RBF: Concepts & Draft Design

1. RBF: Concepts & Draft Design

2. PURCHASER/ PAYER Financial Incentives Health Results RECIPIENT(PROVIDER/ PATIENT) What is RBF for health? Results-based Financing for health is any program that rewards the delivery of one or morehealth outputs or outcomes,through financial incentives, upon verification that the agreed-upon result has actually been delivered.

3. Traditional Input Financing vs. Output Financing: A Shift in Focus INPUTS (human resources, drugs, equipment, etc.) PROCESS (training, protocols and guidelines, financial management, procurement, etc.) OUTPUTS (health service utilization, promotion activities) OUTCOMES (maternal and child mortality, nutritional outcomes, life expectancy) Monitoring of outcomes, evidence based decision making to achieve results Monitoring and paying for outputs, increased leeway for local decision-making, verification of results Line item budgeting, input supply, monitoring of inputs and processes, reporting of results

4. Broad principles of design • Tanzania will approach RBF as part of broad systems reform, not a project • Part of Health Care Financing Strategy Development • Objective is to strengthen overall system, not just to top-up individual workers • Provider empowerment and autonomy is essential • This is not a scale-up of Pwani: We learn from all experiences to develop informed and customized design

5. What results are we purchasing? Principles • Underutilized & poor performing indicators • Management & HSS indicators to ensure results achieved • Preventive services prioritized

6. What and how will we pay for results? • Fee-for-Service and/or coverage targets • Quality of care will be included • Penalty or reward still TBD • Allocation of staff incentives vis-à-vis facility reinvestment • Option 1: Formula to determine allocation • Option 2: No formula, full autonomy of facility to decide • Incentives should vary by performance of staff, by cadre • Further analysis of overall level is needed

7. Next steps for determining what/how to pay: • Decision on incentive mechanism: 1) fee-for-service 2)coverage targets 3) both • Should RHMT & CHMT be paid for results of health facilities? • If yes, then further exploration on how to structure • How to consider equity: • Pay more for same indicator based on poverty, geography • How to measure quality for clinical and non-clinical • How to incorporate client satisfaction • Projections to determine total budget for incentive levels

8. Institutional Set Up Regulator Verifier(internal/3rd party): Provider Purchaser Fund Holder

9. Providers • Establish and enforce minimum standards • Standards should ensure service readiness for all selected RBF services • Include all public providers from the start • Public providers not meeting minimum standards will be given special investment to make them service ready • Include private and faith-based if they meet minimum standards, and if there is service gap • For HSS, explore RHMT, CHMT, DED, MSD, RAS

10. Purchasing • Centralized purchaser: PMO-RALG to act as purchaser with a PS for health. Already, they act as purchaser for roads. • Decentralized purchasing: Local level is closer to ground realities, and can purchase more effectively • Can Regional Administrative Secretary or Council take on purchaser role? • Or RAS to purchase from regional hospital, Council to purchase from PHC, council hospital, dispensary • Long-term vision: NHIF may take over as purchaser once their capacity is built

11. Verification • Internal: • CHMT and RHMT. • Hospitals quality improvement teams going to facilities possible • 3rd Party: • Control and Auditor General with Zonal involvement. • Private agency hired • Research Institutions (SPH, IHI, NIMRI) • Community Verification • Mechanism still needs to be assessed

12. Fundholding • Short-term: • Ministry of Finance using its preferred bank (ie NMB) • Development partners under MOHSW • Long-term: • Maintain short-term arrangements if working; look for alternative options if not working

13. Institutional Set UpConsider possible conflicts of interest Regulator MOHSW Verifier • Purchaser: • PMORLG • RAS • NHIF 3rd Party 1. CAG 2. Private 3. Research institutions Internal 1. CHMT&RHMT 2. Hospital QI teams Provider 1. Clinical: All public, select private & FBO 2. HSS: RHMT, CHMT, DED MSD, RAS • Fund Holder • DPs • MOF (preferred bank)

14. Relationship to Health Financing Strategy (HFS) • Implementation of overarching HFS (including Health Insurance options) will take time • A key principle of HFS discussions is output-based financing • RBF design and timing has significant opportunities to fulfilling the HFS: • RBF could help incentivize the Min. Benefit Package being defined as part of HFS, reinvigorate service agreement mechanisms etc. • Lead the improvement in the health purchasing function at various levels (e.g. LGA level) and for concrete results • RBF would be one of the purchasing approaches guided by the HFS

15. What are the next steps? • Establish and capacitate RBF coordinating and oversight body • Finalize key technical design elements • Capacity assessments • Legal assessments • Autonomy • Engage in stakeholder consultation • Separate consultation with key stakeholder groups such as basket fund partners, providers, regionals, district • Refine, validate and agree on final design • TC-SWAP meeting • Phasing and geographic phasing • Develop objective selection criteria: Poverty, coverage • Criteria for role-out to new regions • Develop timeline for phasing • Financing: Assess cost of options for phasing vis-à-vis available funding • Implementation preparation • Develop TA& training plan for implementation at all levels • Continued linkages and revision as HCF strategy is developed

16. Take Home Messages • General interest on output based/results based financing • P4P is not static but adapts to needs of health system • Intrinsic part of fulfilling new HCF system • Health Systems Strengthening focused