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Results Based Financing: a new policy instrument for African governments

11/5/2013

7 Commentaires

 
Bruno Meessen

In this blog, Bruno Meessen (ITM, Antwerp and facilitator of the PBF CoP) shows how Results Based Financing could be a lever for African governments in the battle for family planning …  and even more so, when other influential actors in society are hostile.

On sticks, carrots and sermons

Whether you are a general, the leader of a gang, the boss of a big company, or a parent desperately trying to maintain authority, you have three main instruments to steer the behavior of your fellows and subordinates: sticks, carrots and sermons.

The metaphor of a ‘stick’ describes the variety of devices you have at your disposal to deter and, if necessary, punish behavior not in line with your objectives.  This is the fine a policeman gives you if he sees you driving without a seatbelt, for example, or the shot in the knee (at best) for the villain who betrays his boss, the non-renewal of a contract for a supplier due to poor service,… 

The ‘carrot’ is of course used as a metaphor for a reward. A medal for a brave soldier, for example, a diploma for a diligent student, the price paid to a baker for his delicious bread and of course, pay for performance, which I’m sure I don’t have to explain on this blog.

By ‘sermons’, we mean all strategies and tools of education and persuasion. Economists will tell you that these aim to change the preferences of economic agents. More prosaically, the aim is a situation where your fellows, convinced by the strength of your discourse, spontaneously adopt behavior aligned with your goals. This usually happens after you have offered convincing arguments, but if you also have a certain moral authority (like the mother has towards her child, the teacher versus his students, or the priest towards the parishioners), you have an additional advantage.

These tools all have their strengths and weaknesses, and need to be assessed in their particular situation. PBF experts, if they believe in the power of ‘carrots’, also know carrots can’t change all behaviors. ‘Sermons’ will be particularly useful when it’s impossible to verify behavior or when behavior that needs to be encouraged is also beneficial for the one adopting the behavior (example: usage of a condom). Note also that the times are changing: our societies cherish more and more individual freedom and responsibility. ‘Sticks’ are thus less and less tolerated and certain forms used in the past are now even prohibited by law.

Let's appreciate the opportunity offered by Results-Based Financing (RBF)

These are thus the three tools available to governments to influence the behavior of their citizens. In this respect, it is clear that RBF, by its very  nature, is a significant enrichment of the toolbox of African governments. But my wish is that they use this instrument in an even more strategic way, more in particular when they face other leaders promoting views contrary to their own vision of development.

Let’s give an example. Imagine a country which faces a serious demographic problem, to the extent that the high birth rate puts more and more pressure on the economy and more fundamentally, undermines the opportunities which could be available to citizens in the future. Imagine that the government has identified family planning by informed parents as a human right, on the one hand, and as a necessity to boost the development of the country, on the other hand. Imagine then that a prominent religious leader promotes a totally different vision … with a sermon, of course.

What should the government do in this case? Should it opt for the ‘stick’ (eg summon the hierarchy of the religious leader, with the threat of a sanction), or for a confrontation of ‘sermon’ (by the president) versus sermon (of the bishop, for example) on the issue at stake? If I were president of this (imaginary) country, I would think twice. If the bishop (for example) has dared to challenge you over this issue, it’s no doubt because he knows that the balance of power is not exactly in favor of you for the moment. At certain times in the life of a politician, a public confrontation on a particular topic can obviously harm his (or her) goals: the church he/she faces can be very powerful; moreover, given the church’s commitment to social sectors (schools, health centers, …) it will remain a partner for the government to work with. So it’s important to choose your battles – but this, we don’t have to tell politicians.

Results-Based Financing: a powerful lever for change

Faced with this situation, are you powerless then? Before RBF, this was probably the case. However, I think RBF now offers new and ‘smart’ opportunities for government action. The first option, if it hasn’t been implemented yet, is to add family planning to the grid of PBF of health centers (i.e. to reward the health centre for each new woman adopting a modern contraceptive method). If family planning indicators are already present, the government could increase reimbursement rates (as it has been done in Burundi late 2012). This may be powerful, but not enough, especially if many health facilities are affiliated to the church challenging your national policy! I supect that the real breakthrough will come from  involving the communities. First, the government could, like in Makamba (Burundi), contract community associations to refer women interested in family planning. But the government could go even further: it could decide to introduce a voucher system which would encourage women to adopt a modern contraception method. To distribute these vouchers in the community, we would mobilize of course the many female community health workers (with a small compensation for every woman they refer to the health center!). Being wives, mothers, sisters, friends and neighbors, I’m sure they would find the right words to convince their peers.  

By mobilizing the women in communities in Africa and tapping a peer-to-peer educational strategy, it seems to be me RBF can mobilize hundreds of thousands of very persuasive agents who can even beat seasoned preachers, if need be! 

Let us forward this message to political leaders of Africa.



Looking for more resources on RBF & family planning? 

