Taking Results Based Financing from Scheme to System: a multi-country study

Zubin Shroff & Bruno MeessenCoP Webinar

January 20th 2017

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Presentation Outline Part 1:• Our research• Scaling up is multidimensional• Scaling up is a four phase process Part 2: • Moving from one phase to the next: context, actors,

policy content and processes• Larger lessons learnt from the cross-country research

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Main question: what are the enablers and barriers for the scale-up of RBF schemes?

Armenia Cameroon Macedonia Tanzania

Burundi Chad Mozambique Uganda

Cambodia Kenya Rwanda

• Mainly qualitative methods• Iterative

Documentary review

Timeline development

Key informant interviews

Source: Sieleunou et al. 2015

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Idea #1: Scale-up occurs over 5 dimensions

Dimension Content Population Coverage Geographical coverage, age and income groups

covered, total people coveredService Coverage Number, types, level, affiliation of services

Health System Integration & Institutionalization

Connections with the six building blocks of the health system

Cross-sectoral diffusion Changes outside the health sector

Knowledge & Ideas Status of the knowledge

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An illustration (1)

Population Coverage

Service Coverage

IntegrationCross sector diffusion

Knowledge

0

5

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An illustration (2)

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Generation(from idea to project)

Adoption(from project to

program)

Institutionalisation(from program to

policy)

Expansion(from policy to

system)

Idea #2: the four phase model of scale-up

• Reason: scaling up require some key resoures/currencies and these resources are themselves partly an outcome of the process.

• This is an emerging pattern, not a law.

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Phase 1: Generation • Movement from initial idea to one or more pilots• End point: pilot implemented as proof of concept

Generation

(from idea to project)Adoption

(from project to program)

Institutionalisation

(from program to policy)

Expansion

(from policy to system)

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Phase 2: Adoption• Movement from pilot project to a national ‘program’: a coherent and

identifiable set of institutional arrangements organising the transfer of resources to service providers is in place (contracts, guidelines…)

• Increased coverage in terms of administrative units implementing and hence people covered → a heavy operational stage

• End point: a national unit, trainers & digital tools are in place to roll out (knowledge!)

Generation

(from idea to project)Adoption

(from project to program)

Institutionalisation

(from program to policy)

Expansion

(from policy to system)

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Phase 3: Institutionalisation • This refers to the transition from a program to a national policy

• Integration within the six ‘building blocks’. • Governance: A stated objective of national strategic documents and decrees• Finance: public funding and harmony with other financing mechanisms.

• End point: PBF is an integrated provider payment mechanism for whole country

Generation

(from idea to project)Adoption

(from project to program)

Institutionalisation

(from program to policy)

Expansion

(from policy to system)

Phase 4: Expansion• This refers to the transition from a mechanism to a set of key

principles informing the design and implementation of public policy in the health sector but, also beyond.

• Paying for results and provider autonomy inform fields like education

Generation

(from idea to project)Adoption

(from project to program)

Institutionalisation

(from program to policy)

Expansion

(from policy to system)

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Generation AdoptionInstitutionalis

ation Expansion

FINDINGS

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Sample: countries at different stages…

Moving Across Phases- Phase 1: Generation

• Contextual factors- – Interaction of global (aid effectiveness), regional (influence of Rwanda) and

national context (RBF as a solution to address a met need)– Previous experience with organizational and financing reforms of the health

systems- voucher schemes, direct cash transfers • Actors

– Seminal Role of Knowledge brokers or Health Financing Experts, along with international agencies (bilaterals, multilaterals, faith based) in sowing the seed

• Content– Broad agreement on general principles and practices among community of

knowledge brokers – Funding agencies had some role in determining focus, over time govts played

increasingly important role

Moving Across Phases- Phase 2: Adoption

• Contextual factors- – National context relatively more important; pre-existing autonomous

institutions; enabling legal frameworks and changes – National agenda of transparency and results hastens process

• Actors– International agencies continue to be important (funding and technical

assistance); though usually one agency takes dominant role (Rwanda, Cameroon, Kenya, Armenia)

– Role for national policy entrepreneurs, from MOH or pilot programs– Development of critical mass of national level practitioners

• Process– Coordination and alignment of stakeholders, task force

Moving Across Phases- Phase 3: Institutionalization

• High Level of continuity between this and previous stage, still needs active management • Contextual factors-

– Legal frameworks continue to evolve – Enabled by increased security of funding, especially from domestic sources

• Actors– Increasing political and technical leadership of MOH and national RBF experts– National ownership goes beyond the MOH, the ‘coalition of change’- MOF, local govts,

social security agency

• Content– Greater country level influence on design, reflecting increased domestic resources and

technical leadership (Cambodia-internal contracting, Rwanda-cPBF)

Moving Across Phases- Phase 4: Expansion • Contextual factors-

– Knowledge on integration in health informs attempts to extend PBF principles to other sectors

• Actors– National level expertise and high level political support to take

forward PBF principles

• Content– Variations develop in extending PBF principles to other sectors

including local government administration

LESSONS

Five broad lessons

• Lesson 1: Some countries stay stuck in phase 1• Lesson 2: Rhetoric and framing matter• Lesson 3: Scale up requires a chain of actors • Lesson 4: Look beyond the label for content

when examining interactions• Lesson 5: Balance technically best against

politically feasible

Lesson 1: Why some countries get stuck in Phase 1

• A pilot is not a pilot. Successful pilot doesn’t ensure scale up– How it is framed- disease focused or health systems strengthening

(Mozambique vs Cameroon)– Who implements it- entity a) largely focused on a single disease, b) with

political, technical, financial influence at country level– Which level of government is engaged ? Engagement at the district or

provincial level initial rapid uptake, but to national level may then be more challenging (Mozambique, Uganda)

– Where it is housed in national government apparatus– Is it implemented largely outside the public system?– More pilots are not always better

→ Forthcoming webinar: Kiendrébéogo et al 2017

Lesson 2: Rhetoric and Framing Matter • RBF programs have been put forth as transparency

enhancing and part of a results agenda• This works in some settings (Cameroon and Rwanda), but

may not be universally the case; potential to directly confront interests keen on status quo

• Needs analysing political situation to see if this is most appropriate strategy and otherwise looking for individuals and groups at national level who can help place transparency and results on the agenda, in other words-create the window of opportunity

Lesson 3: Scale up needs a chain of actors• Seen how dominant actors varied by stage – each control a

key resource for the specific stage • Invest in building your support coalition – anticipate and

involve at an early stage • As stakeholders change, so do their incentives. Incentives for

provincial level governments to adopt PBF pilots may be completely different from national governments

• Adapt your framing - initial PBF pilot framed as solving an urgent need, issues of sustainability may not be immediately important, but as you progress this becomes more important

Lesson 4: Look beyond the label and at the content of other reforms

• Decentralization and increased autonomy, while enabling to PBF programs in a number of ways, also alter who decides what, something that changes incentives for different players

• Devolution in Kenya- increased accountability buy taking decision-making closer to people, but increased chance of reduced spending on public goods and more on visible things like infrastructure

Lesson 5: Balance the technically best program against what is politically

feasible• A technically sub-optimal intervention may be the right

choice when weighed against increased government buy in and therefore likelihood of long term sustainability

• Cambodia example of choice of program, government wanted greater control and chose model of contracting enabling this

Thank You