results-based financing in latin america and the caribbean daniel dulitzky practice manager health,...
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R E S U LT S - B A S E D F I N A N C I N G I N L AT I N A M E R I C A A N D
T H E C A R I B B E A N
D a n i e l D u l i t z k yP ra c ti c e M a n a g e r H e a l t h , N u t r i ti o n a n d Po p u l a ti o n
1RBF in the LAC region 2RBF in the
Caribbean 3Lessons learned
Shift government and donor attention from inputs to outputs and outcomes
– Example: the number of women receiving antenatal care or taking children for regular health and nutrition check ups to reduce child mortality (rather than inputs or processes like training, salaries, medicines).
Strengthen delivery systems (Increase use, quality and efficiency)
1RBF in the LAC region 2Why RBF in the
Caribbean? 3 Lessons learned
A r g e nti n aB a r b a d o s
B e l i zeB o l i v i aB ra z i lC h i l e
C o s t a R i c a
D o m i n i c a n Re p u b l i cH a i ti
N i c a ra g u aPa n a m a
Pe r uU r u g u ay
Countries in LAC already using RBF in health (MCH
and also in NCDs)…1RBF in the LAC region 2Why RBF in the
Caribbean? 3 Lessons learned
62% of LAC countries with RBF have qualified for World Cup finals
33% of LAC countries without RBF have qualified for World Cup finals
Model 1: RBF As Part of Capitation-Based (Insurance) Schemes
Title of Presentation 5
States/regions/municipalities receive a fixed capitation payment for each eligible person that they enroll in the program
Size of capitation payment depends partly on performance indicators at state/region level (e.g. immunization coverage, % of healthy newborns)
States/regions use funds from the capitation payments to pay health providers for services provided to the enrollees
Health providers have high degree of autonomy in use of funds.
In-depth external verification is done at all levels (substantial cost).
Examples in LAC: Argentina, Belize, Bolivia, Brazil, Chile, Costa Rica, Dom. Rep., Nicaragua, Panama, Peru, Uruguay
1RBF in the LAC region 2Why RBF in the
Caribbean? 3 Lessons learned
Model 2: Disbursement-Linked Indicators (DLIs)
Title of Presentation 6
One or more actor receive(s) DLI payments (e.g. State) – usually not health providers
Payments are based on achievement of a set of indicators measured at state level (on service coverage, regulatory actions, others)
Payments are not linked to unit cost or premiums.
Payments often go to Finance Ministry
Common in Brazil. Also done in Argentina, Barbados, Nicaragua.
Independent verification is important, but costs much less than with capitation-based schemes or Output-Based Disbursements.
1RBF in the LAC region 2Why RBF in the
Caribbean? 3 Lessons learned
Title of Presentation 7
Argentina- Plan Nacer / Sumar Capitation payments to insure vulnerable population
Disbursements to provincial governments tied to (i) enrollment and (ii) a set of output and intermediary outcomes goals at provincial level (e.g., the proportion of eligible pregnant women receiving early prenatal care and the proportion of eligible newborns scoring high in the post-delivery neonatal evaluation). Disbursements to health care providers based on service fees for specified outputs (e.g., routine check-ups, vaccinations, and normal and cesarean delivery procedures) to eligible recipients
1RBF in the LAC region 2Why RBF in the
Caribbean? 3 Lessons learned
Country examples in the LAC region
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Argentina- Plan Nacer / Sumar Capitation payments to insure vulnerable population
Results: incorporating clinics into Plan Nacer reduced the probability of low birth weight by 9% for users of those clinics, and by 23% for Plan Nacer beneficiaries. Birth records from larger maternity wards show that Plan Nacer reduced the probability of in-hospital neonatal death by 22% for users of Plan Nacer clinics, and by 74 % for Plan Nacer beneficiaries
1RBF in the LAC region 2Why RBF in the
Caribbean? 3 Lessons learned
Country examples in the LAC region
NCDs account for 75 to 85% of total deaths in Caribbean countries
Population is aging
Paradigm shift requires a different delivery model
Severity of risk factors: 38.4% males, 65.3% females to be obese by 2015; smoking responsible for at least 10% of all deaths in the Caribbean; alcohol consumption (per capita consumption of alcohol of 11.7 liters in STL compared to CA + CAR avg. of 4.5 liters)
1RBF in the LAC region 2RBF in the
Caribbean 3 Lessons learned
Health Sector Challenges in the Caribbean
2012 2015
How close to implementing RBF is the Caribbean?
1RBF in the LAC region 2RBF in the
Caribbean 3 Lessons learned
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Dominican Republic Capitation payments Supports overall goal: improve quality of health expenditures & health servicesPrimary Health Care focusPhased geographical coverage: 2 regions from 2011; 3rd region from Sept. 2013Performance based contracts between MOH and Regions, in coordination with National Health Insurance (NHI)
50% = capitation for essential health services package50% = regional performance for 10 indicators (MCH & comm. diseases; NCDs) of coverage & quality
1RBF in the LAC region 2RBF in the
Caribbean 3 Lessons learned
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Dominican Republic Capitation payments
Results:Better data recording & info verification systems/mechanisms (RBF regions account for ~ 81% of Clinical Mgt. System (CMS) entries nationwide)Notable progress in indicators (2011 to 2013)
% children < than 15 mos. w/ complete vaccination scheme acc. to protocols: up 46.7 % of pregnant women monitored for risk acc. to protocols: up 18.8% of children monitored for growth & devt. acc. to protocols: up 25.8% of individuals > 18 years w/ hypertension screening acc. to protocols: up 45.2
1RBF in the LAC region 2RBF in the
Caribbean 3 Lessons learned
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Belize Capitation payments National Health Insurance (NHI) Pay for Performance Scheme (P4P): (i) commenced in 2001 in Belize City South Side, (ii) incentive scheme introduced in 2004, (iii) in June 2006, NHI coverage was extended to include the Southern Region network of public sector clinics.
World Bank is assessing the Sustainability of the NHI P4P Scheme (Belize City and Southern Districts) and scalability (North and national) of the NHI P4P Scheme.
1RBF in the LAC region 2RBF in the
Caribbean 3 Lessons learned
Dominica and Saint Lucia situational analysis on the
potential use of RBF
ASSESSMENT CONVENING
S2S Exchanges to Argentina, DR and
Belize to learn from RBF experiences
FINANCING
Preparation of a Human Development Project with a Health
Component
2012 2015
1RBF in the LAC region 2RBF in the
Caribbean 3 Lessons learned
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Eastern Caribbean - RBF Awareness Raising Workshops (Jan 2012)- Situational Analysis of RBF in Dominica and Saint Lucia (May 2012)- Findings/Recommendation for Piloting RBF in the Eastern Caribbean (May
2013)- Study Tours for Argentina, Dominican Republic, and Belize (virtual) (Nov
2013 -Feb 2014)- Costing of Service Delivery of RBF (Saint Lucia) (May 2014)
1RBF in the LAC region 2RBF in the
Caribbean 3 Lessons learned
RBF schemes, rather than traditional financing of inputs, successfully foster governance of service delivery and health results.
Performance agreements and financial transfer mechanisms with effective monitoring have offered clear incentives to health providers to accomplish specific health results
Organizational changes introduced by RBF are demanding, both technically and institutionally
RBF linking production of activities to financing can be transformative in a short period of time. Public health activities financing had visible effects in changing behavior even when implemented for a short period and involving a relatively small amount of funds
Contributes to improve data recording & info verification systems/mechanisms
Role of third party verification
1RBF in the LAC region 2Why RBF in the
Caribbean? 3 Lessons learned
Some lessons learned from RBF projects