Reproductive Health Vouchers: from promise to practice, T. Boler & L. Harris, 2010, Marie Stopes International.
Voucher schemes for sexual and reproductive health services: a Marie Stopes International (MSI) perspective, factsheet.
Can incentives strengthen access to quality family planning services? Lessons from Burundi, Kenya and Liberia, L. Morgan, 2012, Health Systems 20/20, USAID.  
7 Commentaires
Kristof Decoster
11/5/2013 02:39:54 am

I do think that family planning is such an important topic that the government needs to organize an open discussion on this issue, including church, civil society, ... in other words, including voices who might favour or disfavour certain policies. So maybe not a 'sermon' vs 'sermon' but facilitation of an inclusive discussion, even if it is perhaps not politically the smartest thing to do for some politicians in the short tem.

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Bruno Meessen
11/5/2013 07:35:16 am

Dear Kristof,
You know that I am a "believer" as far as dialogue is concerned. It is actually one of the greatest policy instruments.
But on the issue of family planning, I see actors who do not want to dialogue.

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Dodou Sowe link
11/5/2013 03:49:25 am

This is a very important issue. Family Planning like nutrition most of the time has strategic indicators which have various bearings a number of which are beyond the services provider and the beneficiary. I believe that sermons’, could be the best idea.
if I would go further, knowledge of any subject matter highly influence the thinking and hence determine attitude. What happen with many religious and traditional leaders, the would rely on orthodox knowledge while they are devoid of recent scientific facts Therefore, providing information to such groups and individuals is very paramount .

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Bruno Meessen
11/5/2013 07:45:59 am

Dear Dodou, thanks for your comment.

Yes, the key will be to communicate and educate. I guess that many governments already do so (but feel free to share your observations in your own country). But it occurs that sermons by some other actors are purposely undermining efforts by official authorities.

I do believe that peer-to-peer communication can be more powerful than speeches by official and religious authorities. However, we need strategies to accelerate the mouth-to-ear process and make it more powerful . I believe that RBF can play a role at this level.


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Ben Bellows link
11/6/2013 04:16:56 am

Bruno, many thanks for a helpful post outlining a choice set for the health system to correct a market failure by offering a voluntary means for poor women to satisfy their own demand for contraceptives that, in the absence of a voucher, may be inaccessible. There are at least 19 FP voucher programs that we have been able to identify in LMIC since the first ones in Korea and Taiwan in the 1960s. The key features include effective and inexpensive poverty-based targeting of demand subsidies, prompt and efficient payment to contracted providers, and transparent information systems to facilitate performance monitoring and service verification. These programmatic features are in line with RBF principles and operations.

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Dr Jean Paul NIYIBIGIRA
11/6/2013 06:59:16 pm

Hello Bruno and All.
The fact that Family planning is key to boosting development for LICs is no secret. Secretary General Kofi Annan in 2002 declared that achieving the MDGs in relation to hunger eradication and poverty reduction were out of reach if the questions of reproductive health were not tackled properly (http://web.unfpa.org/pds/achieving.htm).
The use of PBF to address or boost contraceptive intake has both advantages and inconveniences.

1. As you have already put it, it can be very effective
2. Don't you think that vouchers can be seen as 'buying consciences' to sell a product at best useless at worst harmful. This would probably be the first point which the Church would put against it. It seems that vouchers were used in India (to boost surgical sterilisation) and the poorest were the most affected. A way for the rich to sterilise the poor!
3. There is also another aspect. Most funds used by LICs in family planning are money from donors; and some governments (the USA) for example are strongly opposed to the use of incentives in reproductive matters (see about Tiarht Amandment). And we all know how strong is their voice in the funding institutions.

Of course, it is imperative to find ways to boost family planning uptake but I think it better to work on the offer side on first line and continue 'sermoning' the population in general about the added value for attaining MDGs. it is also important to tailor messages delivered properly. As an example, in Burundi they used to talk of 'giving birth to those one is able to educate': this obviously discriminates the poor on one hand; on the other, there are societal factors to take into account: who pays health, schooling, the roads we walk on, who will employ them?'
All things taken together, it is not "those one can educate" but "those the nation can properly manage"; this underlies the importance of a well talored message and a thoroughly thought policy.

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Bruno Meessen
11/9/2013 03:12:52 am

Hi Jean-Paul,

Thanks for your comment.

The most important is that the choice by the woman (or her husband) is well-informed and her own.

You could imagine the voucher is "for a free family planning consultation without obligation to adopt any technique". The payment to the woman would cover the opportunity cost for attending the consultation at the health centre. The opportunity cost consists of (1) the time to come to the health; (2) the waiting time at the facility. This is not "buying conscience" at all; it is a fair compensation for an actual economic loss.

Furthermore, we can remind to the Church that many women have to walk a long way to the (public) health centre because its own health centres do not deliver family planning services !

My conclusion: start to distribute vouchers in responsibility areas covered by their health centres!

By the way, this suggests an interesting question: it could be interesting to check, for instance with Demographic and Health Surveys (if household identification allows it), whether the affiliation of the closest health centre has an impact on the coverage rate with modern family planning techniques.



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