Motivating Better Health: Why Other Types of Programs So Often Fail—and Results-based Financing Succeeds

There are no magic bullets in life. For fixing a healthcare system, though, there is one approach that comes close: results-based financing. Management Sciences for Health (MSH) pioneered results-based financing in Haiti in 1999, and has been adapting and improving it ever since in sub-Saharan Africa, Latin America, and South-East Asia, including in fragile states.

In my 20-plus years in global health, I’ve seen what happens without results-based financing: A major donor sends millions of dollars’ worth of equipment and supplies to a developing country—and the quality of health services delivered doesn’t improve—or worse, it declines. Why?

Health providers are human, like all of us—sensitive to incentives, motivation, and demotivation. Say a hospital improves and now is well stocked: the community realizes this and the utilization rate doubles. Suddenly, a nurse may be facing 40 patients a day instead of 20, but without any added pay or assistance. It’s only natural he or she might work less under the crushing workload.

Why Results-Based Financing Succeeds

Results-based financing succeeds, in part, because it directly benefits the patients, the facility, and the providers. If the facility and providers reach the health targets, they get a bonus: part for the facility and part for individual staff. It might only be a small amount per worker (e.g., $50/month for a nurse), but that may represent a considerable windfall—perhaps 30 percent of the nurse’s base salary. If the facility performs moderately well, they receive a partial bonus, and the salary stays intact. No one gets docked.

More than financing: a revolutionary step in data management

Providers also quickly get very interested in collecting patient data—because that’s how they prove they’re doing well.  So instead of someone going through the motions of collecting data on maybe 20 programs at the facility and sending them upward never to be seen again—each player is invested in making sure that all their efforts are counted. The change in data management is revolutionary.

Local decisions for local challenges

One of the agreements ministries sign is that the health facility will now make decisions autonomously. This changes everything—responsibility, ownership, planning, and, of course, quality of services. This can be a difficult mind-shift for donors used to micro-managing. But, the benefits are huge. For instance, in Wembonyama Hospital in Democratic Republic of the Congo (DRC), the roof had been crumbling for years, and no one did anything. Then, instead of all directions coming from above, the providers could take initiative themselves—and they fixed the roof immediately.  

MSH fosters better health care and data in DRC

MSH and external evaluators studied mid-term results after one and a half years of using results-based financing in health centers in seven health zones in DRC, supported by USAID’s Integrated Health Project (IHP). Key indicators included attending four antenatal visits, utilization rate of health centers for curative services, and quality of services (measured by MSH’s FOSACOF, or fully functional service delivery point approach).

In the health centers using results-based financing, the percentage of women attending all four prenatal visits soared from 21 to 69 percent.

Patient use of these health centers rose from 49 to 85 percent.

In the health centers using results-based financing, ratings for quality of services improved from 33 to 73 percent. In comparable centers supported by IHP, but not using results-based financing, quality ratings increased from 27 to 52 percent.

At general referral hospitals using results-based financing, the FOSACOF quality score shot up from 39 to 84 percent. At general referral hospitals not using results-based financing, the FOSACOF quality score at rose only from 22 to 39 percent.

The external evaluators said these were the most dramatic changes in a public health system they had seen in two decades.

DRC is one of several fragile states where MSH-supported, results-based financing has fostered better health care, better data, and local control. MSH is now working with the Ministry of Health in Haiti, funded by USAID, World Bank, and the Global Fund, to expand results-based financing at the national level, using lessons learned from the DRC, Rwanda, and other countries.

So—no magic bullet, but close: effective interventions that consistently improve outcomes—even in fragile states.  Would you agree?

Related

• DRC-IHP Effective Innovations: Results-based Financing
• Performance-based Financing as a Health System Reform: Mapping the Key Dimensions for Monitoring and Evaluation
• The PBF Handbook: Designing and Implementing Effective Performance-Based Financing Programs