Results-based Financing for Health in Tanzania

Joint Health Sector Review6th November 2014

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Presentation outline Global Progress toward MDGsAchievement of MDG 4 & 5 in TanzaniaRationale, Definition and RBF conceptRole of RBF in HealthKey elements of the Tanzania designCost for scale up &SustainabilityExpected health outcomesInstitutional set upScaling up plansAction plan

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

Introduction (3):

More needs to be done to improve newborn survivalMore needs to be done to improve newborn survival

28% decline in under five mortality between 2005-2010

Tanzania, Newborn and infant mortality targets need attention

Tanzania is on Track to achieve MDG4

There has been Insufficient progress in reducing maternal mortality

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

MDG Target is 134

Projected

Needed

* Percent deviation from rate predicted by GDP per capitaSource: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002

It is not just a matter of more money

Source: Soucat, A. ‘The Promise of RBF to Reach the Health MDGs and the Evidence Gap: How Impact Evaluation Can Inform Policy Dialogue’.

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)

What is RBF for health?What is RBF for health?

Role of RBF in healthRBF 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

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

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Key Elements of the Tanzania RBF Design

Quantity indicators for dispensaries &health centres

Category Indicator Fee (TZS)OPD Number of new Outpatient consultations TZS 415

OPD Number of TASAF beneficiaries seeking outpatient care TZS 1,240

ANC Number of first antenatal visits, with gestation age < 12 weeks TZS 8,290

ANC Number of pregnant women attending ANC at least 4 times during pregnancy TZS 6,210

ANC; MalariaNumber of pregnant women receiving two doses of intermittent presumptive Therapy of Malaria (IPT2) TZS 1,240

PMTCT; HIV/AIDS Number of HIV positive (infected) pregnant women receiving ARVs TZS 3,310

Labor/Delivery Number of institutional deliveries TZS 20,720

Postnatal Care Number of mothers receiving Post Natal Services within 3-7 days after delivery TZS 8,290

Immunization Number of children under one year immunized against measles TZS 1,650

Nutrition Number of under five receiving Vit. A supplements TZS 820

Family Planning Number of new users on modern Family Planning methods TZS 5,800

HIV/AIDSNumber of clients initiated by health care provider to counsel and Test for HIV (PITC) TZS 620

HIV/AIDS Number of HIV exposed infants receiving ARVs TZS 4,970

TB Number of TB suspect referred (already screened)* TZS 8,290

CommunityNumber of non-institutional maternal and perinatal deaths reported within 24 hours by TBA or CHW TZS 4,145

CommunityNumber of pregnant women escorted for delivery at a health facility by known or registered TBA or CHW TZS 8,290

Community Number of household visits by CHW TZS 1,240

Quality Indicators (examples):The quality checklist will change over time as scores improve, to continuously motivate improvementTechnical 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

Estimated costs for national scale upHF readiness one off 1.6 per capita

HF incentives per year 2.3 per capita

RHMT & CHMT incentives per year 0.2

TA, Cap.build, verfication per year 0.6

Per Capita US$ % TZSH

investment 1.6 73.6 mil 34 117.8 bn

recurrent 3.1 142.6 mil 66 228.2 bn

Sustainability StrategySpeed 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

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)

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 16

Expected Results of RBF

Expected improvement of overall health outcome

Reduced morbidities and mortalities• Particularly related to MDGs

Reduced disease burden and poverty

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Institutional setup - Roles

RBF FunctionsRegulation To lead the RBF system with strategic planning and

policy coordination among the various actors; provide guidelines, norms and standards and overall support and supervision.

Fund Holding

To hold the funding for RBF and distribute funds to service providers as indicated by the Purchaser

Purchasing To enter into contracts with service providers, purchase and pay for the health care services.

Provision To provide health care services to the designated population

Verification To authenticate the actual provision of health care services

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Institutional setup

Counter Verifier

CAG

VerifierRAS

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Institutional setup - Allocation

RBF Functions Allocation

Regulation MoHSW – naturally has this role in the health sector

Fund HoldingMoF – naturally legislated for this function and experienced with fundholding and disbursing

PurchasingNHIF – has capacity as the biggest public health Insurer currently operating in the country

Provision Public and selected private health facilities at council level

VerificationRAS – mobilize a team composed of RHMTs, NHIF, and NGO representative in the region

Facilitation(additional function)

PMO-RALG – direct responsibility for ensuring implementation by RAS, Councils and health facilities

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Selection of RegionsHealth 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

REGION HEALTH MDG COVERAGE

INDEX

SOCIO- ECONOMIC INDEX AVR HEALTH & SOCIO

ECON

SHINYANGA 54 51 53

RUKWA 58 55 57

KIGOMA 56 60 58

TABORA 61 58 60

MWANZA 60 65 63

Years Regions Population size(includes pop growth)

Year 1(9 months)

Kishapu DC (in Shinyanga) 272,000

Year 2 Shinyanga, Pwani 2,783,000

Year 3 Shinyanga, Pwani, Simiyu 4,582,000

Year 4 Shinyanga, Pwani, Simiyu, Rukwa 5,673,000

Note: Simiyu was formerly part of Shinyanga and therefore is considered high priority

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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

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Selection of FacilitiesA 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 establishedFacilities which pass will be provided with a small readiness fund to

make minor improvementsFacilities will be included as they are brought up to standard by the

CHMT

Progress on PreparationDesign 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 developmentOperational Manual under developmentBudget and work plan for pre-pilot finalized Integration of RBF into DHIS2 underwayLinkage with BRN initiatives underway (waiting cabinet

approval of BRN plans and budget)24

Ministry of FinanceMinistry of Finance

Council Health Management Team (CHMT)

Council Health Management Team (CHMT)

MOHSWMOHSW

Health FacilityHealth Facility

Health Facility submits Summary Form to CHMT within 5 working days at end of everymonth

Verification completed and data entered into DHIS-2 by 20 working days after end of the quarter

MoF disburses to health facility bank accounts within 40 working days

Summary Form

Regional Administrative Secretary (RAS)

Regional Administrative Secretary (RAS)

Notification by RAS of completion of verification

within 28 working days

National Health Insurance Fund (NHIF)

National Health Insurance Fund (NHIF)

Full list of facilities and verified payment

amounts (inc. penalties) within 33 working days

Full list of facilities and verified payment amounts

(inc. penalties) and request to disburse

DHIS-2DHIS-2

CHMT enters data into DHIS-2 within 10 working days of end of the quarter

RAS enters verified data, quality scores into DHIS-23 by 25 working days after end of quarter

RBF CYCLE

Immediate next stepsno Activity November 2014

(weeks)December 2014(weeks)

Jan2015

1st 2nd 3rd 4th 1st 2nd 3rd 4th

1 Meeting NHIF, MoF, CAG to agree on detailed roles, M

2 Field test Readiness Tool / Quality Checklists

3 Finalize Training Package / Operational Manual

4 Conduct Readiness Assessment in Shinyanga

5 Orient and Train respective groups in Shinyanga / Kishapu

6 Provide readiness funds to selected facilities

7 START prepilot