RBF through the Public Health Sector

in Low-Income Countries

Essential Design Elements for a Health Center RBF model

György Fritsche

HDNHE

RBF Seminar 27 October, 2009

Learning Objectives

For the Rwandan Health Center RBF model:

1. Describe the performance framework;

2. Describe three key design features;

3. Explain the role of technical assistance

The Performance Framework for Health Center RBF Fee-For-Service Conditional on Quality of Care

Results Based Financing/Performance-Based Financing

15-25 Services with unit fees (measured monthly) Services are ‘PBF SMART’: not all services can be

purchased Quality quantitative checklist (measured quarterly).

Extensive and well-balanced Quality: Carrot or Stick? Payment cycle quarterly

Key Design Elements (i) National level, health district level and health

center level design features District Level Design Features:

Significant Financial Incentives through performance framework for District Health Management Teams and District Hospitals

Separation of Functions: Creation of a quasi-market through internal contracts Transparent district level PBF governance mechanism Separate ‘quantity audit’ from ‘quality supervisory

function (separate teams)

Key Design Elements (ii)

Intense dedicated TA during introduction and subsequently making operational and refining PBF system

Civil Society/NGOs: Participation in data validation and Participation in district level PBF governance

mechanisms (‘quorum’)

Key Design Elements (iii) Health Center Level Design Features:

Performance framework targeting health facilities (as opposed to individual health workers)

Significant financial incentives reaching frontline health workers

Health Center bank account Regular bonus payments to health workers Increased Autonomy Purchase contract

Key Design Elements (iv) ‘Business Plan Approach’ Data Quality Audit of all purchased services

(routine; monthly) Services that are purchased need to be ‘PBF

SMART’ Quality Checklist with strong impact on

performance payments (comprehensive and routine)

Community Client Surveys

Three most important design elements?

1. Fee-For-Service Conditional on Quality of

Care RBF/PBF and incentives are

significant

2. Increased Health Facility Autonomy

3. Health Facility Performance Framework but

incentives trickle down to health workers

The role of technical assistance (i) Dedicated Project Implementation Unit or

Ministry of Health department Dedicated additional TA for program;

coordination of technical assistance; communication; MIS; training and IT support

Leveraging TA with in-country available resources

Strong national technical coordination platform dedicated to PBF (degrees of freedom; secretariat)

The role of technical assistance (ii)

Strong technical coordination platform dedicated to providing TA on PBF to districts (‘bridging the gap between policy and implementation’)

Cost of combined TA estimated at between $0.30 -0.40 /capita/year

First level of Control: Signing of a Contract with a Mayor

Second level: PBF Control is NOT ‘business as usual’ in data gathering

Third level: Discussion in the District PBF Steering Committee

Fourth level: Extended Team: 11 agencies and MOH departments

Fifth level (i) : Two national counter verification mechanisms: the quality counter verification protocol

Fifth level (ii) Two national counter verification mechanisms: the Community Client Surveys

Summary: Learning Objectives

For the Rwandan Health Center RBF model:

1. Describe the performance framework;

2. Describe three key design features;

3. Explain the role of technical assistance