DAR ES SALAAM – TANZANIA, NOVEMBER 2015

RESULTS BASED FINANCING (RBF)

EARLY IMPLEMENTATION RESULTS AND LESSONS LEARNT

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MAP OF TANZANIA & IMPLEMENTING REGION

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TAKE-HOME MESSAGESIncentives to staff do not work without

fundamental health systems strengthening initiatives

The purpose of this pilot in Kishapu is to modify the P4P design on an ongoing basis

The specific details of the verification process needed to be embedded in the design from the start

We under-estimated the: 1.Independence of the verifiers,2.Existence of National RBF team with enough

members, 3

WHERE ARE WE?

More needs to be done to improve newborn survival

28% decline in under five mortality

between 2005-2010

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MATERNAL MORTALITY RATIO:A LONG WAY TO GO

Maternal mortality has declined by 21% between 2004-05 and 2009-10

Concerted efforts are required to achieve the 2015 target

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Pilot Description in Kishapu (Shinyanga)

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RBF KISHAPU PILOT IMPLEMENTATION

9 Month pre-pilot, 4 Quarterly cycles (April- Dec 2015)

Funded by the World Bank

Selected on the basis of social and economic characteristics among the other councils in the region (Shinyanga) which was also selected based on the criteria among the other regions Goal: To inform the Scale up in the following Regions7

BACKGROUND INFORMATION: SHINYANGA REGION

Shinyanga is one of the 30 regions of TanzaniaSelected due to poor health outcome and high poverty

indexThe region is divided into 6 councils The population is projected at 1,534,808 (NBS 2012)There are a total of 212 health care facilities, of which:- 156 (74%) are public, - 19 (9%) are FBOs,- 37 (17%) are Private.Kishapu has 55 Health Facilities in total: 45 are public,

4 are FBOs and 6 are private. Shinyanga has one Regional Hospital and only one

District Hospital which is Kahama Town Council.8

INSTITUTIONAL SET UP

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Quantity & Quality indicators are Selected and Payment is based on Achievements

Quantity Indicators are counted and have no limitation,The fees generated by quantity indicators is based on

the level of discrepancies with verified and DHIS2 Reported data,

Achievement of 100% of the quality assessment receives a full payment.

Data VerificationData Verification is done quarterly by comparing

existing data in DHIS2 and data found in the source of data of the similar indicators

The Verifier was RAS who identified the pool of verifiers in the region.

The RAS and RHMT are assessed by National level Team.10

IMPLEMENTATION OF THE PILOT

SELECTED INDICATORS19 Quantity Indicators for Health Centres &

dispensaries, 18 Areas of Quality assessment of the

Dispensaries & HCs, 26 Areas of Quality assessment of the

District Hospital & Upgraded Health Centres,3 Areas of assessment for the Verifier,10 Areas of assessment of RHMT,12 Areas of assessment of CHMT,6 Indicators for MSD Zonal,4 Indicators for MSD Central.11

Routine verificationSupportive supervision from CHMT and RHMT

includes verification of HMIS data entry and records Spot check verification is also performed by the PMTSpecific Verifications to be conductedRegional Identified Team of Verifiers Composed by

members from RAS, NHIF, RHMT and Health NGOs operating in the region perform internal Verification Quarterly

Independent verifier – Controller Auditor General (separately contracted) has a mandate to assume the function of counter verification twice a year but this activity has not yet been done.

Payments to the Providers is made through an independent fund holder – NHIF after the verification

STRUCTURAL FEATURES OF THE PILOTData collection and verification

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FIRST VERIFICATION (Q. APRIL-JUNE )RESULTS RESULTS

KAHAMA DH: 46.4%; RHMT: 82.4%; KISHAPU CHMT: 59.1% & RAS: 100%

READNESS ASSESSMENT DONE FOR NEXT COUNCILS IN SHINYANGA & MWANZA REGIONS –

USING BRN INITIATIVEThe assessment has been conducted by the Big Results Now (BRN) star rating team.Each facility had to undergo readiness assessment before being enrolled to the RBF system;The minimum readiness criterion is to have one star with adequate staffing (at least one skilled personnel at a dispensary level) but also the following elements are considered in the assessment tool: Communication means, Conducive infrastructures for provision of quality health care,Emergency transportation arrangement for referral, Power supply, Availability of running water; Waste management facilities.14

THE RATING MECHANISM IS DEVISED BASED ON THE CURRENT SITUATION OF HEALTH

FACILITIES IN GENERAL

Major Features

Characteristics of Facility at Each Rating

Score on Assessment

Tool

No Star

0-19%

1 Star

20-39%

2 Star

40-59%

3 Star

60-79%

4 Star

80-89%

5 Star

90-100%

Source(s): BRN Healthcare (2014)

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RESULTS: KISHAPU COUNCIL

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HEALTH FACILITY

HF OWNERSHIP

STARS TOTAL0 1 2 3

DISPENSARIES LGA  8  33 0  0 41PRIVATE  0 5  0 0  5FBO  0  4 0  0  4

HEALTH CENTERS

LGA 0  3  1 0  4

HOSPITALS PRIVATE  0 0  1  0 1TOTAL 8 45 2 0 55 16

RESULTS: ALL COUNCILS IN SHINYANGAHEALTH FACILITY

HF OWNERSHIP

STARS TOTAL0 1 2 3

DISPENSARIES LGA 25 106 7 0 138PRIVATE 13 18 1 0 32FBO 1 8 5 1 15MILITARY 1 1 0 0 2POLICE 0 1 0 0 1PRISON 0 1 0 0 1

HEALTH CENTERS

LGA 0 7 6 0 13PRIVATE 0 2 1 0 3FBO 0 2 0 1 3

HOSPITALS LGA 0 0 1 0 1PRIVATE 0 1 1 0 2FBO 0 1 0 0 1

TOTAL   40 148 22 2 21217

TIMELINE & SCALE UP PLAN

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ISSUES AND CHALLENGES IDENTIFIED DURING IMPLEMENTATION

Inadequate infrastructures which made some facilities to score 0-star during readiness assessment,

Shortage of basic essential equipment and supplies needed to provide Reproductive and Child Health Services beyond health facility control,

Irregular Supportive Supervision by management teams,

Delays in paying 1st Verification Payment, Difficulties in direct incentive payment to the

Health Facilities from the fund holder19

LESSONS LEARNT Essential equipment and supplies are not

available at all times in the facilities, RBF can only work if supportive

supervision visits are regularly conducted at facilities,

Direct payment from the fund holder to the provider is very important to avoid delays and any other risks that may occur,

There is an opportunity for correcting the identified issues

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WAY FORWARD

Ensure incentive funds planned for facility improvement is used to procure missing essential equipment and supplies,

Use lesson learnt from the pilot phase to ensure the scale up is done smoothly.

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SUSTAINABILITY OF RBF AS ENVISIONED BY HEALTH CARE FINANCING STRATEGY

Reimbursement to Facilities Matching Payment to MBP Based on Core Output-

Based Payment Systems, Performance (RBF) and Star Rating (BRN)

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RBF IS EVIDENCE BASED & WE PAY WHAT WE SEE

THANK YOU FOR YOUR ATTENTION