Presented at the Centers for Disease
Control and Prevention (CDC), 6/23/09
An Overview
Joseph F. Naimoli, Senior Health Specialist
The World Bank
Contributions from Amie Batson, Ruth Levine, Magnus Lindelow, and Rena Eichler
Different definitions; common theme
Results-based financing (RBF) ≈ Pay-for-performance (P4P)
Provision of payment for
the attainment of welldefined results
Transfer of money or material goods conditional
on taking a measureable action or achieving a
predetermined performance target (CGD, 2009)
RBF takes many forms…
Payers
Donor
Central government
Local government
Private insurer
Payees
$
Recipients of care
Health care providers
Facilities / NGOs
Central government
Local governments
Schemes vary by country
Madagascar


Supply-side incentives
Demand-side incentives
Increased utilization of MCH
services
•3 ANC visits
•Institutional delivery
•Complete immunization of
children under 1
•Post-partum care within 1
week of birth
Improved
Maternal and
Child Health
Cash payment to women

Often multiple
beneficiaries in a cascading
scheme
Increased $ resources for
health service providers
Increased $ resources for
regional & district health
authorities
Underlying principles

People are motivated by intrinsic forces
(professional pride)

People are motivated by extrinsic forces
(money and recognition)

If designed well, RBF can reinforce
professional pride with money and
recognition, without undermining intrinsic
motivation
Two perspectives
Development
Assistance
Perspective
Country Perspective
(low- and middleincome)
RBF
Business as usual unlikely to achieve
Millennium Development Goals (MDGs)
On track
38%
Insufficient
No progress
24%
38%
MDG4 progress in 68 priority countries
Source: UNICEF, 2008
Frustration with traditional input-based approaches
RBF
Traditional
Inputs necessary
but not sufficient!
CGD, 2009
Tool for strengthening health system s
Health
services
Health system building
blocks, WHO, 2007
Leadership
Health
workforce
Health
information
Technologies
Financing
Governance
RBF
Commodities
Increasing recognition as promising
strategy for MDGs
Taskforce on Innovative Financing for Health Systems
Raising and Channeling Funds
Recommendations:
• Clearly link financing for health to defined outcomes and
to measurable results in broader programmes as well as in
projects, building on the specific experiences from
performance-based funding and SWAps.
• Further develop and scale up systems that effectively
manage development results and provide the incentives for
achieving health outcomes.
Working Group 2 report ,Final Draft , 3 June 2009
Two perspectives
Development
Assistance
Perspective
Country Perspective
(low- and middleincome)
RBF
Ministry of Finance looking to link decision making to
observable results
ARGENTINA: PLAN NACER
Transfers from federal to
provinces (15) based on #
of poor women, children
enrolled in social
insurance program and
performance on key
output measures
Decision:
Devolution of federal budget to
lower levels in the health system
accelerated, in part, by successful
results
Low uptake of services, especially among the poor
Children Fully Immunized, by Poverty
Quintiles, Selected Countries
100
Date of DHS
80
Burkina '03
Cameroon '04
% 60
Mozambique '03
40
Bangladesh '04
20
Vietnam '02
0
Colombia '05
Q1
(Poorest)
Q3
Q5
(Richest)
Source: Yazbeck, 2009; Gwatkin, 2007
Low uptakes of services, especially among the poor
Antenatal care (3 or more visits) by
Poverty Quintiles, Selected Countries
100
Date of DHS
80
Burkina '03
Cameroon '04
% 60
Mozambique '03
40
Bangladesh '04
20
Vietnam '02
0
Morocco '03-04
Q1
(Poorest)
Q3
Q5
(Richest)
Source: Yazbeck, 2009; Gwatkin, 2007
Quality concerns, even following traditional
performance-improvement interventions
(training, follow-up and job aids)
Proportion of children managed correctly in
primary health care facilities in 2 Integrated
Management of Childhood Illness (IMCI) districts
and 2 non-IMCI districts, Tanzania, 1999
% children correctly
managed
100
80
75
65
69
60
40
20
16
23
24
Comparison
districts
IMCI districts
0
All children
Children with
priority
conditions
Children with
non-priority
conditions
Source: Bryce J, et al., Improving quality and efficiency of facility-based child health care through Integrated Management of
Childhood Illness in Tanzania, Health Policy and Planning, 2005, i69-i76
Current incentive structure contributes to poor
performance
• Providers widely dispersed, far from support
• Many lack tools, skills, information
• Many operate without supervision most of the time
• Motivating supervisor-provider relationship rare
• Little recognition, respect from peers, supervisors
• Few opportunities for advancement
• Civil service salaries low, often irregular
• Teamwork, cooperation usually weak
• Absenteeism, local autonomy or innovation limited
Far-ranging experimentation with provider payment reforms
Cambodia
Bangladesh
Bolivia
Guatemala
Haiti
India
Madagascar
Pakistan
RBF
Source: Buying results? Contracting for health service delivery in developing countries, Loevinsohn B.
and Harding A., The Lancet, 2005, 366, 676-681
Recipients of care
(demand)
• Conditional cash transfers to increase service use (Mexico,
Nicaragua, etc.)
• Voucher schemes for free or highly subsidized services
• Conditional cash payments (maternal health in India)
Providers/facilities
(supply)
• Contracts for public, non-profit, and for-profit service providers
(Rwanda, Zambia)
• NGO service delivery contracts (Afghanistan, DRC, Haiti)
• Incentives for health workers for institutional deliveries (India)
Inter- and Intragovernmental
Transfers
• Global health partnerships (GAVI ISS)
• Conditional loan buy-downs (Polio eradication)
• Incentives for provincial governments to improve maternal and
child health (Argentina)
Institutional change
Results and
systems
thinking
Alignment
with other
reforms
Scaling Up
RBF
Political
stewardship
Sustainability
Regulatory
change
Numerous possible implementation hazards
RBF in principle…
Select
action or
output
Define
indicators
Set
targets
Perform
Measure
performance
Reward or
sanction
Gaming the system
But…
Effort in one,
several areas may
result in neglect of
others
Too ambitious, too
easy
Rules of game
Beneficiaries must control
behavior change
Too many, too few
Reliability, validity
of administrative
data
Cost of independent
verification
Unnecessary
provision or demand
Too much $, too little
Quantity trumps
quality
Undermining intrinsic
motivation
RBF
RBF
RBF
Solid evidence on demand side

