and conflict-affected settings: from research to practice Webinar: - - PowerPoint PPT Presentation

Performance based financing in fragile and conflict-affected settings: from research to practice

Webinar:

Hosted by the HSG Thematic Working Group on Health Systems in Fragile and Conflict Affected States 31st October 2018

We will not be using webcams Please keep your microphones muted Please submit your questions through the Questions Box For technical support please write to

n.jalaghonia@curatio.com

Housekeeping rules

Performance based financing in fragile and conflict-affected settings: from research to practice

Introduction:

Professor Sophie Witter IGHD, Queen Margaret University & ReBUILD

Why the FCAS focus?

• Two billion people now live in situations affected by fragility and conflict

(World Bank 2018)

• Share of extreme poor living in conflict-affected situations is expected to

rise to 80% by 2030 if not action is taken

• Conflict and population displacement now at highest level for 30 years
• More than 60% of maternal and child deaths occur in FCAS (OECD 2018)
• A recent study found that armed conflict substantially and persistently

increases infant mortality in Africa (Wagner et al., 2018)

• However, fragile states receive around 50% less aid than predicted,

despite their high needs (Graves et al., 2015), also less health research

• In this context, making progress towards universal health coverage (UHC)

and meeting the Sustainable Development Goals (SDGs) is particularly challenging

ReBUILD

Post conflict is a

neglected area

• f health

system research

Opportunity

to set health systems in a pro-poor direction Useful to think about what policy space there is in the immediate post-conflict period

Choice of focal countries

enable distance and close up view of post conflict

Decisions made early post-conflict/post-crisis can steer the long term development of the health system

Consortium partners (2011-18)

• College of Medicine and Allied Health

Sciences (CoMAHS), Sierra Leone

• Biomedical Training and Research Institute

(BRTI), Zimbabwe

• Makerere University School of Public

Health (MaKSPH), Uganda

• Cambodia Development Research

Institute (CDRI)

• Institute for International Health and

Development (IIHD), Queen Margaret University, UK

• Liverpool school of Tropical Medicine (UK)

Consortium affiliates working in additional countries: Cote d'Ivoire, Nigeria and South Africa; Sri Lanka, Gaza and Liberia Extended work in second phase in northern Nigeria, CAR, DRC, Timor Leste

Why focus on PBF?

• Many different forms and terminology within the RBF school
• PBF aims to improve health services by providing payments to service providers

(usually facilities, but often with a portion paid to individual staff) based on the verified quantity of outputs produced, modified by quality indicators. – In many cases there is a division of functions between regulation, purchasing, fund-holding, and service delivery

• It has expanded rapidly across low and middle countries, over the last decade, and

especially in FCAS settings, but relatively little work on how context affects PBF – Conflicting arguments: some argue that PBF is unlikely to be effective in fragile settings while others point out that precisely in situations of weak institutions there is more potential for PBF to re-align relationships and improve accountability

PBF in sub-Saharan Africa

Source: Fritsche et al., 2014

Patterns of PBF adoption in FCAS

– 23 (43%) out of 53 FCAS countries have/had at least one PBF programme – 19 (56%) out of 34 PBF programmes in SSA are implemented in FCAS

Afghanistan Comoros Guinea Nigeria Burundi Congo (Republic) Guinea Bissau Rwanda Cambodia Cote d’Ivoire Haiti Sierra Leone Cameroon Djibouti Lao PDR Tajikistan Central African Republic DR Congo Liberia Zimbabwe Chad The Gambia Mali

Bertone, M., Falisse, J-B., Russo, G., Witter, S. (2018) Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems. PLOS ONE, 13(4): e0195301.

PBF adoption over time – All PBF programmes in SSA implemented before 2006 are in FCAS settings (Rwanda, Burundi, DRC, Cameroon, Cote d’Ivoire) – The first countries to have scaled-up PBF nationwide are also FCAS: Rwanda (2008), Burundi (2010) and Sierra Leone (2011) – Appears to have been a successor to PBC model supported earlier by donors in FCAS (Cambodia, Haiti, Afghanistan and Liberia) – Often multiple schemes – e.g. DRC (7) and Burundi (6) over past ten years

Why was PBF introduced?

