rbf through the public health sector in low-income countries essential design elements for a health...
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RBF through the Public Health Sector
in Low-Income Countries
Essential Design Elements for a Health Center RBF model
György Fritsche
HDNHE
RBF Seminar 27 October, 2009
Learning Objectives
For the Rwandan Health Center RBF model:
1. Describe the performance framework;
2. Describe three key design features;
3. Explain the role of technical assistance
The Performance Framework for Health Center RBF Fee-For-Service Conditional on Quality of Care
Results Based Financing/Performance-Based Financing
15-25 Services with unit fees (measured monthly) Services are ‘PBF SMART’: not all services can be
purchased Quality quantitative checklist (measured quarterly).
Extensive and well-balanced Quality: Carrot or Stick? Payment cycle quarterly
Key Design Elements (i) National level, health district level and health
center level design features District Level Design Features:
Significant Financial Incentives through performance framework for District Health Management Teams and District Hospitals
Separation of Functions: Creation of a quasi-market through internal contracts Transparent district level PBF governance mechanism Separate ‘quantity audit’ from ‘quality supervisory
function (separate teams)
Key Design Elements (ii)
Intense dedicated TA during introduction and subsequently making operational and refining PBF system
Civil Society/NGOs: Participation in data validation and Participation in district level PBF governance
mechanisms (‘quorum’)
Key Design Elements (iii) Health Center Level Design Features:
Performance framework targeting health facilities (as opposed to individual health workers)
Significant financial incentives reaching frontline health workers
Health Center bank account Regular bonus payments to health workers Increased Autonomy Purchase contract
Key Design Elements (iv) ‘Business Plan Approach’ Data Quality Audit of all purchased services
(routine; monthly) Services that are purchased need to be ‘PBF
SMART’ Quality Checklist with strong impact on
performance payments (comprehensive and routine)
Community Client Surveys
Three most important design elements?
1. Fee-For-Service Conditional on Quality of
Care RBF/PBF and incentives are
significant
2. Increased Health Facility Autonomy
3. Health Facility Performance Framework but
incentives trickle down to health workers
The role of technical assistance (i) Dedicated Project Implementation Unit or
Ministry of Health department Dedicated additional TA for program;
coordination of technical assistance; communication; MIS; training and IT support
Leveraging TA with in-country available resources
Strong national technical coordination platform dedicated to PBF (degrees of freedom; secretariat)
The role of technical assistance (ii)
Strong technical coordination platform dedicated to providing TA on PBF to districts (‘bridging the gap between policy and implementation’)
Cost of combined TA estimated at between $0.30 -0.40 /capita/year
First level of Control: Signing of a Contract with a Mayor
Second level: PBF Control is NOT ‘business as usual’ in data gathering
Third level: Discussion in the District PBF Steering Committee
Fourth level: Extended Team: 11 agencies and MOH departments
Fifth level (i) : Two national counter verification mechanisms: the quality counter verification protocol
Fifth level (ii) Two national counter verification mechanisms: the Community Client Surveys
Summary: Learning Objectives
For the Rwandan Health Center RBF model:
1. Describe the performance framework;
2. Describe three key design features;
3. Explain the role of technical assistance