The need to set better incentives

There is now a wide range of countries implementing RBF, funded through the World Bank, other donor agencies or government funding. For many of these countries, evaluations are in progress and several have completed the evaluations, for example:

In India, a RBF program provided cash incentives to encourage women in rural India to give birth in hospitals. In the program, women who forego traditional home births and deliver in hospitals are given $30 two weeks after delivery. The women were also encouraged to seek postnatal care. A study published in the Lancet showed the program quadrupled the number of women giving birth in hospitals.

The dramatic increase in attended deliveries improved outcomes for both mothers and newborns and provides a model for other countries.

In Tanzania. His Excellency Jakaya Mrisho Kikwete, President of the United Republic of Tanzania has long been a champion for maternal, newborn and child health. The pay for performance program in Tanzania focused on maternal and child health. The program shifted health workers’ focus from routine service provision to a results oriented focus. This led to increased institutional delivery and other MNCH indicators. The incentives provided were used to address bottlenecks in service delivery including motivating health workers and reducing drug shortages.

“Reporting significantly improved in quality and timeliness, and therefore strengthened accountability,” reports Hussein Ali Mwinyi, M.D., Minister for Health and Social Welfare. “The results of the program were two fold - strengthened health systems and improved health outputs.”

In Argentina, the two-tier RBF program paid provinces for the enrollment of poor women and children in health insurance, and for the achievement of health outcomes such as infants born at healthy birth weights. Providers were paid on a fee-for-service basis for mostly preventative maternal and child health services.

The results were “quite dramatic,” reports Paul Gertler, Ph.D., Professor of Economics at the University of California Berkeley who led the evaluation of Argentina’s plan. The assessment found a 32 percent reduction in stillbirths, a 23 percent reduction in low birth weight babies, and a 74 percent reduction in hospital neonatal mortality for RBF program service users. The statistics were all confirmed by examining 300,000 birth certificates, a much larger sample than available ever before for other RBF evaluations.

Based on these results, Argentina’s RBF program has been expanded to include other health issues, including adolescent health, teen pregnancy and other women’s health issues.

RBF in detail

RBF is an umbrella term that encompasses many different kinds of interventions. The formal definition of RBF is that it “covers cash or non-monetary transfers to a national or sub-national government, manager, provider, payer or consumer of health services after predefined results have been attained and verified. Payment is conditional on measureable actions being taken.”

Afghanistan was the first recipient of an HRITF grant in 2007. Now, three quarters of the projects are located in Africa and another 13 percent in South Asia. The remaining projects are in Latin America and the Caribbean, East Asia and the Pacific, the Middle East and North Africa, and East and Central Asia. Three countries—Sierra Leone, Burundi and Rwanda—have nationwide RBF programs.

Rwanda, Burundi, Nigeria, Cameroon, Zimbabwe, and Zambia are all examples where RBF approaches have contributed to significant advances in coverage and quality of maternal and child health services. As an added benefit, these grants have helped to make health systems more accountable by shifting the focus to measureable results.

RBF is a comprehensive health system reform that if well designed and supervised can help address challenges in the health system by:

  Using rigorous verification to make health systems more efficient, and transparent.
  Addressing key bottlenecks in the system, such as prioritization and purchasing, autonomy and resources for frontline health workers.
  Fostering a cultural change that empowers frontline staff and makes them more accountable.
  Addresses financial barriers by using vouchers or removing user fees to enable access to maternal and child health services.
  Improving health equity by reaching the most vulnerable through targeting

Monitoring and evaluation are an integral part of RBF projects. All HRITF-funded programs have rigorous impact evaluations to assess the impact of RBF and to see which design factors cause specific achievements. This makes it possible to identify what works and what doesn’t. For example a design flaw in the Democratic Republic of Congo’s pilot RBF program was identified and is informing the technical design of a new RBF program.

Sharing global knowledge on RBF

HRITF shares knowledge from RBF programs widely, via traditional and digital tools, including for example via Facebook, seminars and the website rbfhealth.org. The All Things RBF blog is also used to provide a place to engage RBF practitioners around the world to share and discuss their experiences.

Based on these results, the next phase will focus on supporting countries scaling up the successful pilot programs.

Health experts and policy makers are beginning to look beyond health for other areas where RBF could be applied. One such area is education, where a system of incentives might be used to keep young girls in school, preparing them for a useful occupation and, at the same time, discouraging child marriages and preventing teen pregnancy.

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Nils Hoffman
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703-967-1490
Hoffman & Hoffman Worldwide