Link with experience of conflict and fragility rarely explicitly made PBF facilitating factors – some hypotheses confirmed:

– Low levels of interpersonal trust and need to strengthen accountability and good governance (Mali, Burundi, Cameroon) – Lack of trust between donors and government and fiduciary concerns (DRC, Cote d’Ivoire, Zimbabwe) – Flexibility (or absence) of existing institutions (Rwanda, Burundi) – Less entrenched interests and power relations (SL) – Push for decentralisation and facility autonomy? Often de facto (inherited from conflict period) and not explicitly acknowledged, although present

Features of implementation – hypotheses & evidence

More variation and adaptation of PBF in FCAS?

→ Copy-and-paste approaches after first scheme in Rwanda → Exception: adaptation to humanitarian and early recovery contexts (Nigeria, CAR, Cameroon, SL)

Challenges sustaining PBF overtime

→ start-stop(-start) approaches (SL, Chad) → More sustainable when linked to broader health financing/system reforms (Rwanda, Burundi)

Components of our PBF work

1. Hypothesis-driven literature review: How does the context of fragile and

conflict-affected settings (FCAS) influence the adoption, adaption, implementation and health system effects of PBF?

2. Political economy of PBF: looking at the dynamics that led to the adoption and expansion of PBF, but also its impact on resource distribution within the health system (Sierra Leone, Zimbabwe) 3. PBF in crises: further explore the emerging adaptations of PBF to humanitarian and early recovery settings (DRC/South Kivu, Nigeria/Adamawa, CAR) 4. Focus on strategic purchasing: as PBF is increasingly considered a potential entry point to strengthen strategic purchasing (and thus the health system), we examined three empirical examples on how PBF has affected the purchasing function (DRC, Uganda, Zimbabwe)

https://rebuildconsortium.com/our-research/research-projects/health- financing/performance-based-financing/

Aims for panel

• To share key findings of research and reflect together on their

relevance

• Create dialogue between researchers and practitioners on

implications for practice

• Shape future research agenda collectively

Do please send in your thoughts and questions on these as we talk….

Our panel

Introduction and moderator Prof Sophie Witter (ReBUILD/QMU)

• 1. The political economy of PBF in fragile settings

Dr Maria Bertone (ReBUILD/QMU) Discussant: Noemi Schramm (CHAI, Sierra Leone)

Our panel

• 2. PBF in humanitarian settings:

principles and pragmatism Eelco Jacobs (KIT) Discussant: Piet Vroeg (Consultant, formerly Cordaid)

• 3. Does PBF strengthen strategic

purchasing? The experience of Uganda, Zimbabwe and the DRC Prof Freddie Ssengooba (ReBUILD/Makerere) Discussant: Dr Inke Mathauer (WHO) Discussion

ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

The political economy of PBF in fragile settings

Maria Bertone IGHD, Queen Margaret University, Edinburgh ReBUILD Research Consortium

Funded by

Introduction

▪ Performance-based financing (PBF) is increasingly implemented in LMICs, including fragile settings ▪ Growing literature on its effects, but less attention to the context and the processes around PBF adoption and implementation ▪ We analyse two case studies:

▪ Sierra Leone (2010-2017): interesting case because of the ‘start-stop-(start again?)’ trajectory ▪ Zimbabwe (2011-2018): one of the few nation-wide PBF scheme in SSAfrica

Methods

▪ Retrospective, qualitative case studies ▪ Analytical frameworks drawing from political economy analysis

▪ Actors: roles, interests & agendas, power & influence, ‘winners & losers’) ▪ Structure: socio-political context, historical legacies, disrupting events, imposed timings ▪ Frames: ideas, meanings, narratives

Sierra Leone Zimbabwe Document review n=68 n=60 Key informant interviews n=25 n=40 Direct observation √ √

Timeline

PBF in Sierra Leone

2009 2010 2011 2012 2013 2014 2015 2016 2017

FHCI announ- cement FHCI launch ‘Simple’PBF at primary care level (start) GAVI scandal PBF external verif. PBF Plus (1 district) Pilot by Cordaid End of ‘simple’ PBF (now called ‘PBF Light’) Discussions

