1. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane University’s School of Public Health Training Resources Group Overview of Steps to Design and Implement Results Based Financing Schemes Susna De, MSc, MPH Results Based Financing to Reduce Maternal, Newborn, and Child Mortality, (Kigali, October 20, 2008)

2. Session Objectives Be introduced to -- the elements of a results based financing approach. the step by step process to be used through the rest of the workshop. Based on the Pay for Performance (P4P) Blueprint Guide* Builds upon experience of 2 RBF regional workshops P4P in the Guide= RBF for purposes of this workshop * Eichler, Rena and Susna De. Paying for Performance in Health: Guide to Developing the Blueprint, USAID/ Health Systems 20/20 Project. May 2008. DRAFT

3. What is a RBF Blueprint?  Definition: a plan of action/ guide to developing a RBF approach  Output: Series of tables containing the main elements of an RBF design and operational approach for a given country  During workshop, you will develop/refine your own country Blueprint

4. Why develop a Blueprint ? RBF concept - relatively simple and logical i.e. use incentives to reward attainment of positive health results Mechanics of implementation need to be planned carefully; ‘Devil is in the details’ Need timely-cash transfers, Ensure accountability Manage and monitor performance Understanding how much is needed to motivate behavior change etc. Blueprint Guide helps organize thought processes and document considerations and decisions Involves a series of 8 steps and associated tasks Steps may seem quite involved; intention is to help you to outline the design process Does NOT address every detail for an operational implementation plan

5. Step 1: Assess and identify top five performance problems that RBF can address. Objective: To select the priority health results that will be addressed by your RBF intervention. Tasks entailed: Examine data on top causes of mortality and morbidity Identify underlying causes- related to motivation, provider and household action Prioritize based on whether change is possible and the benefit would be significant Choose top five Identify broad performance goals

6. Step 2: Determine recipients and how to select them Objective: To identify whose behavior you want to change through the introduction of RBF Tasks entailed: What possible RBF approach should be considered: incentives directed to the user or supplier/producer of services? Identify potential recipients Determine how recipients will be selected: e.g. a competitive process for providers/means testing for households etc

7. Step 3: Determine indicators, targets, and how to measure them Objective: To take initial steps towards defining targets of performance, indicators of measurement, and verification Tasks entailed: Define indicators of performance Determine targets for improvement Describe how indicators will be measured and validated.

8. Step 4: Determine payment mechanisms Objective: To determine mechanism that links reward (or penalty) to attainment of targets. Tasks entailed: Determine how much payment will be linked to performance and how much is not exposed to financial risk? Develop formula that will determine performance payment Clarify where the money will come from

9. Step 5: Determine the entity (ies) that will manage RBF mechanisms and how to make RBF operational Objective: To determine how to operationalize the RBF mechanism and responsible entities. RBF management functions: Management of the bidding process if selection is competitive (supply side) Design and implement targeting strategy (demand side) Design Contracts Negotiate contract terms Establish reporting procedures Monitor performance (routine) Audit and verify performance Generate payments Evaluate and revise contract terms Tasks entailed: Identify capacities needed Select management entity (ies) Determine relevant processes for operationalization Define organizational structure, staffing and systems Identify systems and capacity strengthening needs.

10. Step 6: Identify key stakeholders, positions, and approaches Objective: To determine a strategy for obtaining national buy-in, ownership, and mitigate potential opposition. Tasks entailed: List all potential stakeholders Assess degree of potential support Identify potential RBF champion(s) Identify approaches to generate buy-in

11. Step 7: Develop an evaluation and learning strategy Objective: To build into the RBF design a strategy for determining ‘what worked and what did not work’ Tasks entailed: Research questions for evaluation and learning strategy Determine how (system) interventions will be monitored and evaluated to provide evidence for scale up, revision, and detect (and revise) unintended consequences

12. Step 8: Develop a program of action— next steps Objective: To ensure that the RBF Blueprint will be considered and discussed by national stakeholders. Tasks entailed: Review and refine the blueprint developed thus far What are the immediate next steps needed to turn this blueprint into reality? Who are the key individuals that should be briefed? What key messages should be conveyed? What additional resources/support (financial and technical) will you need to follow-up on your plans? Will you need to assess feasibility of implementing RBF by identifying weaknesses in existing systems and strategies to fill them? What will your team do to continue work towards building RBF?

13. Getting started Review data on major health issues and their underlying causes Have on hand your MTEF and any relevant health sector strategic plans Country Data Top 5 causes of morbidity and mortality Maternal Mortality rate (per 100,000 live births) Infant Mortality rate (per 1000 live births) Antenatal care coverage (rate for those with at least 1 visit vs 4 visits) Vaccination coverage Births attended by a skilled health professional Contraceptive prevalence rate Total fertility rate HIV prevalence (adults 15 – 49) Government health expenditure as % of total government budget Total Health expenditure as % of GDP Total health expenditure per capita Utilization rates for key services e.g. immunizations, prenatal care, assisted deliveries, ARTs, Tb case detection and treatment completion, growth monitoring Utilization of health services by targeted population groups e.g. the poor, urban vs rural, male vs female, children, pregnant women Availability and distribution of health workers Household out of pocket burden of financing for health Financial contributors to providers (amounts and flows)

14. Develop your country blueprint Task: After presentations of each step, outline your country approach to that step Review concepts and considerations in the Guide. Process: work in country teams (sometimes paired) Share thoughts and experiences on assigned step (if applicable with other country) Outline and document your country response to the assigned step. Consult with technical resource people Time Allotted: 1-1.5 hours for each step If not finished, can continue work in evenings Some of you may be further along in RBF designs than others Nevertheless, important to document and discuss response to each step Will focus on addressing issues particular to your RBF mech.… e.g. impact eval Keep in mind: ITERATIVE process

15. Thank you!