Performance-Based Financing Toolkit

Performance-Based

Financing Toolkit

György Bèla Fritsche

Robert Soeters

Bruno Meessen

with Cedric Ndizeye,

Caryn Bredenkamp, and

Godelieve van Heteren

© 2014 International Bank for Reconstruction and Development / The World Bank

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ISBN (paper): 978-1-4648-0128-0

ISBN (electronic): 978-1-4648-0129-7

DOI: 10.1596/978-1-4648-0128-0

Cover design: Naylor Design, Inc.

Library of Congress Cataloging-in-Publication Data

Performance-based financing toolkit / György Bèla Fritsche, Robert Soeters, Bruno Meessen.

p.; cm.

Includes bibliographical references and index.

ISBN 978-1-4648-0128-0 (alk. paper)—ISBN 978-1-4648-0129-7

I. Soeters, Robert, author. II. Meessen, Bruno, 1969– author. III. World Bank, issuing body.

[DNLM: 1. Financial Management, Hospital—economics. 2. Health Facilities—economics.

3. Quality Improvement—standards. 4. Reimbursement, Incentive. WX 157.1]

RA971.3

362.11068'1—dc23

2014002212

Contents

Boxes

Figures

Maps

Screenshots

Tables

Foreword

Across the developing world, there has been encouraging but uneven progress towards the Millennium Development Goals, a set of international targets that come due in 2015. Even as daunting challenges remain, on health and other critical fronts, our immediate and post-2015 ambitions must be bold, reflecting a fundamental shift towards solutions that make a difference to our real clients—the millions of people in the developing world who still endure extreme poverty and are vulnerable to malnutrition, disease, and premature death.

The Health Results Innovative Trust Fund (HRITF) was set up in 2007 and funded by the governments of Norway and United Kingdom to support countries in the design, implementation, and evaluation of results-based financing programs aimed at accelerating progress towards the Millennium Development goals for women’s and children’s health. Programs in 31 countries are currently supported by the HRITF. About US$400 million in HRITF grants are co-financing US$1.6 billion in funding from the International Development Association (IDA), the World Bank Group’s fund for the poorest countries.

These programs focus on delivering better reproductive, maternal, and child health, using an innovative set of approaches known as results-based financing. Pioneered in countries such as Cambodia, Rwanda, and Burundi to extremely good effect, several other countries have begun to experiment with this approach, including Zambia, Cameroon, Zimbabwe, and Nigeria. The World Bank Group is committed to advancing such approaches to help ensure that people get the affordable, quality health care necessary to live long, healthy, and productive lives. In September 2013, the World Bank Group—as part of its mission to eliminate extreme poverty and boost shared prosperity—pledged US$700 million in additional financing through the end of 2015 to help developing countries reach the Millennium Development Goals for women’s and children’s health and survival. This new pledge will help governments to rapidly scale up successful pilot programs to the national level.

At the front line—that is, at primary health centers and district hospitals—the results-based approach is known in many countries more specifically as performance-based financing. With funds being paid to these health centers and hospitals directly upon reaching specific measurable and verifiable targets, including the number of children immunized or the number of births taking place at health centers, performance-based financing has been as good as its name, fostering results and injecting new life into run-down health facilities. But the approach isn’t just about financing; it also represents fundamental shifts in responsibility, transparency, and accountability. To help increase the focus on tangible results, this toolkit has been produced by practitioners for practitioners and embodies the rich experience of a couple of decades of field testing. While there is no cookie-cutter approach that works everywhere, much can be gained from studying various cases that add more to our understanding of what works and what doesn’t, putting the science of service delivery into practice. Delivering services to poor people is a science like any other, and it is important for us to push the frontier of knowledge continually forward.

As this toolkit demonstrates, performance-based strategies have evolved a great deal through testing and modification. There is a huge wave of improvement starting to break across Africa, Asia, and Latin America, enabling poor people to access quality health services and health facilities to motivate their staff and rebuild their dilapidated health infrastructure.

The World Bank Group is helping to shift funding and performance incentives to where the actual work is being carried out. This is growing into a truly transformational exercise, not just because of new funding resources, but also because we are aiming, together with developing country governments, to achieve value for money in health. Universal health coverage is possible if this transformation continues across the developing world.

I hope that you find this toolkit useful.

Timothy Grant Evans

Sector Director, Health, Nutrition, and Population

Human Development Network

The World Bank

Washington, DC

Acknowledgments

The authors thank the thousands of health workers who have taught us so much about performance-based financing (PBF) and the members of the performance-based financing community of practice, with whom we often interact and who work so hard at making PBF a journey of improvements and discoveries. Thanks also to the experts who have criticized PBF and whose dialectic has helped us to improve the strategy of PBF approaches. We gratefully acknowledge funding from the Health Results Innovation Trust Fund, which financed this toolkit.

The authors thank the members of the PBF Expert Advisory Team who contributed to the review of the toolkit as it was drafted: Nicolas de Borman, Maud Juquois, Christophe Lemiere, Benjamin Loevinsohn, Shun Mabuchi, Ronald Mutasa, Jumana Qamruddin, Sunil Rajkumar, Claude Sekabaraga, Gaston Sorgho, Petra Vergeer, and Monique Vledder. Special thanks to Maud Juquois for translating some key Burundi documents. Also, many thanks to Trina Haque, Hadia Samaha, and Abdo Yazbeck, who were instrumental in moving this product forward.

The authors gratefully acknowledge the internal and external reviewers who spent considerable time reviewing the final product: Nicolas de Borman, Jerry de la Forgia, Jumana Qamruddin, Louis Rusa, and Monique Vledder.

