May 20, 2011—As world leaders and dozens of health ministers converge on Geneva, Switzerland, this week for the World Health Organization’s annual World Health Assembly, one topic at the heart of development impact will dominate their discussions: how to vastly improve the health of millions of people around the globe, in keeping with the transformational promises of the 2015 Millennium Development Goals (MDGs).
Because the MDGs for maternal and child health are still out of reach for many countries, governments and their development partners are seeking innovative strategies—such as results-based financing (RBF)—to magnify the impact of investments in health. In low- and middle-income countries, World Bank RBF interventions are driving health service use, improving service quality, increasing efficiency, and enhancing health care quality.
The World Bank’s 2007 Health, Nutrition and Population (HNP) Strategy renewed the Bank’s focus on results, with a key objective of better linking lending and results through increased use of RBF. To support the design and implementation of RBF in countries, the Bank created the Health Results Innovations Trust Fund (HRITF), which plays a major role in scaling up RBF in many countries.
Linking Budgets to Results
The World Health Assembly is meeting a month after a global symposium on RBF for health hosted by the Bank, where officials from ministries of health and finance, non-governmental organizations (NGOs), donor agencies, foundations, and academic and research institutions from more than 15 countries discussed key lessons and challenges in implementing RBF programs.
RBF focuses on results—such as the number of women receiving early antenatal care and delivering their babies in health facilities—rather than inputs—such as the construction of health centers and staff training—and tightly links budgets and financing to results.
“Investing in health systems is the key to breaking the cycle of poverty, improving the health of nations, and saving countless lives. Although making lifesaving technologies available, building clinics, and training workers are essential components of health systems, countries must also establish the incentives to increase the supply and demand of underprovided health services,” said Darren Dorkin, World Bank senior operations officer for health, nutrition, and population.
Some RBF programs work on the “supply side” of health systems, paying incentives to health facilities for performance tied to services—not only paying for quantity of the services provided but also taking into consideration the quality. Other RBF mechanisms on the “demand side” provide financial or “in-kind” incentives to target groups to overcome barriers to health service utilization. Some countries use a combination of demand- and supply-side incentives.
Rwanda, Afghanistan, Argentina Maximize Impact
Countries across the globe are seeing results: In Rwanda, limited resources are maximizing health care impact. Performance-based financing has led to a 21% increase in baby deliveries at health facilities, a 64% increase in preventative visits for children under age 2, and a 133% increase in visits for children ages 2-5. The same results could not have been achieved by simply increasing the amount of resources provided to health facilities. This Rwanda pilot is one of 16 that the Bank is financing through the HRITF.
In Afghanistan, the Bank supported the government to reduce the death rate of infants and children under five by 22% and 26%, respectively, in just three years. In the absence of effective government delivery of health services after the war, the government contracted out health services to NGOs in 2002. Performance-based contracting ensured that NGOs had significant freedom to decide how to use resources innovatively to reach intended results. Performance on quality of care of all contracted health facilities increased by 32%.
In Argentina, Plan Nacer, a social insurance program, is subsidizing providers to provide 80 services free of charge to pregnant women and mothers, as well as children under 6. An early evaluation indicates that among other notable results, the program increased the probability of a first prenatal care visit before week 13 of pregnancy by 8.5% and before week 20 of pregnancy by 18%. Beneficiaries also increased the number of prenatal check-ups by 17%, average birth weights increased, and neonatal mortality decreased.
Although RBF is not a panacea, countries and development partners are increasingly turning to the concept to strengthen health systems, motivate the health workforce, bolster information systems, build local capacity to manage and deliver health services, and ultimately, improve health outcomes.