Results-Based Financing in Afghanistan

Motivation, Design, and Preliminary Results

Tekabe Belay

Senior Economist, South Asia HD, World Bank

Women Deliver

Kuala Lumpur , Malaysia

May 28, 2013

Motivation

In 2002, the health system was in a very poor condition

• Limited capacity in the Ministry of Public Health

• 80% of services provided by NGOs

• Lack of coordination among stakeholders

• Inequitable distribution of health services, with many rural

areas extremely under-served

• Few functioning health facilities

2

Motivation…

Reflected in health indicators that were among worst in

the world

• Life expectancy: women 45 years and men 47 years

• Under-five child mortality: 257 deaths per 1,000 live births

• Maternal mortality ratio: 1600 per 100,000 live births

3

• Focus on stewardship functions o Define the package of services: BPHS and EPHS

o Define the beneficiaries: service areas defined for each provider

o Define the standard of services: inputs requirements for BPHS and EPHS defined

• Partner with the private sector o that has been serving 80% during the conflict

• Use its purchasing power effectively to register results

• The approach is largely along the lines of current thinking on service delivery in fragile states (e.g. Collier)

Strategy: Afghanistan’s Approach to

Health Service Delivery

4

This achieved impressive results…

5

Skilled Birth Attendance - 3 times

6

6.00%

8.40%

18.40%

24.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

2003 2005 2006 2008

7

4.60%

12.60%

30.30%

36.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

2003 2005 2006 2008

Antenatal Care (>1 ANC) - almost 7 times

8

5.10%

10.40%

15.40%

23.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

2003 2005 2006 2008

Contraceptive Prevalence Rate – 3.5 times

9

DPT3 Coverage - doubled

21.20%

17.40%

34.60%

43.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

2003 2005 2006 2008

Infant Mortality - 32% reduction

Under 5 Child Mortality – 35% reduction

10

165

257

129

191

111

166

0

50

100

150

200

250

300

Infant Mortality Rate Under 5 Mortality Rate

2001

2006

2008

...but not enough

11

Coverage of important services remains low by

global standards e.g.

o CPR 15%,

o ANC 36%

o SBA 24 %

Additional effort to increase coverage needed

Results-Based Financing (RBF)

• Since 2010:

o 14 provinces: gradually scaled up

o Primary care and hospitals

• RBF means:

o Payment for additional services

o Payments for improved quality

o Payments for serving the poor

• Rigorously assessed with a gold standard IE design

12

Results after 24 Months of Implementation

13

ANC: in RBF Facilities

0

15

30

45

60

75

90N

um

ber

\mo

nth

ANC1-4 Treatment

14

ANC

0

15

30

45

60

75

90N

um

ber

\mo

nth

ANC1-4 Treatment ANC1-4 Control

15

PNC: in RBF Facilities

0

15

30

45

60

75

90

Nu

mb

er\m

on

th

PNC1-2 Treatment

16

PNC

0

15

30

45

60

75

90

Nu

mb

er\m

on

th

PNC1-2 Treatment PNC1-2 Control

17

SBA: in RBF Facilities

0

2

4

6

8

10

12

14

16

18

20

Nu

mb

er\m

on

th

SBA Treatment

18

SBA

0

2

4

6

8

10

12

14

16

18

20

Nu

mb

er\m

on

th

SBA Treatment SBA Control

19

0

10

20

30

40

50

60

Nu

mb

er\m

oth

DPT3 Treatment

DPT3: in RBF Facilities

20

0

10

20

30

40

50

60

Nu

mb

er\m

oth

DPT3 Treatment DPT3 Control

DPT3

21

RBF Indicators: Changes Between

2010 Q3 and 2012 Q1

21.8

16.5

5.4

1.3

4.3

6

2.6

-0.1

-5

0

5

10

15

20

25

ANC1-4*** PNC1-2*** SBA** DPT3

Treatment

Control

22

The longer RBF is in place, the better

(ANC 1-4)

(highest after 12 months ~ control for seasonality)

9.9

13.5

21.8

6.9

1.4

4.3

0

5

10

15

20

25

3months** 12 Months*** 19 months***

Treatment

Control

23

The longer RBF is in place, the better

(PNC 1-2)

3.9

7.7

16.5

3.1

1.5

6

0

2

4

6

8

10

12

14

16

18

3months** 12 Months*** 19 months***

Treatment

Control

24

The longer RBF is in place, the better

(SBA)

-0.3

1.2

5.4

0.5

-0.2

2.6

-1

0

1

2

3

4

5

6

3mohths 12 Months 19 months**

Treatment

Control

25

Quality improved in most hospitals

with RBF in place

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1 2 3 4 5 6 7 8 9 10 11 12 13

Sco

re

Hospitals

Overall Score

Before

After

26

Improved Quality

0.0

20.0

40.0

60.0

80.0

100.0

120.0

1 2 3 4 5 6 7 8 9 10 11 12 13

Sco

re

Hospitals

Hospital Infection prevention

Before

After

27