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RBF: Can we and should we always check everything?

9/12/2016

9 Commentaires

 
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Matthieu Antony

Verification is an essential function of all RBF programs. At a time when the issue of institutional and financial sustainability of RBF arises in many countries, Matthieu Antony (AEDES) reckons the Pareto principle could help us find a balance between the imperative of control and the objective of efficiency.
 
Verification as the cornerstone of RBF
 

In general, the verification is carried out to ensure that health services for which a payment request has been made have actually been supplied and are of good quality. The reasons for the establishment of such procedure are numerous:
-          Verification helps ensure a certain level of transparency in the payment of RBF credit.
-          Verification helps limit the opportunistic behavior of healthcare providers by imposing the threat of sanctions if they breach their contractual obligations.
-          Finally, a rigorous audit can improve the quality of the routine information system by encouraging the provider to pay more attention to his bookkeeping.
 
Verification of results is therefore essential to ensure the credibility of RBF with all stakeholders. This is especially true at the beginning of an RBF program when actors are not yet familiar with the new institutional arrangements in place.
 
So why redesign the verification procedures?
 
Well, the main reason is because the verification procedures, as they are currently applied in the majority of programs on which I had the chance to work appear costly and inefficient. To illustrate my point I will focus on the quantitative verification, also called the administrative or coherence verification.
 
The quantitative verification is often extremely demanding in terms of human resources and time. This is due to the requirement that ‘verificators’ undertake the review of all healthcare services provided by all health facilities during a given period (usually a quarter). As RBF typically targets about 20 health services (quantitative indicators) and a hundred health facilities (and this only when it is at a pilot project stage), it is easy to understand that the task will be daunting.
In general, the agencies responsible for verification face the problem of establishing strict control while respecting deadlines to ensure payment of RBF bonuses in time to health providers.
 
From my perspective, we tend to underestimate the time required for verification, which can have two consequences:
-          The auditors conduct a quick check which may be of poor quality;
-          Auditors who may have other tasks do not have the time to perform them.
It should be noted indeed that in some cases staff responsible for the audit are also responsible for other technical support whether at central or peripheral level. In this case, verification of services can happen at the expense of other equally important activities, even more important ones (especially when verificators have clinical skills), such as coaching of health facilities.
 
The Pareto principle or the "80/20 rule"
 
Pareto was a 19th-century Italian economist and sociologist who discovered that in several countries in Europe, 20% of the population were typically financing 80% of the tax revenues. From this, he inferred that 20% of the population owned 80% of the country's wealth. This insight has then been turned into a “principle” that can be summarized as follows: 80% of the effects are the result of 20% of the causes (80/20 rule).
 
Since then, this principle, which is purely empirical and has no theoretical foundation, has been observed in many areas: business, management, industry, and has become a powerful analytical tool for separating things into the categories of primary and secondary. Based on my experience, this principle can also be applied to the RBF verification.
 
As described above, one of the main objectives of the quantitative verification is to limit the risk of "over-payment" by verifying that the reported activities that generate payment to the providers are real. In this context, all activities and therefore all RBF target indicators don’t have the same importance. Depending on the volume of activity carried out and fixed unit prices, the financial impact of each indicator will be different. According to an exercise carried out in a sub-Saharan African country that have introduced RBF since more than 4 years, it appears that a third of indicators checked at health centers (32%) contribute to 80% of the total amount saved (therefore unspent) through verification. These results show that it is possible to identify “high risk” indicators and thus priority indicators in terms of verification as well as secondary indicators, with the latter presenting a “moderate” or even “low financial risk”.
 
What can we learn from the Pareto principle?
 
The main lesson we can draw from the Pareto principle in this context is that "maximizing" the verification does not necessarily guarantee the "optimization" of the obtained results. Throughout the verification process, a balance must be found between the efficiency of the procedures and the costs it generates. This is especially true when scaling up an RBF program. Therefore, for purposes of efficiency and sustainability of the verification system, alternatives to a comprehensive and systematic monitoring of care delivery need to be explored.
 
On this last point, the establishment of a verification system based on risk is a track that needs to be explored further. This system would be based on (i) a sample of performance indicators and health facilities according to their level of financial risk and (ii) the adoption of enhanced control measures when the risk is high and simplified measures when the risk is low. Obviously, sampling procedures and verification measures should be defined by the purshaser of the service to avoid collusion between health staff and verificators.
 
Conclusion
 
In conclusion, I come back to the idea that intensive verification may be required at the beginning of the program, but that then we must move towards greater efficiency. It’s about being realistic and admitting that the RBF verification process should not provide absolute certainty on all services provided by health facilities, but some degree of certainty that the service purchaser deems acceptable under the circumstances.
 
What is your opinion and experience on this?

9 Commentaires
Hyacinthe Kankeu
9/13/2016 12:34:17 pm

Thank you Matthieu for this interesting analysis on the need for more efficiency in the verification of results in RBF programs.
Looking at your main recommendation, I wonder if the adoption of a verification system based solely on risk does not bear the... risk to have - in the medium/long run - a transfer of the... risk from priority indicators to those considered as "secondary" when starting the program.
Thus, and to follow in your footsteps on the fact that "sampling procedures and verification measures should be defined by the purshaser of the service to avoid collusion between health staff and verificators", I think that a random sampling of indicators with replacement of a proportion (1/4, 1/3 or 1/2 for example) of them at each verification round deserves consideration. This would indeed address both the need of completeness (e.g. over a year) and the issue of financial risk (which would be "smoothed" over time).

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Antony Matthieu
9/13/2016 10:47:48 pm

Hyacinthe thank you for your suggestion. Actually I did not go into details of the sampling process but it is also the purpose of this blog: try to see what happens in terms of " risk based verification sampling" .

