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.
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.