• n new PBF

scheme Ebola epidemic Salary increase for HWs (HRH TWG+D-HRH) Nationwide PBF implementation PBF negotiations (WB + DPPI)

Short negotiation process

• Resourced-strapped environment (aid

dependency)

• Internal divisions w/in MoH
• Negotiations moved bilaterally (venue

shopping) Little adaptation Low capacity

• Challenges of Simple PBF
• (Unsuccessful) attempt to

shift the narrative

• Externally imposed

timing/ funding cycles

• Dissonance in

framing

Timeline

RBF in Zimbabwe

2008 2010 2011 2012 2013 2014 2015 2016 2017 Peak political and econ crisis Govt of National Unity Pilot in 2 districts (start) WB technical review (price adj) Pilot scaled up (18 distr) HTF support Mid-term review (Cordaid) RBF impact eval Quality checklist revised Tech review (indicators, bonus) Sustainability TWG Start RBF discussion (WB & MoHCC) 2009 2018 HTF adopts RBF for PCUs (42 distr) Pol upheaval ‘new dispensation’ RBF institutionalisation in MoHCC (increased funding), district hosp included

(Relatively) longer negotiation process Initially, RBF = resources in cash-strapped environment

• Ownership develops
• Regular adaptations

and changes

• Model fits the existing

system (eg., RBM)

• Careful not to

marginalise some actors (district managers) Residual capacity Remaining challenges: institutionalisation, funding, transaction costs

Discussion

▪ Differences between FCAS settings

▪ Lack of resources, but residual capacity in Zimbabwe ▪ Resource and capacity-strapped environment, internal divisions/external influences in Sierra Leone

▪ Structural issues (eg., power, rent-seeking) are difficult to overcome ▪ More attention could be paid to other elements to ensure political support and sustainability of reforms

▪ ‘Actual frames’ (timing) should remain flexible, allowing for disrupting events as well as for time to develop national capacity and ownership ▪ Adopting shared (metaphorical) frames to ensure a common and inclusive understanding of technical concepts such as PBF

Concluding thoughts

▪ Some critical elements emerge across the literature:

▪ Taking time, participatory approaches, tailored design, iterative learning from pilots, local ownership ▪ See also “four phases framework”: generation, adoption, instutionalisation, expansion → different critical elements at different times during the PBF scale-up process [Meessen et al, 2017 - https://bit.ly/2F2y3ph]

▪ Key question is “so what?”, how can processes with these characteristics be promoted and sustained?

▪ Some of the bottlenecks are structural and entrenched in the interests and incentives of the different actors. How to effectively operate in that environment? ▪ What is the role of researchers, and the role of practitioners (Ministry of Health, implementing organisations, technical assistants, donors, etc.)?

References

Bertone MP , Wurie H, Samai M, Witter S, The bumpy trajectory of performance-based financing in Sierra Leone: agency, structure and frames shaping the policy process. Globalization and Health, 2018; 14: 99

https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-018-0417-y

Witter S, Chirwa Y, Chandiwana P , Muntati S, Pepukai M, Bertone MP , The political economy of results-based financing: the experience of the health system in Zimbabwe (under review).

…and how can we learn from all of this with our next round of PBF implementation? Some reflections from Sierra Leone.

Noemi Schramm, Sierra Leone

A lot of the problems with the simple PBF stemmed from the initial narrative Fallback narrative until now is the initial narrative – “just get cash to the facilities and workers, as they have none” Push towards seeing PBF as investment into systemic reform / rationalization of health sector (“hubs and spokes”) → Spend time and thought into developing a solid frame/story

Improve on incentive analysis of all stakeholders – e.g. national level MoHS, Cordaid → Think about different incentives and reasons why people and institutions support PBF

Seek and develop champions – identify a group of champions and potential champions, especially in settings like Sierra Leone, and build their capacity from the beginning Maintain champions, even if it means that implementation is slower – in the longrun, it is the only way to maintain the scheme (e.g. MoHS official) → Be wise in who you choose as champion, and if you have chosen them, make sure they are in the driving seat, no matter how slow or fast the car moves!

