Results Based Financing for Primary Care Services with focus on Immunization, Evidence Summary
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Transcript of Results Based Financing for Primary Care Services with focus on Immunization, Evidence Summary
ResultsBasedFinancingforPrimaryCareServices
withfocusonImmunization
EvidenceSummary
Clickheretoentertext.
February,2016
TableofContents
PurposeoftheDocument 1
Background 1
DifferentformsoftheRBF 1
EvidencefromRBFpiloting 2
Majorindicatorsevaluated 2
MainFindings 3
Performance-BasedContracting 5
Performance-BasedFinancing 6
Conclusionandrecommendation 8
References 10
1
PurposeoftheDocument
ThedocumentaimstopresentbriefsummaryofevidencesonapplicationandeffectofResults
BasedFinancing(RBF)schemesinprimarycareinLowandLower-MiddleIncomeCountries
(LLMIC)withfocusofimmunizationservices.Thesummaryisbasedonreviewoflatest
evidences.Itisintendedforoperationalreadership:forpolicymakers,healthcaremanagers
andotheractorsinterestedtolearnmoreonRBFschemes.Moredetailedinformationandfull
resourcescouldbeaccessedatwww.zotero.org-https://www.zotero.org/groups/rbf_for_mch/items
ThedocumentwasdevelopedintheframeofthePolicyInformationPlatformProjectinGeorgia
fundedbytheAllianceforHealthPolicyandSystemsResearch.
Background
Results-BasedFinancing(RBF)isahealth-financingmodeldesignedforimprovinghealth
systemperformance.ThemainareaofitsapplicationisaMaternalandChildHealth(MCH).It
hasbeenimplemented(asapilotornationwide)inmanycountriestoaccelerateprogress
towardsthemillenniumdevelopmentgoals(MDG)forwomen’sandchildren’shealth(MDGs4
andMDG5).MCHserviceshavebeenthemajorareaoftheRBFreasoning,possiblythemain
one.
DifferentformsoftheRBF
RBFforhealthisdefinedasacashpaymentornon-monetarytransfermadeafterpredefined
resultshavebeenattainedandverified.1Afteritsintroduction,therehasbeenshapedvarious
formsoftheRBF,thatworkatdifferentlevelsofthehealthsystem,mainlydifferentiatedas
supply-anddemand-sideapproaches:2
• Performance-BasedContracting(PBC)
• Performance-BasedFinancing(PBF)
• ResultsBasedBudgeting(RBB)
• Vouchersforhealth
• HealthEquityFund(HEF)
• ConditionalCashTransfer(CCT)
2
Table1:Incentivesandchiefsupply-anddemand-sideRBFapproaches
RBF Approaches Provider
Supply-side,withademand-sidecomponent
Performance-BasedContracting(PBC)
Contractdefinesexpectedperformance(inquantity/orquality)aswellaslevelofpayment,plusrewardsorsanctions
Performance-BasedFinancing(PBF)
Levelofpaymentisbasedonachievingperformancetargets,oftenquantityandqualityindicators
Results-BasedBudgeting(RBB)
Alladministrativelevelshaveanincentive:bonusorlargerbudgetonthebasisofpre-agreedperformancetargets
Demand-sidewithsupply-sidecomponent
HealthEquityFund(HEF)
Incentivesareequaltothefeepaidforeacheligiblepatienttreated.Sinceshortpilotwithqualityindicators
Vouchers Incentivesareequaltothefeepaidforeacheligiblevoucher.Qualityindicatorsusedforselection;qualityassurance
Demand-side
ConditionalCashTransfers(CCT)
Providerdoesnotreceiveincentives,butthereisproviderselectionwhichcanincludequalityindicators
(fromGorterAC,IrP,MeessenB:Results-BasedFinancingofMaternalandNewbornHealthCareinLow-
andLower-Middle-IncomeCountries.EvidenceReview,2013)
RBFschemes,designedconsideringthecontext-specificissues,aimtoincreaseautonomy,
strengthenaccountability,andempowerfrontlineprovidersandhealthfacilitymanagersto
makehealthservicedeliverydecisionsthatbestmeettheneedsofthewomenandchildrenin
thecommunitiestheyserve.
EvidencefromRBFpiloting
TheRBFhasbeenpilotedinmanyLowandLowerMiddleIncomeCountries(LLMICs).
