This document summarizes a presentation on scaling up results-based financing (RBF) schemes from pilot programs to national systems. The presentation outlines that scaling up has multiple dimensions and occurs in four phases: from idea to pilot project (generation), from project to national program (adoption), from program to integrated national policy (institutionalization), and from policy to system-wide principles (expansion). Drawing from cross-country research, the presentation identifies factors like context, actors, policy content, and processes that enable or hinder moving between these phases of scale-up. It provides lessons like the importance of framing, developing support coalitions, balancing technical and political considerations, and adapting to changing incentives over time.

1. Taking Results Based Financing from Scheme
to System: a multi-country study
Zubin Shroff & Bruno Meessen
CoP Webinar
January 20th 2017

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Presentation Outline
Part 1:
• Our research
• Scaling up is multidimensional
• Scaling up is a four phase process
Part 2:
• Moving from one phase to the next: context, actors,
policy content and processes
• Larger lessons learnt from the cross-country research

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Main question: what are the enablers and
barriers for the scale-up of RBF schemes?
Armenia Cameroon Macedonia Tanzania
Burundi Chad Mozambique Uganda
Cambodia Kenya Rwanda

4. • Mainly qualitative methods
• Iterative
Documentary
review
Timeline
development
Key informant
interviews
Source: Sieleunou et al. 2015

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Idea #1: Scale-up occurs over 5 dimensions
Dimension Content
Population Coverage Geographical coverage, age and income groups
covered, total people covered
Service Coverage Number, types, level, affiliation of services
Health System
Integration &
Institutionalization
Connections with the six building blocks of the health
system
Cross-sectoral diffusion Changes outside the health sector
Knowledge & Ideas Status of the knowledge

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An illustration (1)
0
1
2
3
4
5
Population Coverage
Service Coverage
IntegrationCross sector diffusion
Knowledge

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An illustration (2)

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Generation
(from idea to project)
Adoption
(from project to
program)
Institutionalisation
(from program to
policy)
Expansion
(from policy to
system)
Idea #2: the four phase model of scale-up
• Reason: scaling up require some key resoures/currencies and
these resources are themselves partly an outcome of the
process.
• This is an emerging pattern, not a law.

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Phase 1: Generation
• Movement from initial idea to one or more pilots
• End point: pilot implemented as proof of concept
Generation
(from idea to project)
Adoption
(from project to
program)
Institutionalisation
(from program to
policy)
Expansion
(from policy to
system)

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Phase 2: Adoption
• Movement from pilot project to a national ‘program’: a coherent and
identifiable set of institutional arrangements organising the transfer of
resources to service providers is in place (contracts, guidelines…)
• Increased coverage in terms of administrative units implementing and
hence people covered → a heavy operational stage
• End point: a national unit, trainers & digital tools are in place to roll out
(knowledge!)
Generation
(from idea to project)
Adoption
(from project to
program)
Institutionalisation
(from program to
policy)
Expansion
(from policy to
system)

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Phase 3: Institutionalisation
• This refers to the transition from a program to a national policy
• Integration within the six ‘building blocks’.
• Governance: A stated objective of national strategic documents and decrees
• Finance: public funding and harmony with other financing mechanisms.
• End point: PBF is an integrated provider payment mechanism for
whole country
Generation
(from idea to project)
Adoption
(from project to
program)
Institutionalisation
(from program to
policy)
Expansion
(from policy to
system)

12. Phase 4: Expansion
• This refers to the transition from a mechanism to a set of key
principles informing the design and implementation of public
policy in the health sector but, also beyond.
• Paying for results and provider autonomy inform fields like
education
Generation
(from idea to project)
Adoption
(from project to
program)
Institutionalisation
(from program to
policy)
Expansion
(from policy to
system)

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Generation Adoption
Institutionalis
ation Expansion

14. FINDINGS

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Sample: countries at different stages…

16. Moving Across Phases- Phase 1: Generation
• Contextual factors-
– Interaction of global (aid effectiveness), regional (influence of Rwanda)
and national context (RBF as a solution to address a met need)
– Previous experience with organizational and financing reforms of the
health systems- voucher schemes, direct cash transfers
• Actors
– Seminal Role of Knowledge brokers or Health Financing Experts, along
with international agencies (bilaterals, multilaterals, faith based) in sowing
the seed
• Content
– Broad agreement on general principles and practices among community
of knowledge brokers
– Funding agencies had some role in determining focus, over time govts
played increasingly important role

