performance-based financing

{Photo credit: Warren Zelman}Photo credit: Warren Zelman

There are no magic bullets in life. For fixing a healthcare system, though, there is one approach that comes close: results-based financing. Management Sciences for Health (MSH) pioneered results-based financing in Haiti in 1999, and has been adapting and improving it ever since in sub-Saharan Africa, Latin America, and South-East Asia, including in fragile states.

In my 20-plus years in global health, I’ve seen what happens without results-based financing: A major donor sends millions of dollars’ worth of equipment and supplies to a developing country—and the quality of health services delivered doesn’t improve—or worse, it declines. Why?

Health providers are human, like all of us—sensitive to incentives, motivation, and demotivation. Say a hospital improves and now is well stocked: the community realizes this and the utilization rate doubles. Suddenly, a nurse may be facing 40 patients a day instead of 20, but without any added pay or assistance. It’s only natural he or she might work less under the crushing workload.

Dr. Jonathan Quick, President and CEO of MSH, tours with Dr. Christian Nzitimira, director of Kibagabaga Hospital in Rwanda. {Photo credit: Jon Jay/MSH.}Photo credit: Jon Jay/MSH.

In a postoperative ward of Kibagabaga Hospital, the district hospital serving Rwanda’s capital city of Kigali, Eric Bizimana sits up in bed. Bizimana, 25, had sought care after severe pain in his right leg forced him to stop work as a barber. He was diagnosed with a bone infection called osteomyelitis. Antibiotics alone couldn’t clear the infection. Without an operation to remove the diseased bone, Eric faced the possibility of losing his leg.

Eric was one of the 40 patients who enter Kibagabaga for surgery every day. In Rwanda’s tiered healthcare delivery system, patients are referred from local health centers up to the district hospital when their conditions require more complex care. Most babies are delivered at health centers, for example, but a woman suffering complications or who was expected to need a C-section would be referred to the district level.

Frieda Komba, a licensed drug dispenser in Tanzania. {Photo credit: MSH.}Photo credit: MSH.

Each year over 10 million men, women, and children in developing countries die as a result of our collective failure to deliver available safe, affordable, and proven prevention and treatment. A recent analysis of innovations in products and practices for global health, from the Hepatitis B vaccine to use of skilled birth attendants, revealed virtually none of these life-saving interventions reaches much more than half their target population—even after as many as 28 years of availability. This reflects a vast gap between knowledge and action in global health.

Successful Health Systems Innovations

Low- and middle-income countries (LMIC) benefit from continued innovations in health products and health practices, such as use of misoprostol to prevent post-partum hemorrhage, and technologies such as internet-based mHealth applications to protect the poor from catastrophic health expenditures.  To ensure such innovations achieve large-scale, widespread coverage, they must be accompanied by much more effective health systems innovations.

It’s common sense that a mother who is on treatment for AIDS, pregnant, has a sick child, and is accompanying a sister debilitated by Tuberculosis should not have to visit four separate service delivery points to receive care. Integrated health services not only make the world a healthier place, but also decrease the burden on health systems.

Integration is a comprehensive approach to service delivery. It is the transition from a vertical or horizontal approach to a diagonal, synergistic approach at all levels of a health system. Smart integration means coordinating disease specific programs (such as HIV and AIDS) with other health programs that have operated independently in the past (for example, family planning) to deliver services at the same time or, more importantly, with the same funding. Integration helps organizations maximize the impact of their health investments while allowing people, information, and funding to flow more easily among collaborating groups and stakeholders. Equally important, integration enables providers to treat the health needs of individuals and families more efficiently---regardless of the initial reason a person seeks care.

As Haitians continue to struggle against many obstacles in improving and developing their country, cholera and sanitation remain challenges to many development efforts.

Since the cholera epidemic started in October, there have been a total of 252,640 confirmed cases. MSH integrated its response, where appropriate, with the national response that was coordinated by the Ministry of Health. Following the earthquake, MSH’s USAID-funded Santé pour le Développement et la Stabilité d’Haíïti (SDSH) Project found that provision of basic health care through mobile kiosks in the settlement camp tents were an effective way to provide services and messages. Educational messages and oral rehydration solution (ORS) therapy are now being delivered via these kiosks. In addition, SDSH distributed cots, buckets, bleach, bottled water, and ORS to combat the disease.

I recently visited Haiti and had the opportunity to meet with some local Haitian non-governmental organizations supported by MSH’s Santé pour le Développement et la Stabilité d’Haíïti (SDSH) project, as well as the central Ministry of Health, and departmental Ministry of Health offices. I was searching for information in an effort to learn more about how Performance-Based Financing (PBF) has affected service delivery in Haiti. The SDSH-supported facilities produce monthly service utilization reports that capture the important information, but I’ve been working to obtain comparable information on other facilities. My first thought was the Health Information System (HIS) Unit at the Ministry of Health (MoH).

Millions of people around the world die each year from preventable diseases because they cannot access affordable health care. Developing countries often struggle with insufficient resources and they face numerous challenges trying to strengthen weak health systems. A strong health system working well at all levels, from the household to the community to health facilities to national authorities, can provide effective services to improve the health of the people they serve.

Health financing is the critical foundation for strengthening health systems and ultimately for achieving health impact. Health financing is the starting point – money is the fuel to start and keep a strong health system running. Health financing includes generating funds, distributing those funds, ensuring effective and efficiency use of funds, and protecting the poor from the financial hardship of accessing health services. Without financial resources and proper management of these resources, health workers, health facilities, and medicines would not exist. In difficult economic times, generating those resources seems an insurmountable task. Yet some countries are showing how it can be done.

January 12, 2011 marks the one year anniversary of the earthquake that devastated Port-au-Prince, Haiti. I have the good fortune of visiting MSH’s USAID-funded SDSH (Santé pour le Développement et la Stabilité d’Haíïti) project team in Port-au-Prince this week, and I traveled out into the city to see the devastation the earthquake caused.

Rubble and dust in Haiti a year after the earthquake.

It has been a catastrophic year for Haitians. The Haitians themselves say this, a people who are used to dealing with poverty, combined with yearly hurricanes, and near constant political instability. However, one thing has been made clear to me in the past few days that I have been on this island: Life Goes On.

At the First Global Symposium on Health Systems Research in Montreux, Switzerland in November, Dr. Yogesh Rajkotia, of USAID Rwanda, moderated a panel discussion noting that Performance-Based Financing (PBF) is an effective health systems strengthening strategy. The presentations were made on behalf of the Rwandan Ministry of Health with the guidance of Dr. Agnes Binagwaho, Permanent Secretary.

In 2000, Rwanda’s health system was perceived as weak: there were human resources shortages, especially in rural areas; poor quality of services; and a high morbidity/mortality rate of women and children. Since 2001, Rwanda has committed itself to better health and to pushing for achievement of the Millennium Development Goals (MDG) by 2015.

PBF is a powerful means for increasing the quantity and quality of health services by providing incentives to health providers to improve performance. A PBF program typically includes performance-based grants or contracts. Health clinics and their staff are rewarded for reaching or exceeding health indicators.

Part three of the blog series: Spotlight on Global Health Initiative Plus Countries

Health Financing is Helping Rebuild Rwanda’s Health Sector

It's been over 15 years since the Rwandan genocide; few would know of the tremendous successes in health that the country has experienced. Rwanda has made good progress towards meeting the Millennium Development Goals since they were identified. These impressive achievements are due to an increase in essential health interventions and the implementation of new health financing mechanisms.

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