If we want to scale up Results Based Financing, we need to understand the minimum levels of system functionality that are necessary to achieve Universal Health Coverage.
As described in the earlier instalment of this series, Results Based Financing has emerged as a key strategy to improve health sector performance whereby monetary incentives are aligned with desired health results.
Interest in RBF is centred principally on how it can improve the health sector’s efficiency and effectiveness. Growing evidence from pilot and demonstration projects suggest that RBF can indeed work, but evidence on efficiency and effectiveness gains beyond the pilot stage are limited.
In the literature and in our own experience, the question of systems receives short shrift. We hear presentations and read journal articles where a significant main effect is cited but there is little reference to that setting’s operating environment. We suspect that Results Based Financing is good. However, if it’s going to realise its potential in practice, there is a pressing need to get a handle on what minimum levels of system functionality are necessary for Results Based Financing to work.
As Health Systems Strengthening people, we knew of the challenge, but we did not fully appreciate its magnitude until we began Results Based Financing implementation. In Nigeria, we initially ran a set of demonstration projects in 2009. These projects developed in close consultation with stakeholders including putative beneficiaries. The Results Based Financing projects combined both supply and demand side interventions related to anti-natal care and assisted delivery, as well as immunisation. While the projects demonstrated proof of principle – that these Results Based Financing approaches could contribute to increasing both quality and quantity of services received – it also became apparent that prospects for going to scale, as designed, were limited. This was due to fundamental and rate-limiting systems constraints. Depending on the setting, there were too few staff to establish a segregation of responsibility, a Health Management Information System too under-developed to provide a basis for counter-verification of reported services, or inadequate material resources to maintain medical supplies. A summary of this work can be found here.
Our experience in northern Uganda was equally insightful, though we were better prepared to respond to the challenge. We knew that the design had to address the capacity and systems constraints in the conflict-affected north. The project was a prospective trial to assess the costs and benefits of RBF as compared with more conventional input-based financing. We therefore negotiated increased finance for the systems strengthening essential to the study, but also to generate evidence on the sort of investment potentially required for RBF work in that environment. A set of document outlining this work can be found here.
In an era when many in the sector are talking about post-ODA development in low- and middle-income counties—trade not aid—our experience suggest that there is some distance to go before local resources (even with the greatest political will) will be adequate to finance the health system development necessary to achieve Universal Health Coverage. Results Based Financing may have an important role in helping to improve the efficiency and effectiveness of domestic budget as well as development assistance spending. However, in that event, it will be necessary to have sober discussion about the systems requirements for Results Based Financing to realise its potential in practice—including the recurrent cost of those systems. The next and final blog in this series touches on the issue of accountability.