There has been an overwhelming interest for the Results-based financing (RBF) initiative launched in November last year and funded by Norway as a multi-donor trust fund in the World Bank. After a short listing, 16 countries were asked to develop brief proposals. Although all proposals met high quality standards, in the end only four countries were selected by a selection panel in this first round (2-3 years) due to budget restrictions.
The countries suggested by the World Bank were Afghanistan, Eritrea, Rwanda and Zambia, following scores on a given set of criteria. They will be supported to further design, implement, monitor and evaluate their respective RBF schemes. If successful, this will end in a plan for sustaining and scaling up RBF activities within the countries.
The countries themselves will establish mechanisms for funding the performance, such as paying for, or providing other incentives for the services provided at health centres and hospitals. The programmes will receive substantial technical advice, and implementation will be subject to close monitoring and evaluation.
Linking Health to Results
Results-based financing, also known as performance-based financing or pay-for-performance, refers to a range of mechanisms or incentives to enhance the performance of health providers and/or users. RBF includes payment for attainment of specific goals, such as service provision or for the use of services, and are either supply-side or demand-side interventions.
Supply-side interventions may be payment to health facilities for number of immunized children over a certain level or for number of assisted deliveries in facilities. GAVI uses a similar mechanism paying a country for increases in coverage. Such incentives may be directed to the district health team, to the health facilities, to groups of staff or to all staff members. Private providers and NGOs may be included in such schemes. Examples of demand-side interventions are conditional cash transfers directly to mothers when delivering in hospitals, transport vouchers or community funds, among other things.
Experience to date with RBF for health in low income countries is limited. The better documented ones include a quite comprehensive RBF system in Rwanda which is mainly supply-side, conditional cash transfer schemes for preventive care in Mexico and Nicaragua, contracting public health services to NGOs in Cambodia, and demand-side interventions in Argentina. However, many of these are limited geographically or in magnitude, and the issue of scaling up is a major challenge. It should also be stressed that RBF is not a goal in itself, but a mechanism to improve maternal- and child health.
Norwegian Country Work on RBF
A similar type of programme is the bilateral Norwegian involvement in the MDG 4&5 initiative, that Norway has established, or is about to establish, in India, Tanzania, Nigeria and Pakistan. There payments for provision and use of maternal and child health services are elements in larger programmes. Through this initiative different payment mechanisms are linked to actual achievements in terms of service delivery or use, all with the aim of reducing maternal and child mortality and morbidity. In India this includes both payments to community health workers for bringing women to the health facilities and for women to get there. In Tanzania the preliminary approach is to provide incentives to service providers e.g. attended deliveries in facilities.
World Bank Health Result Innovation Grant
Norway and the World Bank established a US$ 105 million trust fund in December 2007, which will run over six years until December 2013. As the biggest financier for health in developing countries, the World Bank is seen as a key partner in the MDG 4& 5 campaign. The multi-donor trust fund is linked to IDA credits, and will provide financing to national authorities to pilot RBF programmes. Norway is the sole donor to this trust fund, but welcomes other interested donors in joining.
If approved, the programmes in Afghanistan, Eritrea, Rwanda and Zambia will be implemented in close partnership with other international agencies (WHO, UNICEF, bilaterals, etc.), and implementing partners will also include NGOs. A newly established Inter Agency Working Group for RBF may serve as a resource group, for example to help document evidence and enable information sharing across countries and agencies. The country experiences will be continuously compared, contrasted, and considered in light of RBF experiences; guidance will be developed; and lessons and guidance will be widely disseminated. The World Bank will play a pivotal role also in this.