Just to reinforce your point, I think that a sampling method might be to combine : 1) purposive sampling to systematically target "high risk" indicators (which presupposes putting in place a risk monitoring mechanism) and , 2 ) a random sampling of other indicators in order to maintain a degree of uncertainty about the verified indicators and avoid the transfer phenomenon of which you are talking about.

Now it would be interesting to know if such experiments exist and, if so, whether they have been documented. A word to the wise!

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Paula Quigley link
9/14/2016 05:16:35 pm

Dear Antony and RBF community, in our experience in Uganda on a project called NU Health (http://healthpartners-int.co.uk/our-projects/improving-access-to-health-care-for-the-poor-northern-uganda/) we recommended a number of options in our final write-ups to reduce the burden of both HR needs and costs in verification from 100% in the start of a programme. Options include a random selection of indicators for each visit and/or less frequent visits to a facility. We also recommended identifying high-risk indicators from the initial verification processes as those which had the higher discrepancy rates between reported and verified data, and monitoring those regularly until discrepancy rates improve but also checking additional random indicators to ensure that other areas don't get neglected. So consistent with what you and Hyancinthe are saying... Best regards, Paula

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Bruno Meessen
9/14/2016 09:20:27 pm

Dear Matthieu, thank you for launching this discussion. I do believe that it is indeed time for some PBF programs to update their verification system. There is room for more efficiency. Having said this, it would be good, first, to list the other systemic roles of the PBF verification (in economic terms: the positive externalities). You mention some, but there may be others. Being aware of these other systemic contributions will allow us to make the best decision. I take this opportunity to invite you to continue to work on the theory of change of the verification function. Your presentation in our Dar-es-Salaam workshop (available here:https://fr.slideshare.net/secret/44rbjGPkpEnLSj) was .a very good start. The PBF CoP needs more of such new developments.

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Antony Matthieu
9/16/2016 02:27:37 pm

Dear Bruno, thank you for your contribution. I'll meet you on the fact that it is important to understand all the ins and outs of the verification process before initiating reform (even slight). I am ready to work further on the theory of change behind the verification process.

Maybe we can dedicate a specific blog on it. If other people are interested to contribute, I would be delighted to initiate a collective work on this specific issue.

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Erik Josephson
9/27/2016 09:28:42 pm

Matthieu, Bruno, I would agree that we should think about the positive externalities, or as I prefer to term it, the value of verification. Our verification structures should be justified against this value.

Unfortunately there is precious little data available to substantiate the idea that verification saves money. The reported health services data we examined in the discussion paper referenced in another comment showed as much under- as over-reporting by health facilities and community health workers in Burundi and Rwanda. The level of error observed in Argentina and the UK appears to be very small indeed.

We also have precious little data on the cost of verification. Since many verification agencies carry out a number of activities, but submit one invoice for all of them, we tend to have only rough relative measures (e.g. 15%, 20%) to go by.

On the money angle, I'd say we therefore have little to go on thus far to argue one way or another. It would be great for the community to bring more of these figures to light. One aspect highlighted in our paper is that there is a temporal dimension to reduction of errors as a result of verification - in a relatively short span, say two years, differences between declared and verified figures drop significantly.

As Bruno suggests, aside from the money angle, there are other valuable benefits to verification, and these should be pulled together to help in our thinking. I would cite one example of improved data reporting quality, which has a list of attendant benefits which it would be hard to put a financial value on, but which is considerable.

Matthieu, I'd be ready to join a group to think through the roles of verification.

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Bruno Meessen
9/14/2016 09:27:04 pm

On another point... We, the PBF people, see ourselves as advocates of major changes for better performing health systems. But we are also human beings: we may have our own dogmas and just like others, we may also resist changes. I can anticipate that it will not be easy in some countries to change the verification system. To some extent, the PBF system has created its own bureaucracy and vested interests. It would be interesting that country teams share their experience with streamlining their verification system. We have to identify enablers and barriers. My hypothesis is that technology could be an opportunity to facilitate the adoption of a more efficient system (cf Nicolas de Borman's comment under the blog in French).

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Erik Josephson link
9/27/2016 09:02:24 pm

Hi Matthieu,

Thank you for bringing the discussion of the rationale for verification, and the methodology we use to carry it out, to our collective attention. This is a timely intervention, and the participants at the recent RBF Health IE Workshop in Harare were much taken with the issues around optimal verification setups.

Thank you also for linking to Petra Vergeer et al's presentation from 2014 entitled "Findings and Recommendations from a Cross-case Analysis" in your post. Much of the content of that presentation was drawn from a series of six case studies on verification in RBF (Afghanistan, Argentina, Burundi, Panama, Rwanda and the UK), and a cross-case discussion paper. That paper is to be published shortly, and the authors (of which I am one) wanted to share with this group the executive summary ahead of publication, which includes a number of findings and recommendations which will are directly related to your post, notably one on risk-based verification!

The executive summary can be accessed here: http://www.slideshare.net/ErikJosephson1/verification-in-resultsbased-financing-for-health-summary-of-findings-and-recommendations

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Arjanne Rietsema link
9/29/2016 11:25:10 am

In Zimbabwe @Cordaid applies a risk based verification model. Initial evaluation shows that it is cost effective and does not significantly compromise data quality. Another point I would like to rais is that whereas correct data entry is important, we should not conclude that RBF is (un)succesful based on data only. Without computerised data systems as proposed by Nicolas, it is not easy for a busy nurse to complete the required registers, tally sheets etc (in Zim 38 registers and counting). Errors in registering and tallying patients do not mean that they did not receive good quality care!

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