RBF: Concepts & Draft Design

What is RBF for health?

PURCHASER/PAYER

RECIPIENT(PROVIDER/

PATIENT)

HealthResults

Financial Incentives

Results-based Financing for health is any program that rewards the delivery of one or more health outputs or outcomes, through financial incentives, upon verification that the agreed-upon result has actually been delivered.

OUTPUTS(health service

utilization, promotion activities)

PROCESS(training,protocols

and guidelines,

financial manageme

nt, procuremen

t, etc.)

INPUTS(human

resources, drugs,

equipment, etc.)

OUTCOMES(maternal and child mortality,nutritional outcomes,

life expectancy)

Traditional Input Financing vs. Output Financing: A Shift in Focus

Line item budgeting, input supply,

monitoring of inputs and processes,

reporting of results

Monitoring and paying for outputs,

increased leeway for local decision-

making, verification of results

Monitoring of outcomes, evidence

based decision making to achieve

results

Broad principles of design• Tanzania will approach RBF as part of broad systems reform,

not a project• Part of Health Care Financing Strategy Development

• Objective is to strengthen overall system, not just to top-up individual workers

• Provider empowerment and autonomy is essential

• This is not a scale-up of Pwani: We learn from all experiences to develop informed and customized design

What results are we purchasing?

Principles•Underutilized & poor performing indicators•Management & HSS indicators to ensure results achieved•Preventive services prioritized

What and how will we pay for results?• Fee-for-Service and/or coverage targets

• Quality of care will be included• Penalty or reward still TBD

• Allocation of staff incentives vis-à-vis facility reinvestment• Option 1: Formula to determine allocation• Option 2: No formula, full autonomy of facility to decide• Incentives should vary by performance of staff, by cadre

• Further analysis of overall level is needed

Next steps for determining what/how to pay:

• Decision on incentive mechanism: 1) fee-for-service 2)coverage targets 3) both

• Should RHMT & CHMT be paid for results of health facilities?• If yes, then further exploration on how to structure

• How to consider equity: • Pay more for same indicator based on poverty, geography

• How to measure quality for clinical and non-clinical

• How to incorporate client satisfaction

• Projections to determine total budget for incentive levels

25

Institutional Set Up

Purchaser

Verifier (internal/3rd party):

Provider

Regulator

Fund Holder

26

Providers• Establish and enforce minimum standards

• Standards should ensure service readiness for all selected RBF services

• Include all public providers from the start• Public providers not meeting minimum standards will be given special

investment to make them service ready

• Include private and faith-based if they meet minimum standards, and if there is service gap

• For HSS, explore RHMT, CHMT, DED, MSD, RAS

27

Purchasing• Centralized purchaser: PMO-RALG to act as purchaser with a PS for

health. Already, they act as purchaser for roads.

• Decentralized purchasing: Local level is closer to ground realities, and can purchase more effectively

• Can Regional Administrative Secretary or Council take on purchaser role?• Or RAS to purchase from regional hospital, Council to purchase from PHC,

council hospital, dispensary

• Long-term vision: NHIF may take over as purchaser once their capacity is built

28

Verification• Internal: • CHMT and RHMT. • Hospitals quality improvement teams going to facilities possible

• 3rd Party: • Control and Auditor General with Zonal involvement.• Private agency hired • Research Institutions (SPH, IHI, NIMRI)

• Community Verification• Mechanism still needs to be assessed

29

Fundholding• Short-term: • Ministry of Finance using its preferred bank (ie NMB)• Development partners under MOHSW

• Long-term: • Maintain short-term arrangements if working; look for

alternative options if not working

30

Institutional Set UpConsider possible conflicts of interest

Purchaser:1.PMORLG2.RAS 3.NHIF

Verifier

Provider

1. Clinical: All public,

select private & FBO

2. HSS: RHMT, CHMT, DED

MSD, RAS

Regulator

MOHSW

Fund Holder

1.DPs

2.MOF (preferred bank)

Internal1. CHMT&RHMT

2. Hospital QI teams

3rd Party1. CAG

2. Private

3. Research institutions

Relationship to Health Financing Strategy (HFS)• Implementation of overarching HFS (including Health Insurance options)

will take time

• A key principle of HFS discussions is output-based financing

• RBF design and timing has significant opportunities to fulfilling the HFS:

• RBF could help incentivize the Min. Benefit Package being defined as part of HFS, reinvigorate service agreement mechanisms etc.

• Lead the improvement in the health purchasing function at various levels (e.g. LGA level) and for concrete results

• RBF would be one of the purchasing approaches guided by the HFS

What are the next steps?•Establish and capacitate RBF coordinating and oversight body

•Finalize key technical design elements• Capacity assessments• Legal assessments• Autonomy

•Engage in stakeholder consultation• Separate consultation with key stakeholder groups such as basket fund partners, providers, regionals,

district• Refine, validate and agree on final design• TC-SWAP meeting

•Phasing and geographic phasing• Develop objective selection criteria: Poverty, coverage• Criteria for role-out to new regions• Develop timeline for phasing

•Financing: Assess cost of options for phasing vis-à-vis available funding

•Implementation preparation• Develop TA& training plan for implementation at all levels

•Continued linkages and revision as HCF strategy is developed

Take Home Messages

•General interest on output based/results based financing

•P4P is not static but adapts to needs of health system

•Intrinsic part of fulfilling new HCF system

•Health Systems Strengthening focused