1) Results-based financing was introduced in Afghanistan's health system in 2010 to improve poor health indicators by paying health facilities for additional and higher quality services, especially for the poor. 2) An impact evaluation found that key indicators like antenatal care, postnatal care, and skilled birth attendance increased significantly more in facilities using results-based financing compared to similar control facilities. 3) The longer results-based financing was in place, the greater the improvements in health services. Quality of care also improved in hospitals using results-based financing approaches.

1. Results-Based Financing
in Afghanistan
Motivation, Design, and Preliminary Results
Tekabe Belay
Senior Economist, South Asia HD, World Bank
Women Deliver
Kuala Lumpur , Malaysia
May 28, 2013

2. Motivation
In 2002, the health system was in a very poor condition
• Limited capacity in the Ministry of Public Health
• 80% of services provided by NGOs
• Lack of coordination among stakeholders
• Inequitable distribution of health services, with many rural
areas extremely under-served
• Few functioning health facilities
2

3. Motivation…
Reflected in health indicators that were among worst in
the world
• Life expectancy: women 45 years and men 47 years
• Under-five child mortality: 257 deaths per 1,000 live births
• Maternal mortality ratio: 1600 per 100,000 live births
3

4. • Focus on stewardship functions
o Define the package of services: BPHS and EPHS
o Define the beneficiaries: service areas defined for each provider
o Define the standard of services: inputs requirements for BPHS and EPHS
defined
• Partner with the private sector
o that has been serving 80% during the conflict
• Use its purchasing power effectively to register results
• The approach is largely along the lines of current thinking on
service delivery in fragile states (e.g. Collier)
Strategy: Afghanistan’s Approach to
Health Service Delivery
4

5. This achieved
impressive results…
5

6. Skilled Birth Attendance - 3 times
6
6.00%
8.40%
18.40%
24.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
2003 2005 2006 2008

7. 7
4.60%
12.60%
30.30%
36.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
2003 2005 2006 2008
Antenatal Care (>1 ANC) - almost 7 times

8. 8
5.10%
10.40%
15.40%
23.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
2003 2005 2006 2008
Contraceptive Prevalence Rate – 3.5 times

9. 9
DPT3 Coverage - doubled
21.20%
17.40%
34.60%
43.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
2003 2005 2006 2008

10. Infant Mortality - 32% reduction
Under 5 Child Mortality – 35% reduction
10
165
257
129
191
111
166
0
50
100
150
200
250
300
Infant Mortality Rate Under 5 Mortality Rate
2001
2006
2008

11. ...but not enough
11
Coverage of important services remains low by
global standards e.g.
o CPR 15%,
o ANC 36%
o SBA 24 %
Additional effort to increase coverage needed

12. Results-Based Financing (RBF)
• Since 2010:
o 14 provinces: gradually scaled up
o Primary care and hospitals
• RBF means:
o Payment for additional services
o Payments for improved quality
o Payments for serving the poor
• Rigorously assessed with a gold standard IE design
12

13. Results after 24 Months of
Implementation
13

14. ANC: in RBF Facilities
0
15
30
45
60
75
90Numbermonth
ANC1-4 Treatment
14

15. ANC
0
15
30
45
60
75
90Numbermonth
ANC1-4 Treatment ANC1-4 Control
15

16. PNC: in RBF Facilities
0
15
30
45
60
75
90
Numbermonth
PNC1-2 Treatment
16

17. PNC
0
15
30
45
60
75
90
Numbermonth
PNC1-2 Treatment PNC1-2 Control
17

18. SBA: in RBF Facilities
0
2
4
6
8
10
12
14
16
18
20
Numbermonth
SBA Treatment
18

19. SBA
0
2
4
6
8
10
12
14
16
18
20
Numbermonth
SBA Treatment SBA Control
19

20. 0
10
20
30
40
50
60
Numbermoth
DPT3 Treatment
DPT3: in RBF Facilities
20

21. 0
10
20
30
40
50
60
Numbermoth
DPT3 Treatment DPT3 Control
DPT3
21

22. RBF Indicators: Changes Between
2010 Q3 and 2012 Q1
21.8
16.5
5.4
1.3
4.3
6
2.6
-0.1
-5
0
5
10
15
20
25
ANC1-4*** PNC1-2*** SBA** DPT3
Treatment
Control
22

23. The longer RBF is in place, the better
(ANC 1-4)
(highest after 12 months ~ control for seasonality)
9.9
13.5
21.8
6.9
1.4
4.3
0
5
10
15
20
25
3months** 12 Months*** 19 months***
Treatment
Control
23

24. The longer RBF is in place, the better
(PNC 1-2)
3.9
7.7
16.5
3.1
1.5
6
0
2
4
6
8
10
12
14
16
18
3months** 12 Months*** 19 months***
Treatment
Control
24

25. The longer RBF is in place, the better
(SBA)
-0.3
1.2
5.4
0.5
-0.2
2.6
-1
0
1
2
3
4
5
6
3mohths 12 Months 19 months**
Treatment
Control
25

26. Quality improved in most hospitals
with RBF in place
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
1 2 3 4 5 6 7 8 9 10 11 12 13
Score
Hospitals
Overall Score
Before
After
26

27. Improved Quality
0.0
20.0
40.0
60.0
80.0
100.0
120.0
1 2 3 4 5 6 7 8 9 10 11 12 13
Score
Hospitals
Hospital Infection prevention
Before
After
27