Prioritizing Performance Problems and Choosing

Recipients

Amie Batson

Senior Health Specialist

The World Bank

October 2008

Designing Results Based Financing

1. What are the levels of mortality in your country?

Nationally In various regions In rural vs urban areas Among the poor In specific groups: ethnic minorities

2. What are the causes of mortality

Most mortality causes still avoidable with low cost interventions

Cause-specific proportional mortality in the Africa region

21%

17%

4%

21%

6%2%

7%

17%

Neonatal

HIV/AIDS

Diarrhoealdiseases

Measles

Malaria

Respiratoryinfections

Injuries

Others

3. What are the key high impact interventions which can reduce mortality ?

• Household and Community Level interventions• Population-oriented interventions• Individual Clinical interventions

Household and community level interventions

Insecticide Treated Mosquito Nets

Safe water systems Use of sanitary latrines Hand washing by mother Indoor Residual Spraying

(IRS) Clean delivery and cord

care Early breastfeeding and

temperature management Universal extra

community-based care of LBW infants

Breastfeeding Complementary feeding Therapeutic Feeding Oral Rehydration Therapy Zinc for diarrhea

management Vitamin A - Treatment for

measles Chloroquine for malaria

(P.vivax) Artemisinin-based

Combination Therapy Antibiotics for U5

pneumonia Community based

management of neonatal sepsis

Population oriented interventions Family planning HPV vaccination Tetanus toxoid Preconceptual folate

supplementation Deworming in pregnancy Detection and treatment of

asymptomatic bacteriuria Treatment of syphilis in

pregnancy Prevention and treatment of iron

deficiency anemia in pregnancy Intermittent preventive treatment

(IPTp) for malaria in pregnancy Balanced protein energy

supplements for pregnant women Supplementation in pregnancy

with multi-micronutrients

PMTCT VCT Cotrimoxazole prophylaxis for HIV+ Childhood Immunization

Measles BCG OPV DPT Hib Hepatitis B Yellow fever Meningococcal A/C Pneumococcal Rotavirus

Neonatal Vitamin A supplementation Vitamin A - supplementation Zinc preventive

Individual clinical interventions

Skilled attended delivery Basic emergency obstetric care (B-EOC) Resuscitation of asphyctic newborns at

birth Antenatal steroids for preterm labor Antibiotics for Preterm/Prelabour Rupture

of Membrane (P/PROM) Detection and management of

(pre)ecclampsia (Mg Sulphate) Management of neonatal infections Antibiotics for U5 pneumonia Antibiotics for diarrhea and enteric fevers

Vitamin A - Treatment for measles

Zinc for diarrhea management

Clinical management of neonatal jaundice

Management of severely sick children (referral IMCI)

Chloroquine for malaria (P.vivax)

Artemisinin-based Combination Therapy

Management of complicated malaria (2nd line drug)

Individual clinical interventions

Management of opportunistic infections

Male circumcision Second-line ART Adult second-line ART Comprehensive emergency

obstetric care (C-EOC) Other emergency acute

care

Detection and management of STI

Management of opportunistic infections

First line ART Detection and treatment of TB

with first line drugs (category 1 and 3)

Re-treatment of TB patients with first line drugs (category 2)

MDR treatement with second line drugs

4. What could be achieved if the coverage with high interventions increases ?

Saving 1.3 million lives per year for $ 400 per life saved: jumpstarting community care & outreach

Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost

$ 0.66

$ 0.00

$ 0.43

$ 0.22

0%

5%

10%

15%

20%

25%

Family/community Outreach/schedulable Clinical Total Services

Delivery modes

Mo

rtali

ty r

ed

ucti

on

$0.0

$0.5

$1.0

Neonatal Mortality Under Five Mortality

Maternal Mortality Incremental Economic Costs per capita/year

Scenario I : Africa generic

Saving 2.5 million lives per year for $ 800 per life saved: Full Minimum Package at scale:

Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost

$ 2.48

$ 0.72

$ 1.09

$ 0.67

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Family/community Outreach/schedulable Clinical Total Services

Delivery modes

Mo

rtali

ty r

ed

ucti

on

$0.0

$0.5

$1.0

$1.5

$2.0

$2.5

$3.0

Neonatal Mortality Under Five Mortality

Maternal Mortality Incremental Economic Costs per capita/year

Phase I : Africa generic

Saving 5.5 million lives per year for $ 1,500 per life saved: maximum package at scale.