Conditional Cash Transfers (CCTs) rigorously evaluated

Bulk of evidence from Latin American and Caribbean
countries; some encouraging evidence from Bangladesh,
Cambodia

Effective in reducing poverty in the short term

Substantial increases in use of health services, primarily
preventive services

Impact on outcomes mixed

Typically require complementary supply-side actions
Source: Fiszbein et al., 2009
RBF
RBF
RBF
Limited, mixed evidence on supply side

Supply side: generally weak designs

Argentina: increased enrollment of poor,
previously uninsured women and children

Afghanistan and Cambodia: increases in
immunization, prenatal visits, overall service
use, equity gains

Many confounding factors (increased financing,
TA, feedback, supervision, training, etc.) make it
difficult to isolate effect of “incentive”
Rwanda leading the way in sub-Saharan Africa
Rwanda: performance bonus scheme

Prospective, quasi-experimental design

Effect of incentives was “isolated” from effect of
additional resources

Equal amount of resources without the incentives
would not have achieved the same outcomes

Improved child health outcomes: height for age,
morbidity
Source: Gertler, et al. , 2009
Rwanda leading the way in sub-Saharan Africa

Less impact on demand-sensitive interventions (ANC)

Rwanda now piloting community-based performance
bonus to increase demand

Government adopting culture of results – moving RBF
to Education and other sectors
Source: Gertler, et al. , 2009
Need to open the “black box “ of
implementation

Little information on “why” demand and
supply schemes succeed or fail

Insufficient information on unintended
consequences

Sound monitoring, documentation and
evaluation of new initiatives will be critical
Current initiatives
• GAVI support
through HSS
• Global Fund
support
• Evaluation needed
New initiatives:
Multilaterals
New initiatives:
Bilaterals
• World Bank Health
Results Innovation
Trust Fund ($95m)
• Norway support to
Nigeria, Tanzania,
Ethiopia
• EC ‘s “variable
tranche” approach
to budget support
(Vietnam, Laos)
• AusAid currently
considering
options; funding
seed grants
• USAID providing
technical support
and training

Eight grants linked to IDA credits to finance the national
strategy (International Health Partnership + principles)
with focus on MDGs 4 and 5

Why linked to IDA credits?





Integrates RBF into broader policy dialogue between MOF and MOH
Engages Bank operational staff at country level and headquarters
Embeds RBF into Bank support for HSS
Potentially leverages additional IDA for health
$95 million from Norway supports comprehensive
design, implementation, monitoring and impact
evaluation
Country
Design
End (approx.)
2008
Start
2009
Eritrea
D.R. Congo
2008
2009
2011
Zambia
2008
2009
2011
Rwanda
2008
2009
2012
Afghanistan
2008
2009
2013
Benin
2009
2010
2012-13
Kyrgyz Republic
2009
2010
2012-13
Ghana
2009-10
2011
2014
2011

Afghanistan: performance-based bonus payments to NGOs

DR Congo: performance-based bonus payments to public facilities
and health workers

Eritrea: demand-side incentives to mothers and performance
budgets to administrative levels

Rwanda: performance-based contracting with community
organizations to increase demand

Zambia: performance-based bonuses to public facilities and district
A common M&E Framework for RBF
Monitoring and Documentation
Inputs
Resources (time,
people, money,
commodities,
etc.) mobilized
Health system
platform
strengthened
(policy,
regulations,
HMIS, financial
procedures, etc.)
Activities
Contracted work
program activities
executed
Support activities
implemented
Innovative,
improvised
solutions applied
Impact Evaluation
Outputs
Contractual
services used,
delivered and
reporting verified
Regular, timely,
appropriate
incentive
payments made
or withheld
Outcomes
Improved
coverage of
population with
high impact
interventions
Improved quality
of care
Health promoting
behavior change
Long-run
results
Maternal
mortality
reduction
Infant and child
mortality
Reduction
RBF is appealing to governments

Motivation and creativity to strengthen health
systems

Flexibility to engage all providers (public,
private, NGO)

Culture of results - replacing focus on inputs

Facilitates targeting – at poorest, MDG 4/5

Both demand and supply side matter – and must be
balanced

RBF not panacea! – must be part of broader
dialogue with Ministries of Health and Finance and
linked to investments in health

Still building evidence base but exciting potential
 Accelerate progress toward MDGs
 Implement Paris/Accra Principles – align with the
International Health Partnership