Maarten Oranje, Jos Dusseljee and Carmen Schakel
As stressed in a recent blog by the WHO Health Financing team, the current COVID-19 crisis has far-reaching implications for health financing. In recent decades, many low- and middle-income countries have adopted Results Based Financing (RBF) mechanisms as part of their broader health system strengthening efforts. Such RBF programs, too, are currently under strain as a result of the pandemic, and require adaptations. At the same time, since its mechanisms allow for flexibility, RBF can currently be an asset: a specific COVID-19 response can be embedded into more systemic change. Through the publication of the first edition of a Quick Reference Guide for RBF in Times of COVID-19, Cordaid wishes to engage with the wider community of practitioners on RBF and PBF.
As stressed in a recent blog by the WHO Health Financing team, the current COVID-19 crisis has far-reaching implications for health financing. In recent decades, many low- and middle-income countries have adopted Results Based Financing (RBF) mechanisms as part of their broader health system strengthening efforts. Such RBF programs, too, are currently under strain as a result of the pandemic, and require adaptations. At the same time, since its mechanisms allow for flexibility, RBF can currently be an asset: a specific COVID-19 response can be embedded into more systemic change. Through the publication of the first edition of a Quick Reference Guide for RBF in Times of COVID-19, Cordaid wishes to engage with the wider community of practitioners on RBF and PBF.
A patient seeking treatment in Serbo Health Center in Jimma Zone (Oromia Region, Ethiopia), where Results Based Financing was first introduced in October 2019. The first case of COVID-19 in Jimma Zone was confirmed on April 18th, after which local authorities started the tracing of recent contacts.
Between mid-March and mid-April, the Cordaid Community of Experts on Results Based Financing collaborated to make an inventory of RBF adaptations that could be considered as part of a COVID-19 response, with the dual objective of containing the spread of the virus and preserving availability and quality of vital public health services (such as Reproductive, Maternal, Newborn, Child and Adolescent Health). As an international NGO with long standing experience in the application of RBF, especially in fragile and/or conflict affected settings, Cordaid has seen various such adaptations work in the past. Those past experiences, as well as new ideas that emerged during the onset of the crisis, were captured in a Quick Reference Guide. The objective was to produce a document that could serve as a source of inspiration for RBF practitioners, as well as support their dialogue with donors and government stakeholders. The result, the first edition of RBF in Times of COVID-19: A Quick Reference Guide, is available in both English and French.
What is the content of this Quick Reference Guide?
The suggested adaptations in the guide are of a varying nature, ranging from the high level coordination with authorities and the existing institutional arrangements, to the practicalities of provisional payment and verification mechanisms. The guide looks at temporary adjustments of quality checklists and packages of quantity indicators, as well as at ways to enhance the involvement of communities in the face of the current crisis. Promoting health worker and patient safety is an overarching concern behind the adaptations suggested. Besides these RBF-style interventions, also additional input based interventions are discussed, as in many LMIC settings these will be necessary to safeguard the continuity of the health system. Evidently, no single combination of measures is being proposed, as this is highly context-specific, but the guide gives a practical inventory of options.
In doing so, it of course remains difficult to tell how hard the COVID-19 crisis is going to hit LMICs. Looking at the data, there seem to be signs that in Africa, morbidity and mortality may not reach the levels seen in Asia, Europe and the US. At the same time, countries need to remain extremely cautious and be prepared for a worst case scenario. Beyond the short term, these kind of emergency preparations are all the more necessary given the growing risk of other pandemics in the future.
How does this Guide relate to the broader Health Financing debate?
This wider perspective is clearly reflected also in the core argument that Kutzin and the WHO Financing Team make in their recent blog “Priorities for the Health Financing Response to COVID-19”: the choice now should not be between either health security or Universal Health Coverage (UHC). Investing in core health system functions is key to both, and health financing measures can play a supportive role to facilitate a rapid, organized COVID-19 response. In their analysis, the WHO team identifies two key objectives to be pursued: (1) ensuring sufficient funds for Common Goods for Health, so that necessary public health functions to prepare for and respond to the crisis, are in place and (2) removing financial barriers, to enable the timely diagnosis and treatment for all. What is needed, in short, is a combination of measures on the supply side and on the demand side.
