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Learning from RBF 
Implementation 
Dinesh Nair Sr Health Specialist
Overview of Session 
• Why do we need to “learn from RBF”? 
• Pulling it all together: the conceptual framework 
• Nigeria...
Many opportunities to learn 
Concept 
Design 
Start-up 
Implement 
Implement 
Implement 
Implement 
Comprehensive learning...
A broad approach to learn from RBF 
implementation 
• Holistic conceptual framework which highlights: 
 the intermediate ...
Conceptual 
Framework
A Conceptual Framework for PBF 
What organizational and behavioral changes do you expect PBF 
to bring about?
Learning from RBF 
Implementation: 
Nigeria Experience
RBF in Nigeria combines the PBF at health centers and 
DLIs to state and local governments 
Results Based Financing Approa...
Coverage has been increasing significantly, but further 
improvement is required 
Coverage of health services in Pre-Pilot...
Detailed look at the operational data revealed the large 
variations in performance across Health Centers 
Institutional D...
This performance variation across health centers also 
exists in quality of care 
Quality Score (%) in pre-pilot health ce...
Nigeria team engaged with two qualitative 
studies 
1. Demand-side barrier analysis 2. Case study on key 
determinants 
• ...
Demand-side barrier analysis revealed priority 
issues 
Major Barriers Found through Qualitative 
Analysis 
Demand- 
Side ...
Case study on determinants suggests the importance of 
community engagement and OIC management 
Identified determinants an...
Research findings will drive new demand-side 
interventions with additional financing 
Proposed Transport Voucher and Stre...
Key Lessons Learned 
• RBF performance hinges on how well and quickly we 
can learn from implementation and improve our 
a...
PBF Conceptual Framework and Illustration with The Case of Nigeria
PBF Conceptual Framework and Illustration with The Case of Nigeria
PBF Conceptual Framework and Illustration with The Case of Nigeria
PBF Conceptual Framework and Illustration with The Case of Nigeria
PBF Conceptual Framework and Illustration with The Case of Nigeria
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PBF Conceptual Framework and Illustration with The Case of Nigeria

A presentation by Dinesh Nair, delivered during "Transforming Health Systems Through Results-Based Financing," an event held during the Third Global Symposium on Health Systems Research in Cape Town on September 30, 2014. This event was hosted by the Health Results Innovation Trust Fund at The World Bank, in partnership with the PBF Community of Practice in Africa.

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PBF Conceptual Framework and Illustration with The Case of Nigeria

  1. 1. Learning from RBF Implementation Dinesh Nair Sr Health Specialist
  2. 2. Overview of Session • Why do we need to “learn from RBF”? • Pulling it all together: the conceptual framework • Nigeria Case Study
  3. 3. Many opportunities to learn Concept Design Start-up Implement Implement Implement Implement Comprehensive learning agenda
  4. 4. A broad approach to learn from RBF implementation • Holistic conceptual framework which highlights:  the intermediate outcomes necessary to achieve results  the utility of a multidisciplinary lens  the need for broad methodological approaches
  5. 5. Conceptual Framework
  6. 6. A Conceptual Framework for PBF What organizational and behavioral changes do you expect PBF to bring about?
  7. 7. Learning from RBF Implementation: Nigeria Experience
  8. 8. RBF in Nigeria combines the PBF at health centers and DLIs to state and local governments Results Based Financing Approach in Nigeria Federal Govt. $$ State Govt. Finance based on.. (Examples) • Increase in services • Budget execution • Bonus payment DLI Local Govt. Health Centers • Supervision • HMIS reporting • HR management • Quantity of services delivered • Quality scores of the services PBF $$ $$
  9. 9. Coverage has been increasing significantly, but further improvement is required Coverage of health services in Pre-Pilot facilities in Adamawa state (%) 45 40 35 30 25 20 15 10 5 0 Inst Deliveries Vaccination FP Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct • Significant improvement from very low baseline in all indicators • The is a good contrast with low DHS 2013 results in the North East (institutional delivery 20%, vaccination 14%, FP 11%) • However, the overall utilization is still 30-40%
  10. 10. Detailed look at the operational data revealed the large variations in performance across Health Centers Institutional Delivery in Adamawa, normalized by 100,000 population 140 Pariya HC 120 100 80 60 40 20 - Chigari HC Dasin Hausa HC Farang HC Ribadu HC Furore MCH HC Choli HC Gurin HC Malabu HC Karlahi HC Wuro Bokki HC Kabilo HC Saint Mary's Clinic HC Mayo-Ine HC • Before PBF, all health centers were equally at very low levels • After the PBF, some facilities achieved 100% coverage while others struggle with limited improvement
  11. 11. This performance variation across health centers also exists in quality of care Quality Score (%) in pre-pilot health centers in Adamawa state 90 80 70 60 50 40 30 20 10 0 Dec Mar Jun Sep Dec Mar Jun Sep Malabu HC Wuro Bokki HC Farang HC Furore MCH HC Gurin HC Karlahi HC Kabilo HC Mayo-Ine HC Pariya HC Dasin Hausa HC Ribadu HC Range: ~30% Range: ~23% • The quality score overall improves even in low performers • However, the difference between high and low performers increased from 23% to 30%
  12. 12. Nigeria team engaged with two qualitative studies 1. Demand-side barrier analysis 2. Case study on key determinants • What are the barriers to service utilization in the PBF facilities? • Transport, service fee, culture/perception/ information barriers • Competition of alternatives • Interview and focus group • High and low performers • Design demand-side interventions • What differentiate the good and poor performers under the PBF scheme? • Health center management • Contextual factors • Health systems factors (e.g., supervision) • Interviews, document review, direct observations • Best and poorest performers • Devise appropriate support to poor performers Research question Areas to look into Approaches Potential use
  13. 13. Demand-side barrier analysis revealed priority issues Major Barriers Found through Qualitative Analysis Demand- Side Barriers Transport Cost Community/ Culture Priority demand side intervention Possible approaches • Transport Voucher Services Competition Availability Cost Predictability of cost Hospitals Traditional providers Community support Magnit ude Controlla bility High High High Med High High High High Varies Low Varies Med High High Varies Med • Community transport team •Maternal shelter • CCT • Predictable/discounted pricing (supply-side) • N/A • Incentives for referral to PHCs (supply-side) • Community engagement (supply-side) • Communication and community involvement Culture
  14. 14. Case study on determinants suggests the importance of community engagement and OIC management Identified determinants and non-determinants (preliminary) Non-Determinants • Level of staffing (best performers lack staff) • Remoteness of facilities (best performers are very rural) • Technical qualifications of OIC (many community health workers manage facilities well) • Business planning (none use it effectively yet) Determinants • Community engagement (e.g., involve and reward community leaders, daily visits, incentivize for use of facility) • OIC’s management capacity (e.g., full staff involvement, improve staff environment using performance bonus, rigorous performance review)
  15. 15. Research findings will drive new demand-side interventions with additional financing Proposed Transport Voucher and Strengthening management capacities Implementation Arrangements • Build demand side interventions to support Supply Side RBF interventions Improve Capacities • Community engagement • Management capacity building of health centers • Technical training (e.g., IMCI) for quality improvement (QI) Transport Voucher • ANC standard visit (1-4) • Institutional delivery • Postnatal consultation • Vaccination of children • Growth monitoring • Referred services provided by hospitals
  16. 16. Key Lessons Learned • RBF performance hinges on how well and quickly we can learn from implementation and improve our approaches • Qualitative research can provide a powerful insights and evidence in devising effective approaches • Identifying right research questions and clear plan to use the research results are required to make the qualitative research meaningful

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