Branding – let go of your ego, for the sake

• f national ownership

(e.g. PBF PLUS implementation, ODI Fellows) → National ownership is only possible if other partners stay in the background, behind Government, even if they do a lot of the technical work

The PBF light design was largely copied from other schemes – and then went through an adaptive process during the first 2-3 years where the scheme in the end boiled down to what Sierra Leone actually was able to implement (e.g. local councils as purchaser) We need to get better in responding to the needs of the health sector (e.g. initial PBF ownership was largely driven by lack of resources, and the promise thereof if this type of reform is implemented) → There is no ‘one size fits all’ PBF design

ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

Performance-based financing in three humanitarian settings: principles and pragmatism

Maria Paola Bertone [1], Eelco Jacobs [2], Jurrien Toonen [2], Ngozi Akwataghibe[2], Sophie Witter [1]

• 1. Queen Margaret University, Edinburgh / ReBUILD
• 2. KIT Royal Tropical Institute, Amsterdam

Funded by

Study

• bjectives

Describe how PBF has been adapted during humanitarian crisis and early recovery Explore how these adaptations worked and the underlying factors that sustained/hindered PBF’s implementation and effectiveness in those contexts Document early lessons and (if relevant) point to further gaps and research needs Explore the effects of PBF on and degree of integration with health system and health financing in those settings

Methods

▪ Qualitative, exploratory approach ▪ Study design: comparison of case studies ▪ Data collection ▪ Document review (mostly grey literature and internal documents) ▪ Interviews (KII) and FGDs with key informants at policy and operational levels: ▪ DRC: 13 interviews; CAR: 10 interviews, 6 FGDs; Nigeria: 12 interviews, 10 FGDs ▪ Purposive sample, including MoH at central/federal and at state/provincial/regional/district levels, donors, PBF implementers, PBF experts and consultants, other stakeholders (NGOs, civil society).

Study Settings

Central African Republic Nigeria (Adamawa State) DR Congo (South Kivu) When was PBF introduced? Since 2009 Since 2012 Since 2006 Where? Various regions, using different models Pilot in 3 states – focus

• n Adamawa State

Several pilots – focus on South Kivu Funding Cordaid, EU (Fonds Bekou), World Bank World Bank Cordaid Implementation Cordaid, AEDES National Primary Health Care Development Agency and State-level Primary Health Care Development Board/Agencies Cordaid Context Depending on the areas: humanitarian and protracted crisis or early recovery Adamawa State affected by Boko Haram’s insurgency Cycles of acute crisis and relative stability

Implications of conflict and fragility for the health systems

South Kivu, DR Congo Central African Republic Adamawa State, Nigeria National governance and leadership

• Conflict exacerbated pre-

existing weaknesses related to lack of governance and underfunding

• MoH lost its leadership

role to donors and NGOs

• Structured federal

system with effective decentralisation.

• Federal and state

governments’ efforts to strengthen primary health care delivery despite political instability Consequences

• f conflict on

service delivery

• Violent episodes have left

infrastructure destroyed, equipment pillaged and led to lack of staff in some areas

• By 2016 27% of health

facilities were (partially) destroyed,

• nly 22% had a source
• f energy and 43%

running water

• Insurgency left only

37% of facilities functional with limited staff, facing disease

• utbreaks

Healthcare financing

• No fee exemption policies

(except for some vertically-funded preventative services)

• Reliance on user fees and

external aid

• Since 2014, nationwide

externally funded free healthcare policy for maternal and child health, and ‘emergency’ services. Later scaled down

• User fees in place

generally, though lifted at the height of the crisis in 2014

PBF Adaptations, their drivers and facilitators

Conclusions

▪ Pragmatic adaptation of PBF to local context is important in humanitarian settings for PBF to work ▪ Facilitating or enabling factors for adaptation:

• Local staff and knowledge
• Embedded long-term partners and networks (social capital)
• Organisational flexibility (as opposed to rigid orthodoxy)
• De facto policy void in which PBF can be piloted

Bertone MP, Jacobs E, Toonen J, Akwataghibe N, Witter S (2018) Performance-based financing in three humanitarian settings: principles and pragmatism. Conflict and Health, 12: 28. https://conflictandhealth.biomedcentral.com/track/pdf/10.1186/s13031-018-0166-9

ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

Discussion: Performance-based financing in humanitarian settings

Piet Vroeg Independent consultant

ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

Investigating results-based financing as a tool for strategic purchasing:

comparing the cases of the Democratic Republic of Congo, Zimbabwe and Uganda

Sophie Witter; Maria Bertone; Justine Namakula; Pamela Chandiwana; Yotamu Chirwa; Aloysius Ssennyonjo; Freddie Ssengooba ReBUILD Research Consortium

Funded by

Introduction

▪ RBF has proliferated in low and middle-income settings (incl. in fragile, post-crisis/conflict contexts) in the past decade. ▪ It is often portrayed as a mechanism for strengthening strategic purchasing

“First and foremost, P4P is a strategic purchasing tool, helping to translate stated priorities into

• services. [...] Because P4P involves an explicit link between purchasing and benefits, with

payment driven by verified data on the use of defined services, it is a form of strategic purchasing” [Soucat et al, Pay-for-Performance Debate: Not Seeing the Forest for the

• Trees. Health Systems and Reforms, 2017; 3(2):74–79]

▪ However, few studies have empirically examined how RBF affects prior purchasing arrangements in practice → we looked at the experience of Uganda, Zimbabwe and the DR Congo.

Study settings

DRC Zimbabwe Uganda

History & fragility features

• Violence and pol. instability

since independence.

• Underfunded public service

provision

• Policy vacuum left room for

NGO/ donor-led experiments

• Single government

since independence

• Prolonged economic

and pol crisis (peak in 2008)

• Resource constraints

as trigger for RBF adoption

• Civil war until 1986,

continued in the Northern region until 2006

• RBF adopted to improve

health services RBF program- mes & focus

• f this study
• Since 2005
• Numerous programmes

(~7)

• Focus: EU-funded Fonds

Europeen de Developpement (FED) (2005-2010); WB- funded Programme de developpement de services de santé (PDSS) (2017-ongoing)

• Establishment of semi-

autonomous purchasing agencies (EUPs)

• Since 2011
• WB-funded (Cordaid)

pilot, later scaled up

• HDF-funded (Crown

Agents) for national scale up (2014)

• Since 2009
• Numerous programmes
• Most focusing on PNFP

(mission) sector

• Focus: WB’s Saving Mothers,

Giving Lives (SMGL) (2012- 2017); DFID’s NuHealth (2011-2016); USAID’s Strengthening Decentralisation for Sustainability (SDS) (2011- 2017).

Methods

▪ Comparative case study:

▪ Qualitative ▪ Retrospective

▪ Data collection: ▪ Data analysis:

▪ Thematic coding based on pre-defined list of themes reflecting the functions/key actions included in a framework on strategic purchasing

[ReSYST, What is strategic purchasing for health?, 2014] DRC Zimbabwe Uganda

Document review 23 60 27 Key informant interviews 9 KIIs (remotely) 40 KIIs 49 KIIs (14 KIIs for this study; 35 KIIs for previous study and re-analyzed)

Comparative matrix

Key strategic purchasing actions by government

• Establish clear frameworks for purchaser(s) and providers
• Ensure accountability of purchaser(s)
• Ensure adequate resources mobilised
• Fill service delivery infrastructure gaps

Key strategic purchasing actions in relation to citizens/population served

• Assess needs, preferences, values of the population to specify benefits
• Inform the population of entitlements
• Establish mechanisms for complaints and feedback
• Publicly report on use of resources and performance

Key strategic purchasing actions in relation to providers

• Select (accredit) providers
• Establish service agreements/contracts
• Design, implement, modify provider payment methods to encourage

efficiency and quality

• Establish provider payment rates
• Pay providers regularly
• Allocate resources equitably
• Strategies to promote equitable access
• Monitor user payment policies
• Develop, manage and use information systems to monitor/audit

performance and protect against fraud

• Supervise providers

[Source: adapted from ReSYST, 2014]

Key findings (1)

Key strategic purchasing actions by government

• RBF contracts provided clearer rules and regulations where there was weak

regulatory capacity (DRC). Less so where regulatory frameworks are stronger (Uganda, Zimbabwe). Some changes only for providers/services covered by RBF.

