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

1. Impact Evaluation Note
Country
Dr Tayyab Massod !
Dr Akhtar Rashid
H E A LTH R ESU LTS IN NOVATION TRUS T FU N D

2. 1. Background
• Punjab’s health outcomes have improved but the pace of change
remains slow.
• Punjab’s under-five and infant mortality (MDG 5) at 104 and 82
deaths per 1000 live births in 2011.
• Immunization coverage is suboptimal - only 35% of children aged
12-23 months in Punjab are fully immunized (measles 2)
• Maternal mortality ratio (MDG 4) at 227 per 100,000 live births
is lower than national average.
• Inequities persist in health outcomes and service use between
the poor and non-poor and between rural and urban households
• The efficiency of resource use is low due to pervasive problems
of governance and weak and centralized management.
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3. 1. Background
• GoP has approved a health sector strategy
• The Bank and DFID are supporting this with a $285m
investment
• HRITF grant will be used to test a few pertinent innovations
outlined in the strategy
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4. 2. Description of Intervention
• Facility Based Performance Incentives:
o To enhance performance and improvements in quality of services at facility level
o Facilities will be contracted with specific outputs/ indicators related to primary health care
and incentive will be utilized for individuals as well as recurrent costs
• Demand side voucher for safe delivery :
o Improve institutional delivery and maternal survival targeted on income level
o Voucher will cover ANC, PNC and institutional delivery
o Cash incentive to the beneficiary and pre-determined cost for institutional delivery to be
paid to the health facility (includes public and private).
• Performance based district management contracts :
o To strengthen performance based management at the district level
o Provide performance rewards to good performing districts
o Improving quality of care through better planning, monitoring and supervision
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5. 3. Results Chain
o Cash
Transfers to
facilities…
INPUTS ACTIVITIES OUTPUTS OUTCOMES
LONGER-TERM
OUTCOMES
HIGHER ORDER
GOALS
o Signing of
Contracts:
o Supervision &
Monitoring
o Provision of
identified
Services.
o Improvement
in Preventive
Health
Indicators…
o Decreased
mother and
child
mortality
o Signing of
Contracts:
o Quarterly
evaluations/
meetings
o Improvement in
Preventive
Health
Indicators…
o Decreased
mother and
child
mortality
1. Facility based performance contracts
2. Performance Based District Management Contracts
Verification of Results
o Improvement
in delivery of
Essential
Package of
Health
Services,
including integrated
MNCH/FP, nutrition,
and control of
communicable disease
o Improved
Supervision
and M&R
budgets
o Performance
incentives to
managers
Verification of Results

6. 3. Results Chain
o Awareness
of services,
o Incentive to
provider and
consumer
INPUTS ACTIVITIES OUTPUTS OUTCOMES
LONGER-TERM
OUTCOMES
HIGHER ORDER
GOALS
o Identification of
Beneficiaries
o Voucher
Distribution
o 2+ ANC,
Institutional
Delivery,
PNC
o Decrease
maternal
morbidity
o Decreased
mother and
child
mortality
3. Demand Side Incentives for Safe Delivery (Voucher Scheme)
Verification of Results

7. 4. Primary Research Questions
• Can RBF approaches increase the level of health service
utilization leading to better health outcomes in Punjab
o Which approach will have more effect?
o What is the cost?
• Comparison between Five Approaches
o Outsourcing Primary Care Services (PRSP)
o Performance based district management contracts
o Facility based performance contracts
o Demand side Incentives for safe delivery (vouchers
o Health Protection/ Insurance for the Poor
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8. 5. Outcome Indicators
• District Management Contracts
o performance indicators related to delivery of essential package of
health care, integrated Maternal Neonatal and Child Health program
and communicable disease control
• Facility contracts
o Maternal Neonatal and Child Health program, nutrition,
immunization, family planning and general management.
• Safe Delivery Voucher
o At least 2 Antenatal Care Visits, Delivery by SBA at Health Facility,
Post Natal Care
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9. 6. Identification Strategy/ Method
• Multiple Research methods include
o Data collection will be on a prospective basis, from Community,
Facilities and management
• Statistical Techniques to be used will be:
o Difference in Difference to assess quantitative effect
o Discontinuity Regression to statistically control and validate the Diff
in Diff results
o Ongoing qualitative work: including a political economy study
o Process evaluations will inform implementation
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10. 7. Sample and Data
• The Universe is the worse off 18 out of 36 Districts in
Punjab
• The data collection will be done in six districts
o Two for vouchers
o Two for facility contracts
o Two for health protection/ insurance
• Qualitative : In depth Interviews with managers, community
beneficiaries, health facility staff
• Quantitative: Health Diaries at Household level, Community
surveys, exit interviews, health facility assessment,
management reviews
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11. 8. Time Frame / Work Plan
• Ac#vity
TimeLine
• Project
team
on
board
June 2014
• I.E
team
June 2014
• Comple4on
of
contrac4ng
process
for
:
• (IE
data
collec4on
firm,
University,
VMA,
Health
Facili4es,
District
Management
contracts,
External
Verifica4on
Firm)
December 2014
• Iden4fica4on
of
beneficiaries
for
vouchers
December 2014
• Vouchers
distribu4on
March 2015
•
Midline
Evalua4on
March 2016
• Expansion
of
facility
contracts
June 2016
• End
line
evalua4on
March 2018
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