Althoughsomeformsofitstilllacktheproperevaluations.Forexample,thereviewssuggest
thatVouchershavebeenappliedandevaluatedearlierinhealthsystems,comparedtoPBFand
haveshowedrobustevidencethattheycanimpactonhealthoutcomesinvestigated,whilethe
PBFimpactonhealthoutcomehasnotyetsufficientlystudied.2,3AsofJuly15,2015theWorld
Bank-managedHealthResultsInnovationTrustFund(HRITF)continuedtosupportongoing
workinitsportfolioof36RBFprojectsin30countries(mainlylocatedinAfrica).
Majorindicatorsevaluated
PositiveandnegativeeffectsofRBFonaccesstoandquantity/utilization/coverageofhealth
services:
• FamilyPlanning
3
• Antenatalcarepackage
• Skillednormaldelivery
• Referralofcomplicateddelivery
• NeonatalandPostnatalcare,includingImmunization
BesidesthequantityindicatorsresearcherstriedtoinvestigateRBFimpactonqualityofhealth
servicesprovidedandbeneficiariessatisfactionwiththoseservices,healthequityand
targetingissueshavealsobeenevaluatedinsomecases.
MainFindings
Beforemovingforward,inthissummarywewouldliketoconcentrateonsupply-sideRBF
interventionsthathadbeenintroducedforimprovingtheMCHservicesinmanydifferent
countries.WewillpresentthefindingsofPBCandPBFimpactsontheMCH.
ThelatestreviewofRBFinterventionforMCHservicesproducedbyGorteretal.emphasizes
thelackofrobustevidencefromLLMICsdespitethegrowingnumberofstudiesonthistopic
fromLLMICs.
Althoughitisoftendifficulttodisentangletheeffectsoftheincentivesfromotherinterventions,
thefindingsshowthatwhereRBFisintroduced,itcanmakeasubstantialdifferencein
termsofutilizationandcoverageofthosehealthserviceswhichareincentivised,
especiallyfortargetedindicators,includingmaternalhealthindicators.Thereisgrowing
evidenceonthepositiveeffectsofRBFonaccesstoandutilizationofmaternalhealthservices,
butevidenceontheeffectsonservicequalityandmaternalhealthoutcomesislimited.Also
therehasbeenlittleornoinvestigationonthelong-termandsystem-wideeffectsofRBFon
overallhealthserviceprovisioninacountry.
TheTable2summarizesRBFimpactonoutcomecategories.Forvouchersthereisrobust
evidenceforallthreeoutcomecategories,forPBFrobustevidencewasfoundforitsimpacton
quality/patientsatisfaction,butinsufficientevidenceforothercategories.Aswithvouchers,
whenmorestudiesbecomeavailableitwillbecomemoreclearifindeedPBFcanincrease
utilization.PBChaverobustevidenceforincreasedutilizationandinsufficientforquality.
Table2:SummarytableimpactofRBFapproachesonthethreeoutcomecategories
Typeofeffect Robustevidence(>3studies)
Modestevidence(2-3studies)
Insufficientevidence(<2studiesornoeffect)
#rigorousstudiespositiveeffect
PBC Quantity/utilisation/coverage
X 3
4
Typeofeffect Robustevidence(>3studies)
Modestevidence(2-3studies)
Insufficientevidence(<2studiesornoeffect)
#rigorousstudiespositiveeffect
Quality/satisfaction
X 1
Equity/Targeting
X 2
PBF Quantity/utilisation/coverage
X 1
Quality/satisfaction
X 4
Equity/Targeting
X 1
Vouchers Quantity/utilisation/coverage
X 10
Quality/satisfaction
X 8
Equity/Targeting
X 9
RBB Quantity/utilisation/coverage
X 1
Quality/satisfaction
X -
Equity/Targeting
X 0
AlthoughnostudyfocusesonnegativeeffectsofRBF,anecdotalevidencesuggeststhatsome
potentialundesirableeffectsofRBF,suchasmotivatingunintendedbehaviours,
distortions,gamingorfraud,dilutionofprofessionals’intrinsicmotivation,arepossible
andneedtobecarefullymonitoredandevaluated.TheauthorsorexpertsinvolvedinRBF
impactevaluationdocumentingrevealthattheevaluationtechniquesusedarerelativelyweak
(whichisinherenttothistypeofinvestigations,whereitisnotoriousdifficulttodesignand
applyafullycontrolledexperimentoveralongerperiodoftimetakingintoaccountall
confoundingfactors).
AllRBFschemesaddressoneormorebarriersrelatedtosupply-sideavailability,suchas
waitingtime,motivationofstaff,readinessofthefacilitytoprovideservices(availability
ofdrugs,supplies,equipment),andimprovedreferral.Thesamecountsforacceptability
suchasstaffinterpersonalskills.MostRBFschemesaddressbarriersrelatedtodemand-side
availability,mostlythroughtheprovisionofinformationonhealthcareservicesand
providers.
