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The document aims to present brief summary of evidences on application and effect of Results Based Financing (RBF) schemes in primary care in Low and Lower-Middle Income Countries (LLMIC) with focus of immunization services. The summary is based on review of latest evidences. It is intended for operational readership: for policy makers, health care managers and other actors interested to learn more on RBF schemes. More detailed information and full resources could be accessed at www.zotero.org
Citation preview
ResultsBasedFinancingforPrimaryCareServices
withfocusonImmunization
EvidenceSummary
Clickheretoentertext.
February,2016
TableofContents
PurposeoftheDocument 1
Background 1
DifferentformsoftheRBF 1
EvidencefromRBFpiloting 2
Majorindicatorsevaluated 2
MainFindings 3
Performance-BasedContracting 5
Performance-BasedFinancing 6
Conclusionandrecommendation 8
References 10
1
PurposeoftheDocument
ThedocumentaimstopresentbriefsummaryofevidencesonapplicationandeffectofResults
BasedFinancing(RBF)schemesinprimarycareinLowandLower-MiddleIncomeCountries
(LLMIC)withfocusofimmunizationservices.Thesummaryisbasedonreviewoflatest
evidences.Itisintendedforoperationalreadership:forpolicymakers,healthcaremanagers
andotheractorsinterestedtolearnmoreonRBFschemes.Moredetailedinformationandfull
resourcescouldbeaccessedatwww.zotero.org-https://www.zotero.org/groups/rbf_for_mch/items
ThedocumentwasdevelopedintheframeofthePolicyInformationPlatformProjectinGeorgia
fundedbytheAllianceforHealthPolicyandSystemsResearch.
Background
Results-BasedFinancing(RBF)isahealth-financingmodeldesignedforimprovinghealth
systemperformance.ThemainareaofitsapplicationisaMaternalandChildHealth(MCH).It
hasbeenimplemented(asapilotornationwide)inmanycountriestoaccelerateprogress
towardsthemillenniumdevelopmentgoals(MDG)forwomen’sandchildren’shealth(MDGs4
andMDG5).MCHserviceshavebeenthemajorareaoftheRBFreasoning,possiblythemain
one.
DifferentformsoftheRBF
RBFforhealthisdefinedasacashpaymentornon-monetarytransfermadeafterpredefined
resultshavebeenattainedandverified.1Afteritsintroduction,therehasbeenshapedvarious
formsoftheRBF,thatworkatdifferentlevelsofthehealthsystem,mainlydifferentiatedas
supply-anddemand-sideapproaches:2
• Performance-BasedContracting(PBC)
• Performance-BasedFinancing(PBF)
• ResultsBasedBudgeting(RBB)
• Vouchersforhealth
• HealthEquityFund(HEF)
• ConditionalCashTransfer(CCT)
2
Table1:Incentivesandchiefsupply-anddemand-sideRBFapproaches
RBF Approaches Provider
Supply-side,withademand-sidecomponent
Performance-BasedContracting(PBC)
Contractdefinesexpectedperformance(inquantity/orquality)aswellaslevelofpayment,plusrewardsorsanctions
Performance-BasedFinancing(PBF)
Levelofpaymentisbasedonachievingperformancetargets,oftenquantityandqualityindicators
Results-BasedBudgeting(RBB)
Alladministrativelevelshaveanincentive:bonusorlargerbudgetonthebasisofpre-agreedperformancetargets
Demand-sidewithsupply-sidecomponent
HealthEquityFund(HEF)
Incentivesareequaltothefeepaidforeacheligiblepatienttreated.Sinceshortpilotwithqualityindicators
Vouchers Incentivesareequaltothefeepaidforeacheligiblevoucher.Qualityindicatorsusedforselection;qualityassurance
Demand-side
ConditionalCashTransfers(CCT)
Providerdoesnotreceiveincentives,butthereisproviderselectionwhichcanincludequalityindicators
(fromGorterAC,IrP,MeessenB:Results-BasedFinancingofMaternalandNewbornHealthCareinLow-
andLower-Middle-IncomeCountries.EvidenceReview,2013)
RBFschemes,designedconsideringthecontext-specificissues,aimtoincreaseautonomy,
strengthenaccountability,andempowerfrontlineprovidersandhealthfacilitymanagersto
makehealthservicedeliverydecisionsthatbestmeettheneedsofthewomenandchildrenin
thecommunitiestheyserve.
