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Scaling up and integrating your Results-Based Financing scheme: a progression in four phases

4/17/2017

2 Commentaires

 
Bruno Meessen

In a previous post, I have proposed to understand scaling up and integration of a results-based financing (RBF) scheme as a progression on five dimensions. In this second post, I present the second main lesson from the “Taking Results Based Financing from Scheme to System” research program: this progression, often, occurs in four phases.
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There were several great things in the “Taking Results Based Financing from Scheme to System” implementation research program, but one I appreciated a lot was the opportunity to use our own experiential knowledge for developing and implementing the research: an interesting option, when you have in the research team, experts like Maryam Bigdeli, Por Ir, Joël-Arthur Kiendrébéogo, Eric Bigirimana or Isidore Sieleunou (among others), who have had hands-on experience on scaling up Results-Based Financing.

What I knew from my own policy involvement with RBF over the last 15 years in countries like Cambodia, Rwanda or Burundi is that scale up is a process going through several phases. At the launching workshop, I presented a four phase view to the rest of research team; we agreed that this was one of the things to investigate with the project.

So, what have learned on the process of scaling up and integration after field work in 11 countries?

Four phases of policy development

Thanks to the excellent work of the country teams, we have now quite a good understanding of how countries progress with their RBF schemes. From our sample of ten country reports, we see emerging pivotal points at which a RBF scheme gains a more advanced policy status. First, let’s review the four phases.

The generation phase refers to the movement of RBF from an initial idea to the establishment of one or more pilot projects demonstrating the feasibility of the idea. The end point or measure of success at this phase is a proof of concept, which is a significant progress on knowledge (‘it works in our context and we have learned how to do it’). If we take Cambodia as an example, this is a status that was already reached in 2001 for the New Deal (a ‘proto-PBF’) and in 2002, for the health equity fund. If we take Rwanda, we can probably say that PBF reached this status in 2003. All the schemes documented in our multi-country research went through this first pilot phase. It is important to note that a few got stuck at that stage and failed to move to the next one. This is for instance, the case of Chad.

The adoption phase refers to the transition from a pilot project to a program. By ‘program’, we mean a centralized organizational structure endowed and mandated by the national authorities to expand benefits of a specific strategy to a large population. For a RBF program to function, a unified, coherent and identifiable set of institutional arrangements has to be put in place. This includes among others, contracts, guidelines and management tools to administer the RBF scheme. If we refer to my previous blog on the five dimensions, this phase of ‘roll-out’ equates to significant progress on the two dimensions of population and service coverage. This progression is made possible thanks to significant progress on a the dimension of ‘knowledge’ as well (knowledge increases both in terms of number of trained experts at the national level and in the depth of their expertise).

By the end of this phase there is typically a central body, agency or task force, which manages a single national scheme (particularly key if there were several pilot experiments to harmonize). Yet the scheme is usually still a parallel entity since resources are generally not on-budget. By the time of our study, 8 of the 11 study countries had reached this phase. No surprise, this is a heavy phase, especially from an operational perspective. This is even more so in big countries like Cameroon and Tanzania.

The institutionalization phase refers to the movement of RBF from a program to national policy. The later will often be enabled by national resources and commitment from the Ministry of Finance. The RBF scheme becomes an integral part of the country’s health financing policy inscribed in national strategic documents and decrees, with a stated objective to cover the country as a whole. This phase is characterized by significant progress on the dimension of ‘health system integration’, which will lead the emergence of new knowledge to handle the related potentially complex issues (how to adapt to public finance procedures, how to contribute to the permanent improvement of quality of care…).

By the end of this phase, the RBF arrangement is a central part of provider payment mechanisms in the whole country and contributes in a coherent manner to main objectives of the Ministry of Health such as Universal Health Coverage.

Phase 3 is one full of complexity. The challenge is not so much operational anymore: it is about securing a smooth integration of the RBF scheme into the national system. You can’t do anymore “cut & paste” from another country. A few countries managed this phase very well – Burundi and Rwanda are certainly the best examples. The story in Armenia is interesting. Cambodia took more time, but eventually move to good ownership.

Our last phase or that of expansion refers to RBFs transition from a provider payment mechanism for health to a key principle informing the design and implementation of public policy in general, including in areas and sectors beyond health. In the health sector, PBF inspires further reforms, spurring other transformative processes (e.g. strategic purchasing). Outside the health sector, RBF principles including paying for results and provider autonomy are considered relevant for other public services. This lateral thinking has been enabled by the expansion of national level knowledge on PBF and confidence gained by experience in integrating it within the health system. This phase marks the progression on the ‘cross-sectoral diffusion’ dimension.

Very few countries have already this phase. Rwanda is one of them. Burundi is not far from it, but the political crisis of the last two years has undermined the progress.

Meanings of these four phases

Let’s remind that as any framework, this four phase view is a simplified representation of reality. It is there to focus our attention on a few key issues related to the dynamics of a scale up process. It is also a simplified representation of these dynamics. In reality, things will not be always clear-cut; there is continuity and possible overlaps. Still, we see quite some power in this view.

The four phase view has some analytical power. Zubin Shroff and I used the four phases to organize our analysis of enablers and barriers to scale-up and integration. It emerges from our analysis that these enablers and barriers are phase-specific. The main reason behind this is that scaling up and integrating a RBF scheme is about persuading a moving set of stakeholders. You will not move from phase 1 to phase 2 without convincing the Ministry of Health, one or two donors with deep pockets; you will not move from phase 2 to phase 3 without persuading national programs and the Ministry of Finance; you will not move from phase 3 to phase 4 without the highest national authority developing strong leadership towards societal reform.

For obtaining buy-in from these different stakeholders in the chain, different strategies will have to be adopted. Actually, even the identity of the actor championing the RBF scheme may have to change: for instance, our study shows that while international experts are often pivotal to succeed phase 1, technical leadership should be with senior cadres of the Ministry of Health from phase 2. 

And what about prescriptive power? Is it required – in order to bring one’s RBF to scale – to follow the four phases, with due fidelity? Personally, I do not see the four phase view as a ‘universal law’ – there are probably countries, which merge phases 1 and 2 or phases 2 and 3. Still, one may wonder why so many countries do follow the same trajectory.  There are probably several reasons for that. Let me point at one.

Much has been said about policy as a complex process which rarely develops in a linear way. This is very true; still, a policy is an intentional action : expect the policy entrepreneur and any other driving actor to act in a strategic way. Addressing challenges one by one, ‘converting’ stakeholders progressively, may facilitate success. Knowledge is also a key resource for actors championing the policy: if they learn that a sequence of actions worked in other countries, expect them to take inspiration from this lesson.

Directions for our community

Many of you work in countries which are still in an early phase of the scale up & integration of their PBF scheme. We hope that this multi-country research will help you to structure your action at country level. Please, refer to our cross-country policy brief for tips how to navigate the phases (or the related paper).

The study also shows possible directions for the whole community of actors committed to PBF. I see at least two. First, we should not sleep on our first successes: this is a long journey, setbacks are possible, and many challenges remain ahead. It is also our responsibility to consolidate the global momentum – our prime responsibility is to  permanently improve our solution(s). In 2017, the PBF CoP will launch a series of working groups to work on the main weaknesses we do observe at country level. One has already been launched on verification; another one is about to start on family planning. More working groups will follow. We hope that many of you will support this dynamic. Second, we  have also acknowledge that we belong a more global movement. PBF is not an end in itself : it is an entry point for consolidating a more comprehensive transformation of health systems to sustain progress towards UHC (do not miss this recent paper by WHO colleagues
). As a community, we have to consolidate links with other groups. We will do that step by step. You may have noticed our emerging collaboration with WHO around strategic purchasing. Several members of our CoP will be next week at the meeting in Geneva. Stay tuned: more exciting developments are coming!

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2 Commentaires

Performance Based Financing and Quality of Care: ready for an upgrade?

