Implementation Research Taking Results-Based Financing from Scheme to System Maryam Bigdeli Third Global Symposium on Health Systems Research Satellite meeting – 30 September 2014 Bridging the worlds of research and policy

Call for Expressions of Interest S upport the development of analytical case studies on RBF and similar initiatives in selected LMICs Answer questions on enablers and hindrances in the transition of these types of initiatives from a scheme/project to being fully integrated into the health system A multi-country study aimed at drawing cross-cutting lessons on enablers and challenges to scaling-up RBF Support from a technical coordinating centre : Bruno Meessen and team at Institute of Tropical Medicine in Antwerp Protocol development workshop in October 2014

Our working definitions Results-Based Financing Purchasing mechanism that links payments (to producers or consumers) to process or output measures (which may be quantitative or quality measures or a mix of both) that can serve as indicators of, or proxies for, improved health outcomes Implementation Research The scientific study of the effective delivery of health interventions in diverse settings and within the existing range of health systems. Implementation research goes beyond understanding what is and is not working, to explain also how and why implementation is going right or wrong in that particular setting Program scale-up: Coverage: geographical, population coverage, services System integration: institutional arrangements for purchasing function, relationships with health system reforms or financial management reforms etc. Sustainability: ownership, sustainability and institutionalization of verification mechanisms, whether RBF has been made a part of national policy

Research questions Overarching question: What are the dynamics (actors and factors) that enable or hinder RBF scale-up decisions and/or implementation? Sub-questions: What was the motivation behind the decision to scale up? Who were the drivers, actors and what were the processes followed? To what extent is the scale up of the RBF program being achieved? What are the factors explaining this? What are the key health system and wider government reforms that should be considered? Which strategies and processes have been effective in sustaining the scale up and integration of RBF? What were the expected, unexpected, positive, and negative consequences of RBF on and beyond the health system, including for example fiscal and governance implications that had to be taken into account during scaling-up?

Selected proposals TitlePIOrganizationCountry PBF policy formulation, implementation, and scale up in RwandaJames Humuza National University of Rwanda, School of Public Health Rwanda A stakeholder analysis to understand why performance-based financing (PBF) scheme in Chad discontinued Lamoudi YonliResearch Department of CSSIChad Financial and governance reforms during scale-up of PBF in CameroonIsidore Sieleunou Research for Development International (Cameroon) Cameroon Barriers & enabling factors to scale up RBF in MozambiqueJoana Falcao Colaboracion Desenvolvimento de Mozambique Mozambique Actors and factors in the scaling up of results-based financing in Kenya. Analysis of institutionalism and challenges of a newly- devolved health care system Erick Otieno Nyambedha Maseno UniversityKenya RBF national roll out in Tanzania: monitoring drivers of policy formulation and early implementation. Masuma MamdaniIfakara Health Institute United Republic of Tanzania Learning from multiple schemes for scale up and sustainability of RBF in Uganda Freddie Ssengooba Makerere University School of Public health Uganda Scaling up internal contracting in Cambodia: Lessons and implications for further expansion and integration into the health system Keovathanak KhimUniversity of Health SciencesCambodia Taking Results- Based Financing (RBF) from scheme to system : Burundi Case Study Eric BigirimanaBregmans Consulting & ResearchBurundi Armenia Results-Based Financing Case StudyAkaki Zoidze Curatio International Foundation and Center for Health Services Research and Development at American University of Armenia Armenia Pay for Performance in Macedonia: From pilot project, to national reformVladimir LazarevikHealthgrouperMacedonia

Rationale for selecting Quality of proposals and skills of applicants– reviewed by ITM, AHPSR, WHO HSF, WB Scale up achieved vs about to start / in the pipeline Pilot failed to scale up Multiple pilots / experiences Structural challenges to scale (e.g. devolution process or poor governance European perspective on pay for performance experience

Next steps Adopt a common view –Different stages of scaling-up (Meessen et al) –Different approach for each stage -> Brainstorming and protocol workshop October 2014 in Antwerp Field data collection and analysis – 12 months Final workshop –Cross-cutting lessons –Common outputs and publications Adoption (from project to scheme) Institutionalisation (from scheme to policy) Perpetuation (from policy to system)

Questions to Maryam Bigdeli Bruno Meessen Thank you!