EvidencefromRBFpiloting
TheRBFhasbeenpilotedinmanyLowandLowerMiddleIncomeCountries(LLMICs).
Althoughsomeformsofitstilllacktheproperevaluations.Forexample,thereviewssuggest
thatVouchershavebeenappliedandevaluatedearlierinhealthsystems,comparedtoPBFand
haveshowedrobustevidencethattheycanimpactonhealthoutcomesinvestigated,whilethe
PBFimpactonhealthoutcomehasnotyetsufficientlystudied.2,3AsofJuly15,2015theWorld
Bank-managedHealthResultsInnovationTrustFund(HRITF)continuedtosupportongoing
workinitsportfolioof36RBFprojectsin30countries(mainlylocatedinAfrica).
Majorindicatorsevaluated
PositiveandnegativeeffectsofRBFonaccesstoandquantity/utilization/coverageofhealth
services:
• FamilyPlanning
3
• Antenatalcarepackage
• Skillednormaldelivery
• Referralofcomplicateddelivery
• NeonatalandPostnatalcare,includingImmunization
BesidesthequantityindicatorsresearcherstriedtoinvestigateRBFimpactonqualityofhealth
servicesprovidedandbeneficiariessatisfactionwiththoseservices,healthequityand
targetingissueshavealsobeenevaluatedinsomecases.
MainFindings
Beforemovingforward,inthissummarywewouldliketoconcentrateonsupply-sideRBF
interventionsthathadbeenintroducedforimprovingtheMCHservicesinmanydifferent
countries.WewillpresentthefindingsofPBCandPBFimpactsontheMCH.
ThelatestreviewofRBFinterventionforMCHservicesproducedbyGorteretal.emphasizes
thelackofrobustevidencefromLLMICsdespitethegrowingnumberofstudiesonthistopic
fromLLMICs.
Althoughitisoftendifficulttodisentangletheeffectsoftheincentivesfromotherinterventions,
thefindingsshowthatwhereRBFisintroduced,itcanmakeasubstantialdifferencein
termsofutilizationandcoverageofthosehealthserviceswhichareincentivised,
especiallyfortargetedindicators,includingmaternalhealthindicators.Thereisgrowing
evidenceonthepositiveeffectsofRBFonaccesstoandutilizationofmaternalhealthservices,
butevidenceontheeffectsonservicequalityandmaternalhealthoutcomesislimited.Also
therehasbeenlittleornoinvestigationonthelong-termandsystem-wideeffectsofRBFon
overallhealthserviceprovisioninacountry.
TheTable2summarizesRBFimpactonoutcomecategories.Forvouchersthereisrobust
evidenceforallthreeoutcomecategories,forPBFrobustevidencewasfoundforitsimpacton
quality/patientsatisfaction,butinsufficientevidenceforothercategories.Aswithvouchers,
whenmorestudiesbecomeavailableitwillbecomemoreclearifindeedPBFcanincrease
utilization.PBChaverobustevidenceforincreasedutilizationandinsufficientforquality.