3/20/2017

1 Commentaire

 
Bruno Meessen
Performance Based Financing (PBF) is now being implemented in a large number of countries. Ensuring that the PBF strategy is continuously improved must get our full attention. In this blog post, I focus on the challenge of quality care. I also present what the Community of Practice intends to do on this key issue. We are currently looking for experts willing to help us organize a first international meeting. Why not you ?
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The fact that PBF aims to increase the production of health services in countries where services are largely underutilized, is well known. It is also easy to understand the logic: if you are paid according to the number of units you produce, as long as your marginal cost of production is lower than the price you are paid, you have an incentive to increase your production.

From very early on, PBF was also introduced as a quality improvement strategy. When it comes to  improving quality, however, the theory of change is more complex, because the channels are multiple and potentially contradictory. Without being exhaustive, here are some important elements.


Paying for volume already has an influence on quality...

A first channel is the 'resources' effect. PBF will inject financial resources into the health facility. With these resources, the manager can make many decisions to strengthen the quality of care or services. For example, he/she may recruit more qualified staff; he/she can also improve the quality of the service (eg transforming a consultancy room to protect the privacy of users). It is my conviction that such improvements happen spontaneously in many health facilities under PBF.

Another channel stems from the fact that certain quality elements are determinants of quantitative performance. By remunerating the latter, staff are also indirectly encouraged to improve these quality elements. For instance, a health center keen on vaccinating more children will try to avoid stock-outs of vaccines; in its desire to attract more users, it will modify its opening hours ... or as it was, with a refreshing honesty, reported to us by a Rwandan nurse during a qualitative study in 2004: "From now on, we smile at our patients ".

But there are also elements of quality of care that are not determinants of volume. This is particularly the case for all quality elements that are not observable by the user (eg sterility of the surgical material) or which are ignored by the staff. A nurse who, due to lack of training, makes a diagnostic mistake in a systematic way will a priori continue to do so, regardless of the number of patients in consultation. Finally, there are situations of perverse incentives where quantity comes at the expense of quality. This is the case of the nurse who, to increase his quantity bonus, rushes through his consultation.

One can then wonder what effect purchasing quantity has on quality. The truth is that we don’t really know. One can suspect that some quality elements are improving – this is probably true for the aspects of quality noticed by the users. But one cannot exclude that on other aspects, quality suffers.


A solution: the introduction of quality checklists

To address this problem, PBF systems quickly introduced quality checklists into the payment system. Those who were in Rwanda at the very beginning of the PBF scheme will remember that this introduction was not straightforward: we discussed it thoroughly (among PBF experts).

The arguments in favor of these checklists were: "As a buyer, I do not want to buy only quantity; I want to make sure that every service I buy is of quality"; "By paying only for the quantity, there is a risk of incentivizing the health facilities to boost their volume, at the expense of quality"; "By paying for quality, we send the signal to the health staff that quality is important".

Arguments raised against these grids were: "Quality is multidimensional; many important elements are difficult to measure; we risk to only incentivize among staff what is easily measurable"; "Many determinants of quality arise from deeper causes, such as the initial training of health care workers; PBF does not address these causes".

As is often the case, there was some truth in both visions. In many countries adopting PBF, the initial level of quality is often very low - it is then relevant to create incentives for the presence of basic equipment and compliance with essential rules. You need an autoclave to sterilize surgical instruments. All health facilities must have clean toilets. Etc. PBF systems thus developed long lists of indicators with a focus on the availability of equipment and inputs. Routine data have shown almost everywhere that health facilities are sensitive to these incentives and that the quality index improves over time.

But those who were concerned about the bias in the measure of quality were also right. Those among you who attended our conference in Dar-es-Salaam will recall the presentation of a review of the lists of quality indicators in PBF systems. It showed that the indicator grids are biased towards what is easily measurable - equipment (hardware, etc.) (this study has now been published here).

The PBF quality checklists ignore important determinants of quality of care (eg knowledge of health personnel) and do not attempt to measure the outcome of the health services (e.g. cure). There is therefore a real risk that what is captured by the quarterly reviews is not enough to guarantee a level of quality that generates health benefits. In short, it is important for the nurse to have a stethoscope and medication, but if he does not know how to do a quality pediatric consultation and neglects to check some key parameters, there is a high risk that the diagnosis will be erroneous or incomplete.

This poses problems of different kinds. But for the sake of brevity, let’s just say that we could end up with a result contrary to our ambition: higher coverage rates, but mortality rates that do not move, simply because the quality of services is too low. 


The battle for quality care is also our responsibility

Questions abound. Have we used all the power of PBF to improve the quality of care? Or, on the contrary, do we not overestimate the contribution that PBF can make? What are the right mechanisms to change the behavior of clinicians? What is measurable and sensitive to an incentive system? How do we boost synergies between PBF and other strategies to improve quality of care (quality assurance circles, accreditation, etc.)? 

These and many other questions should be on the agenda. Some of the questions go beyond the PBF community, clearly. Currently, the whole international health community is concerned about the quality of care problem. A special commission has just been set up by The Lancet Global Health.

However, on the
PBF CoP side, we must also do our fair share in this global learning program. To this end, our CoP will launch a series of activities in 2017. We will proceed step by step as we obviously need to take into account our organizational capacities and resources when investing in this agenda  (if you are a possible sponsor, do not hesitate to contact us!).

Our attention should focus on two points. On the one hand, we must reopen the reflection on the theories of change of PBF. The mechanisms set in motion by PBF are quite complex, much more so than what has been said so far about this. The question of the theories of change is key, also for other purposes, but is particularly important for the issue of quality of care. We have already discussed this point in Dar-es-Salaam; we must now move into high gear. Expect some blogs and articles in the coming weeks and months.

On the other hand, we must also reflect on the quality indicators currently being collected in PBF systems. The time for critical analysis has come. This second project is ambitious (and as long as some checklists, perhaps!) - so we will take it step by step. As a first step, we decided to focus on quality indicators of family planning services. This challenge has the advantage of being well confined. It is also an area in which quality work has already been produced by different groups. Concretely, we have decided to organize an international meeting to which we will invite both family planning experts and PBF experts. Together, they will review existing indicators, identify areas for improvement, and formulate an implementation research agenda.

To support this process, we are currently looking for experts from both disciplines. We have already created a project on our Collectivity platform. The first responsibility for the volunteers will be to help us organize this meeting of experts. If you want to give us a hand, this is the time to apply! The meeting is scheduled for late summer and will take place in the beautiful city of Antwerp. Hope to see you there.
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Recherche sur le passage à l’échelle du Financement Basé sur les Résultats : les progrès réalisés à ce jour

7/28/2015

1 Commentaire

 
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Por Ir

En octobre 2014, l'Alliance pour la Recherche sur la Politique et les Systèmes de Santé  (AHPSR) a lancé un programme de recherche axé sur les expériences des pays en ce qui concerne la transformation des initiatives de Financement Basé sur les Résultats (FBR),du stade de projets-pilotes à leur intégration totale dans les systèmes  nationaux de santé. La recherche est en cours de réalisation  dans 11 pays (1). Dans ce blog, Dr Por Ir, l'un des chercheurs en charge de la coordination scientifique générale, nous rapporte où en est cette recherche.

Comme indiqué dans de précédents blogs (ici, ici, et ici), la première phase de ce projet de recherche a été lancée par un atelier de développement de protocole, dans les locaux de l'Institut de Médecine tropicale d'Anvers. Par la suite, les équipes-pays ont élaboré leur protocole de recherche, ainsi que leurs outils de collecte de données et les formulaires de consentement. Le tout a été validé par les comités éthiques nationaux respectifs et celui de l’OMS. La deuxième phase, actuellement en cours,  consistait en l’identification des principaux informateurs, la collecte de données primaires et secondaires, l’élaboration d’une ligne du temps  multidimensionnelle retraçant relatif au processus le passage à l’échelle, l’analyse des données, ainsi que la rédaction et la diffusion de l'analyse des études de cas nationales.

