RBF in Zimbabwe Results & Lessons from Mid-term Review - PowerPoint PPT Presentation

RBF in Zimbabwe Results & Lessons from Mid-term Review Ronald Mutasa, Task Team Leader, World Bank May 7, 2013

Outline • Country Context • Technical Design • Implementation Timeline • Midterm Review • Results • Evaluation • Lessons Learned • Key Directions

Country Context Population: +/-13 million , brain-drain and highly skilled diaspora • Political and economic decline, weakened public service delivery • Low governance rankings Transparency CPI Index Ranking in 2010, 134 out of 178 • Decline in public sector financing & management & control systems • High household out-of-pocket expenditures (39%) • Maternal Mortality Ratio Time Trend

Life expectancy at birth, total (years – Maternal mortality ratio (per 100,000 peak of crisis – 2008) live births – peak of crisis – 2008) 65 900 830 62 790 869 59 800 60 700 55 52 600 645 50 48 500 390 44 45 400 41 300 40 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Zimbabwe Sub-Saharan Africa (all income levels)

Technical Design  RBF aligned with & supports national health strategy and policy  User fee removal  Increase access to priority maternal, family planning and child health services  Decentralized service delivery and revitalized primary health care  Prioritized package of services directly linked to burden of disease for mothers, newborns and children under 5  RBF used to operationalize GoZ Results-Based Management Strategy

Three components Fee-for-services : quality and quantity • 1. Results-Based Functions separated: purchaser, provider, regulator • & external verifier Contracting Key role for community –Health Center Committees • Strengthening planning and RBF management • 2 . Management and capacity (management of RBF cycle @ facility level, District, Provincial and National Levels Capacity Building Purchasing, verification, strategic management • Capture effect on health outcomes and various • aspects of the health system 3. Monitoring and Emphasis on Process Monitoring and Evaluation – • Documentation mixed methods approach Contextual factors linked to health provider • performance Two cohorts – on-going and purposively sampled •

Implementation Arrangements MoHCW Contract CORDAID Private Purchasing Agency (NPA) National Steering Policy and Supervision Committee Provincial Health Contract + Payment Executive Policy and CORDAID Local Purchasing Unit Supervision Payment District Health Contract Executive District Steering Policy and Committee Supervision Payment Health Facilities and Contract + Verification HCC (387) Tracing clients and client satisfaction Community Based Organisations Clients External verification

Package of RBF Services Rural Health Centers District Hospital Normal deliveries in district hospital 1. OPD new consultations 1. 2. Deliveries with complications (caesareans First ANC visit during the first 16 weeks of 2. excluded) and post partum complications pregnancy (October 2012) Caesareans performed 3. Ante natal care 4 visits completed 3. 4. Family planning: Tuba Ligations Post natal care 2 or more 4. 5. Counter referral note arrives at RHC (October 5. Normal deliveries 2012) 6. HIV VCT in ANC Syphilis RPR test 7. IPT (x2 doses) 8. Tetanus TT2+ 9. 10. ARVs to HIV+ preg. Women (PMTCT) 11. Family planning short and long term methods High risk perinatal referrals 12. Vitamin A supplementation 13. Children fully immunized 14. 15. Growth monitoring, children < 5yrs 16. Cure discharged acute malnutrition children < 5yrs (October 2012)

Participating Districts ZIneter

Implementation Timeline July 2011 Marondera and Zvishavane • 28 health facilities • March 2012 + 16 districts, 8 rural provinces, 387 facilities • Technical Review June 2012 • Technical Adjustments – Prices and services September 2012 • RBF National Sustainability Task Force – November 2012 • February 2013 Mid-term Review • Technical Modifications • Roll-out PME – April 2013 • Additional Funding – DFID & Norway US$ 20 million – urban • component

Mid-term Review  The extent of progress –  Multi-stakeholder process Project Development  In-depth data analysis to Objective inform decisions  Interactions between RBF  Key policy recommendations and various pillars of health & lessons for management systems improvement  Comparison of RBF & comparison district performance.

