A presentation by Dinesh Nair, delivered during "Transforming Health Systems Through Results-Based Financing," an event held during the Third Global Symposium on Health Systems Research in Cape Town on September 30, 2014. This event was hosted by the Health Results Innovation Trust Fund at The World Bank, in partnership with the PBF Community of Practice in Africa.

1. Learning from RBF
Implementation
Dinesh Nair Sr Health Specialist

2. Overview of Session
• Why do we need to “learn from RBF”?
• Pulling it all together: the conceptual framework
• Nigeria Case Study

3. Many opportunities to learn
Concept
Design
Start-up
Implement
Implement
Implement
Implement
Comprehensive learning agenda

4. A broad approach to learn from RBF
implementation
• Holistic conceptual framework which highlights:
 the intermediate outcomes necessary to achieve
results
 the utility of a multidisciplinary lens
 the need for broad methodological approaches

5. Conceptual
Framework

6. A Conceptual Framework for PBF
What organizational and behavioral changes do you expect PBF
to bring about?

12. Learning from RBF
Implementation:
Nigeria Experience

13. RBF in Nigeria combines the PBF at health centers and
DLIs to state and local governments
Results Based Financing Approach in Nigeria
Federal
Govt.
$$ State
Govt.
Finance based on.. (Examples)
• Increase in services
• Budget execution
• Bonus payment
DLI
Local
Govt.
Health
Centers
• Supervision
• HMIS reporting
• HR management
• Quantity of services delivered
• Quality scores of the services
PBF
$$
$$

14. Coverage has been increasing significantly, but further
improvement is required
Coverage of health services in Pre-Pilot facilities in Adamawa state (%)
45
40
35
30
25
20
15
10
5
0
Inst Deliveries
Vaccination
FP
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
• Significant improvement
from very low baseline in all
indicators
• The is a good contrast with
low DHS 2013 results in the
North East (institutional
delivery 20%, vaccination
14%, FP 11%)
• However, the overall
utilization is still 30-40%

15. Detailed look at the operational data revealed the large
variations in performance across Health Centers
Institutional Delivery in Adamawa, normalized by 100,000 population
140 Pariya HC
120
100
80
60
40
20
-
Chigari HC
Dasin Hausa HC
Farang HC
Ribadu HC
Furore MCH HC
Choli HC
Gurin HC
Malabu HC
Karlahi HC
Wuro Bokki HC
Kabilo HC
Saint Mary's Clinic HC
Mayo-Ine HC
• Before PBF, all
health centers
were equally at
very low levels
• After the PBF,
some facilities
achieved 100%
coverage while
others struggle
with limited
improvement

16. This performance variation across health centers also
exists in quality of care
Quality Score (%) in pre-pilot health centers in Adamawa state
90
80
70
60
50
40
30
20
10
0
Dec Mar Jun Sep Dec Mar Jun Sep
Malabu HC
Wuro Bokki HC
Farang HC
Furore MCH HC
Gurin HC
Karlahi HC
Kabilo HC
Mayo-Ine HC
Pariya HC
Dasin Hausa HC
Ribadu HC
Range: ~30%
Range: ~23%
• The quality score
overall improves
even in low
performers
• However, the
difference
between high and
low performers
increased from
23% to 30%

17. Nigeria team engaged with two qualitative
studies
1. Demand-side barrier analysis 2. Case study on key
determinants
• What are the barriers to
service utilization in the PBF
facilities?
• Transport, service fee,
culture/perception/
information barriers
• Competition of alternatives
• Interview and focus group
• High and low performers
• Design demand-side
interventions
• What differentiate the good
and poor performers under
the PBF scheme?
• Health center management
• Contextual factors
• Health systems factors (e.g.,
supervision)
• Interviews, document review,
direct observations
• Best and poorest performers
• Devise appropriate support to
poor performers
Research
question
Areas to
look into
Approaches
Potential
use

18. Demand-side barrier analysis revealed priority
issues
Major Barriers Found through Qualitative
Analysis
Demand-
Side
Barriers
Transport
Cost
Community/
Culture
Priority demand side
intervention
Possible approaches
• Transport Voucher
Services
Competition
Availability
Cost
Predictability
of cost
Hospitals
Traditional
providers
Community
support
Magnit
ude
Controlla
bility
High High
High Med
High High
High High
Varies Low
Varies Med
High High
Varies Med
• Community transport team
•Maternal shelter
• CCT
• Predictable/discounted
pricing (supply-side)
• N/A
• Incentives for referral to PHCs
(supply-side)
• Community engagement
(supply-side)
• Communication and
community involvement
Culture

19. Case study on determinants suggests the importance of
community engagement and OIC management
Identified determinants and non-determinants (preliminary)
Non-Determinants
• Level of staffing (best performers
lack staff)
• Remoteness of facilities (best
performers are very rural)
• Technical qualifications of OIC
(many community health workers
manage facilities well)
• Business planning (none use it
effectively yet)
Determinants
• Community engagement (e.g.,
involve and reward community
leaders, daily visits, incentivize
for use of facility)
• OIC’s management capacity
(e.g., full staff involvement,
improve staff environment using
performance bonus, rigorous
performance review)

20. Research findings will drive new demand-side
interventions with additional financing
Proposed Transport Voucher and Strengthening management capacities
Implementation Arrangements
• Build demand side interventions to support Supply Side RBF
interventions
Improve Capacities
• Community engagement
• Management capacity building
of health centers
• Technical training (e.g., IMCI) for
quality improvement (QI)
Transport Voucher
• ANC standard visit (1-4)
• Institutional delivery
• Postnatal consultation
• Vaccination of children
• Growth monitoring
• Referred services provided by
hospitals

21. Key Lessons Learned
• RBF performance hinges on how well and quickly we
can learn from implementation and improve our
approaches
• Qualitative research can provide a powerful insights
and evidence in devising effective approaches
• Identifying right research questions and clear plan to
use the research results are required to make the
qualitative research meaningful