5
Performance-BasedContracting
TheCochranereviewoftheimpactcontractingoutinterventiononhealthservicesutilization(3
separatePBCinterventionslocatedin3countries:Bolivia,CambodiaandPakistan)provides
evidencethatPBCresultedinincreasedaccesstoandutilizationofhealthservices,mainly
fortargetedindicators.ThestudyinPakistanshowedanimmediateincreaseofmorethan
130%inconsultationvisitstothebasichealthunits(+144%ondailyvisitsand+135%for
monthlyvisits),butthisincreasedidnotsustainasbothoutcomesdeclinedconsiderablyinthe
18monthsfollowingthestartoftheintervention.InCambodia,thererevealedanincreaseinthe
useofpublicfacilitiesby29%.ButPBChadnothadasignificantimpactonimmunizationrates
(authorsconcludethattheincreasemaybeexplainedbythegeneralsecularincreaseofservice
provisioninCambodiaatthetime).4
Thereviewidentifiesanumberofdifferentcomponentsincontractoutservicestonon-public
providersthatmaybeinstrumentalintheobservedeffect.Theseincludethepossibleroleofa
newmanagementstyle,thepotentialroleoftheincentivesandobjectivesincludedinthecontract,
ortheimplementationofthoroughmonitoringsystemsandsanctions(whichareusuallyabsentin
thedeliveryofhealthserviceswithinthepublicsector).Severalelementsmightpotentially
altertheeffectsofcontractingoutstrategies.Firstly,Weakcapacitywithinthegovernment
mightthereforecompromisethesuccessfulimplementationofcontractingoutstrategies.The
broadertheservicescontracted,theharderitwillbetodefineacontractprecisely.The
feasibilityofadequatelymonitoringservicedeliveryinremoteareasisalsoakey
implementationissue.4
Thereviewrecommendsthatthegovernmentsshouldpayparticularattentiontotheelements
includedinthecontracttheydrawupwithprivateproviders,inparticularthetargetsonwhich
theirperformancewillbeassessed.Forexample,ifthecontractfocusesonadefinedsetof
outcomes,thereisariskthatcontracteesmightdiverttheireffortfromunmeasuredto
measuredoutcomes.4
PBCwasintroducedinHaitiwhereNGOs(3intotalforpilotstage)werecontractedtodeliver
healthcareservices.PilotingrevealedpositiveimpactofPBCtoanincreasedchildimmunization
coverage.HoweveritwasnotpossibletoisolateeffectofRBF,becauseRBFschemewas
confoundedbywithotherfactors(combinationwithfixedpricecontract,increasedfunding,
aggressivetechnicalassistance,datavalidation,sharedlearningactivities).5,6
6
Table3:PBCpilotingresultsinHaiti
NGO1 NGO2 NGO3 Indicator Baseline Target Results Baseline Target Results Baseline Target ResultsImmunizationcoverage
40 44 79 49 54 69 35 38 73
Performance-BasedFinancing
PBFexperienceshavebeendocumentedinBurundi,DRC,TanzaniaandZambia,where
considerabledifferenceofstaffandhealthserviceproductivitywasfoundbetweenbeforeand
aftertheintroductionofPBFinseveralprojects;withanincreaseinhealthserviceutilizationfor
almostalltargetedindicators,includingmaternalhealthindicatorsandinqualityofcareas
perceivedbytheclients;andnoperverseeffectsweredirectlyobservable.7
ForPBFrobustevidencewasfoundforitsimpactonquality/patientsatisfaction,but
insufficientevidencefortheotheroutcomecategories.Aswithvouchers,whenmore
studiesbecomeavailableitwillbecomemoreclearifindeedPBFcanincreaseservice
utilisation,andwhenitdoesifthisistheninfavourofthemorevulnerableandpoor.2
InRwanda,56%and132%increasewasobservedinthenumberofpreventivecarevisitsby
childrenagedbelow23monthsandagedbetween24-59monthsrespectivelyinthetreatment
facilities.PBFimprovedqualityofprenatalcare(anincreaseof0.157standarddeviations(95%
CI0·026–0·289)inprenatalqualityasmeasuredbycompliancewithRwandanprenatalcare
clinicalpracticeguidelines:7.6%morewomenreceivedatetanusvaccineduringpregnancy
thanatbaseline.),butnoimprovementswereseeninthenumberofwomencompletingfour
prenatalcarevisitsorofchildrenreceivingfullimmunizationschedules.8
AftertheintroductionofPBFinIndonesia,2programyears,8targetedMCHhealthindicators