L'atelier de recherche intermédiaire          

 Dans la conduite de tels projets multi-pays, les échéances intermédiaires sont importantes. La seconde pour ce projet a été un autre atelier, qui s’est tenu à nouveau à l'Institut de Médecine Tropicale d'Anvers, du 22 au 25 juin 2015. L'objectif de cet atelier était de réunir les chercheurs principaux des 11 équipes pays afin de présenter et discuter collectivement de leurs  résultats préliminaires, ainsi que de s’accorder sur les prochaines étapes en vue de la finalisation des études de cas nationales. L'atelier a été coordonné par l'équipe scientifique de l'Institut de Médecine Tropicale (dirigée par le professeur Bruno Meessen) et l'équipe en charge du projet au sein de l'Alliance (Mme. Maryam Bigdeli et M. Zubin Shroff). 


Ce furent à nouveau quatre jours d’échanges très instructifs, accompagnés de nombreuses occasions d’apprentissage croisé entre les pays sur la manière dont les projets de FBR ont évolué ou continuent d'évoluer dans différents contextes. En quelques mots… L'atelier a débuté par une présentation par chacun des 11 chercheurs. Ils ont partagé leur collecte de données, leurs résultats préliminaires. Après chaque présentation, venait une séance de questions et observations de la part des autres participants.  


Ces deux jours de session de présentations ont été suivis par  une  séance méthodologique consacrée à l’analyse de données qualitatives, et de conseils pour la rédaction d’un article scientifique. Un temps significatif a été consacré à des réunions techniques bilatérales entre chaque chercheur principal et les membres de l’équipe scientifique de l'IMT et de l'Alliance. Ceci a permis aux coordinateurs de mieux comprendre les attentes et les besoins des chercheurs, et d’acquérir ainsi une connaissance plus approfondie  des problèmes spécifiques à certains pays. Cette information devrait permettre un accompagnement adapté pour la suite du processus. L'atelier s'est terminé avec des discussions d'ordre général sur les thèmes et questions d’actualités communs au pays et la planification des prochaines étapes vers la finalisation des études de cas, dont les stratégies de diffusion. Vous pouvez accéder au programme de l'atelier ici  .       

De nombreux progrès accomplis… et cela aussi grâce à vous !

De manière générale, tous les pays ont bien progressé dans leurs travaux sur le terrain, et la plupart d’entre eux sont sur la bonne voie, avec certaines équipes plus avancées que d'autres. Beaucoup ont fini leur collecte et analyse de données et ont commencé à rédiger. Certains ont déjà terminé leur première ébauche du rapport de recherches. Quelques équipes toutefois sont encore en train de réaliser des entrevues auprès de personnes clés. Nous avons observé trois facteurs de succès : (i) l'engagement de l'équipe et, peut-être, son degré d’expérience; (ii) la clarté et la simplicité du cas, en partie lié à un protocole bien élaboré; et (iii) le contexte du pays et l'appui des intervenants clés. Le retard pris pour obtenir les approbations éthiques a constitué un problème pour un certain nombre de pays.  

Les équipes de recherche ont adopté un vaste ensemble de stratégies visant à recueillir des renseignements sur les projets et processus politiques  FBR, dont, notamment: l’examen de documents, la réalisation d’entretiens avec des informateurs clés, des discussions de groupe, une observation participative… Au passage… Nous aimerions profiter de cette occasion pour exprimer nos sincères remerciements à tous ceux qui parmi vous ont consacré leur temps à soutenir cette étude, en participant à  des entretiens  ou en permettant l’accès à vos bases de données et documents clés. Vos contributions ont été très précieuses !   


L'atelier a relevé un certain nombre de défis, dont plusieurs avaient été anticipés au cours de la   phase initiale de développement du protocole. Ceux-ci incluent la mesure multidimensionnelle de l'ampleur du passage à l’échelle et l'élaboration de la ligne du temps connexe, la mise en place d'un cadre analytique approprié afin de déterminer les facteurs favorables et défavorables affectant le passage à l’échelle,  ainsi que la meilleure manière de mener les comparaisons entre pays.   

Les premières résultats 

Un résultat de cette recherche est constitué par les lignes du temps de chaque pays  décrivant le processus d’extension du FBR, dans ses différentes dimensions. Le développement de ces lignes du temps a nécessité une utilisation créative du logiciel Excel (vous pouvez avoir un aperçu sur cette technique ici si vous êtes intéressés, et n'hésitez pas à contacter Matthieu Antony, notre expert en ligne du temps!). 

Les résultats préliminaires des 11 études de cas pays révèlent d'intéressantes découvertes  en ce qui concerne les processus et les facteurs déterminants (obstacles et facilitateurs) du  processus d’extension du RBF, dont certains sont communs à la plupart des pays. Alors que dans certains pays l'ensemble du processus de passage à l’échelle découle d'un seul projet de FBR, dans d'autres, le processus est beaucoup plus complexe, et implique l’expansion et l’harmonisation de plusieurs projets de FBR. Dans deux pays, il n’a pas (encore ?) été envisagé de faire passer les projets pilotes à l’échelle. Les  éléments déterminants identifiés varient entre les pays. Deux d’entre eux  sont notamment: (i) la diffusion internationale (régionale) du FBR et (ii) l’esprit d’entrepreneuriat des acteurs, en particulier de la part du réalisateur/initiateur du projet pilote et des décideurs politiques. Toutefois, il est trop tôt pour tirer une quelconque conclusion à cette étape.  


La nature diverse des onze études de cas (en ce qui concerne le contenu, le type et les caractéristiques des projets de BRF) ainsi que des résultats (c'est-à-dire le processus, l'ampleur et les déterminants d’un passage à l’échelle) rendent difficiles les comparaisons entre pays. Cependant, nous espérons être en mesure de finaliser et valider un  cadre descriptif multidimensionnel qui aura sa pertinence au-delà du monde du FBR. 

Prochaines étapes          

Comme dans les précédentes phases de ce projet, la principale priorité de l’équipe de coordination scientifique continue d'être le maintien d’une communication étroite avec les équipes pays, de les  assister individuellement, afin de surmonter leurs difficultés spécifiques et de les aider à finaliser leurs études de cas. Toutes les équipes pays devraient présenter leur rapport de recherche final avant la fin du mois d'octobre 2015. En parallèle, l'équipe de coordination élaborera les cadres conceptuels, en particulier celui servant à  mesurer l'ampleur multidimensionnelle du passage à l’échelle. 
 

Dans le même temps, l'équipe de coordination examinera les ébauches de rapports disponibles (par exemple, celui de la Tanzanie) et fournira des observations accompagnées de commentaires en vue de l'amélioration et de la finalisation du rapport. De même, seront suivis de près les progrès de ceux qui sont encore pour le moment en plein processus de rédaction de leur première ébauche de rapport.  

Au cours de l'atelier, nous avons également discuté des idées/plans préliminaires de dissémination et publication, à l’intérieur des pays ou à l’international. Les disséminations/publications au sein des pays consisteront à partager le rapport avec les informateurs/personnes clés (en copies papier, mais aussi par l'intermédiaire de courriels ou d’une version en ligne), à présenter  les résultats clés durant les réunions des groupes de travail technique de santé ou lors d'autres  ateliers pertinents dans les pays concernés.  

Plusieurs suggestions ont été formulées concernant la communication scientifique et la diffusion internationale des résultats de recherche. Le groupe pourra probablement exploiter l’opportunité du Symposium Mondial sur la Recherche en Systèmes de Santé qui se tiendra à Vancouver en 2016, que ce soit par des présentations individuelles, par l’organisatio d’une  session scientifique ou même par un événement satellite. Nous avons également discuté d’une publication des articles dans des journaux scientifiques (un supplément ou une série dans une revue à accès libre). L'équipe de l’IMT désire également développer des processus innovants, afin de communiquer efficacement les conclusions de la recherche au groupe cible principal: les nombreux décideurs des pays à faible et moyen revenu, en charge de l’extension de projets FBR (une communauté qui s'étend bien au-delà du consortium des 11 pays impliqués dans ce programme de recherche en particulier). Bien entendu, nous vous tiendrons informés de tous ces développements sur ce blog, mais si vous avez connaissance d'autres possibilités, n’hésitez pas à contacter Bruno. Tout ceci nécessitera sans doute quelques ressources supplémentaires provenant de l'AHPSR... mais ceci demande bien sûr qu’en premier lieu, les rapports de recherche des pays soient finalisés.  

