Prioritizing Performance Problems and Choosing Recipients Amie Batson Senior Health Specialist The World Bank October 2008

Designing Results Based Financing

1. What are the levels of mortality in your country? Nationally In various regions In rural vs urban areas Among the poor In specific groups: ethnic minorities

2. What are the causes of mortality

Most mortality causes still avoidable with low cost interventions

3. What are the key high impact interventions which can reduce mortality ? Household and Community Level interventions Population-oriented interventions Individual Clinical interventions

Household and community level interventions Insecticide Treated Mosquito Nets Safe water systems Use of sanitary latrines Hand washing by mother Indoor Residual Spraying (IRS) Clean delivery and cord care Early breastfeeding and temperature management Universal extra community-based care of LBW infants Breastfeeding Complementary feeding Therapeutic Feeding Oral Rehydration Therapy Zinc for diarrhea management Vitamin A - Treatment for measles Chloroquine for malaria (P.vivax) Artemisinin-based Combination Therapy Antibiotics for U5 pneumonia Community based management of neonatal sepsis

Population oriented interventions Family planning HPV vaccination Tetanus toxoid Preconceptual folate supplementation Deworming in pregnancy Detection and treatment of asymptomatic bacteriuria Treatment of syphilis in pregnancy Prevention and treatment of iron deficiency anemia in pregnancy Intermittent preventive treatment (IPTp) for malaria in pregnancy Balanced protein energy supplements for pregnant women Supplementation in pregnancy with multi-micronutrients PMTCT VCT Cotrimoxazole prophylaxis for HIV+ Childhood Immunization Measles BCG OPV DPT Hib Hepatitis B Yellow fever Meningococcal A/C Pneumococcal Rotavirus Neonatal Vitamin A supplementation Vitamin A - supplementation Zinc preventive

Individual clinical interventions Skilled attended delivery Basic emergency obstetric care (B-EOC) Resuscitation of asphyctic newborns at birth Antenatal steroids for preterm labor Antibiotics for Preterm/Prelabour Rupture of Membrane (P/PROM) Detection and management of (pre)ecclampsia (Mg Sulphate) Management of neonatal infections Antibiotics for U5 pneumonia Antibiotics for diarrhea and enteric fevers Vitamin A - Treatment for measles Zinc for diarrhea management Clinical management of neonatal jaundice Management of severely sick children (referral IMCI) Chloroquine for malaria (P.vivax) Artemisinin-based Combination Therapy Management of complicated malaria (2nd line drug)

Individual clinical interventions Management of opportunistic infections Male circumcision Second-line ART Adult second-line ART Comprehensive emergency obstetric care (C-EOC) Other emergency acute care Detection and management of STI Management of opportunistic infections First line ART Detection and treatment of TB with first line drugs (category 1 and 3) Re-treatment of TB patients with first line drugs (category 2) MDR treatement with second line drugs

4. What could be achieved if the coverage with high interventions increases ?

Saving 1.3 million lives per year for $ 400 per life saved: jumpstarting community care & outreach

Saving 2.5 million lives per year for $ 800 per life saved: Full Minimum Package at scale:

Saving 5.5 million lives per year for $ 1,500 per life saved: maximum package at scale.

5. So why is it not happening ? Supply issues ? Do people have physical access to services ? Infrastructure? Equipment? Are human resources available? Are commodities and pharmaceuticals available? Is quality of care a major problem Demand issues ? Is demand for services low? Is continuity of services or compliance low? Is low demand due to financial barriers, social and cultural barriers ?

Who should be the recipient of RBF? What is the reasons for low coverage? Where should the RBF incentive be targeted? Health worker Individual action (working harder) all that is needed. Benefits outweigh the high costs of monitoring and rewarding performance at this level Health facility: Work of facility team is needed System changes are needed Improve performance of different providers: public, private, NGO Consumer (community, family, mother): Hidden costs (transport, food) constraining demand Community needed to support families / encourage demand

How might you target recipients? Health facilities Are all health facilities eligible? Or does scheme target public sector facilities? Private sector? NGO? Does the scheme target facilities in specific provinces (e.g., poorest) Consumer (community, family, mother) Geographic – target all living in poorest provinces or districts Means test – target poorest families in an area Target all demanding/requiring a priority service All pregnant women to encourage institutional delivery

Example from MCH Performance problem: Low % of women delivering in facility with trained health worker Underlying causes: Consumer side: can’t afford transportation, mother-in-law or community discourages it, can’t afford food or cost of drugs Provider side: poor quality service, rude to mothers, no effort to follow up after antenatal visits. Provider paid a fixed salary regardless of performance. Other: Drugs not available. Health workers not well trained Potential results-based incentives Patient side: subsidies to cover transportation costs, food packages or money when deliver at the institution Provider: Payment for increased number of women delivering in facilities

Examples: Objectives and Recipients Objective Recipient Increase institutional deliveries as means for reducing MMR Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, Increase % of childen/mothers sleeping under LLINs last night, especially among the poor Improve demand: Mothers, TBA Increase supply: TBA, Service provider Increase supply: Service providers (NGO, public, private, sub-national) Increase use of services: community, household Service provider (NGO, public, private) in a poorly performing district

Designing RBF questions 1. What are the levels of mortality in your country? 2. What are the causes of mortality? 3. What are the key high impact interventions which can reduce mortality? 4. What could be achieved if the coverage with high interventions increases? 5. So why is it not happening ? 6. Who should be the recipient of RBF?

What is the potential for RBF? Rwanda: back on track for the MDGs