Taking RBF From Scheme to System
-
Upload
cophha -
Category
Healthcare
-
view
146 -
download
0
Transcript of Taking RBF From Scheme to System
Taking Results Based Financing from Scheme to System: a multi-country study
Zubin Shroff & Bruno MeessenCoP Webinar
January 20th 2017
asd
Presentation Outline Part 1:• Our research• Scaling up is multidimensional• Scaling up is a four phase process Part 2: • Moving from one phase to the next: context, actors,
policy content and processes• Larger lessons learnt from the cross-country research
asd
Main question: what are the enablers and barriers for the scale-up of RBF schemes?
Armenia Cameroon Macedonia Tanzania
Burundi Chad Mozambique Uganda
Cambodia Kenya Rwanda
• Mainly qualitative methods• Iterative
Documentary review
Timeline development
Key informant interviews
Source: Sieleunou et al. 2015
asd
Idea #1: Scale-up occurs over 5 dimensions
Dimension Content Population Coverage Geographical coverage, age and income groups
covered, total people coveredService Coverage Number, types, level, affiliation of services
Health System Integration & Institutionalization
Connections with the six building blocks of the health system
Cross-sectoral diffusion Changes outside the health sector
Knowledge & Ideas Status of the knowledge
asd
An illustration (1)
Population Coverage
Service Coverage
IntegrationCross sector diffusion
Knowledge
0
5
asd
An illustration (2)
asd
Generation(from idea to project)
Adoption(from project to
program)
Institutionalisation(from program to
policy)
Expansion(from policy to
system)
Idea #2: the four phase model of scale-up
• Reason: scaling up require some key resoures/currencies and these resources are themselves partly an outcome of the process.
• This is an emerging pattern, not a law.
asd
Phase 1: Generation • Movement from initial idea to one or more pilots• End point: pilot implemented as proof of concept
Generation
(from idea to project)Adoption
(from project to program)
Institutionalisation
(from program to policy)
Expansion
(from policy to system)
asd
Phase 2: Adoption• Movement from pilot project to a national ‘program’: a coherent and
identifiable set of institutional arrangements organising the transfer of resources to service providers is in place (contracts, guidelines…)
• Increased coverage in terms of administrative units implementing and hence people covered → a heavy operational stage
• End point: a national unit, trainers & digital tools are in place to roll out (knowledge!)
Generation
(from idea to project)Adoption
(from project to program)
Institutionalisation
(from program to policy)
Expansion
(from policy to system)
asd
Phase 3: Institutionalisation • This refers to the transition from a program to a national policy
• Integration within the six ‘building blocks’. • Governance: A stated objective of national strategic documents and decrees• Finance: public funding and harmony with other financing mechanisms.
• End point: PBF is an integrated provider payment mechanism for whole country
Generation
(from idea to project)Adoption
(from project to program)
Institutionalisation
(from program to policy)
Expansion
(from policy to system)
Phase 4: Expansion• This refers to the transition from a mechanism to a set of key
principles informing the design and implementation of public policy in the health sector but, also beyond.
• Paying for results and provider autonomy inform fields like education
Generation
(from idea to project)Adoption
(from project to program)
Institutionalisation
(from program to policy)
Expansion
(from policy to system)
asd
Generation AdoptionInstitutionalis
ation Expansion
FINDINGS
asd
Sample: countries at different stages…
Moving Across Phases- Phase 1: Generation
• Contextual factors- – Interaction of global (aid effectiveness), regional (influence of Rwanda) and
national context (RBF as a solution to address a met need)– Previous experience with organizational and financing reforms of the health
systems- voucher schemes, direct cash transfers • Actors
– Seminal Role of Knowledge brokers or Health Financing Experts, along with international agencies (bilaterals, multilaterals, faith based) in sowing the seed
• Content– Broad agreement on general principles and practices among community of
knowledge brokers – Funding agencies had some role in determining focus, over time govts played
increasingly important role
Moving Across Phases- Phase 2: Adoption
• Contextual factors- – National context relatively more important; pre-existing autonomous
institutions; enabling legal frameworks and changes – National agenda of transparency and results hastens process
• Actors– International agencies continue to be important (funding and technical
assistance); though usually one agency takes dominant role (Rwanda, Cameroon, Kenya, Armenia)
– Role for national policy entrepreneurs, from MOH or pilot programs– Development of critical mass of national level practitioners
• Process– Coordination and alignment of stakeholders, task force
Moving Across Phases- Phase 3: Institutionalization
• High Level of continuity between this and previous stage, still needs active management • Contextual factors-
– Legal frameworks continue to evolve – Enabled by increased security of funding, especially from domestic sources
• Actors– Increasing political and technical leadership of MOH and national RBF experts– National ownership goes beyond the MOH, the ‘coalition of change’- MOF, local govts,
social security agency
• Content– Greater country level influence on design, reflecting increased domestic resources and
technical leadership (Cambodia-internal contracting, Rwanda-cPBF)
Moving Across Phases- Phase 4: Expansion • Contextual factors-
– Knowledge on integration in health informs attempts to extend PBF principles to other sectors
• Actors– National level expertise and high level political support to take
forward PBF principles
• Content– Variations develop in extending PBF principles to other sectors
including local government administration
LESSONS
Five broad lessons
• Lesson 1: Some countries stay stuck in phase 1• Lesson 2: Rhetoric and framing matter• Lesson 3: Scale up requires a chain of actors • Lesson 4: Look beyond the label for content
when examining interactions• Lesson 5: Balance technically best against
politically feasible
Lesson 1: Why some countries get stuck in Phase 1
• A pilot is not a pilot. Successful pilot doesn’t ensure scale up– How it is framed- disease focused or health systems strengthening
(Mozambique vs Cameroon)– Who implements it- entity a) largely focused on a single disease, b) with
political, technical, financial influence at country level– Which level of government is engaged ? Engagement at the district or
provincial level initial rapid uptake, but to national level may then be more challenging (Mozambique, Uganda)
– Where it is housed in national government apparatus– Is it implemented largely outside the public system?– More pilots are not always better
→ Forthcoming webinar: Kiendrébéogo et al 2017
Lesson 2: Rhetoric and Framing Matter • RBF programs have been put forth as transparency
enhancing and part of a results agenda• This works in some settings (Cameroon and Rwanda), but
may not be universally the case; potential to directly confront interests keen on status quo
• Needs analysing political situation to see if this is most appropriate strategy and otherwise looking for individuals and groups at national level who can help place transparency and results on the agenda, in other words-create the window of opportunity
Lesson 3: Scale up needs a chain of actors• Seen how dominant actors varied by stage – each control a
key resource for the specific stage • Invest in building your support coalition – anticipate and
involve at an early stage • As stakeholders change, so do their incentives. Incentives for
provincial level governments to adopt PBF pilots may be completely different from national governments
• Adapt your framing - initial PBF pilot framed as solving an urgent need, issues of sustainability may not be immediately important, but as you progress this becomes more important
Lesson 4: Look beyond the label and at the content of other reforms
• Decentralization and increased autonomy, while enabling to PBF programs in a number of ways, also alter who decides what, something that changes incentives for different players
• Devolution in Kenya- increased accountability buy taking decision-making closer to people, but increased chance of reduced spending on public goods and more on visible things like infrastructure
Lesson 5: Balance the technically best program against what is politically
feasible• A technically sub-optimal intervention may be the right
choice when weighed against increased government buy in and therefore likelihood of long term sustainability
• Cambodia example of choice of program, government wanted greater control and chose model of contracting enabling this
Thank You