The World Bank and RBF for Health:

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1 The World Bank and RBF for Health: The Role of Civil Society Organizations in RBF Petra Vergeer Health, Nutrition and Population Unit Human Development Network September 27, 2011

2 Challenges for Countries and Partners Slow progress toward the health Millennium Development Goals (MDGs) MDG 1c Halve the proportion of people who suffer from hunger MDG 4 Reduce child mortality MDG 5 Reduce maternal mortality; achieve universal access to reproductive health Source: World Bank Global Monitoring Report, 2010

3 Source: presentation by A. Soucat (African Development Bank) The promise of RBF to reach the Health MDGs and the Evidence Gap: How Impact Evaluation Can Inform Policy Dialogue It is not just a matter of More Money to Health * Percent deviation from rate predicted by GDP per capita Source: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002

4 What is RBF? Financial Incentives PURCHASER/ PAYER RECIPIENT (PROVIDER/ PATIENT) Health Results Incentives may be directed to service providers (supply side), program beneficiaries (demand side) or both. Payments or other rewards are not made unless and until results or performance are satisfactory. Results-based Financing for health is any program that rewards the delivery of one or more health (HNP) outputs or outcomes through financial incentives, upon verification that the agreedupon result has actually been delivered.

5 Why RBF in Health? RBF in the health sector to: Help focus government and donor attention on outputs and outcomes -- for example, percentage of women receiving antenatal care -- rather than inputs or processes (e.g., training, salaries, medicines). Strengthen delivery systems and accelerate progress toward national health objectives, particularly those linked to MDGs 1c, 4 and 5. Increase use, quality and efficiency of services in a variety of country settings as shown by early evidence of e.g. Argentina and Rwanda impact evaluation.

6 Demonstrating Results in Rwanda RBF 18% RBF Impacts on Maternal Health Outputs Non-RBF 2008 RBF 24% 30% 71% 65% 70% 50% 56% 35% RBF Impacts on Child Health Outputs Non-RBF 2008 RBF 21% 23% 33% 8% 8% 14% Source: Basinga et al ANC visits Tetanus vaccine Institutional Delivery Preventive Care Visit 0-23 months Source: Basinga et al 2011 Preventive Care Visit months RBF impacts on Standardized Prenatal effort score Baseline (2006) Follow up (2008) 0 15 % Standard deviation increase due to PBF Control facilities Treatment (PBF facilities)

7 RBF for Health in the World Bank The World Bank s 2007 Health, Nutrition and Population (HNP) Strategy renewed the Bank s focus on HNP results; A key objective in the HNP Strategy aims at tightening the links between lending and results through increased use of Resultsbased Financing (RBF).

8 Health Results Innovation Trust Fund (HRITF) to Support RBF Financing HRITF is a multi-donor trust fund supported by the Governments of Norway and the United Kingdom, with commitments totaling US$575 million from Objective Support RBF approaches for achievement of the health-related MDGs, particularly focusing on MDGs 1c, 4 and 5 HRITF aims to: Support the design, implementation, monitoring and evaluation of RBF mechanisms Develop and disseminate the evidence base for implementing successful RBF mechanisms Build country institutional capacity to scale up and sustain the RBF mechanisms Attract additional financing to the health sector

9 The Role of CSOs in RBF- 1. Contracted to deliver services CSO contracted to deliver services: Contracted (by Government or other purchaser) to deliver a certain package of services Autonomy to decide on allocation of resources to best deliver the services Paid according to verified quantity and/or quality of services delivered Example: Afghanistan

10 The Role of CSOs in RBF- 2. Verification agent and contributors to good governance CSO as a verification agent in RBF: Verifies the reported quantity and quality of services at health facility level prior to payment Verifies at household level whether the reported services have actually been delivered. Sometimes includes client satisfaction. Counter-verifies the verification process for quality assurance purposes Often there is a public-private partnership with a mix of CSOs and government agencies involved. Including in the decision making process to initiate payments for results so as to ensure transparency and good governance. Example: Burundi

11 The role of CSOs in RBF- 3. The Purchaser CSO as a purchaser of services in RBF: Contracts health providers to purchase (quantity and/or quality) services Verifies the results prior to payment Supports and trains stakeholders on their often new roles in RBF and the RBF rules and procedures Examples: Zimbabwe, DRC, Zambia

12 The role of CSOs in RBF- 4. The trainer CSO as a trainer in RBF: Supports and trains stakeholders on their often new roles in RBF and the RBF rules and procedures Training health facility staff to improve service quality and/or support the underperforming facilities Examples: Afghanistan, Burundi, Zimbabwe

13 Opportunities and Challenges- Important Role for CSOs in RBF There are significant opportunities for CSOs to play an important role in RBF as purchaser; contracted provider; verification agent; contributing to good governance; or as trainer. The role of CSOs can be vital to the success of RBF, particularly in low-income countries. However, many CSOs do not (yet) have the experience and capacity to play this role.

14 Opportunities and Challenges- Important Role for CSOs in RBF Design and institutional set up of RBF is important. (i.e., whether supply and/or demand side incentives work best in the particular context; institutional arrangements) CSOs can be an important contributor to RBF design discussions. However, the challenge is to ensure CSOs are part of the stakeholder consultation on RBF.

15 Discussion Is there an interest for CSOs to play a role in RBF? What kind of role(s)? How can the World Bank help promote CSO involvement in consultations on RBF design and implementation? What can CSOs do to gain needed experience and capacity for RBF implementation?