Table2:SummarytableimpactofRBFapproachesonthethreeoutcomecategories
Typeofeffect Robustevidence(>3studies)
Modestevidence(2-3studies)
Insufficientevidence(<2studiesornoeffect)
#rigorousstudiespositiveeffect
PBC Quantity/utilisation/coverage
X 3
4
Typeofeffect Robustevidence(>3studies)
Modestevidence(2-3studies)
Insufficientevidence(<2studiesornoeffect)
#rigorousstudiespositiveeffect
Quality/satisfaction
X 1
Equity/Targeting
X 2
PBF Quantity/utilisation/coverage
X 1
Quality/satisfaction
X 4
Equity/Targeting
X 1
Vouchers Quantity/utilisation/coverage
X 10
Quality/satisfaction
X 8
Equity/Targeting
X 9
RBB Quantity/utilisation/coverage
X 1
Quality/satisfaction
X -
Equity/Targeting
X 0
AlthoughnostudyfocusesonnegativeeffectsofRBF,anecdotalevidencesuggeststhatsome
potentialundesirableeffectsofRBF,suchasmotivatingunintendedbehaviours,
distortions,gamingorfraud,dilutionofprofessionals’intrinsicmotivation,arepossible
andneedtobecarefullymonitoredandevaluated.TheauthorsorexpertsinvolvedinRBF
impactevaluationdocumentingrevealthattheevaluationtechniquesusedarerelativelyweak
(whichisinherenttothistypeofinvestigations,whereitisnotoriousdifficulttodesignand
applyafullycontrolledexperimentoveralongerperiodoftimetakingintoaccountall
confoundingfactors).
AllRBFschemesaddressoneormorebarriersrelatedtosupply-sideavailability,suchas
waitingtime,motivationofstaff,readinessofthefacilitytoprovideservices(availability
ofdrugs,supplies,equipment),andimprovedreferral.Thesamecountsforacceptability
suchasstaffinterpersonalskills.MostRBFschemesaddressbarriersrelatedtodemand-side
availability,mostlythroughtheprovisionofinformationonhealthcareservicesand
providers.
5
Performance-BasedContracting
TheCochranereviewoftheimpactcontractingoutinterventiononhealthservicesutilization(3
separatePBCinterventionslocatedin3countries:Bolivia,CambodiaandPakistan)provides
evidencethatPBCresultedinincreasedaccesstoandutilizationofhealthservices,mainly
fortargetedindicators.ThestudyinPakistanshowedanimmediateincreaseofmorethan
130%inconsultationvisitstothebasichealthunits(+144%ondailyvisitsand+135%for
monthlyvisits),butthisincreasedidnotsustainasbothoutcomesdeclinedconsiderablyinthe
18monthsfollowingthestartoftheintervention.InCambodia,thererevealedanincreaseinthe
useofpublicfacilitiesby29%.ButPBChadnothadasignificantimpactonimmunizationrates
(authorsconcludethattheincreasemaybeexplainedbythegeneralsecularincreaseofservice
provisioninCambodiaatthetime).4
Thereviewidentifiesanumberofdifferentcomponentsincontractoutservicestonon-public
providersthatmaybeinstrumentalintheobservedeffect.Theseincludethepossibleroleofa
newmanagementstyle,thepotentialroleoftheincentivesandobjectivesincludedinthecontract,
ortheimplementationofthoroughmonitoringsystemsandsanctions(whichareusuallyabsentin
thedeliveryofhealthserviceswithinthepublicsector).Severalelementsmightpotentially
altertheeffectsofcontractingoutstrategies.Firstly,Weakcapacitywithinthegovernment
mightthereforecompromisethesuccessfulimplementationofcontractingoutstrategies.The
broadertheservicescontracted,theharderitwillbetodefineacontractprecisely.The
feasibilityofadequatelymonitoringservicedeliveryinremoteareasisalsoakey
implementationissue.4
Thereviewrecommendsthatthegovernmentsshouldpayparticularattentiontotheelements
includedinthecontracttheydrawupwithprivateproviders,inparticularthetargetsonwhich