Results

System and outcome level effects 1. HMIS Improvement  timeliness  accuracy of reporting  accountability 2. Efficiency -accessing of care at appropriate levels 3. Strengthening referral & patient management 4. Equity 5. Results-based M&E and supportive supervision culture 6. HRH – motivation and management 7. Health Facility Entrepreneurship

Lost RBF revenue due to errors Income Loss Due to the 5% Difference Rule Total income lost From March to September 2012 = $157,529.30 35% 30% 25% 20% 15% 10% 5% 0% mrt-12 apr-12 mei-12 jun-12 jul-12 aug-12 sep-12

Increased coverage - select indicators 100 75 Inst. Deliveries Percent ANC 50 PNC Vaccination 25 0 Mar Apr May Jun Mul Aug Sep Oct Nov Dec 2012

Mar. to Nov. 2012 - increase in high risk perinatal referrals from participating RHCs 1000 900 Total n. of cases 800 700 600 500 400 300 200 100 0 Mar Apr May Jun Jul Aug Sep Oct Nov

Institutional deliveries, Jul. 2011 to Aug. 2012 – RHC vs. hospital 250 200 Number of deliveries 150 100 50 0 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Deliveries in RHC Deliveries in Hospital Linear (Deliveries in RHC) Linear (Deliveries in Hospital)

Mar. 2012- strong increase in pregnant women completing 4 ANC visits in RBF districts compared to 16 non-RBF districts 40 35 per 10,000 population 30 25 20 15 10 5 0 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 RBF districts non RBF districts

Mar. 2012 - relatively strong increase in normal deliveries in RBF facilities compared to 16 non-RBF districts Normal deliveries 35 30 per 10,000 population 25 20 15 10 5 0 RBF non RBF

No evidence that RBF districts neglect non-incentivized services compared to 16 non-RBF districts Hypertension cases all ages 70 per 10,000 population 60 50 40 30 20 10 0 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 RBF non RBF

No improvement in HIV counseling and testing in context of ANC; presumably because this is already covered under HIV program HIV VCT in ANC 8000 7000 6000 No. of tests 5000 4000 3000 2000 1000 0 Mar Apr May Jun Jul Aug Sep Oct Nov

Mar. to Dec. 2012 – quality scores Average score - RHCs and hospitals combined 90 80 70 60 DHE/PHE 50 % Score 40 CBOs 30 Score 20 10 - T1 T2 T3 T4

Evaluation Work and Design  IE Question: What is the causal impact of Process Evaluation HRBF on service provision and population  Application health indicators of interest?  Opens up the “Black Box” of RBF  Given the design of the HRBF, a quasi- interventions experimental approach  Documents and describes how the program operates, the services it  Treatment: Facilities and patients residing delivers, and functions it carries out in districts that introduce the HRBF  Better understand contextual factors program  Mixed methods  Control: Facilities and households in  Sequential (quant –qualitative) matched “business as usual” districts  Selection by performance (best,  A difference-in-difference estimator medium and worst) between matched facilities in treatment and control will estimate program impact

Main Lessons on Quality 1. Performance contracting stimulates District Health Executives, Provincial Health Executives; and HE s and PHEs to perform quarterly supervision. 2. Feedback to health centers stimulates them to improve (and increase earnings) 3. All or none award principle for quality performance or a scale 4. Integration of quality indicators with vertical disease control programs, in line with MOHCW quality policy 5. Relevance of some indicators changes over time

Key Directions Post-MTR 1. Scale-up Process Monitoring and 5. Establish a system to better monitor Evaluation plus country-level equity effects and verification on dissemination (delivery science) user-fees 2. Demand and supply side 6. Improvements to supervision tool – innovations in low-income urban emphasis on clinical quality of care areas (DFID & Norway funding) Scaling up efforts by Government to 7. 3. Broaden donor dialogue & develop plan for RBF sustainability – joint learning agenda National Task Force Strong interest to expand services – Support Government and 4. 8. TB/HIV/AIDS –Government development partners efforts to scale-up RBF 45 districts – Health  Possible domestic co-financing Transition Fund for TB/HIV indicators