1. Results-based Financing
for Health
Health Results Innovation Trust
Fund

2. World Bank Objectives
Improve health results through strengthening

health systems
Incentives to motivate health staff and consumers to

achieve results – quantity and quality
Potential to open door to improve governance,

accountability and transparency
Potential to improve efficiency and effectiveness of

resources
Improve the effectiveness of ODA

Harmonized

Lower transaction cost

Fewer earmarks but measurable results


3. RBF and Partners
RBF contributes to IHP+

IHP+ is all about results

Results-based plans and budgets are likely to be

strengthened through Results-based financing
“One” M&E framework implemented through a strong HMIS

receive attention if results matter.
RBF is an instrument that works under all aid modalities

(budget support, pooled funding, project funding, …)
If structured correctly, RBF will provide incentives to

strengthen the health systems for MDGs 4, 5 and 1c results.
RBF efforts are country-led and require country-level

support

4. Results-based financing can be used at any level but
it must trickle down to the point of contact between the
provider and household to impact results
D ono r
s
N a tiona l
G o vernm
ent S ub-
na tiona l
Results Based Aid
R eg ion/D is tr
ic t
Results Based
Budgeting and Financing
Results Based
Financing
CCP,
CCT, RB
Providers Households
bonuses
Health Centers
or Individuals
Hospitals

5. RBF Mechanisms
Many mechanism and names. Effort focuses on

those using incentives to change behavior
Pay for Performance (P4P)

Performance-based Financing (PBF)

Performance-based Incentives (PBI)

Output-based Aid

Fee for Services

Vouchers

Conditional cash payments

Conditional cash transfer

Contracting


6. Health Results Innovation
Trust Fund
Support 7-8 countries to design, implement, monitor

and evaluate RBF mechanisms to accelerate
progress toward MDG 1c, 4 and 5
Increase learning and sharing of country and global

knowledge on RBF through documentation and
rigorous impact evaluations of RBF and broad
dissemination of information
Explore the value of linking grant financed RBF

projects to IDA credits

7. Scope of Activities
1. Country-level grants
Pilot grant to design, implement, monitor, evaluate:

Eritrea, Rwanda, Zambia, Afghanistan and DR Congo
+3
Seed grant support to other countries with interest

3. Building the evidence base and sharing lessons
 Documentation of project design & implementation
 Impact Evaluation and cost-effectiveness
 Capacity building/training/dissemination
5. Explore value of linking RBF grant to broader IDA
credits

8. 1. Pilots and seed grants
Competitive selection pilots:

Limited number of interested countries invited to submit

proposals and given $50,000 to support activity
Proposals include analysis of goals, why RBF as a solution,

likely approach and letters of commitment of government to be
part of in-depth evaluation and assessment
Independent Review Panel

Selected countries receive $10-$14 million for design,

implementation and evaluation over 3-5/years
Seed grants: small grants ($50,000) for activities to

explore RBF

9. 2. Monitoring, Verification &
Validation of Results
RBF requires timely, credible monitoring

often requiring strengthening of routine
reporting and HMIS
Verification of self-reported results

supplemented by validation
Household surveys, peer review, externally

contracted sources and CSOs to increase
accountability and reduce gaming

10. Characteristics of Current Pilots
Afghanistan: performance-based bonus payments to health workers

and provincial health staff (complementary to existing scheme)
DR Congo: performance-based bonuses for health workers; facility-

based payments based on targeted MCH services delivered
(complementary to existing scheme)
Eritrea: demand-side incentives for institutional deliveries and priority

MCH interventions (transfer, transport, lottery) and performance-
bonuses to regional and national levels (new scheme)
Rwanda: performance-based contracting with community

organizations, and in-kind commodity incentives for institutional
deliveries (complementary to existing scheme)
Zambia: performance-based bonuses for health workers and district

management teams- sanctions for mis-reporting; bonuses for
community health teams (new scheme)

11. 2. Knowledge Generation
What are the right questions?

Does RBF have an impact in each country? Is it

cost-effective? Are there unintended effects?
How does it work?

Is it useful in all countries or only in certain

conditions?
How should a country design its RBF program?

What are the pitfalls?

How should it strengthen systems to implement

RBF?

12. 2. Documentation: Learning
by doing
Documenting process:

Why this design? How was it designed?

What problems arose/how addressed?

Did the country implement its plan?

What happened? What problems arose?

Were critical inputs in place?

Value of documentations

Continual review and revision as learn

Critical info to interpret impact evaluation

Valuable lessons to share with governments and

development partners (national and global)

13. 2. Impact Evaluation
Required of each pilot

$1 million per country

Country teams and Expert network

Two workshops on Impact Evaluation

conducted
Protocol/approach developed

Impact evaluation website


14. 2. Knowledge Dissemination
Workshop

2008: 2 in Rwanda for total of 19 countries

2009:

 Philippines – 10 countries (USAID, NORAD,
AUSAID…)
 Francophone Africa (February?)
 Africa technical partners consultation
 Global – expert meeting on RBF building blocks
Website: rapidly available, digestible information

Case studies, tools, guidelines, fact sheets

Temporary site: www.worldbank.org/hnp/rbf

Inter-agency Working Group for Development

Partners

15. 3. Piloting link of RBF grant to IDA
• RBF grants link to existing or new IDA credits in
health can leverage additional money for health
• Ensures RBF thinking is part of broader financing
and reform discussions with MOF and MOH
• IDA credit and RBF grant can reinforce each other
• Focus on results
• Investment in strengthening systems and
ensuring inputs
• Builds on established operational capacity

16. Roles for development partners
Help build quality technical capacity at global,

regional and national level
Engage in workshops, training of trainers…

Support countries to design pilots

Support countries to implement, document learning

and revise program
Prepare case studies, guidelines, tools for

dissemination on the web
Identify key problems that require technical

specialists (e.g. Fiduciary systems, verification
systems, public health analysis)