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Presented at the Centers for Disease Control and Prevention (CDC), 6/23/09. An Overview. Results-Based Financing. Joseph F. Naimoli, Senior Health Specialist The World Bank Contributions from Amie Batson, Ruth Levine, Magnus Lindelow, and Rena Eichler. What is RBF?.

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an overview

Presented at the Centers for Disease

Control and Prevention (CDC), 6/23/09

An Overview

Results-Based Financing

Joseph F. Naimoli, Senior Health Specialist

The World Bank

Contributions from Amie Batson, Ruth Levine, Magnus Lindelow, and Rena Eichler

what is rbf
What is RBF?

Different definitions; common theme

Results-based financing (RBF) ≈ Pay-for-performance (P4P)

Provision of payment for the attainment of well-defined results

Transfer of money or material goods conditional on taking a measureable action or achieving a predetermined performance target (CGD, 2009)

RBF takes many forms…



DonorCentral governmentLocal governmentPrivate insurer

Recipients of careHealth care providersFacilities / NGOsCentral governmentLocal governments


what is rbf3

Increased utilization of MCH services

  • 3 ANC visits
  • Institutional delivery
  • Complete immunization of children under 1
  • Post-partum care within 1 week of birth
What is RBF?

Schemes vary by country


  • Supply-side incentives
  • Demand-side incentives
  • Often multiple beneficiaries in a cascading scheme

Improved Maternal and Child Health

Cash payment to women

Increased $ resources for health service providers

Increased $ resources for regional & district health authorities

what is rbf4
People are motivated by intrinsic forces (professional pride)

People are motivated by extrinsic forces (money and recognition)

If designed well, RBF can reinforce professional pride with money and recognition, without undermining intrinsic motivation

What is RBF?

Underlying principles

why rbf
Why RBF?

Two perspectives


why rbf development assistance perspective
Why RBF?Development Assistance Perspective

Business as usual unlikely to achieve Millennium Development Goals (MDGs)

MDG4 progress in 68 priority countries

Source: UNICEF, 2008

why rbf development assistance perspective7
Why RBF?Development Assistance Perspective

Frustration with traditional input-based approaches

Inputs necessary

but not sufficient!

CGD, 2009

why rbf development assistance perspective8
Why RBF?Development Assistance Perspective

Tool for strengthening health system s

Health system building blocks, WHO, 2007

why rbf development assistance perspective9
Why RBF?Development Assistance Perspective

Increasing recognition as promising strategy for MDGs

Taskforce on Innovative Financing for Health Systems

Raising and Channeling Funds

  • Recommendations:
  • Clearly link financing for health to defined outcomes and to measurable results in broader programmes as well as in projects, building on the specific experiences from performance-based funding and SWAps.
  • Further develop and scale up systems that effectively manage development results and provide the incentives for achieving health outcomes.

Working Group 2 report ,Final Draft , 3 June 2009

why rbf10
Why RBF?

Two perspectives


why rbf country perspective
Why RBF? Country Perspective

Ministry of Finance looking to link decision making to observable results

Argentina: Plan Nacer

Transfers from federal to provinces (15) based on # of poor women, children enrolled in social insurance program and performance on key output measures


Devolution of federal budget to

lower levels in the health system

accelerated, in part, by successful


why rbf country perspective12
Why RBF? Country Perspective

Low uptake of services, especially among the poor

Date of DHS


Source: Yazbeck, 2009; Gwatkin, 2007

why rbf country perspective13
Why RBF?Country Perspective

Low uptakes of services, especially among the poor

Date of DHS


Source: Yazbeck, 2009; Gwatkin, 2007

why rbf country perspective14
Why RBF?Country Perspective

Quality concerns, even following traditional performance-improvement interventions (training, follow-up and job aids)

Source: Bryce J, et al., Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania, Health Policy and Planning, 2005, i69-i76

why rbf country perspective15
Why RBF?Country Perspective

Current incentive structure contributes to poor performance

why rbf country perspective16
Why RBF? Country perspective

Far-ranging experimentation with provider payment reforms


Source: Buying results? Contracting for health service delivery in developing countries, Loevinsohn B. and Harding A., The Lancet, 2005, 366, 676-681

rbf challenges
RBF Challenges

Institutional change

rbf challenges19
RBF Challenges

Numerous possible implementation hazards

RBF in principle…

Select action or output

Define indicators

Set targets


Measure performance

Reward or


Gaming the system

Reliability, validity of administrative data

Cost of independent verification


Effort in one, several areas may result in neglect of others

Too ambitious, too easy

Rules of game

Unnecessary provision or demand

Quantity trumps quality

Too much $, too little

Undermining intrinsic motivation

Beneficiaries must control behavior change

Too many, too few

does rbf work
Does RBF work?