Looking at some specific health financing actions identified by the WHO team to help achieve these two objectives – besides simply increasing public funding for the health system response – some stark similarities with the adaptations proposed in this reference guide can be observed. Granting greater flexibility and spending authority to health facility managers is of course already part and parcel of the RBF approach. The suggestion of additional incentives for health workers, to compensate them for over time, can quite easily be integrated. Similarly, the proposed temporary adaptation of payment models and pricing, to reinforce changes in the location and delivery mode of services, can be addressed through temporary adjustments of quantity or quality indicators. In the end, compensating health facilities for loss of income, due to fluctuations in regular service utilization, was one of the core considerations for this Reference Guide, as it was for the WHO team.
In short, we fully agree with the conclusion that health financing arrangements need to adapt to the current context quickly, and will have to be simplified, streamlined and accompanied by clear communication to the population. Such actions are key in supporting health security and UHC.
What are the next steps?
Cordaid’s efforts so far, in the development of the Quick Reference Guide, were primarily guided by the need to make practical adaptations to the RBF programs we are directly involved in, but we of course know that there are many experts and good ideas out there. An inventory like this is never exhaustive, and any suggestions for additions and adjustments would be very welcome. Moreover, as the COVID-19 epidemic unfolds, the scientific and experiential evidence will grow rapidly, which may lead to new insights.
We welcome your feedback to this Quick Reference Guide, in English or in French. This feedback can be provided either by replying this blog, or by using our contact details which can be found on the final page of the document. Depending also on your interest, we envision to capture external contributions in a second edition, compiled and owned by a much wider community than Cordaid alone, in the third quarter of 2020. Depending on how this crisis evolves, that second edition could be fully focused on the COVID-19 pandemic, or it could have a broader scope: RBF adaptability in view of any infectious disease epidemic that affects the health system. We look forward to hearing your ideas!
Please find here the link to the Quick Reference Guide for RBF in Times of COVID-19 (English and French): https://www.cordaid.org/en/publications/quick-reference-guide-rbf-times-covid-19/
This first edition of a ‘RBF in Times of COVID-19: A Quick Reference Guide’ was compiled by the core members of Cordaid’s Community of Experts on Results Based Financing (CoE RBF) and brings together their past experiences as well as new ideas that emerged at the onset of the current COVID-19 crisis. The core contributors represent a large array of countries: Jos Dusseljee, Maarten Oranje and Carmen Schakel (all Cordaid Global Office, The Netherlands), Polite Dube (Cordaid Ethiopia), Inoussa Malam Issa (Cordaid DRC), Juvénal Ndayishimiye (Cordaid Burundi), Athanase Nduhira (Cordaid CAR), Endris Mohammed Seid (Cordaid Zimbabwe), Eubert Vushoma (Cordaid Liberia), Eric Bigirimana (Bregmans Consulting, formerly Cordaid CAR) and Samar Al-Qadi (Yamaan, Yemen).
Between mid-March and mid-April, the Cordaid Community of Experts on Results Based Financing collaborated to make an inventory of RBF adaptations that could be considered as part of a COVID-19 response, with the dual objective of containing the spread of the virus and preserving availability and quality of vital public health services (such as Reproductive, Maternal, Newborn, Child and Adolescent Health). As an international NGO with long standing experience in the application of RBF, especially in fragile and/or conflict affected settings, Cordaid has seen various such adaptations work in the past. Those past experiences, as well as new ideas that emerged during the onset of the crisis, were captured in a Quick Reference Guide. The objective was to produce a document that could serve as a source of inspiration for RBF practitioners, as well as support their dialogue with donors and government stakeholders. The result, the first edition of RBF in Times of COVID-19: A Quick Reference Guide, is available in both English and French.
What is the content of this Quick Reference Guide?
The suggested adaptations in the guide are of a varying nature, ranging from the high level coordination with authorities and the existing institutional arrangements, to the practicalities of provisional payment and verification mechanisms. The guide looks at temporary adjustments of quality checklists and packages of quantity indicators, as well as at ways to enhance the involvement of communities in the face of the current crisis. Promoting health worker and patient safety is an overarching concern behind the adaptations suggested. Besides these RBF-style interventions, also additional input based interventions are discussed, as in many LMIC settings these will be necessary to safeguard the continuity of the health system. Evidently, no single combination of measures is being proposed, as this is highly context-specific, but the guide gives a practical inventory of options.