theirperformancewillbeassessed.Forexample,ifthecontractfocusesonadefinedsetof
outcomes,thereisariskthatcontracteesmightdiverttheireffortfromunmeasuredto
measuredoutcomes.4
PBCwasintroducedinHaitiwhereNGOs(3intotalforpilotstage)werecontractedtodeliver
healthcareservices.PilotingrevealedpositiveimpactofPBCtoanincreasedchildimmunization
coverage.HoweveritwasnotpossibletoisolateeffectofRBF,becauseRBFschemewas
confoundedbywithotherfactors(combinationwithfixedpricecontract,increasedfunding,
aggressivetechnicalassistance,datavalidation,sharedlearningactivities).5,6
6
Table3:PBCpilotingresultsinHaiti
NGO1 NGO2 NGO3 Indicator Baseline Target Results Baseline Target Results Baseline Target ResultsImmunizationcoverage
40 44 79 49 54 69 35 38 73
Performance-BasedFinancing
PBFexperienceshavebeendocumentedinBurundi,DRC,TanzaniaandZambia,where
considerabledifferenceofstaffandhealthserviceproductivitywasfoundbetweenbeforeand
aftertheintroductionofPBFinseveralprojects;withanincreaseinhealthserviceutilizationfor
almostalltargetedindicators,includingmaternalhealthindicatorsandinqualityofcareas
perceivedbytheclients;andnoperverseeffectsweredirectlyobservable.7
ForPBFrobustevidencewasfoundforitsimpactonquality/patientsatisfaction,but
insufficientevidencefortheotheroutcomecategories.Aswithvouchers,whenmore
studiesbecomeavailableitwillbecomemoreclearifindeedPBFcanincreaseservice
utilisation,andwhenitdoesifthisistheninfavourofthemorevulnerableandpoor.2
InRwanda,56%and132%increasewasobservedinthenumberofpreventivecarevisitsby
childrenagedbelow23monthsandagedbetween24-59monthsrespectivelyinthetreatment
facilities.PBFimprovedqualityofprenatalcare(anincreaseof0.157standarddeviations(95%
CI0·026–0·289)inprenatalqualityasmeasuredbycompliancewithRwandanprenatalcare
clinicalpracticeguidelines:7.6%morewomenreceivedatetanusvaccineduringpregnancy
thanatbaseline.),butnoimprovementswereseeninthenumberofwomencompletingfour
prenatalcarevisitsorofchildrenreceivingfullimmunizationschedules.8
AftertheintroductionofPBFinIndonesia,2programyears,8targetedMCHhealthindicators
(e.g.ANC,assisteddelivery,immunization,growthmonitoring)wereanaverageof0.03
standarddeviationshigherinincentivizedareasthaninnon-incentivizedareas.9
InEgyptPBFhadlittleimpactonchildvaccinations,whichmightbeexplainedinpartbythefact
thatbaselineimmunizationrateswerealreadyhigh:closeto65percent.ButPBIdidincrease
theprobabilitythatachild0-23monthsvisitedahealthcenterforpreventivecare(a64%
increaseoverbaseline)andtheprobabilitythatachild24-59monthshadapreventivevisit–by
awhopping133%overthebaselineprobabilityforthetreatmentgroup.Significant
improvementsinthequalityoffamilyplanning,antenatalcare,andchildhealthservices
reportedbywomenseeninclinicswheretheincentivepaymentschemewasinoperation.10,11
7
Canavanetal.reviewednotonlytheeffects,butalsoinstitutionalarrangements,including
factorsdeterminingsuccess,costsandsustainabilityofRBFinLLMICs.Theyfoundthatthe
introductionofRBFinvarioussettingsledtoremarkableimprovements,mainlyin
targetedoutputandoutcomesindicatorssuchasutilisation,coverageandemergency
referrals,withenhancedqualityofproviderperformance.WhileRBFachievedsome
positiveresultsonthelevelofmeetingqualitativehealthindicators,theextenttowhichit
contributestoimprovedqualityofcareremainsaquestion.AsforRBF,thereisariskof
compromisingqualityofcaretomeetutilisationtargets.ThepercapitacostofRBFvaries
fromUS$0.25inDRCtoUS$4.82inAfghanistan.
