TheWorldofInitiatives-RBFHomepageRBFHealth举措-世界的RBFRBF健康主页

StocktakingofResults-BasedFinancing(RBF)ExperiencesintheWorldBankLoganBrenzel,HDNHEJuly8,2021

1QuestionstobeAddressedby

theStocktakingReviewWhatpolicyorhealthsystemissueswereRBFmechanismstryingtoaddressincountries?Whatisthescale,scopeandtypesofRBFmechanismsthathavebeensupportedbytheWorldBankacrossregions?WhoarethebeneficiariesofRBFmechanismsandtowhatextentaretheneedsofthepoorbeingaddressed?WhattypeoflendinginstrumentshasbeenusedandwhatisthelevelofWorldBanklendingforRBF?WhatweresomeofthedesignfeaturesoftheRBFmechanisms?WhathasbeentheexperiencewithmonitoringandevaluatingRBFmechanisms?Whatresultshavebeenachievedintheseprojects?WhathavebeenthechallengesinthedesignandimplementationofRBFmechanisms?Whatarethelessonslearnedfromthereviewofprojects,andwhataretheprospectsforsustainability?WhataresomerecommendationsforthewayforwardfortheWorldBankonRBF?2MethodsReviewoftheportfolio(BoardapprovalFY1995-2021)Healthsectorperformanceastheprimarytheme(code67)Reviewof260activeandclosedprojectsProjectportalsourceofinformationDeskreviewofPIDs,PADs,ICRs,otherdocumentsSomefollow-upwithTTLsQuickreviewtotriagethetotalsampleMoredetailedreviewofprojectsanddataentryintospreadsheetsforcomparisonusingTable1tocategorizeRBFactivitiesLimitations:ProjectdocumentsareintentionsandreviewislimitedtowhatisinthosedocumentsICRsreflectothers’opinionsandestimatesofresultsReviewedsimilardocumentsacrossprojectsbutdidnotdrilldownintodetailsofindividualprojectsHealthSystemsPerformancethemewillnotcaptureallactivitiesinthisarea(conservativeestimates)3DefinitionofRBFforHealthUsedintheReviewRBFforhealthisacashpaymentornon-monetarytransfermadetoanationalorsub-nationalgovernment,manager,provider,payer,orconsumerofhealthservicesafterpredefinedresultshavebeenattainedandverified.Paymentisconditionalonmeasureableactionsbeingundertaken.

4CategoriesofRBFActivities(Table1)RecipientsRBFMechanismBehaviorChangeNationalGovernmentTransferofaportionoftheloanorgrantonthebasisofverifiedachievementofhealthtargetsfromasetofpre-specifiedindicatorsNationalgovernmentputsinplacethenecessarypolicyframeworkandprogrammaticsupporttoachieveresults.MinistryofHealthAdministrativeLevels(entitiesthatmanage,support,andsupervisedeliveryofservicesatcentral,provincial,districtlevels,and/ortheirmanagers)

