Learning from RBF

Implementation

Dinesh Nair Sr Health Specialist

Overview of Session

• Why do we need to “learn from RBF”? • Pulling it all together: the conceptual framework• Nigeria Case Study

Many opportunities to learn

Concept

Design

Start-up

Implement

Implement

Implement

Implement

Comprehensive learning agenda

A broad approach to learn from RBF implementation

• Holistic conceptual framework which highlights: the intermediate outcomes necessary to achieve

results the utility of a multidisciplinary lens the need for broad methodological approaches

Conceptual

Framework

A Conceptual Framework for PBF

What organizational and behavioral changes do you expect PBF to bring about?

Learning from RBF Implementation:

Nigeria Experience

RBF in Nigeria combines the PBF at health centers and DLIs to state and local governments

Results Based Financing Approach in Nigeria

Federal Govt.

$$ State Govt.

Finance based on.. (Examples)

• Increase in services• Budget execution• Bonus payment

DLILocal Govt.

Health Centers

• Supervision• HMIS reporting • HR management

• Quantity of services delivered• Quality scores of the services

PBF

$$

$$

Coverage has been increasing significantly, but further improvement is required

Coverage of health services in Pre-Pilot facilities in Adamawa state (%)

DecJan Fe

bM

ar AprM

ay Jun Ju

lAug

Sep

Oct0

5

10

15

20

25

30

35

40

45Inst DeliveriesVaccinationFP

• Significant improvement from very low baseline in all indicators

• The is a good contrast with low DHS 2013 results in the North East (institutional delivery 20%, vaccination 14%, FP 11%)

• However, the overall utilization is still 30-40%

Detailed look at the operational data revealed the large variations in performance across Health Centers

Institutional Delivery in Adamawa, normalized by 100,000 population

December

January

February

March AprilMay

JuneJuly

August

September -

20

40

60

80

100

120

140 Pariya HC

Chigari HC

Dasin Hausa HC

Farang HC

Ribadu HC

Furore MCH HC

Choli HC

Gurin HC

Malabu HC

Karlahi HC

Wuro Bokki HC

Kabilo HC

Saint Mary's Clinic HC

Mayo-Ine HC

• Before PBF, all health centers were equally at very low levels

• After the PBF, some facilities achieved 100% coverage while others struggle with limited improvement

This performance variation across health centers also exists in quality of care

Quality Score (%) in pre-pilot health centers in Adamawa state

Dec Mar Jun Sep Dec Mar Jun Sep0

10

20

30

40

50

60

70

80

90

Malabu HCWuro Bokki HCFarang HCFurore MCH HCGurin HCKarlahi HCKabilo HCMayo-Ine HCPariya HCDasin Hausa HCRibadu HCCholi HCChigari HC

Range: ~30%

Range: ~23%

• The quality score overall improves even in low performers

• However, the difference between high and low performers increased from 23% to 30%

Nigeria team engaged with two qualitative studies

1. Demand-side barrier analysis 2. Case study on key determinants

• What are the barriers to service utilization in the PBF facilities?

• Transport, service fee, culture/perception/ information barriers

• Competition of alternatives

• Interview and focus group• High and low performers

• Design demand-side interventions

• What differentiate the good and poor performers under the PBF scheme?

• Health center management• Contextual factors• Health systems factors (e.g.,

supervision)

• Interviews, document review, direct observations

• Best and poorest performers

• Devise appropriate support to poor performers

Research question

Areas to look into

Approaches

Potential use

Demand-side barrier analysis revealed priority issues

Demand-Side Barriers

TransportCost

Major Barriers Found through Qualitative Analysis

Community/Culture

• Transport Voucher

Possible approaches

Services

Competition

Availability

Cost

Predictability of cost

Hospitals

Traditional providers

Community support

Magnitude

Controllability

High High

High Med

High High

High High

Varies Low

Varies Med

High High

Varies Med

• Community transport team • Maternal shelter

• CCT

• Predictable/discounted pricing (supply-side)

• N/A

• Incentives for referral to PHCs (supply-side)

• Community engagement (supply-side)

• Communication and community involvement

Priority demand side intervention

Culture

Case study on determinants suggests the importance of community engagement and OIC management

Identified determinants and non-determinants (preliminary)

Non-Determinants

• Level of staffing (best performers lack staff)

• Remoteness of facilities (best performers are very rural)

• Technical qualifications of OIC (many community health workers manage facilities well)

• Business planning (none use it effectively yet)

Determinants

• Community engagement (e.g., involve and reward community leaders, daily visits, incentivize for use of facility)

• OIC’s management capacity (e.g., full staff involvement, improve staff environment using performance bonus, rigorous performance review)

Research findings will drive new demand-side interventions with additional financingProposed Transport Voucher and Strengthening management capacities

Implementation Arrangements

• Build demand side interventions to support Supply Side RBF interventions

Improve Capacities • Community engagement• Management capacity building

of health centers• Technical training (e.g., IMCI) for

quality improvement (QI)

Transport Voucher• ANC standard visit (1-4)• Institutional delivery • Postnatal consultation• Vaccination of children• Growth monitoring • Referred services provided by

hospitals

Key Lessons Learned

• RBF performance hinges on how well and quickly we can learn from implementation and improve our approaches

• Qualitative research can provide a powerful insights and evidence in devising effective approaches

• Identifying right research questions and clear plan to use the research results are required to make the qualitative research meaningful