Authors and Contributors

About the Authors

György Bèla Fritsche is a medical doctor specializing in tropical medicine. He received a postgraduate degree in health policy, planning, and financing from the London School of Hygiene and Tropical Medicine. For the past twenty years he has been living and working as a practitioner, public health manager, and advisor in Zambia, Senegal, Afghanistan, Kenya, South Sudan, and Rwanda. For the past ten years he has been closely involved in designing, implementing, and scaling up performance-based financing (PBF) programs in Afghanistan, Rwanda, Burundi, Kyrgyzstan, Nigeria, Djibouti, Lesotho, the Democratic Republic of Congo, and the Republic of Congo. Since 2009 he has worked for the World Bank in Washington, DC as a senior health specialist. He advises colleagues and governments in appropriate design and implementation issues related to results-based financing programs.

Robert Soeters, an independent public health and health-financing specialist, is the director of SINA Health, a consultancy firm that organizes courses, conducts studies, and provides technical support mainly for performance-based health financing programs. He conducted around 200 health-care-related missions since the mid 1980s for such organizations as the World Bank, the Dutch-based international NGO Cordaid, the European Union, several bilateral organisations, local governments, and the World Health Organization. He has worked in more than thirty countries, mostly in Africa, Asia, and Eastern Europe. Soeters has a medical degree from the University of Amsterdam, a MPH degree from the Royal Tropical Institute in Amsterdam, and a PhD in public health and health economics from the University of Amsterdam. In 2013, he obtained a Dutch Royal Knighthood for his complete work.

Bruno Meessen holds a master of arts and a PhD in economics (Université Catholique de Louvain, Belgium). He started his international career with Médecins Sans Frontières, where he served six years as an economist, mainly in sub-Saharan Africa and Asia. In 1999, he joined the Institute of Tropical Medicine, Antwerp, Belgium, where he is today a professor of health economics. As a researcher and policy adviser, he played a pioneer role in the design, implementation and evaluation of performance-based financing schemes in Cambodia and Rwanda. His theoretical and empirical works contributed to the worldwide dissemination of the strategy. He is currently the lead facilitator of the performance-based financing community of practice, a group gathering more than 1,000 experts.

About the Contributors

Cedric Ndizeye holds an MD from the Catholic University of Bukavu, Democratic Republic of Congo, and an MPH from the Institute of Tropical Medicine, Antwerp, Belgium. He has been involved in performance-based financing since 2002, when he was the district director of health of Gakoma district in Rwanda, during one of the early PBF pilot schemes in that country. Since then he has worked as a technical advisor for HealthNet-TPO and for Management Sciences for Health as a monitoring and evaluation specialist. He was closely involved in the scaling-up processes for PBF in Rwanda and Burundi, and has provided technical advice on PBF in the Democratic Republic of Congo and Madagascar. He currently works for Management Sciences for Health as the principal technical advisor on performance-based health financing mechanisms.

Caryn Bredenkamp, PhD, specializes in health equity and financial protection, advising and training development professionals and government staff from countries around the world on how to measure equity and design pro-poor health policy. Attracted by the potential of results-based financing to bring health services to the poor, she joined the World Bank’s results-based financing team in 2008 and has worked on PBF in the Democratic Republic of Congo and Vietnam, among other countries. Caryn holds a master of arts (economics) from the University of Stellenbosch, Stellenbosch, South Africa, and a PhD in public policy (health economics) from the University of North Carolina–Chapel Hill. She started her working career as a university lecturer in her native South Africa before moving to the World Bank’s Washington office to work on Albania and India in 2006. She is now the senior health economist for the Philippines, based in Manila.

Godelieve van Heteren is a physician, senior health systems reform specialist, and director of the Rotterdam Global Health Initiative, a global health innovation coalition, which involves Erasmus University institutes, several international NGOs specializing in health, the City of Rotterdam, and a number of social entrepreneurs. She was trained in Leyden (medical school) and London (postgraduate studies at the Wellcome Institute/UCL). From 1988 to 2002 she was a full-time university lecturer and comparative health systems researcher at Nijmegen University medical school, before entering the Dutch Parliament. As a member of parliament she was spokesperson for health, biotechnology, innovation, and security, and chair of the standing committee on European affairs. In 2008–09 Van Heteren was director of the international development agency Cordaid before moving to her current position. Van Heteren’s present chief areas of interest are health policy and reform processes, social sector innovation, transition management and how to build new institutions for the 21st century. She applies these interests to her work as an international PBF consultant and trainer.

Abbreviations

Introduction

I.1 The Toolkit

What is performance-based financing (PBF)? Why is this used to finance health services in lower- and lower-middle-income countries? If practitioners want to introduce PBF in their country, how shall they do it?

This toolkit addresses the questions what and why, while focusing on the answer to how it can be done. The toolkit is pervaded by answers to the first question, while explaining the how to: the process, the planning, the design, and the implementation of PBF schemes. It is written and reviewed by practitioners who have experimented with various methods and who have designed, implemented, witnessed, and evaluated its effects. Methods and approaches in PBF evolve continuously. Even though the toolkit provides guidance based on experience, the experience itself is based on trial and error and constant testing, assessing, and reassessing. And this approach is why the toolkit is not meant as a final product. It attempts to capture the current state of affairs and best practices, while attempting to stay abreast by updating the methods, experiences, and tools used.

Introducing PBF can be a daunting undertaking. For instance, the practitioner will need to complete the following tasks:

• Introduce autonomy

• Introduce revolving drug funds

• Introduce health facility management tools such as the indice tool, the business plan, and individual performance evaluations

• Design and