Portionofbudgetsorperformancebonusesreceivedatsub-nationaladministrativelevelscontingentonachievementofpre-agreedperformancetargetsoftencodifiedwithinacontractedarrangement.Sub-nationaladministrativelevelsoftenhaveperformanceagreementswithhealthfacilities.Central,provincial,and/ordistrictlevelmanagershaveanincentivetosupportachievingresultsandtoorganizetheirplanning,budgeting,supervisionandmonitoringsystemsaccordinglyHealthInsuranceEntitiesPaymentsmadetohealthinsuranceentitiesconditionalontheirmeetingpre-agreedtargetsfornumbersofnewenrolleesperperiod.HealthinsuranceentityorganizesitselftomeetcoveragetargetsHealthFacilities(entitiesthatdeliverservices,suchashospitals,healthcentersandclinics,grouppractices,publicandprivatesector,includingNGOs)Paymentsmadetohealthfacilities(fee-for-serviceortarget-basedpayments)onthebasisofprovidinganagreed-upontype,level,andqualityofservices.Paymentsareretainedinthehealthfacilitytoimprovequalityofservicesandperformance.Facilityorganizesitselftodeliverservicesand/ormeetperformancetargetsandachieveresultstoreceivepaymentorbonuses.5CategoriesofRBFActivities(cont’d)RecipientsRBFMechanismBehaviorChangeHealthCareWorkers(individuals,managers,ortheteamasawhole)Payments(performancebonusesorin-kindrewards)madetoindividualhealthworkers,managers,ortoteamsofhealthworkersonthebasisofservicesprovidedorachieving/exceedingpre-agreedtargetsandresultsbetweenthehealthfacilityandthehealthworker(s).Healthworkersmotivatedtoprovidespecifiedtypesandqualityofservices,andtobepresentatthefacilityCommunity-levelorganizationsPaymentprovidedtocommunity-levelorganizationsconditionalonachievementofresultsspelledoutinagreementsbetweenthecommunityandthehealthfacilityorotheradministrativelevelinthegovernment.CommunitygroupssolveproblemsandorganizethemselvesandcommunitymemberstoachieveresultsHouseholdsFinancialpaymentsmadetohouseholdsasawelfaretransferconditionalonhouseholdmembersutilizingspecifichealthandeducationservices(CCTs)Householdsaremotivatedtoseekanduseservicestoreceivethewelfaretransferthathasbothapriceeffect(thecostofseekingcareandtheopportunitycostoftimeiswhollyorpartiallysubsidized)andanincomeeffect(transferislargeenoughtoaffecthouseholdincomeandalterintra-householdresourceallocationtowardhealthierconsumption)Consumers/patientsPaymentsmadetoanindividualthroughavoucher,one-timecashpayment(CCP)orin-kindpaymentconditionaluponuseofspecifichealthservice(e.g.,institutionaldeliveries)ortocompleteaspecifictreatmentprotocol(e.g.compliancewithDOTS)Individualismotivatedtouseaservicebecauseofapriceeffect(thecostofseekingcareandtheopportunitycostoftimeiswhollyorpartlysubsidized)6DatabaseBasicprojectinformationprojectidentificationnumber,datesofWorldBankBoardapproval,dateofprojecteffectiveness,lendingamounts(IBRD,IDA,orgrants),proportionoftheprojectallocatedtohealth,taskteamleader,lendinginstrument)RationaleforpursuinganRBFstrategyBeneficiariesandwhethertheprojectfocusedonpoororvulnerablegroupsDescriptionofRBFmechanismsWhethertheprojectfocusesonmonetaryornon-monetaryincentivesScopeoftheRBF(entireproject,component,pilotactivities,studies)DevelopmentandprojectindicatorsTypeofevaluationforeseenFinancinganddisbursementImplementingagencyandprojectmanagementProspectsforsustainability7RationaleandObjectivesforRBFApproachImproveefficiency,equity,effectivenessoraccesstoservicesIncreaseservicedeliverytothepoorAddressIMR/U5MR/MMRAddressworseninghealthconditionsClosedprojectstendedtofocuson“systems〞outputs/outcomesmoreActiveprojectstendingtoaddresshealthoutputs/outcomes8RBFExperienceoftheWorldBankIndicatorActiveClosedTotalTotalHNPprojectsreviewed148112260HNPprojectswithanRBFelement281240PercentofHNPprojectsreviewedwithanRBFelement19%11%15%CountrieswithanHNPprojectwithanRBFelement191029HNPprojectswithasubstantialRBFelement17724ProjectswithasubstantialRBFelementasapercentofHNPprojectsreviewed11%6%9%

9RBFActivitiesbyRegionRegionActiveClosedTotalPercentSubstantialRBFPercentSubstan-tialAFR71820%450%EAP72922.5%667%ECA225%150%LCR671332.5%1077%MNASAR80820%337.5%Total281240100%24Percent70%30%100%60%10EvolutionofBankSupportfor

RBFActivitiesOverTime11BeneficiariesofRBFActivitiesBeneficiariesActiveProjects(n=28)ClosedProjects(n=12)Total(n=40)Geographicalarea13(46%)6(50%)19(48%)Healthcareworkers/clients1(3.5%)1(8%)2(5%)Poorhouseholds15(54%)4(33%)19(48%)WomenandChildren10(36%)5(42%)15(38%)Other1(3.5%)PopulationwithHIV1(3%)12RBFMechanismsFoundinWorldBankProjectsRegion/TypeAFREAPECALACSARTotalPercentLoanDisbursementBasedonNationalGovernmentPerformance2004288.9%PerformanceAgreementswithSub-nationalGovernmentAdministrativeEntities350831921.1%PerformanceAgreementswithInsuranceEntities1015077.8%Performance-basedAgreementswithPublicFacilities412721617.8%Performance-basedAgreementswithPrivateProviders300431011.1%Performance-basedAgreementswithNGOs611151415.6%Performance-BasedHealthWorkerIncentives1300266.7%Performance-basedAgreementswithCommunities0000112.5%Vouchersandconditionalcashpayments13001512.5%Conditionalcashtransfer00013410.0%Total21134302290100.0%Percentofmechanisms23.3%14.4%4.4%33.3%24.4%100.0%

