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
Country Context 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%) 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) 65 60 59 62 900 800 869 830 790 55 50 48 52 700 600 500 645 45 41 44 400 390 40 300 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 1. Results-Based Contracting Fee-for-services : quality and quantity Functions separated: purchaser, provider, regulator & external verifier Key role for community Health Center Committees 2. Management and Capacity Building 3. Monitoring and Documentation Strengthening planning and RBF management capacity (management of RBF cycle @ facility level, District, Provincial and National Levels Purchasing, verification, strategic management 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
Implementation Arrangements Policy and Supervision Policy and Supervision Policy and Supervision MoHCW Provincial Health Executive District Health Executive Health Facilities and HCC (387) Clients Tracing clients and client satisfaction Contract National Steering Committee Contract + Payment Payment Contract District Steering Committee Payment Contract + Verification Community Based Organisations CORDAID Local Purchasing Unit CORDAID Private Purchasing Agency (NPA) External verification
Package of RBF Services Rural Health Centers 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) District Hospital 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)
ZIneter Participating Districts
Implementation Timeline July 2011 Marondera and Zvishavane 28 health facilities March 2012 + 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 February 2013 Mid-term Review Technical Modifications Roll-out PME April 2013 Additional Funding DFID & Norway US$ 20 million urban component
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
System and outcome level effects 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
Lost RBF revenue due to errors Income Loss Due to the 5% Difference Rule Total income lost From March to September 2012 = $157,529.30 35% 30% 25% 20% 15% 10% 5% 0% mrt-12 apr-12 mei-12 jun-12 jul-12 aug-12 sep-12
Increased coverage - select indicators 100 Percent 75 50 25 Inst. Deliveries ANC PNC Vaccination 0 Mar Apr May Jun Mul Aug Sep Oct Nov Dec 2012
Mar. to Nov. 2012 - increase in high risk perinatal referrals from participating RHCs Total n. of cases 1000 900 800 700 600 500 400 300 200 100 0 Mar Apr May Jun Jul Aug Sep Oct Nov
Institutional deliveries, Jul. 2011 to Aug. 2012 RHC vs. hospital 250 200 Number of deliveries 150 100 50 0 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 Deliveries in RHC Deliveries in Hospital Linear (Deliveries in RHC) Linear (Deliveries in Hospital)
Mar. 2012- strong increase in pregnant women completing 4 ANC visits in RBF districts compared to 16 non-rbf districts 40 per 10,000 population 35 30 25 20 15 10 5 0 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 RBF districts non RBF districts
Mar. 2012 - relatively strong increase in normal deliveries in RBF facilities compared to 16 non-rbf districts 35 Normal deliveries 30 per 10,000 population 25 20 15 10 5 0 RBF non RBF
No evidence that RBF districts neglect non-incentivized services compared to 16 non-rbf districts 70 Hypertension cases all ages 60 50 40 30 20 10 0 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 non RBF
No improvement in HIV counseling and testing in context of ANC; presumably because this is already covered under HIV program 8000 7000 HIV VCT in ANC No. of tests 6000 5000 4000 3000 2000 1000 0 Mar Apr May Jun Jul Aug Sep Oct Nov
Mar. to Dec. 2012 quality scores 90 Average score - RHCs and hospitals combined % 80 70 60 50 40 30 20 10 DHE/PHE Score CBOs Score - T1 T2 T3 T4
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 quasiexperimental 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)
Main Lessons on Quality 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
Key Directions Post-MTR 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