• Little change to accountability of purchasers:
• in the DRC the EUPs were supposed to increase this, but the govt did not exercise

their oversight role.

• in Uganda and Zimbabwe, RBF created parallel systems with external purchasers

accountable to funder as well as to govt.

• RBF does mobilise additional resources to support entitlements for some services

(usually MCH).

Key strategic purchasing actions in relation to citizens/ population served

• Engagement and consultation on needs, preferences and values remains limited in

all settings

• Some improvements in specifying and informing of entitlements. For example,
• facilities are require to post the price list on the wall (DRC, Zimbabwe)
• strengthening of Health Management Committees (DRC, Zimbabwe)
• community verification or client satisfaction surveys, although with delays in data

collection and no/little analysis and feedback of results.

• public IT portal (DRC)

Key findings (2)

Key strategic purchasing actions in relation to providers

• No impact on providers’ accreditation and selection (all settings)
• More contractual relations for some providers (those covered by the RBF

programme). However, contract are rarely enforceable with limited room for sanctions

• Some evidence of quality improvements (eg. drug availability), mixed picture on

efficiency.

• Partial improvements in payment systems, often introduced by RBF
• however, for ex in Uganda, payment methods complex and not well understood by
• providers. Different schemes have different indicators and rates, depending on

funders‘ preferences and budget and payment decisions are often unilateral and poorly communicated.

• Some improvements in equitable strategies:
• bonus for remote facilities (DRC, Zimbabwe), but seen as not sufficient
• reduction/removal of fees for certain services (all settings)
• equity funds to reimburse services provider to the very poor (DRC)
• Some improvements in data quality and systems, especially where HMIS was already

stronger (Uganda, Zimbabwe), but challenges with multiple data reporting systems

Discussion

▪ Overall, overoptimistic views of widespread, systemic transformation through RBF are not supported ▪ However, there are gains in specific areas and for a subset of services ▪ Differences across cases due to:

▪ Nature of RBF programmes (e.g., providers included) ▪ Contextual differences (e.g., stronger govt leadership vs. weak institutions)

▪ EUPs experience in DRC as a possible option for extremely fragile settings?

▪ High expectations in terms of catalytic role for raising and pooling funds and increasing strategic purchasing ▪ In practice, original vision of becoming a joint, integrated pooling and purchasing agency remains unfulfilled

Conclusions

▪ Possible reasons for limited impact

▪ RBF viewed and implemented as stand-alone financing mechanisms rather than part of a mixed provider payment system ▪ RBF run as pilot/project, not integrated with existing systems → fragmentation and duplication of strategic purchasing actions.

▪ RBF as a ‘first exposure’ to strategic purchasing?

▪ However, there are a number of outstanding challenges in integrating RBF into health systems, aligning it with other payment mechanisms and PMF, and achieving broader changes in strategic purchasing

▪ Expectations should be nuanced

▪ Focus on expanding areas of potential gain and ensuring better integration and institutionalisation

www.who.int

Performance based financing in fragile contexts: An entry point for strategic purchasing?

Inke Mathauer, MSc., PhD

Senior Health Financing Specialist Department of Health Systems Governance and Financing

Webinar: PBF in fragile states 31 October 2018

50 |

Overview

• I. Seeing PBF as an add-on payment method
• II. What is the evidence?
• III. What are the real questions?

How to move forward? IV.Conclusion

51 |

PBF is a tool for strategic purchasing

Purchasing: allocation of resources to providers Strategic purchasing: allocation driven by information

• n provider

performance and the health needs

• f the

population they serve PBF makes an explicit link between purchasing and benefits, using performance data PBF is an add-on payment method that comes along with a base payment method (e.g., line-item budgets, capitation)

Slide adapted from Elina Dale

I.

52 |

Health system benefits of PBF

⚫ Shifted focus from merely executing budgets to a more data- driven output orientation

– Can change system culture and shake up bureaucratic inertia

⚫ Brought more money to frontline providers ⚫ Increased provider autonomy (some degree needed in spending authority) ⚫ In aid dependent countries, provided a mechanism for harmonizing donor support for an essential service package ⚫ Strengthened the focus on measuring quality (PBF has created demand to establish and improve information management systems)

II.