Ainsi  à ce stade allons-nous encourager les équipes  pays à se concentrer sur leurs principaux livrables. Et, en temps utile, nous reviendrons vers vous avec une meilleure connaissance du défi universel qui consiste à passer d'un simple projet pilote à une grande politique nationale.                                               
 


Remarque : (1) Les pays sont les suivants: Arménie, Burundi, Cambodge, Cameroun, Tchad, Kenya, Macédoine, Mozambique, Rwanda, Tanzanie, Ouganda.




Traduction : Emi Symenouh ; Valérie Gagon

1 Commentaire

Taking Results Based Financing from scheme to system: progress to date

7/22/2015

4 Commentaires

 
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Por Ir

In October 2014, the Alliance for Health Policy and Systems Research (AHPSR) launched an implementation research program focused on country experiences with transitioning of Results Based Financing (RBF) initiatives from pilot schemes to full integration into national health systems. The research is being carried out in 11 countries (1). In this blog post, Dr Por Ir, one of the researchers in charge of the overall scientific coordination, reports on research progress to date.

 
As reported in previous blogposts (here, here and here), the first phase of this research project kickstarted with an introductory protocol development workshop at the Institute of Tropical Medicine  in Antwerp, followed by further development of individual research protocols at country level, including data collection tools and consent forms, and their validation by national and WHO ethics review committees. The second and current phase of this research  includes identification of key informants, primary and secondary data collection, pulling together the multi-dimensional timeline for the scaling up process, data analysis, and writing up and dissemination of the analytical country case studies.

The intermediary research workshop        

The second milestone for the project was another workshop held at the Institute of Tropical Medicine (ITM) in Antwerp, from 22 to 25 June 2015. The aim of the workshop was to bring together lead researchers from the eleven country teams to jointly present and discuss their preliminary research findings, as well as to agree on their next steps towards finalisation of the country case studies. The workshop was coordinated by the scientific team of the Institute of Tropical Medicine (led by Professor Bruno Meessen) and the team in charge of the project within the Alliance (Mrs. Maryam Bigdeli and Mr Zubin Shroff).

It was a very useful four day discourse with plenty of cross-country learning on how the RBF schemes have evolved or continue to evolve in different contexts. In brief, the workshop started with individual country presentations on their research progress to date, including preliminary results, followed by questions and comments from other participants. These presentations were complemented by  a technical capacity building session on qualitative data analysis and how to write a qualitative research report and scientific paper. Sufficient time was devoted to bilateral technical meetings between individual country lead researchers and the ITM scientific and Alliance team members, which allowed the organizers to better understand the expectations and needs of the lead researchers, as well as lend a deeper insight into  country specific issues and help identify how best to address them. The workshop was wrapped up with some general discussions on the common cross-country emerging themes and issues, and planning for the next steps towards finalization of  country case studies, including dissemination plans. You can access the program of the workshop here.           

A lot of progress achieved… also thanks to you 
 
In general, all the countries have made good progress with their field work and most are on track, with some country teams being more advanced than others. Many have finished their data collection and analysis and have started writing up. Some have already completed their first draft of the research report. A few are still in the process of completing their key informant interviews. We observed three success factors: (i) team commitment, and perhaps, capacity; (ii) clarity and simplicity of the case, partly related to a well thought out protocol; and (iii) the country context and support from key stakeholders. A considerable delay in obtaining ethical approvals was an issue for a few countries. 


The research teams have adopted a diverse set of strategies to collect information on the RBF schemes and policy processes, including: review of documents, key informant interviews, focus group discussions, participatory observation… By the way… We would like to take this opportunity to express our sincere thanks to all of you who have dedicated some valuable time to support this study, including participation in key informant interviews and making your key documents and data base accessible. Your inputs have been very valuable!   

The workshop raised a number of challenges, many of which were foreseen during the initial protocol development phase. These include the multi-dimensional measurement of the magnitude of scaling up and the development of the related timeline, the application of an appropriate policy framework to determine barriers and enablers to scaling up and the best way to conduct the cross-country comparisons.  Early findings An output of this research is individual country timelines describing the RBF scaling up process along the different dimensions. The development of these timelines required a creative utilization of the Excel software (you can have a glimpse on this technique here – if you are interested, and do not hesitate to contact Matthieu Antony, our timeline expert!).     

Preliminary results from the eleven country case studies reveal some interesting findings on the process and determinants (barriers and enablers) of the RBF scaling up process, some of which cut across countries. While in some countries the entire scaling up process stems from a single RBF scheme, in others, the process is much more complex involving the expansion of  multiple RBF schemes. In two countries, the pilot scheme(s) have not been considered for scaling up (yet?). The reported determinants of scaling up vary across countries and two of the emerging determinants are: (i) the international (regional) diffusion of RBF and (ii) the entrepreneurship of the actors, in particular the in-country (pilot) scheme implementer/initiator and policy makers. However, it is too early to draw any conclusion at this stage. 

The varying nature of the eleven case studies (with respect to content, type and characteristics of the RBF schemes) and results (i.e. the process, magnitude and determinants of scaling up) make cross-country comparisons challenging. Yet, we hope to be able to finalize and validate a multidimensional descriptive framework, which will have relevance beyond the world of RBF. 

Next steps 

As in the earlier stages of this project, the main priority for the scientific coordination team continues to be to maintain close communication with the country teams and to technically assist individual research teams to overcome their specific challenges and help finalize their case studies. All country teams are expected to submit their final country research report before the end of October 2015. In parallel, the coordination team will further elaborate the conceptual frameworks, especially the one for measuring the multi-dimensional magnitude of scaling up. 


At the same time, the coordination team will review available draft country research reports (e.g. Tanzania), and provide feedback with relevant comments for further improvement and finalization of the report, and closely follow up the progress of those who are in the process of writing their first draft. 

During the workshop, we also discussed tentative ideas/plans for in-country and international disseminations and publications. The in-country disseminations/publications include sharing the report with key informants (in hard copies, through emails or an online version), presentations of key findings at Technical Working Group-Health meetings or during other relevant in-country workshops. 

Several suggestions were put forward for scientific communication and international dissemination of research outcomes. The group can capitalize on the Global Symposium on Health Systems Research in Vancouver in 2016, combining both individual presentations with  an organized scientific or a satellite session. Journal publications (supplement/series in an open access journal) is another possibility. The ITM team is also eager to develop innovative processes to effectively communicate findings to the main target group: the many policy makers of low- and middle-income countries in charge of scaling up RBF schemes (a community which extends way beyond the 11 consortium countries involved in this particular research program). Of course, we will keep you informed of all such developments on this blog, but if you know of other potential opportunities, please do not hesitate to contact Bruno. All this will no doubt require some extra resources from the AHPSR... but first and foremost, country research reports need to be finalized. 

So at this stage, we will encourage the country teams to focus on their main deliverables. And in  due time we will come back to you with more insights to the universal challenge of moving from a tiny pilot to a grand national policy.                                                


Note: (1) The countries are: Armenia, Burundi, Cambodia, Cameroon, Chad, Kenya, Macedonia, Mozambique, Rwanda, Tanzania, Uganda.

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Scaling up Results Based Financing:  the study starts in 11 countries

2/25/2015

3 Commentaires

 
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Matthieu Antony

Last October, we informed you of the launch of the multi-country research project "Taking Results Based Financing from scheme to system”. We also expressed our desire to inform you regularly on the progress of this program and to share with you possible lessons, including on the process. The preparatory phase is coming to an end now. In the coming days, research teams from 11 countries will kick off their qualitative research with a major wave of interviews.