In doing so, it of course remains difficult to tell how hard the COVID-19 crisis is going to hit LMICs. Looking at the data, there seem to be signs that in Africa, morbidity and mortality may not reach the levels seen in Asia, Europe and the US. At the same time, countries need to remain extremely cautious and be prepared for a worst case scenario. Beyond the short term, these kind of emergency preparations are all the more necessary given the growing risk of other pandemics in the future.
How does this Guide relate to the broader Health Financing debate?
This wider perspective is clearly reflected also in the core argument that Kutzin and the WHO Financing Team make in their recent blog “Priorities for the Health Financing Response to COVID-19”: the choice now should not be between either health security or Universal Health Coverage (UHC). Investing in core health system functions is key to both, and health financing measures can play a supportive role to facilitate a rapid, organized COVID-19 response. In their analysis, the WHO team identifies two key objectives to be pursued: (1) ensuring sufficient funds for Common Goods for Health, so that necessary public health functions to prepare for and respond to the crisis, are in place and (2) removing financial barriers, to enable the timely diagnosis and treatment for all. What is needed, in short, is a combination of measures on the supply side and on the demand side.
Looking at some specific health financing actions identified by the WHO team to help achieve these two objectives – besides simply increasing public funding for the health system response – some stark similarities with the adaptations proposed in this reference guide can be observed. Granting greater flexibility and spending authority to health facility managers is of course already part and parcel of the RBF approach. The suggestion of additional incentives for health workers, to compensate them for over time, can quite easily be integrated. Similarly, the proposed temporary adaptation of payment models and pricing, to reinforce changes in the location and delivery mode of services, can be addressed through temporary adjustments of quantity or quality indicators. In the end, compensating health facilities for loss of income, due to fluctuations in regular service utilization, was one of the core considerations for this Reference Guide, as it was for the WHO team.
In short, we fully agree with the conclusion that health financing arrangements need to adapt to the current context quickly, and will have to be simplified, streamlined and accompanied by clear communication to the population. Such actions are key in supporting health security and UHC.
What are the next steps?
Cordaid’s efforts so far, in the development of the Quick Reference Guide, were primarily guided by the need to make practical adaptations to the RBF programs we are directly involved in, but we of course know that there are many experts and good ideas out there. An inventory like this is never exhaustive, and any suggestions for additions and adjustments would be very welcome. Moreover, as the COVID-19 epidemic unfolds, the scientific and experiential evidence will grow rapidly, which may lead to new insights.
We welcome your feedback to this Quick Reference Guide, in English or in French. This feedback can be provided either by replying this blog, or by using our contact details which can be found on the final page of the document. Depending also on your interest, we envision to capture external contributions in a second edition, compiled and owned by a much wider community than Cordaid alone, in the third quarter of 2020. Depending on how this crisis evolves, that second edition could be fully focused on the COVID-19 pandemic, or it could have a broader scope: RBF adaptability in view of any infectious disease epidemic that affects the health system. We look forward to hearing your ideas!
Please find here the link to the Quick Reference Guide for RBF in Times of COVID-19 (English and French): https://www.cordaid.org/en/publications/quick-reference-guide-rbf-times-covid-19/
This first edition of a ‘RBF in Times of COVID-19: A Quick Reference Guide’ was compiled by the core members of Cordaid’s Community of Experts on Results Based Financing (CoE RBF) and brings together their past experiences as well as new ideas that emerged at the onset of the current COVID-19 crisis. The core contributors represent a large array of countries: Jos Dusseljee, Maarten Oranje and Carmen Schakel (all Cordaid Global Office, The Netherlands), Polite Dube (Cordaid Ethiopia), Inoussa Malam Issa (Cordaid DRC), Juvénal Ndayishimiye (Cordaid Burundi), Athanase Nduhira (Cordaid CAR), Endris Mohammed Seid (Cordaid Zimbabwe), Eubert Vushoma (Cordaid Liberia), Eric Bigirimana (Bregmans Consulting, formerly Cordaid CAR) and Samar Al-Qadi (Yamaan, Yemen).
