with newborn sepsis case-management standards; N=30 cases) Integrating Quality into RBF Projects: Selecting standards and Defining Quality of Care Measures
  12. 12. Illustrative quality measure: Quality of Partogram Completion (not so simple!) Quality  Measure   Opera/onal  Defini/on      %  partograms  in  last  quarter   completed  per  standard         NUMERATOR:   Number   partograms   documen/ng  cervical  dila/on,  maternal  BP,   pulse,  temperature  at  admission  and  at  least   every  4  hours  un/l  delivery       DENOMINATOR:     Total   number   of   partograms  reviewed  
  13. 13. Lesson No commodities : No program Worry about supply chains and drug availability !!!!!! 6
  14. 14. Improving Medicine supply chains to debottleneck RBF Programs •  A useful first step is to diagnose the root causes of poor availability using an appropriate diagnostic tool. Poor quantification/ requisitions, lack of transport, and procurement delays are common reasons. •  Range of options for RBF programs to tackle these challenges. E.g., better requisitioning tools, contracted transport for obtaining supplies from district or regional stores, negotiated prices with private sector supply sources etc.
  15. 15. Lesson Seeing is Believing !!!!! Verify and Counter Verify to Ensure You pay for real outputs !!!! 6
  16. 16. Factors influencing verification: A Conceptual Framework Context   Verifica/on  Characteris/cs   Impact  on   accuracy,   cost,   sustainability   RBF  Characteris/cs   RATIONALE  FOR  RBF   CONTRACT  TYPE   USE  OF  RBF  RESULTS   Improving  health  outcomes/HSS   RelaFonal   Payment,  improving  performance     Financial  accountability/Cost  control   Classic   Transparency,  Naming  and  Shaming   Monthly                          Annual   Yes   Large   Whole  universe                      Risk-­‐based  approach     Internal   Verifica/on  Results  and  Their  Use   FREQUENCY   ALLOWABLE  ERROR  MARGIN   SAMPLE  SIZE   INSTITUTIONAL  SETUP   ADVANCE  WARNING   No   Small   Third  party   Learning,  Error  correcFon   Cost  recovery,   SancFon   PAYMENT  FREQUENCY   Monthly   Annual   POLITICAL  ENVIRONMENT   GOVERNANCE   CULTURE  
  17. 17. Key Recommendations Verification 1.  Consider context to determine whether merging functions is appropriate (be mindful of conflict of interest) 2.  Analyze and use data available from verification and counter-verification 3.  Verification strategies should be dynamic, not static, and use a risk-based approach
  18. 18. Lesson Capable People Matter !!!!! Invest in Your RBF Institutions & Teams 6
  19. 19. Scaling up capacity building and human resources for RBF and its sustainability •  South-South TA with appropriate backstopping can lead to a successful home bred PBF pilot experience •  Faculty members in Medical Schools are keen to embrace PBF, teach PBF and spread its principles and success stories, provided that they got the opportunity to be exposed to PBF in theory and in practice •  Creating local contract management and verification capacity by selecting local non-governmental organizations and training and coaching them in PBF can be an attractive strategy in some countries. •  Use of locals has made it possible to increase knowledge and capacity on RBF, research, and MNCH in-country. Ensure there is no bias and missing out on other international experiences
  20. 20. Lesson Let RBF Leave its Mark !!! Think beyond tomorrow 6
  21. 21. RBF Institutional Set up and Ensuring Buy in •  There are 3 main stages in the integration of RBF into a national health system   Adoption: to move from PILOT to SCHEME   Institutional: to move from SCHEME to POLICY   PERPETUATION: to move from POLICY to SYSTEM •  Key issues are in terms of: Actors, Resources (including $$ $$), RBF design, and Process •  Context shapes the trajectory

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