1. Learning from RBF Implementation Dinesh Nair Sr Health Specialist

2. Overview of Session • Why do we need to “learn from RBF”? • Pulling it all together: the conceptual framework • Nigeria Case Study

3. Many opportunities to learn Comprehensive learning agenda

4. A broad approach to learn from RBF implementation • Holistic conceptual framework which highlights: • the intermediate outcomes necessary to achieve results • the utility of a multidisciplinary lens • the need for broad methodological approaches

5. Conceptual Framework

6. A Conceptual Framework for PBF • What organizational and behavioral changes do you expect PBF to bring about?

12. Learning from RBF Implementation: Nigeria Experience

13. RBF in Nigeria combines the PBF at health centers and DLIs to state and local governments Results Based Financing Approach in Nigeria Federal Govt. Finance based on.. (Examples) • Increase in services • Budget execution • Bonus payment $$ State Govt. DLI • Supervision • HMIS reporting • HR management Local Govt. $$ $$ • Quantity of services delivered • Quality scores of the services Health Centers PBF

14. Coverage has been increasing significantly, but further improvement is required Coverage of health services in Pre-Pilot facilities in Adamawa state (%) Inst Deliveries Vaccination FP • Significant improvement from very low baseline in all indicators • The is a good contrast with low DHS 2013 results in the North East (institutional delivery 20%, vaccination 14%, FP 11%) • However, the overall utilization is still 30-40%

15. Detailed look at the operational data revealed the large variations in performance across Health Centers Institutional Delivery in Adamawa, normalized by 100,000 population • Before PBF, all health centers were equally at very low levels • After the PBF, some facilities achieved 100% coverage while others struggle with limited improvement

16. This performance variation across health centers also exists in quality of care Quality Score (%) in pre-pilot health centers in Adamawa state • The quality score overall improves even in low performers • However, the difference between high and low performers increased from 23% to 30%

17. Nigeria team engaged with two qualitative studies 2. Case study on key determinants 1. Demand-side barrier analysis • What differentiate the good and poor performers under the PBF scheme? • What are the barriers to service utilization in the PBF facilities? Research question • Transport, service fee, culture/perception/ information barriers • Competition of alternatives • Health center management • Contextual factors • Health systems factors (e.g., supervision) Areas to look into • Interviews, document review, direct observations • Best and poorest performers • Interview and focus group • High and low performers Approaches • Design demand-side interventions • Devise appropriate support to poor performers Potential use

18. Demand-side barrier analysis revealed priority issues Priority demand side intervention Major Barriers Found through Qualitative Analysis Magnitude Controllability Possible approaches Cost High High • Transport Voucher Transport • Community transport team • Maternal shelter Availability High Med Cost High High • CCT Services Demand-Side Barriers • Predictable/discounted pricing (supply-side) Predictability of cost High High Hospitals Varies Low • N/A Competition • Incentives for referral to PHCs (supply-side) Traditional providers Varies Med • Community engagement (supply-side) Community support High High Community/Culture • Communication and community involvement Culture Varies Med

19. Case study on determinants suggests the importance of community engagement and OIC management Identified determinants and non-determinants (preliminary) Determinants Non-Determinants • Community engagement (e.g., involve and reward community leaders, daily visits, incentivize for use of facility) • OIC’s management capacity (e.g., full staff involvement, improve staff environment using performance bonus, rigorous performance review) • Level of staffing (best performers lack staff) • Remoteness of facilities (best performers are very rural) • Technical qualifications of OIC (many community health workers manage facilities well) • Business planning (none use it effectively yet)

20. Research findings will drive new demand-side interventions with additional financing Proposed Transport Voucher and Strengthening management capacities Transport Voucher Improve Capacities • ANC standard visit (1-4) • Institutional delivery • Postnatal consultation • Vaccination of children • Growth monitoring • Referred services provided by hospitals • Community engagement • Management capacity building of health centers • Technical training (e.g., IMCI) for quality improvement (QI) Implementation Arrangements • Build demand side interventions to support Supply Side RBF interventions

21. Key Lessons Learned • RBF performance hinges on how well and quickly we can learn from implementation and improve our approaches • Qualitative research can provide a powerful insights and evidence in devising effective approaches • Identifying right research questions and clear plan to use the research results are required to make the qualitative research meaningful