Learning from RBF Implementation Dinesh Nair Sr Health

Learning from RBF Implementation Dinesh Nair Sr Health Specialist

Overview of Session • Why do we need to “learn from RBF”? • Pulling it all together: the conceptual framework • Nigeria Case Study

Many opportunities to learn Concept Start-up Design Implement Comprehensive learning agenda

A broad approach to learn from RBF implementation • Holistic conceptual framework which highlights: Ø the intermediate outcomes necessary to achieve results Ø the utility of a multidisciplinary lens Ø the need for broad methodological approaches

Conceptual Framework

A Conceptual Framework for PBF àWhat organizational and behavioral changes do you expect PBF to bring about?

Learning from RBF Implementation: Nigeria Experience

RBF in Nigeria combines the PBF at health centers and DLIs to state and local governments Results Based Financing Approach in Nigeria Federal Govt. $$ $$ Finance based on. . (Examples) State Govt. • Increase in services • Budget execution • Bonus payment Local Govt. • Supervision • HMIS reporting • HR management Health Centers • Quantity of services delivered • Quality scores of the services $$ DLI PBF

Coverage has been increasing significantly, but further improvement is required Coverage of health services in Pre-Pilot facilities in Adamawa state (%) Inst Deliveries Vaccination FP 45 40 35 30 25 • Significant improvement from very low baseline in all indicators • The is a good contrast with low DHS 2013 results in the North East (institutional delivery 20%, vaccination 14%, FP 11%) 20 15 10 5 Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec 0 • However, the overall utilization is still 30 -40%

Detailed look at the operational data revealed the large variations in performance across Health Centers Institutional Delivery in Adamawa, normalized by 100, 000 population 140 Pariya HC Chigari HC 120 Dasin Hausa HC Farang HC 100 Ribadu HC 80 Furore MCH HC Choli HC 60 Gurin HC 40 Malabu HC Karlahi HC 20 be r m t gu s pt e Se Au Ja be r ce Ju ly Saint Mary's Clinic HC nu a Fe ry br ua ry M ar ch Ap ril M ay Ju ne Kabilo HC m Wuro Bokki HC - De • Before PBF, all health centers were equally at very low levels Mayo-Ine HC • After the PBF, some facilities achieved 100% coverage while others struggle with limited improvement

This performance variation across health centers also exists in quality of care Quality Score (%) in pre-pilot health centers in Adamawa state 90 Malabu HC 80 Wuro Bokki HC Farang HC 70 Furore MCH HC 60 Gurin HC 50 Range: ~30% 40 Kabilo HC Pariya HC 20 10 Karlahi HC Mayo-Ine HC 30 Dasin Hausa HC Ribadu HC Range: ~23% Choli HC 0 Dec Mar Jun Sep • The quality score overall improves even in low performers Chigari HC • However, the difference between high and low performers increased from 23% to 30%

Nigeria team engaged with two qualitative studies 1. Demand-side barrier analysis 2. Case study on key determinants Research question • What differentiate the good • What are the barriers to and poor performers under service utilization in the PBF scheme? facilities? Areas to look into • Transport, service fee, culture/perception/ information barriers • Competition of alternatives • Health center management • Contextual factors • Health systems factors (e. g. , supervision) • Interview and focus group • High and low performers • Interviews, document review, direct observations • Best and poorest performers Approaches • Design demand-side Potential use interventions • Devise appropriate support to poor performers

Demand-side barrier analysis revealed priority issues Priority demand side Major Barriers Found through Qualitative Analysis Transport Services Demand. Side Barriers Competition Community/ Culture intervention Magnit ude Controlla bility Possible approaches Cost High • Transport Voucher Availability High Med • Community transport team • Maternal shelter Cost High • CCT Predictability of cost High • Predictable/discounted pricing (supply-side) Hospitals Varies Low • N/A Traditional providers Varies Med • Incentives for referral to PHCs (supply-side) Community support High • Community engagement (supply-side) Varies Med • Communication and community involvement Culture

Case study on determinants suggests the importance of community engagement and OIC management Identified determinants and non-determinants (preliminary) Determinants Non-Determinants • Community engagement (e. g. , involve and reward community leaders, daily visits, incentivize for use of facility) • OIC’s management capacity (e. g. , full staff involvement, improve staff environment using performance bonus, rigorous performance review) • Level of staffing (best performers lack staff) • Remoteness of facilities (best performers are very rural) • Technical qualifications of OIC (many community health workers manage facilities well) • Business planning (none use it effectively yet)

Research findings will drive new demand-side interventions with additional financing Proposed Transport Voucher and Strengthening management capacities Transport Voucher • ANC standard visit (1 -4) • Institutional delivery • Postnatal consultation • Vaccination of children • Growth monitoring • Referred services provided by hospitals Improve Capacities • Community engagement • Management capacity building of health centers • Technical training (e. g. , IMCI) for quality improvement (QI) Implementation Arrangements • Build demand side interventions to support Supply Side RBF interventions

Key Lessons Learned • RBF performance hinges on how well and quickly we can learn from implementation and improve our approaches • Qualitative research can provide a powerful insights and evidence in devising effective approaches • Identifying right research questions and clear plan to use the research results are required to make the qualitative research meaningful