Learning from rbf implementation
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Learning from RBF Implementation. Dinesh Nair Sr Health Specialist. Overview of Session. Why do we need to “learn from RBF”? Pulling it all together: the conceptual framework Nigeria Case Study. Many opportunities to learn. Comprehensive learning agenda.

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Learning from RBF Implementation

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Learning from RBF Implementation

Dinesh Nair Sr Health Specialist

Overview of Session

  • Why do we need to “learn from RBF”?

  • Pulling it all together: the conceptual framework

  • Nigeria Case Study

Many opportunities to learn

Comprehensive learning agenda

A broad approach to learn from RBF implementation

  • Holistic conceptual framework which highlights:

    • the intermediate outcomes necessary to achieve results

    • the utility of a multidisciplinary lens

    • the need for broad methodological approaches



A Conceptual Framework for PBF

  • What organizational and behavioral changes do you expect PBF to bring about?

Learning from RBF Implementation: Nigeria Experience

RBF in Nigeria combines the PBF at health centers and DLIs to state and local governments

Results Based Financing Approach in Nigeria

Federal Govt.

Finance based on.. (Examples)

  • Increase in services

  • Budget execution

  • Bonus payment


State Govt.


  • Supervision

  • HMIS reporting

  • HR management

Local Govt.



  • Quantity of services delivered

  • Quality scores of the services

Health Centers


Coverage has been increasing significantly, but further improvement is required

Coverage of health services in Pre-Pilot facilities in Adamawa state (%)

Inst Deliveries



  • Significant improvement from very low baseline in all indicators

  • The is a good contrast with low DHS 2013 results in the North East (institutional delivery 20%, vaccination 14%, FP 11%)

  • However, the overall utilization is still 30-40%

Detailed look at the operational data revealed the large variations in performance across Health Centers

Institutional Delivery in Adamawa, normalized by 100,000 population

  • Before PBF, all health centers were equally at very low levels

  • After the PBF, some facilities achieved 100% coverage while others struggle with limited improvement

This performance variation across health centers also exists in quality of care

Quality Score (%) in pre-pilot health centers in Adamawa state

  • The quality score overall improves even in low performers

  • However, the difference between high and low performers increased from 23% to 30%

Nigeria team engaged with two qualitative studies

2. Case study on key determinants

1. Demand-side barrier analysis

  • What differentiate the good and poor performers under the PBF scheme?

  • What are the barriers to service utilization in the PBF facilities?

Research question

  • Transport, service fee, culture/perception/ information barriers

  • Competition of alternatives

  • Health center management

  • Contextual factors

  • Health systems factors (e.g., supervision)

Areas to look into

  • Interviews, document review, direct observations

  • Best and poorest performers

  • Interview and focus group

  • High and low performers


  • Design demand-side interventions

  • Devise appropriate support to poor performers

Potential use

Demand-side barrier analysis revealed priority issues

Priority demand side intervention

Major Barriers Found through Qualitative Analysis



Possible approaches




  • Transport Voucher


  • Community transport team

  • Maternal shelter







  • CCT


Demand-Side Barriers

  • Predictable/discounted pricing (supply-side)

Predictability of cost






  • N/A


  • Incentives for referral to PHCs (supply-side)

Traditional providers



  • Community engagement (supply-side)

Community support




  • Communication and community involvement




Case study on determinants suggests the importance of community engagement and OIC management

Identified determinants and non-determinants (preliminary)



  • Community engagement (e.g., involve and reward community leaders, daily visits, incentivize for use of facility)

  • OIC’s management capacity (e.g., full staff involvement, improve staff environment using performance bonus, rigorous performance review)

  • Level of staffing (best performers lack staff)

  • Remoteness of facilities (best performers are very rural)

  • Technical qualifications of OIC (many community health workers manage facilities well)

  • Business planning (none use it effectively yet)

Research findings will drive new demand-side interventions with additional financing

Proposed Transport Voucher and Strengthening management capacities

Transport Voucher

Improve Capacities

  • ANC standard visit (1-4)

  • Institutional delivery

  • Postnatal consultation

  • Vaccination of children

  • Growth monitoring

  • Referred services provided by hospitals

  • Community engagement

  • Management capacity building of health centers

  • Technical training (e.g., IMCI) for quality improvement (QI)

Implementation Arrangements

  • Build demand side interventions to support Supply Side RBF interventions

Key Lessons Learned

  • RBF performance hinges on how well and quickly we can learn from implementation and improve our approaches

  • Qualitative research can provide a powerful insights and evidence in devising effective approaches

  • Identifying right research questions and clear plan to use the research results are required to make the qualitative research meaningful

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