TrendsinoperationaldataindicatethatsincethePBFprogramwasimplementedinCameroon
2012,thecoverageofkeyhealthservicessuchasinstitutionaldelivery,antenatalcare,family
planning,andimmunizationshasincreased.Freeoutpatientcareforthepoorandvulnerable
hasalsoincreased.Thequalityofcare,asmeasuredbytheaveragetotalqualityofcarescore
increasedfrom43percentto64percentbetween2012and2015.12
PreliminaryresultsfromtheimpactevaluationinZambiaindicatethatRBF(introducedin
2008)significantlyincreasesutilizationofselectMCHservices,suchasearlyantenatalcare
(ANC)-seekingbehaviorandin-facilitydeliverywhenthe
RBFdistrictsarecomparedtothedistrictsoperatingas
“businessasusual”—womenfromhealthfacilitiesinthe
RBFdistrictssoughtANCaboutthreeweeksearlierthan
womenreceivingcareinnon-RBFdistricts.Performance
onsomepost-natalcare(PNC)measuresincreasedinRBF
districts.PNCcoverageandimmediatebreastfeeding
increasedbynearly10%and14%,respectively,andwere
statisticallysignificant.12
ThepreliminaryresultsofPBFinterventioninBenin,introducedin2012,showthatthereis
improvedsomeaspectsofhealthworkerperformance.Theyindicateapositiveimpacton
qualityofcareandresponsivenesstowardspatientsbutnosignificantimpactonclinical
productivity.Forexample,acomparisonbetweenPBFtreatmentandcontrolgroupshighlights:
ImprovementsinthequalityofANCinPBFfacilities,withincreasesinthequalityofphysical
examinationsconducted,historytakingandadvicegivenbyahealthworker(measuredthrough
DirectClinicalObservations),ascomparedtobothcontrolgroups.Increasedconsultation
timewithalmost4additionalminutesforANCinPBFfacilitiescomparedtofacilitieswithno
intervention.IncreasedresponsivenessofhealthworkerstowardspatientsinPBF
facilities,withpregnantwomenreceivingANCvisitsandpatientsgettingcurativecarebeing
8
respectivelymoresatisfiedwithstaffattitudeandstaffcompetence(asmeasuredthrough
DirectClinicalObservationsandexitpatientinterviews).AsignificantimpactofPBFonthe
politenessofstaffduringANCvisits.12
AfterNigerialaunchedaPBFpilotuptakeofserviceshasbeenveryencouraging,withutilization
ofcoreMCHserviceslikeimmunization,
deliveriesinfacilities,andfamilyplanning,
showingmuchimprovement.Figureshows
animmunizationcoverageincreaseinpre-
pilotfacilitiesfrom5percentto44percent;
anincreasefrom14percentto44percentin
thefirstphasescaleupfacilities;andshowing
promiseinthemostrecentscaleupfacilities.