17. Moving Across Phases- Phase 2: Adoption
• Contextual factors-
– National context relatively more important; pre-existing autonomous
institutions; enabling legal frameworks and changes
– National agenda of transparency and results hastens process
• Actors
– International agencies continue to be important (funding and technical
assistance); though usually one agency takes dominant role (Rwanda,
Cameroon, Kenya, Armenia)
– Role for national policy entrepreneurs, from MOH or pilot programs
– Development of critical mass of national level practitioners
• Process
– Coordination and alignment of stakeholders, task force

18. Moving Across Phases- Phase 3: Institutionalization
• High Level of continuity between this and previous stage, still needs active management
• Contextual factors-
– Legal frameworks continue to evolve
– Enabled by increased security of funding, especially from domestic sources
• Actors
– Increasing political and technical leadership of MOH and national RBF experts
– National ownership goes beyond the MOH, the ‘coalition of change’- MOF, local
govts, social security agency
• Content
– Greater country level influence on design, reflecting increased domestic resources
and technical leadership (Cambodia-internal contracting, Rwanda-cPBF)

19. Moving Across Phases- Phase 4:
Expansion
• Contextual factors-
– Knowledge on integration in health informs attempts to extend
PBF principles to other sectors
• Actors
– National level expertise and high level political support to take
forward PBF principles
• Content
– Variations develop in extending PBF principles to other sectors
including local government administration

20. LESSONS

21. Five broad lessons
• Lesson 1: Some countries stay stuck in phase 1
• Lesson 2: Rhetoric and framing matter
• Lesson 3: Scale up requires a chain of actors
• Lesson 4: Look beyond the label for content
when examining interactions
• Lesson 5: Balance technically best against
politically feasible

22. Lesson 1: Why some countries get stuck in
Phase 1
• A pilot is not a pilot. Successful pilot doesn’t ensure scale up
– How it is framed- disease focused or health systems strengthening
(Mozambique vs Cameroon)
– Who implements it- entity a) largely focused on a single disease, b) with
political, technical, financial influence at country level
– Which level of government is engaged ? Engagement at the district or
provincial level initial rapid uptake, but to national level may then be more
challenging (Mozambique, Uganda)
– Where it is housed in national government apparatus
– Is it implemented largely outside the public system?
– More pilots are not always better
→ Forthcoming webinar: Kiendrébéogo et al 2017

23. Lesson 2: Rhetoric and Framing Matter
• RBF programs have been put forth as transparency
enhancing and part of a results agenda
• This works in some settings (Cameroon and Rwanda), but
may not be universally the case; potential to directly
confront interests keen on status quo
• Needs analysing political situation to see if this is most
appropriate strategy and otherwise looking for
individuals and groups at national level who can help
place transparency and results on the agenda, in other
words-create the window of opportunity

24. Lesson 3: Scale up needs a chain of actors
• Seen how dominant actors varied by stage – each control a
key resource for the specific stage
• Invest in building your support coalition – anticipate and
involve at an early stage
• As stakeholders change, so do their incentives. Incentives for
provincial level governments to adopt PBF pilots may be
completely different from national governments
• Adapt your framing - initial PBF pilot framed as solving an
urgent need, issues of sustainability may not be immediately
important, but as you progress this becomes more important

25. Lesson 4: Look beyond the label and at the
content of other reforms
• Decentralization and increased autonomy, while enabling
to PBF programs in a number of ways, also alter who
decides what, something that changes incentives for
different players
• Devolution in Kenya- increased accountability buy taking
decision-making closer to people, but increased chance
of reduced spending on public goods and more on visible
things like infrastructure

26. Lesson 5: Balance the technically best
program against what is politically
feasible
• A technically sub-optimal intervention may be the right
choice when weighed against increased government buy
in and therefore likelihood of long term sustainability
• Cambodia example of choice of program, government
wanted greater control and chose model of contracting
enabling this

27. Thank You