Solid evidence on demand side

  • Conditional Cash Transfers (CCTs) rigorously evaluated
  • Bulk of evidence from Latin American and Caribbean countries; some encouraging evidence from Bangladesh, Cambodia
  • Effective in reducing poverty in the short term
  • Substantial increases in use of health services, primarily preventive services
  • Impact on outcomes mixed
  • Typically require complementary supply-side actions

Source: Fiszbein et al., 2009

does rbf work21
Does RBF work?

Limited, mixed evidence on supply side

  • Supply side: generally weak designs
  • Argentina: increased enrollment of poor, previously uninsured women and children
  • Afghanistan and Cambodia: increases in immunization, prenatal visits, overall service use, equity gains
  • Many confounding factors (increased financing, TA, feedback, supervision, training, etc.) make it difficult to isolate effect of “incentive”
does rbf work22
Does RBF work?

Rwanda leading the way in sub-Saharan Africa

Rwanda: performance bonus scheme

  • Prospective, quasi-experimental design
  • Effect of incentives was “isolated” from effect of additional resources
  • Equal amount of resources without the incentives would not have achieved the same outcomes
  • Improved child health outcomes: height for age, morbidity

Source: Gertler, et al. , 2009

does rbf work23
Does RBF work?

Rwanda leading the way in sub-Saharan Africa

  • Less impact on demand-sensitive interventions (ANC)
  • Rwanda now piloting community-based performance bonus to increase demand
  • Government adopting culture of results – moving RBF to Education and other sectors

Source: Gertler, et al. , 2009

does rbf work24
Does RBF work?

Need to open the “black box “ of implementation

  • Little information on “why” demand and supply schemes succeed or fail
  • Insufficient information on unintended consequences
  • Sound monitoring, documentation and evaluation of new initiatives will be critical
world bank health results innovation trust fund
World BankHealth Results Innovation Trust Fund
  • Eight grants linked to IDA credits to finance the national strategy (International Health Partnership + principles) with focus on MDGs 4 and 5
  • Why linked to IDA credits?
    • Integrates RBF into broader policy dialogue between MOF and MOH
    • Engages Bank operational staff at country level and headquarters
    • Embeds RBF into Bank support for HSS
    • Potentially leverages additional IDA for health
  • $95 million from Norway supports comprehensive design, implementation, monitoring and impact evaluation
the wb health results innovation trust fund
The WB Health Results Innovation Trust Fund



End (approx.)







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characteristics of selected rbf trust fund projects
Characteristics of Selected RBF Trust Fund Projects
  • Afghanistan: performance-based bonus payments to NGOs
  • DR Congo: performance-based bonus payments to public facilities and health workers
  • Eritrea: demand-side incentives to mothers and performance budgets to administrative levels
  • Rwanda: performance-based contracting with community organizations to increase demand
  • Zambia: performance-based bonuses to public facilities and district

A common M&E Framework for RBF

Monitoring and Documentation

Impact Evaluation





Long-run results

Resources (time, people, money, commodities, etc.) mobilized

Health system platform strengthened (policy, regulations, HMIS, financial procedures, etc.)

Contracted work program activities executed

Support activities implemented

Innovative, improvised solutions applied

Contractual services used, delivered and reporting verified

Regular, timely, appropriate incentive payments made or withheld

Improved coverage of population with high impact interventions

Improved quality of care

Health promoting behavior change

Maternal mortality


Infant and child mortality



RBF is appealing to governments

  • Motivation and creativity to strengthen health systems
  • Flexibility to engage all providers (public, private, NGO)
  • Culture of results - replacing focus on inputs
  • Facilitates targeting – at poorest, MDG 4/5
  • Both demand and supply side matter – and must be balanced
  • RBF not panacea! – must be part of broader dialogue with Ministries of Health and Finance and linked to investments in health
  • Still building evidence base but exciting potential
    • Accelerate progress toward MDGs
    • Implement Paris/Accra Principles – align with the International Health Partnership