Increaseinimmunizationcoveragehasbeenidentifiedsincecompletionofscale-upin
December2014(post-scaleupimmunizationcoverageincrease).Intwostatesimmunization
coverageincreasedfrom30%to50%andhigherlevels.Moreover,datashowthatqualityof
servicesalsoimproved,alongwiththeincreasesincoverage.Aqualitychecklistappliedona
quarterlybasisfoundthatstructuralandprocessqualitymeasuressawrapidandsustained
improvements.Finally,PBFfacilitiesachievedgoodpatientsatisfaction,withratingsof80and
95%inNasarawaandinOndoStates,respectively.Itisworthhighlightingthattheseresults
havebeenachievedatamarginaladditionalcostof$0.8percapitaperyear.12
TheRBFprograminZimbabwewaslaunchedin2011.Impactevaluationwasimplementedwith
controlledbeforeandaftermethod.Theresultsdescribedinthe2014AnnualReportindicate
thatthereweresubstantialimprovementsinthequantityandqualityofservicesdeliveredin
RBFdistricts,whencomparedtotheirnon-RBFcounterparts.Resultsfromthequalitative
componentoftheimpactevaluationindicatethatwhentheRBFprogramisimplementedas
intendedandplanned,ittriggersandfacilitateschangesinthefacilitystaff’sperformance;andit
influencestheperformanceofhealthfacilities,andthemotivationandsatisfactionofstaffat
thesefacilities.RBFfacilitieshavemoreeffectivemonitoringandreportingmechanisms,
andbetterstaffcoordinationthannon-RBFfacilities.ResultsfromthePMEindicatethat
improvingfeedbackmechanismsalongwithsupervisionimprovesthequalityofservices.12
Conclusionandrecommendation
TheevidencebaseofRBFisnotyetstabilizedandisstillgrowing.Thereisanemergingbodyof
evidenceshowingthatRBFisabletoimproverelevantparametersrelatedtoMCHservices.
Impactonutilizationofthoseincentivizedserviceshasbeenthemostinvestigatedissueand
9
findingsarerathersupportive,eveniftheevidenceisrarelyofarandomizedcontrolledtrial
standard.ThefactthatRBFincreasestheamountofservicesutilizedbythetargetpopulation
(orcoveragerates)istrueforspecificprioritygroups(withvouchers)andalsoforlarge
populations(withPBFforinstance).
ThereisalsosomeevidencethatRBFcanleadtoimprovementinqualityofservices,specifically
forPBFandvouchers.ThereisgoodevidenceforvouchersandemergingevidenceforPBCthat
theseapproachescanimpactonequityinhealthcareutilization.
TheefficiencyofRBFcomparedtothestatusquoorotherhealthfinancingapproacheshasbeen
under-documentedandobviouslyforotherdimensionsevenmorecomplextodocumentsuch
asthelong-termeffectofRBFonproviders’behaviorsandexpectations.Thereisnosubstantial
evidenceonthenegativeandunintendedside-effectsofRBF.mainlyhypothesesexist.Other
dimensions,suchassustainabilityisneitherwelldocumented.
AnotherareastillinsufficientlystudiedistheeffectofacombinationoftwoormoreRBF
approacheswhichmighthaveagreaterimpactthaneachonitsown.Forexampleanationally
implementedPBF,whichincreasesthequalitycombinedwithvoucherstoreachthemost
underservedpopulations.
Inordertoensureweatherthehealthsector–whatevertheaffiliationoftheirproviders–
deliversqualityhealthservicestoallinanefficientway,withoutpushinghouseholdsinto
poverty,itiscrucialtoacknowledgethestatusofthecountryshealthsector.Today,health
systemsofmanyLLMICsarecharacterizedbyi)apublichealthsystemwhichdoesnotperform
asexpectedandii)anunregulatedprivatehealthmarketwhosequalityisnotassuredand
pricesnotregulated.Onthesetwosegmentsofthemarket,therearebothsupplysideand
demandsidebarrierswhichpreventthepopulationtoaccesscriticalservices.RBFcreates
systemicopportunities(e.g.itisanopportunityfortheministryofhealthtobemoreacquainted
withstrategicpurchasing),butalsorisks(e.g.iftheRBFapproachleadstoimprovedMNCHcare
tothedetrimentoftheprovisionofotherpriorityservices).
AsageneralrecommendationRBFinterventionhavetobedesignedconsideringother
contextual,publichealth,healthsystemfactors.Itshouldbeapartofapackageofreformor
overallstrategyinthehealthsector.RBFshouldcovermorethanasub-groupofMNCH
problems.RBFapproachedmaybevaluablefortheirancillarybenefits(likeincreasing
competitionandengagingwithprivatesector),howevertheseeffectsneedtobecarefully
monitored.2
10
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