Expected Impact on Neonatal, Under Five and Maternal Mortality and Additional Economic Cost

$ 9.26

$ 1.31

$ 4.11 $ 3.84

0%5%

10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%

Family/community Outreach/schedulable Clinical Total Services

Delivery modes

Mo

rtali

ty r

ed

ucti

on

$0

$1

$2

$3

$4

$5

$6

$7

$8

$9

$10

Neonatal MortalityUnder Five MortalityMaternal MortalityIncremental Economical Costs per capita/year

Phase III : Africa generic

5. So why is it not happening ? Supply issues ?

Do people have physical access to services ? Infrastructure? Equipment?

Are human resources available? Are commodities and pharmaceuticals available? Is quality of care a major problem

Demand issues ? Is demand for services low? Is continuity of services or compliance low? Is low demand due to financial barriers, social and

cultural barriers ?

Who should be the recipient of RBF? What is the reasons for low coverage? Where should the RBF

incentive be targeted?

Health worker Individual action (working harder) all that is needed. Benefits outweigh the high costs of monitoring and rewarding

performance at this level

Health facility: Work of facility team is needed System changes are needed Improve performance of different providers: public, private,

NGO

Consumer (community, family, mother): Hidden costs (transport, food) constraining demand Community needed to support families / encourage demand

How might you target recipients?

Health facilities Are all health facilities eligible? Or does scheme target public sector facilities? Private

sector? NGO? Does the scheme target facilities in specific provinces (e.g.,

poorest)

Consumer (community, family, mother) Geographic – target all living in poorest provinces or districts Means test – target poorest families in an area Target all demanding/requiring a priority service

All pregnant women to encourage institutional delivery

Example from MCH

Performance problem: Low % of women delivering in facility with trained health worker

Underlying causes: Consumer side: can’t afford transportation, mother-in-law or

community discourages it, can’t afford food or cost of drugs Provider side: poor quality service, rude to mothers, no effort to

follow up after antenatal visits . Provider paid a fixed salary regardless of performance.

Other: Drugs not available. Health workers not well trained

Potential results-based incentives Patient side: subsidies to cover transportation costs, food packages

or money when deliver at the institution Provider: Payment for increased number of women delivering in

facilities

Examples: Objectives and Recipients

Objective Recipient

Increase institutional deliveries as means for reducing MMR

Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA,

Increase % of childen/mothers sleeping under LLINs last night, especially among the poor

Improve demand: Mothers, TBA

Increase supply: TBA, Service provider

Increase supply: Service providers (NGO, public, private, sub-national)

Increase use of services: community, household

Service provider (NGO, public, private) in a poorly performing district

Designing RBF questions

1. What are the levels of mortality in your country?

2. What are the causes of mortality?3. What are the key high impact interventions

which can reduce mortality?4. What could be achieved if the coverage with

high interventions increases?5. So why is it not happening ?6. Who should be the recipient of RBF?

What is the potential for RBF? Rwanda: back on track for the MDGs

Progress towards the MDGs

$8.83

$19.98

$29.35

0%

10%

20%

30%

40%

50%

60%

70%

80%

Phase I Phase II Phase III

$0

$5

$10

$15

$20

$25

$30

$35

Anaemia Reduction of Low Birth weight Estimated reduction in stunting U5MR reduction

IMR reduction NNMR reduction MMR reduction Lifetime Risk of Dying

Total fertility rate (TFR) Reduction of Malaria Mortality Reduction in AIDS mortality Reduction in TB Mortality

Quality of drinking water Use of sanitary laterin Hand washing by mother Cost per capita per year in US$

MDG 1 MDG4 MDG 7MDG 6MDG5