As a reminder

Launched by the Alliance for Health Policy and Systems Research (AHPSR) and funded by Norway, this research project aims to examine the experiences of eleven low- and middle-income countries to identify the characteristics and factors that allow (or don’t allow) RBF programs to move from pilot stage to full integration into national health systems. [1]

The first stage of this research project mainly comprised the development of research protocols of the eleven country projects and their validation by ethics review committees and in particular WHO’s ethics review committee.

The protocol development workshop

In order to launch the research project under the best auspices, a workshop was held at the Institute of Tropical Medicine (ITM) in Antwerp, from 20 to 24 October 2014. The aim of this meeting was to bring together lead researchers from different country teams to jointly work on the development of their research protocols and in particular on defining their research questions. In addition to the principal investigators of each country team, the scientific team of the ITM (led by Professor Bruno Meessen) and the team in charge of the project within the Alliance (Mrs. Maryam Bigdeli and Mr Zubin Shroff) attended the workshop. A representative of the World Bank (Mr Kent Ranson) and WHO (Mrs. Inke Mathauer) were also present.


The event worked out the way we wanted:  as a platform for meaningful exchange that enabled everyone to relate his/her experience with the research issue to be tackled and to share his/her own reflection and analysis. The organization of a bilateral meeting also allowed the organizers to adjust to the expectations and needs of the various participants. This facilitated in turn a shared and collaborative dynamic to achieve the anticipated results. You can access the program of the workshop here.

One of the concerns of the scientific coordinators was to ensure the feasibility of the research (a mistake often made by researchers is that they are too ambitious in terms of the number of questions they want to answer). Consequently, it was decided that each country would have to focus on two research questions. The first one is common to all countries, and will involve describing the nature and process of scaling up RBF. The development of a timeline is one of the tools which will be used to describe the different dimensions of the RBF scaling up process. The second research question aims to be more analytical and varies from one country to another depending on the context and national issues.

Finally, the concept of ‘scaling up’ sparked quite some discussion. There is often this somewhat simplistic notion and wish to understand the process of scaling up in its geographical dimension (only). But other dimensions such as the number of services covered or the level of integration in the health system shouldn’t be overlooked either. We also hope to advance the state of knowledge in this respect.

Interviews at the country level are about to start

After the Antwerp workshop, a remote technical support system was set up to assist research teams. This technical support addresses two major challenges: maintaining a dynamic exchange and sharing process throughout the project; and support the teams in conducting their research.

One of the challenges of this research is the rather short time frame to carry it out, due to external constraints. The pressure was therefore high during the weeks following the workshop to finalize and review protocols. During this revision, particular emphasis was placed on the methodological approach - which will consist primarily of a document review and key informant interviews – and on the ethical considerations, including on a valid system to anonymize the interviews (at the workshop, we  clearly identified the sometimes highly political nature of a reform like RBF).

More importantly, several tools were used to ensure smooth communication between support teams (ITM and AHPSR) and research teams after the workshop. For example, the creation of a shared Dropbox folder with research teams facilitated the sharing of key methodological documents related to: (i) the application of theoretical and analytical frameworks, when analyzing health policies, (ii) the methods and practices for in-depth interviews, (iii) the literature on the scaling up process of policies, and (iv) stakeholder analysis methods. We have also started using webinar technology.

Over the last days, country teams have received the reports of the WHO ethics review committee. The comments were minor and are currently being integrated. Several teams also received the report of their national ethics committee. This will allow researchers to begin their round of interviews very soon. So if you are active in one of the 11 countries studied (or have played an important role in one of these countries in the past), maybe the interviewers will soon come knocking at your door. We hope that you will give them a warm welcome. Your knowledge matters: it is by documenting and analyzing the experiences in your country that we can produce lessons for all.

Note:
1. The countries are: Armenia, Burundi, Cambodia, Cameroon, Chad, Kenya, Macedonia, Mozambique, Rwanda, Tanzania, Uganda.


3 Commentaires

Taking Results Based Financing from scheme to system: a multi-country study

9/10/2014

2 Commentaires

 
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Bruno Meessen

This blogpost introduces a multi-country research project looking at how at country level, Results Based Financing (RBF) schemes move from pilot to full integration into national health systems. The study is led by the Alliance for Health Systems and Policy Research and scientifically coordinated by the Institute of Tropical Medicine (ITM) and will be carried out by national research teams of eleven countries.




Worldwide, more than 30 low or middle-income countries are today developing, within their health sector, experience with so-called RBF strategy. While a few of them have already moved to a full-fledged national policy, most of them are still in pilot stages. This large international movement is facilitated and boosted by a number of forces and positive synergies: political will, aid agencies’ leadership and financial resources, enthusiasm of experts, commitment of major stakeholders, pro-active knowledge management…

The main goal of every RBF scheme is to improve the performance of the health system (measured in terms of quality of the health service delivered, coverage rate…). The ultimate goal of every - successful - pilot scheme is to be scaled up. From a knowledge management perspective, though, a pilot scheme which failed to improve some target indicators is actually still a success if the operational lessons which have been drawn from the experience allowed stakeholders to improve the national health system. This is an outcome which matters for an RBF strategy, as many have argued that its transformative power is one of its key attributes. A key metric of the ‘success’ of an RBF experience should therefore be its ability, through the core principles it promotes, to reinvigorate the national health system. One can foresee transformations/scale up on many different dimensions.

Launch of a multi-country research project

The possible journey “from scheme to system” will be the main focus of a  multi-country research project coordinated by the Alliance for Health Policy and Systems Research and the Health Economics Unit of the Institute of Tropical Medicine. This research program is sponsored by NORAD, the Norwegian Aid Agency.

The call for proposals launched by the Alliance sparked quite some interest: 34 research teams submitted a proposal. Eleven countries have been selected – you can discover which ones by clicking here.(1) Selected research teams have been informed. The next step will be a protocol development workshop to which the principal investigators of the eleven countries will be invited. Together, we will explore the commonalities across the 11 cases and assess whether we can adopt a common framework and select a limited number of common research questions.

After approval of the protocols by ethical committees, each national research team will document how the journey from scheme to policy is going in their respective country (although among the 11 countries, we have also interesting stories of pilot schemes which did not materialize into national policies). While our sampled countries are mostly from sub-Saharan Africa (the most dynamic continent, as far RBF is concerned), we are happy to have also three experiences from outside Africa. In Africa, we will cover a nice mix of settings: a few post-conflict countries, some Francophone and Anglophone countries, a mix of small and big countries.

Our communication strategy

While the PBF Community of Practice is not formally involved in this research at this stage, we will make sure throughout this project to keep you informed about the progress being made. We are indeed very aware that moving from scheme to system is a challenge that some of you are already facing today. So you may learn from what we discover… but we also value the knowledge you will share with us. This interaction with you will take different forms, but our online forum and this blog will be major tools (do not hesitate, for instance, to contact us if you want to write a blogpost on the situation in your country or just share some reflections). We will also seize opportunities offered by face-to-face encounters to discuss on this topic with you (as we did already in Buenos Aires and as we will do again at the Cape Town symposium, in a satellite session co-organized with the World Bank).

This promises to be an exciting journey. We hope that you will be with us all the way long.

 
Note:
(1) We are very aware that some readers of this blog post are disappointed by the non-selection of their proposal. Proposals went through  a systematic appraisal system set up by the Alliance. Feel free to contact Mrs Maryam Bigdeli at the Alliance to know the reasons why your proposal has not been selected.


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Performance based financing and community health workers: A new breakthrough in Rwanda

5/13/2014

10 Commentaires

 
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Bruno Meessen

You are international health expert and you distrust the strategy of community health workers, hate performance based financing and don’t believe in community participation anymore? Press on the key “Rwanda” for an update!

