What’s the Evidence: Does RBF lead to better results? Rena Eichler, PhD Broad Branch Associates renaeichler@comcast.net Results Based Financing to Reduce Maternal, Newborn, and Child Mortality, (Session 2.2; October 20, 2008)

RBF is being implemented in a “big way” … Argentina Transfers from the federal to province level are based on the number of poor women and children enrolled in a social insurance program and performance on key output measures, implemented in 15 provinces with plans to extend nationwide. China In half of China’s province, providers who refer smear positive patients to a TB dispensary receive a financial payment and those responsible for managing treatment receive a payment when the patient is cured. Mexico A government run program that has evolved over 8 years now provides 25 million people (1/4 of the population) a monthly payment that is conditional on school attendance, obtaining preventive care and health education

Why consider Results Based Financing? Other approaches have not worked. There is a growing body of evidence that RBF does work. Much evidence comes from contexts with weak capacity and far from “ideal” enabling environments. Evidence is presented 2 ways: with a “disease” lens and a “health systems” lens. But the devil is in the details.

Previous solutions have not adequately addressed the incentive environment. Poor health outcomes result from: Underutilization of essential services Inequitable access Poor quality Inefficiencies in the use of health resources One “underlying cause” common to all is a dysfunctional incentive environment. Strategies that counteract disabling incentives and complement other systemic interventions may be what’s needed for significant progress. Train people and build buildings (1960’s- 1970’s>>>) Develop Managers (1980’s >>>) Expand the role of the private sector (1990s>>>) Enhance the steering role of the public sector (1990s>>>) Implement Quality Assurance Programs (1980’s>>>) Give more money (ODA for health has grown from $2.6 billion in 1990 to $10 billion in 2003) And others But we are far off track from achieving the MDGs, quality continues to be inadequate, and equitable access appears to be a dream.

What to expect… Time limited measurable interventions respond quickly. Immunizations, vitamin A, generic curative care visits, deliveries. Extended duration, time limited interventions take longer to show results- but results do come. Prenatal care, family planning, tuberculosis treatment completion Chronic conditions requiring considerable lifestyle change pose the toughest challenge- but evidence suggests promise. ART, diabetes, hypertension, obesity, addiction

Time limited measureable interventions are good candidates Immunization coverage: Supply side in Haiti: NGOs paid partly for results achieved a more than 13% increase in immunization coverage per year over those paid for inputs. Nicaragua CCT (both D and S): Increase of over 30% compared to control areas- even larger increases for the extreme poor. LAC CCTs (largely D only): Often begin with high baseline- so program wide improvement has been tough to show. Significant impact, however, seen with hard to reach groups.

Time limited continued… Generic curative services: Supply side in Rwanda: increasing use of formal services after the genocide was a priority. Pilot regions with RBF saw increase in per capita curative services from .22 to .55 while comparison regions increased from .2 to .3. Attended deliveries: Supply side in Haiti: Significant increase in attended deliveries under RBF. NGOs paid partly based on results achieved a more than 19 percentage point increase in assisted deliveries over NGOs paid for inputs.

Extended duration, time limited interventions take longer to show results Child nutrition outcomes CCTs in LAC (demand side): Reduced child stunting by: Colombia: 6.9% points Nicaragua: 5.5% points Mexico : 29% girls, 11% boys Prenatal Care Supply side in Haiti: Took 2 years before RBF increased the proportion of pregnant women receiving all prenatal care visits.

Extended duration, but time limited cont… Tuberculosis treatment Demand and Supply in Tuberculosis control: Many TB programs use food to encourage adherence, some use other material goods, others use financial rewards. In 3 Russian oblasts, food, travel subsidies, clothes and hygienic kits caused default rates to drop from 15-20% to 2-6%. In the US, $5 payment increased proportion of homeless people following up after a positive TB test from 53% to 84% and regular monetary incentives increased treatment completion.

Chronic conditions requiring considerable lifestyle change pose the toughest challenge. ART Adherence US demand side: Small monetary incentives to HIV-infected patients led to an increase from 70% to 88% in the short term. When incentives stopped, adherence reverted back. Diabetes US supply side: Managed care plan provided bonuses linked to performance on a composite score of effective output (completion of screening tests) and outcome (hemoglobin and blood pressure levels). Average composite score for participating physicians increased 48%, compared to only 8% among non-participators.

Chronic conditions continued… Demand and supply side incentives have also been tried for conditions that are addictive and require considerable lifestyle change: Smoking cessation (UK, US) Alcohol and cocaine use (US) Obesity (US) Many show short term results while incentives are paid- but behavior often reverts if/when the program stops.

RBF to Solve Health System Problems RBF to achieve over-arching goals : Improve equity Increase utilization Enhance quality Increase efficiency Solutions can be on the supply side, demand side, or both. Example: Poor household, low use. Describe a story of poor household that faces barriers to access. Show how CCTs and other demand side can increase use and improve equity. Also discuss how supply side incentives can solve by inspiring providers to overcome consumer obstacles to achieve targets and bonuses. Refer to Table 3.1 Increasing Utilization Overcoming financial and physical barriers to access that poor households face Overcoming information and cultural barriers that inhibit utilization Strengthening capacity to provide services Catalyses changes that strengthen management. Improves information systems and the use of information for decisions. Motivates health workers. Improving quality Preventive care services utilized by more people Rewards correct diagnosis and treatment Improving efficiency Better use of inputs to achieve health results

Contrast RBF with “business as usual” RBF catalyzes actions of many individuals and service providers to find solutions from the bottom up. “Other” solutions are often top down, implemented by planners and managers. Q: In environments with weak regulatory capacity, questionable governance, and spotty records of achieving results does it really make sense to continue to rely on the “usual” top down solutions?

Contextual implications Performance-based incentives may be particularly useful in the following contexts: Weak-state settings Afghanistan Haiti Presence of strong NGOs Bangladesh case of TB control Most contracting out examples Where current incentive structures encourage poor performance Most government systems Most FBOs

Limitations of the evidence Cost-effectiveness analyses lacking Small sample size Few rigorous evaluations Cannot isolate demand- and supply-side factors Little info about what’s inside the “black box”

Some lessons from the evidence Given limitations, we can still conclude from the evidence that performance-based incentives can work for Preventive care Single and simple interventions An intervention with a proven link to an expected outcome An intervention that is easy to be measured and reported

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