Nigeria State Health Investment Project (NSHIP) Qualitative Study on Key Differentiating Factor for Performance
Under Performance Based Financing (PBF) Approach
March 2015
Process Monitoring and Evaluation II of Zimbabwe’s Results-Based Financing Project
Introduction
This report presents the second cycle of the process monitoring and evaluation (PME) for the Results-Based Financing (RBF) project in Zimbabwe, formally the Health Sector Development Support (HSDS) Project. The study’s findings demonstrate the linkages between the first and second PME evaluations. The study prioritizes performance of incentivized indicators, quality of care (QoC) and expenditure/payment data aspects of the health system and program.
The overarching goal of the PME study is to help the Ministries of Health and Child Care (MOHCC) and Finance and Economic Development (MOFED), Cordaid, the World Bank Task Team and interested local and international stakeholders learn from the RBF project; make mid-course adjustment to the technical design and operational processes; and enhance evidence-based project management decision making. Given that quantitative performance of health facilities is monitored every quarter, the study seeks to go beyond the quantitative performance trends to better understand qualitative factors at district, health facility, health worker and community levels that explain performance under the RBF project. This PME is an exploration of the causal pathways from implementation to results. It is a study of the links between activities, outcomes and context of the RBF project. In a way, the study unravels the “black-box” of implementation of performance-based financing interventions in a bid to deepen knowledge of the RBF intervention in Zimbabwe and how reality links with the original design and theoretical assumptions with which the Government, Cordaid and the Bank worked when the intervention was conceptualized.
The RBF project design is anchored on three components: 1) results-based contracts, 2) management and capacity building, and 3) monitoring and documentation. It is anticipated that through this project, both supply and demand for health services— particularly maternal and child health—will be significantly improved, contributing to a reduction in maternal and child mortality and morbidity. The project’s monitoring and evaluation activities are currently tracking the performance of incentivized indicators, QoC and expenditure/payment data. While this ongoing analysis has provided very useful insight into the performance of the project to date, it is essential to go beyond the numbers and explore the underlying processes and dynamics in the trajectory of change. For example to fully understand variation in performance by facility or district it was essential to explore non-quantitative factors in order to deepen knowledge of RBF so as to improve outcomes further; enhance it for sustainability and future application and adapt to other contexts. See Annex 1 Project Design Summary.
Burundi: Questions on the Financial Sustainability of Performance-Based Financing and Free Health Care
This article focuses on the financial sustainability of the strategy linking performance-based financing (PBF) and free health care (FHC), which has been implemented nationwide in Burundi since 2010. It concentrates on the financial re- sources invested by the government and its technical and financial partners. It seeks to establish whether government resources alone can guarantee the financial sustainability of PBF-FHC or whether other inputs are required.
This article first defines the concept of financial sustainability used in the context of PBF-FHC. It subsequently analyzes financial sustainability based on three indicators: (i) the reliability and stability of financing; (ii) the availability and ade- quacy of both current and long-term financing; and, (iii) the appropriate and timely allocation of resources by the gov- ernment.
Through the establishment of a budget line dedicated to PBF-FHC, the government contributes to the reliability and stability of financing. This is further compounded by its formal commitment to provide PBF-FHC with an annual alloca- tion representing 1.4 percent of its general budget. Analyzes show that this government contribution remained sta- bled; it even exceeded the annual rate of 1.4 percent between 2010 and 2013.
Despite encouraging results, PBF-FHC is faced with an important financial gap which cannot currently be bridged by the government or TFPs. In addition, health facilities are faced with cash shortages – placing them at risk of stock outs of both drugs and other inputs – caused by important reimbursement delays.
Finally, this article examines the approaches recommended to address financial sustainability in the context of PBF- FHC, namely: (i) the reduction of PBF-FHC implementation costs; (ii) the mobilization of government and TFPs re- sources; (iii) guaranteed regular payment of health facilities’ invoices; and (iv) the integration of PBF-FHC in the nation- al health financing strategy, which seeks to increase efficiency by integrating different health financing mechanisms.
The main conclusion of this analysis is that although government involvement and financing are requisite, they are not sufficient to guarantee the financial sustainability of PBF-FHC in Burundi.