13TypesofIncentivesFoundinWorldBankProjectswithRBFActivitiesRegion/Character-isticMonetaryIncen-tivesIn-kindIncen-tivesEntirePro-jectProjectCompo-nentPilotActivi-tiesExplorationandStudiesAFR712521EAP82461ECA221LCR1318332SAR822532Total3861219156Percent95%15%30%48%38%15%14LendingInstrumentsUsedforRBFActivitiesRegion/TypeSILSIMAPLERLPRSCTotalAFR41218EAP729ECA22LCR336113SAR32

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8Total19883240Percent47.5%20.0%20.0%7.5%5.0%100.0%15FundingforRBFActivitiesImpossibletoknowfundingforRBFactivitiesspecificallywithanydegreeofaccuracyTotalvalueofsupport(IBRD/IDA/grants)forentireprojectswithRBFActivities:$3.79billion(FY95-08)$2.29billioninactiveprojects1.5billioninclosedprojectsIDAloansrepresent68%ofsupportinactiveprojectsandonly9%inclosedprojectsConclusion:moreRBFactivitiesbeingsupportedinlowerincomesettingsPossibleareatotrackinthefuture16ProjectswithSubstantialRBFActivitiesDefinition:wholeprojectorsignificantcomponent(s)devotedtoRBF24ProjectsidentifiedashavingsubstantialRBFActivities17activeprojects7closedprojectsLAChad43%oftheseprojects;AFR27%71differenttypesofRBFmechanismssupported(2.3perproject)Performanceagreementswithsub-nationaladministrativelevelsPerformance-basedcontractswithpublicfacilitiesandNGOs$2.4billioninsupport(63%oftotalsupportforprojectsasawhole)17TypesofEvaluationsPlannedforProjectswithRBFActivitiesTypeofEvaluationActiveProjects(n=28)ClosedProjects(n=12)Total(n=40)Annualassessmentofprojectperformance10(36%)3(25%)13(33%)Pre/postevaluation5(18%)1(8%)6(15%)Baselinesurvey14(50%)014(35%)Impactevaluation(randomizedcontrolledtrial)8(29%)4(33%)12(30%)Otherevaluations6(21%)2(17%)8(20%)18LessonsLearnedfromtheICRReview(n=12)Politicalcommitment&countryownership–particularlyfordecentralizedlevelsInvolvementofallstakeholdersindesign(tomitigateresistancetoreforms)QualityimprovementsimportantcomplementtoquantityofcareimprovementsImportanttoanalyzecurrentincentivestructurebeforelayeringadditionalincentivesontopofthemSuccessoftenfacilitatedbycomplementaryreforms(decentralization,autonomyofproviders,legal/regulatoryframeworks,etc)Focusedandgradual(LACexperience)vs.immediate(fragilestates)AdequateorganizationalstructuresandinstitutionalcapacityarecriticalPilotsnotwell-connectedwithbroaderprogramorpolicydialogueofreformssonochanceforscaling-upSelectionofperformanceindicatorscritical–adequatemonitoringandevaluationframeworksnecessary.Limitedattentionpaidinprojectstoperverseincentives,gaming,andunintendedconsequencesofRBFImpactevaluationlacking19ProjectResultsAchieved(fromICRs,n=12)Increaseinambulatorycarevisitsby60%(Uruguay)Costsavingsby9%andsavingsonpharmaceuticalexpenditures(Uruguay)Mexicoprojectreached90%oftargetedbeneficiariesandsupportedProgresaALOSdeclined(Uruguay,RussianFederation)Purchaser-providersplitthwartedbyspecialinterestgroups(Armenia)Pilottoocomplicatedtoscale-up(Russia)Ecuador:33%reductioninMMR&IMR;29%reductioninU5MRIndonesia:supportforpilotsweakatsub-nationallevel;implementedtoolatetomakeadifferenceBolivia:IMRreducedfrom67to54/1000LB;projectexceededtargetsin6outof8indicators;SeguroBasicodeSaludestablishedArgentina:reachedhig