This document discusses implementation research on scaling up Results-Based Financing (RBF) programs from pilot schemes to integrated national health systems. It calls for case studies on RBF initiatives in select low and middle-income countries to identify factors that enable or hinder this transition. Selected proposals will examine RBF scale-up experiences in multiple countries. Next steps include a protocol development workshop to design the research and analyze findings to draw cross-cutting lessons on scaling up RBF.

1. 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

2. Call for Expressions of Interest
• Support 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

3. 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

4. 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?

5. Selected proposals
Title PI Organization Country
PBF policy formulation, implementation, and scale up in Rwanda James 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 Yonli Research Department of CSSI Chad
Financial and governance reforms during scale-up of PBF in Cameroon Isidore Sieleunou Research for Development
International (Cameroon)
Cameroon
Barriers & enabling factors to scale up RBF in Mozambique Joana 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 University Kenya
RBF national roll out in Tanzania: monitoring drivers of policy formulation
and early implementation.
Masuma Mamdani Ifakara 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 Khim University of Health Sciences Cambodia
Taking Results- Based Financing (RBF) from scheme to system : Burundi Case
Study
Eric Bigirimana Bregmans Consulting & Research Burundi
Armenia Results-Based Financing Case Study Akaki 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 reform Vladimir Lazarevik Healthgrouper Macedonia

6. 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

7. Next steps
• Adopt a common view
– Different stages of scaling-up (Meessen et al)
Adoption
(from project to scheme)
Institutionalisation
(from scheme to
policy)
Perpetuation
(from policy to system)
– Different approach for each stage
-> Brainstorming and protocol workshop
20-24 October 2014 in Antwerp
• Field data collection and analysis – 12 months
• Final workshop
– Cross-cutting lessons
– Common outputs and publications

8. Questions to
Maryam Bigdeli bigdelim@who.int
Bruno Meessen bmeessen@itg.be
Thank you!