In August 2013, during a visit in Burundi, I had the opportunity to discover a pilot experience of community PBF. That experience, led by the ONG IADH overcame the reluctances I had so far, as many others, regarding the strategy of community health workers. I knew that this strategy was already applied countrywide in Rwanda, the neighboring country. I benefited from a recent request from the Government of Rwanda and the United States Government’s Integrated Health Systems Strengthening Project (led by Management Sciences for Health) to learn more about it. My conviction was strengthened: we are facing a breakthrough.

Development of community PBF in Rwanda

The Rwanda’s experience in community PBF occurred in two times. The first experience- since 2006- thoroughly played the game of decentralization: the local government had transferred the budget for the community health workers to the local authorities (the administrative district). That approach, the G2G (government to government), to some extent, failed in its early stage. As Dr. Claude Sekabaraga, who I met again in Kigali, reminded me, the money didn’t reach the beneficiaries and was sometimes used by the decentralized administrative structures to fund other activities (infrastructures…) that seemed to be a higher priority. The second experience - started in 2009 - has been funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Because of the donor's rules, the funds for the community health workers  have been transferred through the health centres.

The originality of the Rwandan model lies in the organisation of the community health workers (CHWs). The MOH opted for the setting of cooperatives of CHWs. Cathy Mugeni, who leads, since the beginning, the program at the MOH in Kigali, explained that this choice was, among others, due to the national political context: in comparison to an 'association' (like in Burundi), the cooperative is an institutional formula that permits more easily an economic activity, additional to the support to routine community health activities - it was more conform to the country’s objective to progress towards a lesser dependency to external aid for the funding of its health sector.

I was of course curious to discover the strategy on the field. By chance, my stay in Rwanda coincided with that of a delegation of the Lesotho’s Ministry of Health. I was thus able to join them for a visit of the Gikomero health center (1).

Lessons

The community health workers must henceforth be recognized as an integral component of the health system. I say “henceforth” because it was not and is still not the practice in most CHW programs: in many countries, the strategy of CHWs has been impeded for longtime by its fragmentation (each vertical program having its own CHWs); it had also been accused of paving the way for apprentice doctors, uncontrollable once equipped with drugs. I can’t take position for each context, but what I’ve seen in Rwanda, what told me different informants and what I’ve read besides convinced me: ignoring the CHWs is depriving ourselves of a true accelerator for numerous health objectives that are dear to us, especially those under the MDGs 4,5 and 6.

Dr. Michel Gasana, National Director of the National Tuberculosis Control Programme, thus explained me that CHWs played henceforth a key role in the identification and referral of persons suspected of having tuberculosis. They also play a role in the administration of the treatment (DOTS). At Gikomero, the CHWs showed us a lot of their activities, including the integrated management of childhood diseases (fever, diarrhea and pneumonia) at the community level, the promotion of the use of family planning services, the delivery of contraceptive methods and drugs to manage tuberculosis, the behavior change communication, and the community-based nutrition program: all high impact interventions. We also appreciated the quality of their different tools.

As many health system experts, my attention these last years has been drawn to the health facilities. Our first concern was to reinforce them so they may be able to deliver their health package. What stroke me at Gikomero was the very high integration that exists between the activities of CHWs and those of the health center. If the CHWs provide some services (e.g. treatment of diarrhea with ORS and Zinc, treatment of pneumonia, treatment of malaria), a good part of their contribution is the promotion of the use of the health center (they also are permanently in touch with the health center and the Ministry of Health thanks to mobile phones that permit to lead fast interventions to save lives at the community level). The key advantage of the CHW is that he/she lives in the village. He/she is trusted by the community and is thus welcomed in each household. Later, the same day, we visited, in another district, the Rutongo hospital. In the pediatric ward, we were able to interview a mother with her baby who has kwashiorkor. She told us her journey: her notice of a change in the behavior of her baby, her contact with 'her' CHW, the decision to go together to the health center (despite that the anthropomorphic measures were in the “green”),  and after the diagnosis of a severe malnutrition by the health center, the immediate referral to the hospital (using an ambulance).

One of the great strengths of the Makamba experience in Burundi and the one from Rwanda is the establishment of a joint entity to all the CHWs of one health center.  Firstly, this removes the previous problem of fragmentation of the strategies using CHWs (each program having his). This also greatly facilitates the communication with the health center; this permits for example passing at the scale of a strategy in a quicker way. More fundamentally, the existence of an association of a cooperative permits to pass from a model where the CHW is strictly instrumental to a model that really favors a collective decision- which is, for me, the real stake of the community action.

For that, it was needed to create a stake for collective decision. Our hypothesis is that community PBF, with its injunction of funds into these self-managed entities (associations or cooperatives), creates that involvement. Because if the community PBF envisages that the joint entity will have to remunerate each CHW for its own contribution, the payment by the Ministry of Health is high enough for the group to put a part of its revenue aside. With that money, investment decisions can be made. 

At Gikomero, Ms. Concessa Kiberinka, CHW and accounting of the CHWs cooperative, presented us the different activities led by the cooperative: a piggery, a banana plantation, real estate investments… She also told us about their future project: to build a production unit of pork! In business management schools, this is called to move up the value chain…

I asked her if there was no risk that the economic success of the cooperative corrupts the project, whose first finality was health. We could for example imagine that in the future, the candidates to the post of CHW are “opportunists”, mainly interested by the economic gain.  She explained me that each village chose, democratically, its CHW, and that criteria were the dedication for the village, the integrity, the ability to gain the trust to visit households… (2). It’s difficult to describe, but during the different oral interventions of CHWs during our visit, all these values emanated from them.

Emergence of a model

So there is a model extremely well designed and structured that emerges: CHWs, democratically elected by the community, trained on an effective health interventions package, working collectively and under the supervision of a health center, locally organized into a cooperative, itself remunerated by a PBF and fostered to launch economic activities, all of that in a context of strong political mobilization.

One can predict that the next Demographic and Health Survey (2015) will confirm the health impact of that global strategy. Some will ask which component will have been the most determinant. Dr. Ina Kalisa Rukundo (School of Public Health of Kigali), who is coordinating a study in the impact of the community PBF funded by the World Bank told me: “Between the baseline and the final assessment, three years have passed. In Rwanda, everything goes very fast. There has been a very strong mobilization of the national and local authorities in favor of CHWs. It is also a small country and the good ideas are quickly shared. Our study tries to isolate the effect of PBF, but we would not be surprised if finally, the study reveals that the different arms of the study have similar results”. It is also probable that the numerous beneficial effects related to that policy (especially in terms of governance and economic impact) will never be well identified.  This is the case for societies in rapid transformation.

A renewed vision

One must of course be careful with the experiences from Rwanda and Burundi. Factors like the high density of population, the democracy at the village level, or the high implication of women in the collective action could be elements more difficult to find in other contexts. It is also possible that more that the “what” to do, it is the “how” to do it that matters. It is by the experimentation elsewhere that we will know it.

This shows a more general lesson, surely valid for the academic world engaged in global health: it is greatly time to review some of our dogmas and mental categories. We live in a world in permanent change, in Africa as well. What was unimaginable yesterday can happens tomorrow… and is already occurring in Rwanda! In public health, many of our references are based on a static, or even worse, wrong reading of the societies. As teachers, we must have the humility to recognize that part of our teaching is shaped by our past experiences and determined by analysis frameworks maybe conceptually elegant, but out of phase with the reality.

Notes

(1)    Thanks to Health Development Performance and to the School of Public Health for having accepted us as visitors for this visit!
(2)    The cooperatives include 2/3 of women; as a man, I see there a very wise decision (moreover, not surprising for Rwanda).

10 Commentaires

The PBF Toolkit: a neat contribution to the science of delivery

3/26/2014

6 Commentaires

 
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Designing and implementing a Performance Based Financing (PBF) scheme is an art. Isidore Sieleunou interviews an  artist who is happy that his latest piece of art finally saw the light : Gyuri Fritsche from the World Bank. Gyuri introduces the freshly released PBF Toolkit to us. You can access the full document here.

