what pbf can achieve; example from rwanda claude sekabaraga, md, mph world bank, nairobi hub....
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What PBF can achieve; Example from Rwanda
Claude SEKABARAGA, MD, MPH
World Bank, Nairobi Hub.
January 2010January 2010
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U5MR (per 1,000) in sub-Saharan Africa – MDG4 Target and Actual
0
20
40
60
80
100
120
140
160
180
200
1990 1995 2000 2005 2010 2015
Target
Actual
184
158
61
Source: Global Monitoring Report 2008
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Actual U5MR (DHS) vs. MDG4 target in Rwanda – 35% reduction from 2005 - 2008
0
40
80
120
160
200
1992 2000 2005 2008 2012 2015
Actual
Target
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REDUCTION OF INFANT MORTALITY
1/3 in years
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Modern contraception prevalence (% 15 -49 year-old women)
13
410
27
70
0
10
20
30
40
50
60
70
80
1990 2000 2005 2008 2015
63% of increase in three years
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Births attended by skilled health personnel (% of births)
2631
39
52
95
0
10
20
30
40
50
60
70
80
90
100
1990 2000 2005 2008 2015
25% of increase in three years
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MAL AR IA C AS E F AT AL IT Y R AT E IN H E AL T H C E NT E R
0.3
2
4.6
6.25.7
7.7
10.1
0.6
2.9
5.25.75.8
8.1
9.3
0
5
10
15
2001 2002 2003 2004 2005 2006 2007
Yea rs
Perc
entag
e
Malaria cas e fata lity rate < 5 Malaria cas e fata lity rate
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IMIHIGO: Performance based services for territorial administration
Strong political commitment to results Contract between the President of the Republic
and the district mayors and different local administration levels;
Key health indicators integrated in the contract (in 2007: ITNs, Mutuelles, FP, safe deliveries, hygiene..)
Quartely review with Prime Minister, President attending twice a year
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Autonomy of providers institutions
Based on Bamako Initiative Delegation of management Health centers and hospitals fully autonomous Subsidized by the government: PBF, needs
based block grant (initially for wages) Support to planning: Strategic and operational
planning are the fundament of the approach.
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Human resources management
Decentralization of wages; Community through facility committee have the authority to
hire and fire; Community through facilities receive block grant from
government; “People follow the money”; Retention of health personnel in rural areas increased.
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Trend in the financing of district health personnel
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Evolution of the number of selected staff in rural and urban districts (public sector)
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RESULTS BASED FINANCING PRINCIPLES
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What is Results Based Financing?
Incentives targeting provider’s behavior to produce more results and to comply on quality standards;
Incentives targeting household or individual behavior to use more services
Financing mechanism for defined quantity and quality outputs and outcomes.
PURCHASER
PROVIDER
HealthResults
Financial Incentives
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Verification of quantity and quality
Why to finance results vs. inputs?
Payment result
Financing strategy
Actions for results
Objective
Result
Equipment, consumables,Drugs, salaries, etc.
Supervision, training, audit
and Sanction?Investment ?TIME
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RBF PRIORITY AREAS AND BENEFITS
Based on major bottlenecks; Priority to composite indicators and avoid
selective performance; Quantity preventive interventions and quality of
both prevention and curative services; Promotion of local creativity and spirit for
performance; Improvement of remuneration of personnel and
equipment linked to services to community: ACCOUNTABILITY.
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How to finance results?
Evaluator/verificator
Regulator
ProviderPurchaserBeneficiary
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What systems are needed to implement RBF successfully? Does the regulatory framework require
change? How will results be routinely monitored
(HMIS?) and verified?
How to sustain? How will the government decide if it will continue to fund through RBF mechanism? How will you show impact? How will you show cost-effectiveness?
Concerns
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THE PERFORMANCE FINANCING SYSTEM
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SUSTAINABILITY OF RWANDA PBF FINANCING
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Results:Services produced (after 27 months of extention)
Results:Services produced (after 27 months of extention)
Indicateurs FBR Janvier 2006moyenne
mensuelle par centre pour 258 centres de santé
Mars 2008moyenne
mensuelle par centre pour 286 centres de santé
Pourcentage d’augmentation
Accouchements Assistés
21 37.5 78%
Nouvelles consultations curatives
985 1,489 51%
CPN: 2ième dose Anti-tétanique
21 52.5 150%
Nouvelles utilisatrices PF
15.5 47.9 209%
Utilisatrices de PF à la fin du mois
175.2 711.6 306%
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FAMILY PLANNING
R2 = 0.8635
0
5
10
15
20
25
30
35
40
45
50
55
60
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8
2006 2007
Per
cen
tag
e
50
194% increase
17
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Impact on quality of prenatal care
-0.10
0
-0.13
0.15
-0.15
-0.10
-0.05
0.00
0.05
0.10
0.15
0.20
Baseline (2006) Follow up (2008)
Stan
dard
ized
Pre
nata
l eff
ort s
core
Control facilities Treatment (PBF facilities)
15 % Standard deviation increase due to PBF
24
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Impact on institutional delivery
36.3
49.7
34.9
55.6
30.0
40.0
50.0
60.0
Baseline (2006) Follow up (2008)
Prop
ortio
n of o
f ins
tituti
onal
deliv
erie
s
Control facilities Treatment (PBF facilities)
7.3 % increasedue to PBF
25
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HEALTH CENTER(46.8 M USD)
Mutuelles
Amount: 13.8 M USD User Fees
Amount: 6.6 M USD
RAMA, MMI, PRIVATE INSURANCES
Amount: 5 M USD
Earmarked transfers from Minecofin
Formula: Norms of personnelAmount: 13 . 6 M USD
Performance Based FinancingGovernment: 4.2 M USDDonors: 3.6 M USD USG and BELGIUM
Formula: performance
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DISTRICT HOSPITAL
(31.162 M USD)
Performance Based Financing:
Formula: quality performance
Amount: 2.4 M USD
.
Mutuelles: 7 M USD
User FeesAmount: 5 M USD
RAMA, MMI, PRIVATE INSURANCES
Amount: 162, 000 USD
Earmarked transfers from MinecofinFormula: Norms personnelAmount: 16.6 M USD
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COMMUNITY, HEALTH CENTER and
DISTRICT HOSPITAL
Development Partners in kind transfers
Total amount: 60.6 M USD
GoR In kind transfers
Total amount: 12.2 M USD
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COMMUNITY PBF
To reduce child mortality: Malaria, pneumonia, diarrhea and monitoring of malnutition), and family planning;
Five CHW (a lady and a man for IMCI package) by village;
Organized in cooperatives and paid based on a package of services produced and checked by health center in term of quantity and quality.
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Conclusion BUILDING CULTURE OF RESULTS MORE THAN
INPUTS AND PROCEDURES
For ACCOUNTABILITY:1. Separation of functions: Purchasers, providers and direct
beneficiaries;2. Clear link between public funds and direct services to
community; Priority on high impact interventions (Family planning &
reproductive health, prevention interventions and family & community services)