(e.g.ANC,assisteddelivery,immunization,growthmonitoring)wereanaverageof0.03
standarddeviationshigherinincentivizedareasthaninnon-incentivizedareas.9
InEgyptPBFhadlittleimpactonchildvaccinations,whichmightbeexplainedinpartbythefact
thatbaselineimmunizationrateswerealreadyhigh:closeto65percent.ButPBIdidincrease
theprobabilitythatachild0-23monthsvisitedahealthcenterforpreventivecare(a64%
increaseoverbaseline)andtheprobabilitythatachild24-59monthshadapreventivevisit–by
awhopping133%overthebaselineprobabilityforthetreatmentgroup.Significant
improvementsinthequalityoffamilyplanning,antenatalcare,andchildhealthservices
reportedbywomenseeninclinicswheretheincentivepaymentschemewasinoperation.10,11
7
Canavanetal.reviewednotonlytheeffects,butalsoinstitutionalarrangements,including
factorsdeterminingsuccess,costsandsustainabilityofRBFinLLMICs.Theyfoundthatthe
introductionofRBFinvarioussettingsledtoremarkableimprovements,mainlyin
targetedoutputandoutcomesindicatorssuchasutilisation,coverageandemergency
referrals,withenhancedqualityofproviderperformance.WhileRBFachievedsome
positiveresultsonthelevelofmeetingqualitativehealthindicators,theextenttowhichit
contributestoimprovedqualityofcareremainsaquestion.AsforRBF,thereisariskof
compromisingqualityofcaretomeetutilisationtargets.ThepercapitacostofRBFvaries
fromUS$0.25inDRCtoUS$4.82inAfghanistan.
TrendsinoperationaldataindicatethatsincethePBFprogramwasimplementedinCameroon
2012,thecoverageofkeyhealthservicessuchasinstitutionaldelivery,antenatalcare,family
planning,andimmunizationshasincreased.Freeoutpatientcareforthepoorandvulnerable
hasalsoincreased.Thequalityofcare,asmeasuredbytheaveragetotalqualityofcarescore
increasedfrom43percentto64percentbetween2012and2015.12
PreliminaryresultsfromtheimpactevaluationinZambiaindicatethatRBF(introducedin
2008)significantlyincreasesutilizationofselectMCHservices,suchasearlyantenatalcare
(ANC)-seekingbehaviorandin-facilitydeliverywhenthe
RBFdistrictsarecomparedtothedistrictsoperatingas
“businessasusual”—womenfromhealthfacilitiesinthe
RBFdistrictssoughtANCaboutthreeweeksearlierthan
womenreceivingcareinnon-RBFdistricts.Performance
onsomepost-natalcare(PNC)measuresincreasedinRBF
districts.PNCcoverageandimmediatebreastfeeding
increasedbynearly10%and14%,respectively,andwere
statisticallysignificant.12
ThepreliminaryresultsofPBFinterventioninBenin,introducedin2012,showthatthereis
improvedsomeaspectsofhealthworkerperformance.Theyindicateapositiveimpacton
qualityofcareandresponsivenesstowardspatientsbutnosignificantimpactonclinical
productivity.Forexample,acomparisonbetweenPBFtreatmentandcontrolgroupshighlights:
ImprovementsinthequalityofANCinPBFfacilities,withincreasesinthequalityofphysical
examinationsconducted,historytakingandadvicegivenbyahealthworker(measuredthrough
DirectClinicalObservations),ascomparedtobothcontrolgroups.Increasedconsultation
timewithalmost4additionalminutesforANCinPBFfacilitiescomparedtofacilitieswithno
intervention.IncreasedresponsivenessofhealthworkerstowardspatientsinPBF
facilities,withpregnantwomenreceivingANCvisitsandpatientsgettingcurativecarebeing
8
respectivelymoresatisfiedwithstaffattitudeandstaffcompetence(asmeasuredthrough
DirectClinicalObservationsandexitpatientinterviews).AsignificantimpactofPBFonthe
politenessofstaffduringANCvisits.12
AfterNigerialaunchedaPBFpilotuptakeofserviceshasbeenveryencouraging,withutilization
ofcoreMCHserviceslikeimmunization,
deliveriesinfacilities,andfamilyplanning,
showingmuchimprovement.Figureshows
animmunizationcoverageincreaseinpre-
pilotfacilitiesfrom5percentto44percent;
anincreasefrom14percentto44percentin
thefirstphasescaleupfacilities;andshowing
promiseinthemostrecentscaleupfacilities.