Could you tell us the main motivations that led to the production of this Toolkit? 

The main motivation for creating this toolkit was a sense that although there was a massive interest in PBF, the knowledge on PBF approaches was very limited and confined to a few early PBF pioneers. The idea was to make such knowledge which is based on years of experimentation, widely available to other experts. There was a sense (and such a sense still exists) that many ‘PBF’ projects were started that had significant design and implementation flaws while such design and implementation experimentation had been done previously, and lessons had been learned on the ‘how to’ (the ‘science of delivery’) already. Our credo was therefore: ‘make mistakes, but make original mistakes and do not repeat those that have been made before’. I believe there is a strong demand for the experiential knowledge contained in this toolkit which comprehensively rehashes the experience from key pioneers over the past, say, 15 years.

Three years ago, some authors wrote that the PBF strategy underestimated important constraints to its implementation. Do you agree with this assessment?

First, what is a ‘PBF strategy’? There is no such thing as a “PBF strategy”, there are various PBF approaches, and these approaches evolve continuously. Second: if PBF were easy, it would have been done before. So PBF is not an easy fix, but it is a set of principles that are adapted to each specific context. PBF is unpredictable as a ‘strategy’ in a specific context, as there are so many variables that will influence whether it will succeed or not. The best that one can do as an implementer is to apply as much as possible all elements of PBF approaches that are known to be linked positively with some effect. It is not an exact science, but I guess this is the best advice I can give. The most important constraint is having effective local champions that advocate for the approach. It is a health reform and because it is a reform, we need to appreciate that it has political economy aspects. PBF is not a technical fix, or some sort of vertical program; it is a systemic multi-layered intervention. And this is exactly why we wrote this toolkit: to ‘demystify’ PBF, to describe what worked best and how, and also, what failed.

So far, knowledge on how to implement a PBF scheme has largely been disseminated through the mobility of experts, with a massive involvement of experts from Africa – something remarkable if we compare with previous practices. Still the support from implementing agencies from the North has remained important. Which evolution do you expect in the close future? Any role to be played by the toolkit?  

I expect Southern experts to play even more important roles in the future. Already, the most effective local champions are those who move from their own contexts to other contexts. Quite a few are very effective experts. This toolkit will enable these experts to access knowledge held previously by a few pioneers and to become even better experts. Also, this toolkit is not a final product, but rather a look back in time, up to plus or minus the current period, and say: this is what has been done, this is how it was done, and this is what seemed to work better and this is what was tried and did not work well. In this sense, this toolkit is a benchmark: experts will need to get acquainted with its content, and then move on and build on the knowledge contained in it (and produce a next version). Northern technical assistants will have to adapt to these changing realities: they will have to devise business models that will focus on creating local capacity and be flexible and nimble.  

Some experts, including within the PBF community, are a bit afraid that on some aspects, we move too quickly towards a doctrine. This could create rigidities or too much ‘cut & paste’ of solutions. How does the toolkit deal with this risk?

I am not too afraid of this ‘cut and paste’ labelling. The toolkit was written with a keen eye on this theoretical danger of being labelled as a ‘cookie cutter approach’ and I believe sufficient care has been taken to present a balanced view wherever possible. Nevertheless; this is a TOOLKIT and some degree of advice is necessary and also expected from a toolkit. I will give an example. If for instance you decide to disregard the element of health facility autonomy in your PBF design, do not be surprised if you do not find any effects of PBF in the near future. Even worse, sometimes designs are framed as ‘Rwanda/Burundi type of PBF’ whereas there are major departures from that design. The issue in my opinion is a misunderstanding or lack of knowledge on the contexts where these PBF approaches have evolved so successfully. And this is why this toolkit is so important: the toolkit tells many stories about many different design and implementation elements, which, if pieced together and read as a whole, tell a much more comprehensive story on PBF approaches and especially, on how to make them more effective.

A challenge obviously is that the knowledge on PBF is evolving very quickly. If you had to add a new chapter, let’s say, next year, which new topic would you cover?

Information and Communication Technology (ICT) is an area which evolves rapidly. For instance, the development of tablet based software for the quality checklists with automatic uploads to a web-based platform/dashboard. Also the web-enabled applications through OpenRBF are evolving as we speak, with major work being done in inter-operability with other ICT solutions such as DHIS2. Another area is the increasing interest in moving towards process elements of quality, such as for instance the use of criterion based medical audits or vignettes (case-studies). Furthermore, the issue of urban PBF, where public funds are used to contract private for profit providers through PBF will be a major growth area. Also, the area of equity, of how we target the poor, is evolving really fast. In the World Bank we now work systematically hand in hand with our social protection colleagues, and there is a fair amount of cross-fertilization here.

In the foreword, Tim Evans reminds us that delivering services is important to push the frontier of knowledge forward. Some people think that when the World Bank adopts a new idea, trickle-down effects swiftly follow. So when Jim Kim, the Bank’s President, announces that ‘the science of delivery’ will be a hallmark of his tenure, this raised a lot of expectations among practitioners. Should we interpret this important document as the sign that the World Bank gets serious about implementation issues?

I cannot speak for the World Bank, but I agree that there is a general wave inside the Bank to become much more focused on the poor and to become more effective and efficient in what we do for the poor. This toolkit does just that. If you look at our health portfolio in Africa for instance, you will see that PBF is BIG. And it is set to become even bigger in Africa, while it is slowly taking off in Central and South-East Asia, and trickling into the Arab world and Latin America too.

Do you agree with the view that the experts of the PBF Community of Practice (PBF CoP) should contribute to the next edition? Do you have any plan in this respect?

This is a toolkit written by experts from the PBF – CoP. The way it was done, will enable adding tools to on-line folders in the appropriate chapters which will remain accessible through the links in the e-book, and through the WB website. In the near future I believe that various chapters will need updating and this can be done in various ways. It is my hope that this toolkit, which will be produced in three languages (EN; FR and SP), will be used by our PBF-CoP colleagues who will further enrich and expand it. 


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Results-Based Financing: going from scheme to system – a research program in the making

2/6/2014

3 Commentaires

 
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The Alliance for Health Policy & Systems Research, a global partnership hosted within WHO, is about to launch a new implementation research programme focused on results-based-financing (RBF). A few experts of the Performance Based Financing Community of Practice (CoP PBF) attended a preparatory meeting in Geneva on 23-24 January. In this blog post, they report on the two-day event.

 The Alliance for Health Policy & Systems Research is known for its commitment to enhancing the dialogue between researchers and research users, policy makers in particular, in developing countries. As readers of this website know, the Harmonization for Health in Africa communities of practice fully embrace this agenda. Late December, several of us were contacted by Joe Kutzin (WHO, Geneva - Department of Health Systems Governance and Financing) and Nhan Tran (Alliance) to join them, together with other RBF and provider payment reform experts, for a consultation meeting to prepare a new call dedicated to implementation research on RBF. Olivier Basenya, Por Ir, Bruno Meessen and Laurent Musango made the trip to Geneva.

Participants were asked to assist the Alliance in identifying main implementation research questions related to the scale up and integration of RBF initiatives into national health systems and policies, and in identifying priority countries where such research would have a greater impact. After two days of intense interactive deliberations, it was decided that the research program will focus on the enabling factors and barriers for RBF (pilot) schemes to be scaled up and integrated into national health systems and  policies, taking into account RBF design features and implementation process, health systems characteristics, and socio-economic and political context. We agreed that the importance (extent) of the scaling-up and integration would  be assessed on several dimensions such as population and service coverage, institutionalization, financial integration in the public budget and so on. While some countries have been relatively successful in making progress on this multidimensional scale, others have been encountering quite serious obstacles in doing so.We are hopeful that this research program will bring interesting insights into how one needs to successfully navigate the policy process, combining efficiency with ownership and a sufficiently inclusive process, with the aim of strengthening health system and moving towards Universal Health Coverage (UHC). We know from previous meetings that national PBF champions are looking for guidance in this respect.

