Insights from a controlled trial on results based financing

There is a growing body of experience in a range of RBF-related programmes, but there remain key gaps in the evidence including how cost-effective programme approaches can be adapted to circumstances of fragility, poor governance and weak systems, where unmet need in reproductive, maternal, newborn and child health is often greatest.

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With the launch of the Sustainable Development Goals, the UN Secretary General’s revised Global Business Plan for Maternal and Child Health, and the World Bank-hosted Global Financing Facility, there is a renewed imperative in understanding how Results Based Financing (RBF) can improve efficiency, effectiveness and accountability in programming towards Universal Health Coverage  and improved health outcomes at scale.

Evidence, experience and insights on Results Based Financing with non-state providers from a controlled trial in Northern Uganda is summarised in a set of three publications. Together these publications provide an overview of insights generated over the course of the Northern Uganda Health (NU Health) programme, with the aim of informing programme efforts by other health service providers, government agencies or cooperating agency partners.

A final report and an accompanying technical annex (36 pp. 1.3 MB) aim to contribute to the growing body of evidence related to Results Based Financing,  what determines its effectiveness, and how stakeholders – both providers and putative beneficiaries – have come to receive it. The NU Health Insights Report is aimed at programme planners and managers and provides a practical summary of the key learnings from NU Health, with greater detail on context, design and learning.

The NU Health Policy Brief is aimed at decision makers and provides a concise outline of the implications for policy and programme arising from NU Health. While the supplementary Technical Annexes are aimed at technicians and investigators complement the NU Health Policy Brief and NU Health Insights Report to provide additional detail on the approaches, methodologies and evidence presented in those documents.

Key messages include:

  1. Results Based Financingcan lead to improvements in quality of care for major childhood killers such as malaria, diarrhoea and pneumonia.
  2. Results Based Financing can significantly improve data management and reporting, and lead to better decision making for resource allocation.
  3. When designing an Results Based Financing programme, practitioners should consider factors such as the balance between Input Based Financing and Results Based Financing and the supply and demand side of Results Based Financing, the level of autonomy over fund use, and the means for maintaining effective results verification at scale as well as the requisite financial management.

Mothers-waiting-room-Karin-UgandaFunded by UK aid from the UK government and implemented by Health Partners International and Montrose International, NU Health is a controlled implementation study to assess the costs and benefits of RBF relative to conventional Input Based Financing. The study design aimed to isolate the main effect of the financing modality in terms of quality and quantity of health service provision. Programme data and the results of an independent evaluation conducted by Liverpool School of Tropical Medicine confirm a range of key findings. These include:

  • A significant reduction in barriers to access and increase in health service utilisation;
  • A massive three to eight fold improvement in adherence to standard treatment algorithms/quality of care for the major childhood killers:  diarrhoea, malaria and pneumonia; and,
  • Particularly dramatic improvements in care and utilisation at the lowest level facilities, harbouring the promise of real progress toward Universal Health Coverage!

In addition, an independent impact evaluation articulates the detailed effects on service delivery and, certain health outcomes, and an associated qualitative review examines the impact of different financing methods on incentives and behaviour of facility managers.

Images

Top centre: District health team and facility staff work together in a RBF supported facility, Comboni, Uganda. NU Health. Photo credit: Helena Vidalic

Bottom right: Mothers in a health facility waiting room, Karin, Uganda, NU Health. Photo credit: Helena Vidalic

Jeffrey W. Mecaskey

Jeffrey W. Mecaskey

Jeffrey Mecaskey is Technical Lead for Economics and Financing and Co-Lead for Evidence and Learning at HPI with 35 years’ experience in international development with a focus on health and political economics, health policy and management. He was chair of the programme management board for the UK aid funded Improving Access to Health Care for the Poor, Northern Uganda (NU Health), and is currently a Senior Technical Expert on the EU-funded EU-Strengthening Immunisation Governance in Nigeria (EU-SIGN) and Maximising the Quality of Scaling Up Nutrition+ (MQSUN+) programme.

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