53 |

What is the evidence

• n the impact of PBF/P4P on health systems?

⚫ P4P combining quality and quantity criteria also prompted purchasers to pay attention to other key issues, e.g.

– setting coherent strategic objectives, – putting in place appropriate info systems, – continuously reassessing incentives of provider payments

Cashin C. et al. (eds.) (2014): Paying For Performance in Healthcare: Implications for health system performance and accountability, Paris: OECD

II.

54 |

Moving forward (1) What should the real questions be about?

⚫ Broader question beyond PBF: How to move from passive to strategic purchasing for UHC? ⚫ How to design PBF payment method to support SP, what are the entry points into SP? ⚫ How to link this with other key reform issues: decentralization, provider and purchaser autonomy, human resources

III.

55 |

Moving forward (2) From scheme to system ”Don’t look at the trees, look at the forest!”

⚫ There should be no isolated “PBF debate” ⚫ Don’t run PBF as a scheme or vertical programme ⚫ Look at the interactions between PBF and the rest of the system, design PBF as part of broader health system reforms

– Align PBF incentives with HS objectives – Align with service delivery reforms

III.

56 |

Moving forward (3) Integration with other system components

⚫ Put focus on the base payment - understand PBF as part of a mixed payment system incentives

– Think through the incentives set by the payment mix – If not coherent, can create undesirable provider behaviour

⚫ Output based payment needs to be embedded in national budget process and PFM

– Requires some degree of provider autonomy

⚫ Integrate PBF in the wider/national reporting and information management system ⚫ Think through the institutional setup

– E.g., is a separate purchasing agency required?

III.

57 |

Moving forward (3) Integration with other system components

⚫ Put focus on the base payment - understand PBF as part of a mixed payment system incentives

– Think through the incentives set by the payment mix – If not coherent, can create undesirable provider behaviour

⚫ Output based payment needs to be embedded in national budget process and PFM

– Requires some degree of provider autonomy

⚫ Think through the institutional setup

– E.g., is a separate purchasing agency required?

III.

58 |

• IV. Conclusions

⚫ If well designed and implemented, PBF as an add-on payment method brings in elements of strategic purchasing, i.e.

– out-put orientation, adjustment of PFM rules, provider autonomy, information system, monitoring

⚫ This can be achieved in an incremental way, also in fragile context BUT ⚫ Health systems strengthening and “classical support” (supervision, recognition of staff, promotion, quality management, etc.) and other PPM remain crucial.

59 |

Thank you very much Questions? Comments!

mathaueri@who.int www.who.int/health_financing

60 |

References

Soucat A, Dale E, Mathauer I, Kutzin J (2017): Pay-for-performance debate: Not seeing the forest for the trees, health Systems & Reform, 3:2, 74-79. DOI: 10.1080/23288604.2017.1302902, http://www.who.int/health_financing/documents/pay-for-performance-debate/en/ Mathauer, I., E. Dale and B. Meessen (2017). Strategic purchasing for Universal Health Coverage: Key policy issues and questions. A summary from expert and practitioners’ discussions. Geneva: WHO (WHO/HGF/Working Paper 17.8), http://www.who.int/health_financing/documents/strategic-purchasing-discussion- summary/en/ WHO (2017). Strategic purchasing for Universal Health Coverage: Unlocking its

• potential. Global meeting summary and key messages. Geneva: WHO.

http://www.who.int/health_financing/events/strategic-purchasing-meeting-2017- report.pdf?ua=1 Cashin C. et al. (eds) (2014): Paying For Performance in Healthcare: Implications for health system performance and accountability, Paris: OECD

ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

Discussion

Over to you! Please type in your thoughts and questions to the panel Aims of the panel

• To share key findings of research and reflect together on their relevance
• Create dialogue between researchers and practitioners on implications for

practice

• Shape future research agenda collectively

ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

Thank you

ReBUILD:

www.rebuildconsortium.com @REBUILDRPC

Thematic Working Group on Health Systems in Fragile and Conflict Affected States:

www.bit.ly/TWGFCAS