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

• 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%)

Country Context

Maternal Mortality Ratio Time Trend

Life expectancy at birth, total (years – peak of crisis – 2008) Maternal mortality ratio (per 100,000 live births – peak of crisis – 2008)

59 62 41 44 48 52 40 45 50 55 60 65 390 830 790 869 645 300 400 500 600 700 800 900 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
• Functions separated: purchaser, provider, regulator

& external verifier

• Key role for community –Health Center Committees
• 1. Results-Based

Contracting

• Strengthening planning and RBF management

capacity (management of RBF cycle @ facility level, District, Provincial and National Levels

• Purchasing, verification, strategic management
• 2. Management and

Capacity Building

• Capture effect on health outcomes and various

aspects of the health system

• Emphasis on Process Monitoring and Evaluation –

mixed methods approach

• Contextual factors linked to health provider

performance

• Two cohorts – on-going and purposively sampled
• 3. Monitoring and

Documentation

Contract

Tracing clients and client satisfaction Policy and Supervision Policy and Supervision Policy and Supervision

MoHCW Provincial Health Executive Health Facilities and HCC (387) District Health Executive National Steering Committee District Steering Committee

CORDAID Private Purchasing Agency (NPA)

Contract + Payment Payment Community Based Organisations Clients

CORDAID Local Purchasing Unit

Payment Contract + Verification Contract

External verification

Implementation Arrangements

Rural Health Centers District Hospital

1.

OPD new consultations

2.

First ANC visit during the first 16 weeks of pregnancy (October 2012)

3.

Ante natal care 4 visits completed

4.

Post natal care 2 or more

5.

Normal deliveries

6.

HIV VCT in ANC

7.

Syphilis RPR test

8.

IPT (x2 doses)

9.

Tetanus TT2+

10.

ARVs to HIV+ preg. Women (PMTCT)

11.

Family planning short and long term methods

12.

High risk perinatal referrals

13.

Vitamin A supplementation

14.

Children fully immunized

15.

Growth monitoring, children < 5yrs

16.

Cure discharged acute malnutrition children < 5yrs (October 2012)

1.

Normal deliveries in district hospital

2.

Deliveries with complications (caesareans excluded) and post partum complications

3.

Caesareans performed

4.

Family planning: Tuba Ligations

5.

Counter referral note arrives at RHC (October 2012)

Package of RBF Services

ZIneter

Participating Districts

Implementation Timeline

• Marondera and Zvishavane
• 28 health facilities

July 2011

• + 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

March 2012

• Mid-term Review
• Technical Modifications
• Roll-out PME – April 2013
• Additional Funding – DFID & Norway US$ 20 million – urban

component

February 2013

Mid-term Review

 The extent of progress –

Project Development Objective

 Interactions between RBF

and various pillars of health systems

 Comparison of RBF &

comparison district performance.

 Multi-stakeholder process  In-depth data analysis to

inform decisions

 Key policy recommendations

& lessons for management improvement

Results

• 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

System and outcome level effects

Income Loss Due to the 5% Difference Rule Total income lost From March to September 2012 = $157,529.30

0% 5% 10% 15% 20% 25% 30% 35% mrt-12 apr-12 mei-12 jun-12 jul-12 aug-12 sep-12

Lost RBF revenue due to errors

25 50 75 100 Mar Apr May Jun Mul Aug Sep Oct Nov Dec 2012

Percent

• Inst. Deliveries

ANC PNC Vaccination

Increased coverage - select indicators

100 200 300 400 500 600 700 800 900 1000 Mar Apr May Jun Jul Aug Sep Oct Nov Total n. of cases

• Mar. to Nov. 2012 - increase in high risk perinatal referrals

from participating RHCs

Institutional deliveries, Jul. 2011 to Aug. 2012 – RHC vs. hospital

50 100 150 200 250 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 Number of deliveries Deliveries in RHC Deliveries in Hospital Linear (Deliveries in RHC) Linear (Deliveries in Hospital)

5 10 15 20 25 30 35 40

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

per 10,000 population RBF districts non RBF districts

• Mar. 2012- strong increase in pregnant women completing 4

ANC visits in RBF districts compared to 16 non-RBF districts

5 10 15 20 25 30 35

per 10,000 population

Normal deliveries

RBF non RBF

• Mar. 2012 - relatively strong increase in normal deliveries in RBF

facilities compared to 16 non-RBF districts

10 20 30 40 50 60 70

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

per 10,000 population

Hypertension cases all ages

RBF non RBF

No evidence that RBF districts neglect non-incentivized services compared to 16 non-RBF districts

1000 2000 3000 4000 5000 6000 7000 8000

Mar Apr May Jun Jul Aug Sep Oct Nov

• No. of tests

HIV VCT in ANC

No improvement in HIV counseling and testing in context of ANC; presumably because this is already covered under HIV program

• 10

20 30 40 50 60 70 80 90 T1 T2 T3 T4

%

Average score - RHCs and hospitals combined

DHE/PHE Score CBOs Score

• Mar. to Dec. 2012 – quality scores

Evaluation Work and Design



IE Question: What is the causal impact of HRBF on service provision and population health indicators of interest?

 Given the design of the HRBF, a quasi-

experimental approach



Treatment: Facilities and patients residing in districts that introduce the HRBF program



Control: Facilities and households in matched “business as usual” districts

 A difference-in-difference estimator

between matched facilities in treatment and control will estimate program impact Process Evaluation



Application

 Opens up the “Black Box” of RBF

interventions

 Documents and describes how the

program operates, the services it delivers, and functions it carries out

 Better understand contextual factors



Mixed methods

 Sequential (quant –qualitative)  Selection by performance (best,

medium and worst)

• 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

Main Lessons on Quality

• 1. Scale-up Process Monitoring and

Evaluation plus country-level dissemination (delivery science)

2.

Demand and supply side innovations in low-income urban areas (DFID & Norway funding)

3.

Broaden donor dialogue & develop joint learning agenda

4.

Strong interest to expand services – TB/HIV/AIDS –Government



Possible domestic co-financing for TB/HIV indicators

5.

Establish a system to better monitor equity effects and verification on user-fees

6.

Improvements to supervision tool – emphasis on clinical quality of care

7.

Scaling up efforts by Government to plan for RBF sustainability – National Task Force

8.

Support Government and development partners efforts to scale-up RBF 45 districts – Health

Transition Fund

Key Directions Post-MTR