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Results-Based Financing in Afghanistan
Motivation, Design, and Preliminary Results
Tekabe Belay
Senior Economist, South Asia HD, World Bank
Women Deliver
Kuala Lumpur , Malaysia
May 28, 2013
Motivation
In 2002, the health system was in a very poor condition
• Limited capacity in the Ministry of Public Health
• 80% of services provided by NGOs
• Lack of coordination among stakeholders
• Inequitable distribution of health services, with many rural
areas extremely under-served
• Few functioning health facilities
2
Motivation…
Reflected in health indicators that were among worst in the world
• Life expectancy: women 45 years and men 47 years
• Under-five child mortality: 257 deaths per 1,000 live births
• Maternal mortality ratio: 1600 per 100,000 live births
3
• Focus on stewardship functionso Define the package of services: BPHS and EPHSo Define the beneficiaries: service areas defined for each providero Define the standard of services: inputs requirements for BPHS and EPHS defined
• Partner with the private sector o that has been serving 80% during the conflict
• Use its purchasing power effectively to register results
• The approach is largely along the lines of current thinking on service delivery in fragile states (e.g. Collier)
Strategy: Afghanistan’s Approach to
Health Service Delivery
4
This achieved impressive results…
5
Skilled Birth Attendance - 3 times
6
2003 2005 2006 20080.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
6.00%
8.40%
18.40%
24.00%
7
2003 2005 2006 20080.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
4.60%
12.60%
30.30%
36.00%
Antenatal Care (>1 ANC) - almost 7 times
8
2003 2005 2006 20080.00%
5.00%
10.00%
15.00%
20.00%
25.00%
5.10%
10.40%
15.40%
23.00%
Contraceptive Prevalence Rate – 3.5 times
9
DPT3 Coverage - doubled
2003 2005 2006 20080.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
21.20%
17.40%
34.60%
43.00%
Infant Mortality - 32% reduction
Under 5 Child Mortality – 35% reduction
10
Infant Mortality Rate Under 5 Mortality Rate0
50
100
150
200
250
300
165
257
129
191
111
1662001
2006
2008
...but not enough
11
Coverage of important services remains low by global standards e.g. o CPR 15%, o ANC 36% o SBA 24 %
Additional effort to increase coverage needed
Results-Based Financing (RBF)
• Since 2010:o 14 provinces: gradually scaled upo Primary care and hospitals
• RBF means:o Payment for additional serviceso Payments for improved qualityo Payments for serving the poor
• Rigorously assessed with a gold standard IE design
12
Results after 24 Months of
Implementation
13
ANC: in RBF Facilities
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
15
30
45
60
75
90
ANC1-4 Treatment
Num
ber\
month
14
ANC
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
15
30
45
60
75
90
ANC1-4 Treatment ANC1-4 Control
Num
ber\
month
15
PNC: in RBF Facilities
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
15
30
45
60
75
90
PNC1-2 Treatment
Num
ber\
month
16
PNC
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
15
30
45
60
75
90
PNC1-2 Treatment PNC1-2 Control
Num
ber\
month
17
SBA: in RBF Facilities
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
2
4
6
8
10
12
14
16
18
20
SBA Treatment
Num
ber\
month
18
SBA
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
2
4
6
8
10
12
14
16
18
20
SBA Treatment SBA Control
Num
ber\
month
19
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
10
20
30
40
50
60
DPT3 Treatment
Num
ber\
moth
DPT3: in RBF Facilities
20
Oct-1
0
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct-1
1
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
20
10
20
30
40
50
60
DPT3 Treatment DPT3 Control
Num
ber\
moth
DPT3
21
RBF Indicators: Changes Between 2010 Q3 and 2012 Q1
ANC1-4*** PNC1-2*** SBA** DPT3
-5
0
5
10
15
20
25
21.8
16.5
5.4
1.3
4.3
6
2.6
-0.1
TreatmentControl
22
The longer RBF is in place, the better
(ANC 1-4)
(highest after 12 months ~ control for seasonality)
3months** 12 Months*** 19 months***0
5
10
15
20
25
9.9
13.5
21.8
6.9
1.4
4.3
TreatmentControl
23
The longer RBF is in place, the better
(PNC 1-2)
3months** 12 Months*** 19 months***0
2
4
6
8
10
12
14
16
18
3.9
7.7
16.5
3.1
1.5
6
TreatmentControl
24
The longer RBF is in place, the better
(SBA)
3mohths 12 Months 19 months**
-1
0
1
2
3
4
5
6
-0.3
1.2
5.4
0.5
-0.2
2.6 TreatmentControl
25
Quality improved in most hospitals with RBF in place
1 2 3 4 5 6 7 8 9 10 11 12 130.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Overall Score
BeforeAfter
Hospitals
Score
26
Improved Quality
1 2 3 4 5 6 7 8 9 10 11 12 130.0
20.0
40.0
60.0
80.0
100.0
120.0Hospital Infection prevention
BeforeAfter
Hospitals
Score
27