Results-based Financing for Health in Tanzania Joint Health Sector Review 6 th November 2014

1. Results-based Financing for Health in Tanzania Joint Health Sector Review 6th November 2014

2. Presentation outline • Global Progress toward MDGs • Achievement of MDG 4 & 5 in Tanzania • Rationale, Definition and RBF concept • Role of RBF in Health • Key elements of the Tanzania design • Cost for scale up &Sustainability • Expected health outcomes • Institutional set up • Scaling up plans • Action plan

3. Global Progress toward the MDGs varies Broad progress towards achieving the Millennium Development Goals (MDGs) but some challenges remain for health-related MDGs, including the epidemiological transition Source: World Bank Global Monitoring Report, 2012

4. Tanzania, Newborn and infant mortality targets need attention Introduction (3): Tanzania is on Track to achieve MDG4 28% decline in under five mortality between 2005-2010 More needs to be done to improve newborn survival

5. There has been Insufficient progress in reducing maternal mortality Projected Needed MDG Target is 134 Data on the status of maternal, new born and child mortality in Tanzania shows some progress towards Millennium Development Goal (MDG) 5, but we may not achieve MDG 5 by 2015

6. It is not just a matter of more money * Percent deviation from rate predicted by GDP per capita Source: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002 Source:Soucat, A. ‘The Promise of RBF to Reach the Health MDGs and the Evidence Gap: How Impact Evaluation Can Inform Policy Dialogue’.

7. What is RBF for health? Results-Based Financing (RBF) – Umbrella term applicable to many sectors RBF for Health– “a cash payment or non-monetary transfer made to a national or subnational government, manager, provider, payer or consumer of health services after predefined results have been attained and verified” (www.rbfhealth.org)

9. Role of RBF in health RBF in the health sector is needed to: • Help focus attention on outputs and outcomes • Example: the number of women receiving antenatal care or taking children for regular health and nutrition check ups to reduce child mortality rather than inputs or processes (i.e., training, salaries, medicines). • Balance resource allocations to elevate low performing indicators and maintain existing achievements (like immunizations) to accelerate progress toward national health objectives. • Increase use, quality and efficiency of services

10. Key Elements of the Tanzania RBF Design • Focus on primary health care (dispensaries, health centers and hospitals at district level ) • Quantity and Quality indicators • 17 quantity indicators for HC and dispensary (14 for health facility & 3 for Community Health Workers). • Quantity earning is adjusted by the Quality score • Hospital – quality indicators only • Focus on immediate needs, which will change over time as the needs change • Payment to be made after internal verification • Annual counter-verification of 25% of facilities

11. Quantity indicators for dispensaries &health centres

12. Quality Indicators (examples): The quality checklist will change over time as scores improve, to continuously motivate improvement Technical quality: • Conditions to provide quality care (e.g. availability of essential supplies and equipment, water, infection control) • Patient care according to standard guidelines (e.g. use of partogram) • System strengthening (e.g. Number of New members enrolled in CHF in the facility in each quarter; Availability of quarterly technical and financial reports for RBF implementation) • Management and governance (e.g. HFGC meetings, patient complaints) Patient satisfaction: • Exit interview

13. Estimated costs for national scale up

14. Sustainability Strategy • Speed of RBF roll out depends on availability of financial resources, implementation capacity and human resources • In order to achieve financial sustainability, the country : • has included RBF in the health financing strategy as a step towards moving from input financing to output based financing • can reformulate the allocation of existing resources for PHC (block grants, DP financing and own sources) to implement RBF • Can modify the resource allocation formula to combine per capita financing and RBF payments • Benefits: • faster roll-out, • better predictability, • increase transparency/accountability, and provider autonomy, • linking results to funds financing

15. Available resources for RBF • Various DP’s in the RBF Task force (SDC, GIZ, USG & WB) • $ 850,000 - Preparatory activities - pre-pilot in Kishapu council • $ 40,000,000 from HRITF & IDA • 4 years • Focus in 4 regions (Shinyanga, Pwani, Simiyu and Rukwa)

16. Expected Results of RBF • Increased utilization of priority area • Improved quality of services • Strengthened health systems • Empowered health facilities • Efficiency utilisation of resources • Increased supportive supervision of HF by CHMTs • Improved management of Council health services • As measured by results of CHMT quarterly-assessed indicators

17. Expected improvement of overall health outcome • Reduced morbidities and mortalities • Particularly related to MDGs • Reduced disease burden and poverty

18. Institutional setup - Roles

19. Institutional setup Verifier RAS Counter Verifier CAG

20. Institutional setup - Allocation

21. Selection of Regions • Health MDG coverage and the poverty index for each region were taken to calculate the average region score. The lower the score the first the priority to be enrolled to RBF system • Bottom 5 regions by this ranking are as listed below

22. Phasing • Pwani will be taken 2nd since the P4P program will be ending there next year • The inclusion of new regions in years 3 and 4 will be subject to change dependent on revised assessment of priority • Additional regions may be included within this timeframe should resources become available Note: Simiyu was formerly part of Shinyanga and therefore is considered high priority

23. Selection of Facilities • A facility readiness assessment tool has been created which will be used to assess the following areas : (align with the accreditation assessment tool) • infrastructure ( state of buildings, emergency transport, communication, water availability etc.) • equipment • Staffing (at least one staff in a dispensary) • services provided • pharmaceuticals • data management, governance • Active bank account • All facilities will be assessed with a passing score being established • Facilities which pass will be provided with a small readiness fund to make minor improvements • Facilities will be included as they are brought up to standard by the CHMT

24. Progress on Preparation • Design Document 95% finalized • Quality checklists finalized (dispensary / HC and upgraded HC / hospital) • MoU templates developed and under review • RBF Team roles and responsibilities defined • Initial monitoring indicators elaborated • Training package under development • Operational Manual under development • Budget and work plan for pre-pilot finalized • Integration of RBF into DHIS2 underway • Linkage with BRN initiatives underway (waiting cabinet approval of BRN plans and budget)

25. RBF CYCLE Health Facility submits Summary Form to CHMT within 5 working days at end of every month Health Facility Summary Form Verification completed and data entered into DHIS-2 by 20 working days after end of the quarter Regional Administrative Secretary (RAS) DHIS-2 RAS enters verified data, quality scores into DHIS-23 by 25 working days after end of quarter Council Health Management Team (CHMT) Notification by RAS of completion of verification within 28 working days CHMT enters data into DHIS-2 within 10 working days of end of the quarter National Health Insurance Fund (NHIF) Full list of facilities and verified payment amounts (inc. penalties) within 33 working days MOHSW MoF disburses to health facility bank accounts within 40 working days Full list of facilities and verified payment amounts (inc. penalties) and request to disburse Ministry of Finance

26. Immediate next steps