RBF through the Public Health Sector in Low-Income Countries

1. RBF through the Public Health Sector in Low-Income Countries Essential Design Elements for a Health Center RBF model György Fritsche HDNHE RBF Seminar 27 October, 2009

3. Learning Objectives For the Rwandan Health Center RBF model: • Describe the performance framework; • Describe three key design features; • Explain the role of technical assistance

4. The Performance Framework for Health Center RBF • Fee-For-Service Conditional on Quality of Care Results Based Financing/Performance-Based Financing • 15-25 Services with unit fees (measured monthly) • Services are ‘PBF SMART’: not all services can be purchased • Quality quantitative checklist (measured quarterly). Extensive and well-balanced • Quality: Carrot or Stick? • Payment cycle quarterly

5. Key Design Elements (i) • National level, health district level and health center level design features • District Level Design Features: • Significant Financial Incentives through performance framework for District Health Management Teams and District Hospitals • Separation of Functions: • Creation of a quasi-market through internal contracts • Transparent district level PBF governance mechanism • Separate ‘quantity audit’ from ‘quality supervisory function (separate teams)

6. Key Design Elements (ii) • Intense dedicated TA during introduction and subsequently making operational and refining PBF system • Civil Society/NGOs: • Participation in data validation and • Participation in district level PBF governance mechanisms (‘quorum’)

7. Key Design Elements (iii) • Health Center Level Design Features: • Performance framework targeting health facilities (as opposed to individual health workers) • Significant financial incentives reaching frontline health workers • Health Center bank account • Regular bonus payments to health workers • Increased Autonomy • Purchase contract

8. Key Design Elements (iv) • ‘Business Plan Approach’ • Data Quality Audit of all purchased services (routine; monthly) • Services that are purchased need to be ‘PBF SMART’ • Quality Checklist with strong impact on performance payments (comprehensive and routine) • Community Client Surveys

9. Three most important design elements? • Fee-For-Service Conditional on Quality of Care RBF/PBF and incentives are significant • Increased Health Facility Autonomy • Health Facility Performance Framework but incentives trickle down to health workers

10. The role of technical assistance (i) • Dedicated Project Implementation Unit or Ministry of Health department • Dedicated additional TA for program; coordination of technical assistance; communication; MIS; training and IT support • Leveraging TA with in-country available resources • Strong national technical coordination platform dedicated to PBF (degrees of freedom; secretariat)

11. The role of technical assistance (ii) • Strong technical coordination platform dedicated to providing TA on PBF to districts (‘bridging the gap between policy and implementation’) • Cost of combined TA estimated at between $0.30 -0.40 /capita/year

12. First level of Control: Signing of a Contract with a Mayor

13. Second level: PBF Control is NOT ‘business as usual’ in data gathering

14. Third level: Discussion in the District PBF Steering Committee

15. Fourth level: Extended Team: 11 agencies and MOH departments

16. Fifth level (i) : Two national counter verification mechanisms: the quality counter verification protocol

17. Fifth level (ii) Two national counter verification mechanisms: the Community Client Surveys

18. Summary: Learning Objectives For the Rwandan Health Center RBF model: • Describe the performance framework; • Describe three key design features; • Explain the role of technical assistance