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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

Rbf afghanistan women deliver

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Page 1: Rbf afghanistan women deliver

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

Page 2: Rbf afghanistan women deliver

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

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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

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Page 4: Rbf afghanistan women deliver

• 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

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Page 5: Rbf afghanistan women deliver

This achieved impressive results…

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Page 6: Rbf afghanistan women deliver

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%

Page 7: Rbf afghanistan women deliver

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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

Page 8: Rbf afghanistan women deliver

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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

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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%

Page 10: Rbf afghanistan women deliver

Infant Mortality - 32% reduction

Under 5 Child Mortality – 35% reduction

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Infant Mortality Rate Under 5 Mortality Rate0

50

100

150

200

250

300

165

257

129

191

111

1662001

2006

2008

Page 11: Rbf afghanistan women deliver

...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

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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

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Results after 24 Months of

Implementation

13

Page 14: Rbf afghanistan women deliver

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

Page 15: Rbf afghanistan women deliver

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

Page 16: Rbf afghanistan women deliver

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

Page 17: Rbf afghanistan women deliver

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

Page 18: Rbf afghanistan women deliver

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

Page 19: Rbf afghanistan women deliver

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

Page 20: Rbf afghanistan women deliver

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

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Page 21: Rbf afghanistan women deliver

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

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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

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Page 23: Rbf afghanistan women deliver

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

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Page 24: Rbf afghanistan women deliver

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

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Page 25: Rbf afghanistan women deliver

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

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Page 26: Rbf afghanistan women deliver

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

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Page 27: Rbf afghanistan women deliver

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

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