Increaseinimmunizationcoveragehasbeenidentifiedsincecompletionofscale-upin
December2014(post-scaleupimmunizationcoverageincrease).Intwostatesimmunization
coverageincreasedfrom30%to50%andhigherlevels.Moreover,datashowthatqualityof
servicesalsoimproved,alongwiththeincreasesincoverage.Aqualitychecklistappliedona
quarterlybasisfoundthatstructuralandprocessqualitymeasuressawrapidandsustained
improvements.Finally,PBFfacilitiesachievedgoodpatientsatisfaction,withratingsof80and
95%inNasarawaandinOndoStates,respectively.Itisworthhighlightingthattheseresults
havebeenachievedatamarginaladditionalcostof$0.8percapitaperyear.12
TheRBFprograminZimbabwewaslaunchedin2011.Impactevaluationwasimplementedwith
controlledbeforeandaftermethod.Theresultsdescribedinthe2014AnnualReportindicate
thatthereweresubstantialimprovementsinthequantityandqualityofservicesdeliveredin
RBFdistricts,whencomparedtotheirnon-RBFcounterparts.Resultsfromthequalitative
componentoftheimpactevaluationindicatethatwhentheRBFprogramisimplementedas
intendedandplanned,ittriggersandfacilitateschangesinthefacilitystaff’sperformance;andit
influencestheperformanceofhealthfacilities,andthemotivationandsatisfactionofstaffat
thesefacilities.RBFfacilitieshavemoreeffectivemonitoringandreportingmechanisms,
andbetterstaffcoordinationthannon-RBFfacilities.ResultsfromthePMEindicatethat
improvingfeedbackmechanismsalongwithsupervisionimprovesthequalityofservices.12
Conclusionandrecommendation
TheevidencebaseofRBFisnotyetstabilizedandisstillgrowing.Thereisanemergingbodyof
evidenceshowingthatRBFisabletoimproverelevantparametersrelatedtoMCHservices.
Impactonutilizationofthoseincentivizedserviceshasbeenthemostinvestigatedissueand
9
findingsarerathersupportive,eveniftheevidenceisrarelyofarandomizedcontrolledtrial
standard.ThefactthatRBFincreasestheamountofservicesutilizedbythetargetpopulation
(orcoveragerates)istrueforspecificprioritygroups(withvouchers)andalsoforlarge
populations(withPBFforinstance).
ThereisalsosomeevidencethatRBFcanleadtoimprovementinqualityofservices,specifically
forPBFandvouchers.ThereisgoodevidenceforvouchersandemergingevidenceforPBCthat
theseapproachescanimpactonequityinhealthcareutilization.
TheefficiencyofRBFcomparedtothestatusquoorotherhealthfinancingapproacheshasbeen
under-documentedandobviouslyforotherdimensionsevenmorecomplextodocumentsuch
asthelong-termeffectofRBFonproviders’behaviorsandexpectations.Thereisnosubstantial
evidenceonthenegativeandunintendedside-effectsofRBF.mainlyhypothesesexist.Other
dimensions,suchassustainabilityisneitherwelldocumented.
AnotherareastillinsufficientlystudiedistheeffectofacombinationoftwoormoreRBF
approacheswhichmighthaveagreaterimpactthaneachonitsown.Forexampleanationally
implementedPBF,whichincreasesthequalitycombinedwithvoucherstoreachthemost
underservedpopulations.
Inordertoensureweatherthehealthsector–whatevertheaffiliationoftheirproviders–
deliversqualityhealthservicestoallinanefficientway,withoutpushinghouseholdsinto
poverty,itiscrucialtoacknowledgethestatusofthecountryshealthsector.Today,health
systemsofmanyLLMICsarecharacterizedbyi)apublichealthsystemwhichdoesnotperform
asexpectedandii)anunregulatedprivatehealthmarketwhosequalityisnotassuredand
pricesnotregulated.Onthesetwosegmentsofthemarket,therearebothsupplysideand
demandsidebarrierswhichpreventthepopulationtoaccesscriticalservices.RBFcreates
systemicopportunities(e.g.itisanopportunityfortheministryofhealthtobemoreacquainted
withstrategicpurchasing),butalsorisks(e.g.iftheRBFapproachleadstoimprovedMNCHcare
tothedetrimentoftheprovisionofotherpriorityservices).
AsageneralrecommendationRBFinterventionhavetobedesignedconsideringother
contextual,publichealth,healthsystemfactors.Itshouldbeapartofapackageofreformor
overallstrategyinthehealthsector.RBFshouldcovermorethanasub-groupofMNCH
problems.RBFapproachedmaybevaluablefortheirancillarybenefits(likeincreasing
competitionandengagingwithprivatesector),howevertheseeffectsneedtobecarefully
monitored.2
10
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