All participants made relevant contributions, with some as delicate as the tiny paper cranes produced by Professor Winnie Yip from Oxford University (picture illustrating this blog post). Others (like ourselves),  conveyed their message in a more straightforward way. One of the things we emphasized was that it’s vital to ensure that the research process involves country health authorities in such a way that it allows them to reflect on the extent to which they have actually achieved health systems strengthening via the integration/scale up of their pilot schemes – a shift from scheme to system and policy.

Interestingly enough, the research program will not have a purely instrumental aim. Eligibility criteria will also allow applications by research teams willing to document processes which were wrong from the start, e.g. a pilot project with insufficient or no (government) ownership,  or one that failed to be scaled up. It was suggested that the research areas should be a mixture of countries that have advanced in RBF implementation at national level, countries in pilot experiences phase and some others with a demand side component. 

The planning of the Alliance is ambitious. We expect the call to come out soon, so keep an eye on their website (ourselves, we will of course inform CoP experts through our online forum). We hope that many of you will apply and submit letters of intention as this is a research program fully in line with priorities pursued by the PBF CoP.


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Scaling up Results-Based Financing for faster progress towards the Health MDGs: reflections on a recent donor meeting in Oslo

1/6/2014

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Bruno Meessen (ITM, Antwerp) and Olivier Basenya (MoH, Burundi) report on a donor meeting hosted by the Ministry of Foreign Affairs of Norway dedicated to developing a road map for results-based financing (Oslo 11-12 December).

The countdown has begun: there are only 750 days left till the MDG deadline. On the side of donors and agencies, the ticking clock is only increasing the eagerness to accelerate progress. Politically speaking, this timeframe is indeed important in the North, especially in countries like Norway or the UK, where several political leaders have used much of their political capital to lobby for global health at national and international level. Against this backdrop, the PBF CoP facilitation team is fully aware that it also needs to attend donor meetings to explain, bring evidence and share experiences about Performance Based Financing. We were therefore happy to make the trip to Oslo to discuss with donors and aid agencies a road map for the scaling up of RBF(1).

The meeting was opened by Anthony Lake, the executive director of UNICEF, a strong indication that UNICEF is joining the club of agencies committed to integrating RBF in their policy toolbox. The first half-day of the meeting was dedicated to reporting on Results-Based Financing (RBF) progress. We heard about experiences in Tanzania, Zambia and Argentina – all of them belonging to the category of PBF schemes, which focus on barriers on the supply side (2). Olivier Basenya also presented the experience of Burundi. If you are involved in PBF projects, you probably won’t be surprised to learn that PBF is boosting indicators of key health services, especially those aligned with the MDGs, while also leveraging the whole system (in terms of work culture, accountability…).

On the second half-day, we first listened to aid agencies dwelling on recent developments on their part; some of these developments seem very favorable to RBF. For instance, we learned that the Global Fund has realized that their system of granting funding through ‘rounds’ created incentives for countries to avoid risks and in many cases led to proposals with very vertical approaches. The Global Fund will now adopt a more ‘health systems’-style approach, or at least to a greater extent than before. In the future, countries will be expected to organize a country dialogue going beyond the CCM (Country Coordination Mechanism). The new grant system of the Global Fund will also be much more supportive to strategies like PBF, which is seen as a great platform for integrating health service delivery at country level. Prospects seem also good on the side of the GAVI initiative. During the discussion about collaboration between agencies, the case of Benin was of course mentioned, as it is a country where PBF is being co-developed by the World Bank, GAVI and the Global Fund.

We then listened to donors’ (USA, Germany, Sweden, Japan, the UK and the Bill & Melinda Gates Foundation) own stance on RBF. All of them are positive about RBF, even if their involvement and financial commitment vary. Most obviously want to move at their own speed, for a number of reasons, including in line with the concern  not to outpace the progressive building of the evidence base. We realized that donor support to countries is still highly determined and shaped by their existing aid instruments (and national aid operators). So changes will perhaps come more slowly than we would like, in this respect, but we should already appreciate that Germany, the US,  the UK and the Bill & Melinda Gates Foundation are already funding pilot RBF schemes in different countries.

What are the key messages for countries?

In Oslo, we discussed of course many things. Here are some interesting messages for the ones among you who are involved in formulating and implementing RBF at country level.

  • RBF is recognized by the international community of aid actors as a key mechanism to accelerate progress towards the MDGs by focusing on frontline services. At country level, your own responsibility may be to use the MDG deadline to put pressure on donors and your government to commit to an agenda focusing on results. 
  • Having said that, it is also crucial to keep in mind that RBF must be anchored in broader and longer term agendas such as health systems strengthening and universal health coverage. This has important consequences: for instance, there was a consensus in Oslo that aid agencies adopting the RBF approach should support a single national RBF strategy (and not develop their own schemes). Hence, at country level, keep on working on the integration of your RBF strategy in the national health care financing strategy. Among other advantages, PBF is a great entry point for your Ministry of Health to learn to purchase health services in a strategic manner. 
  • Donors and agencies are willing to explore the many possible ways that exist for collaborating around RBF. For instance, it is of course possible to fund a RBF scheme without going through the Trust Fund managed by the World Bank. We felt a lot of commitment at this level, but some questions remain. We offered the service of the CoP to document and share some successful experiences (cf. Rwanda, Burundi, Benin…). 
  • Senior conference participants highlighted one of the greatest assets of RBF: the emphasis the strategy puts on learning and the opportunity it offers to improving one’s action. As illustrated by the experiences from different countries presented at the meeting, and aptly summarized by Tore Godal, the convenor of the meeting, RBF is a problem-solving strategy. Having said this, we believe that even more efforts could be taken to improve PBF, among other things, by better taking into account evidence generated outside the RBF community. For instance, to our knowledge, very few RBF schemes have already responded to the large body of evidence showing that neonatal mortality is one of the new priorities in sub-Saharan Africa. By the way, this is one of the many areas where UNICEF could contribute. 
  • Several experts shared their concern that at country level, RBF could suffer from system bottlenecks, such as poor availability of drugs and medical commodities. We agreed to coordinate our efforts to try to overcome this problem. On the side of the PBF CoP, our wish is to organize an event in 2014 whereby central medical stores would be able to meet their clients (health facilities). We believe that PBF has created a new ecosystem in which health facilities are much more demanding in terms of ancillary services. More about this soon.
  • One of the objectives of the meeting was to discuss the next stage (what needs to happen after the pilot stage). While it is hoped that donors will maintain and expand their support, the consensus is increasingly that domestic financing – or at the very least co-financing - will be the main solution in the future, especially in non-fragile countries. Our own assessment is that there still remains much to do at this level in many countries; in terms of advocacy and engagement (especially towards the Ministries of Finance), but also in terms of support (e.g. on how to adapt public finance mechanisms). 
 
A global learning agenda

As observed by the participants affiliated to the World Bank, the Global Fund and GAVI, a key asset of the RBF approach could be that it will lead to more cooperation between these three agencies, something which failed to happen so far, by and large. The first signs are encouraging. This needs to be confirmed at country level, of course, but we are optimistic.

In Oslo, we all agreed that RBF is a global learning agenda and that learning should not be limited to the demonstration of the impact (or not) of a strategy. In many settings, adjustment of policies will need to take place, in an iterative process, which confirms that the knowledge agenda will have to be connected with implementation. The community of practice has its work cut out, in other words.

Notes:
(1) We also had the opportunity to attend the gala concert in honor of this year’s Nobel Peace Prize winner, the Organisation for the Prohibition of Chemical Weapons, a great experience which  compensated for the fact that this time of the year is not exactly the ideal period for visiting Norway.
(2) More about PBF in Argentina (and global football icon Lionel Messi!) in a forthcoming blog post. 

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