Results Based Financing

The program builds on the pilot program implemented by the USAID-funded Santé pour le Development et la Stabilité d'Haiti (SDSH II) project and is modeled after the Burundi and Rwanda RBF schemes. The program aims to strengthen the delivery of health services throughout the country. Results-based financing is a broad term that covers various approaches to reward the provision of more and better health care services. The design, scope, and types of incentives vary broadly from country to country. In one end of the spectrum, RBF financing represents a complete shift in purchasing from a traditional budget system to a 'fee-for-service' payment structure with very little to no additional funding given to support the operation of the clinics. In this arrangement, health facilities bear the majority of the risks of poor performance, and the payer is protected from potential ineffective and inefficient use of funds. On the other end of the spectrum, RBF incentives are bonus payments made on top of operation budgets designed to motivate improvements in service delivery. In this model, health facilities continue to receive public funding that finances day-to-day operations and are eligible to receive additional incentive payments when targets are reached. This model requires full financing of health services – both operational costs and RBF incentives – by parties external to the health facility. The RBF system in Haiti has evolved over time, with key elements including implementing partner disbursed funding to health facilities on a quarterly basis and health facilities eligible to receive up to 10% of additional funding through RBF. In 2011, MSPP re-designed the RBF program, changing several important features, including RBF financial incentives being largely driven by unit-price per indicator and health facilities eligible to make up to an additional 25% of the total incentive amount based on quality of services. The SSQH-CS team in consultation with MSPP team has developed a two-tier program. The first tier includes no clear guidelines on payment of operating cost, leaving open options to either continue fully funding operating costs or reduce operating cost subsidies and shift some of the risk to facilities by making RBF incentives necessary to fully cover the cost of operation. Based on preliminary analysis, the proportion of the overall budget represented by RBF incentive payment ranges from 1% of operating cost for HCR to as high as 38% of operating cost for health facilities. Given current funding, SSQH cannot support the addition of RBF payments and continue to fully fund operation costs at the current level of funding. To address the funding gap, SSQH-CS presents three scenarios for consideration for how the project could feasibly roll-out RBF in its catchment area. The scenarios aim to balance cost constraints while proposing a reasonable roll-out plan. The variables considered include a review of the operational costs of service delivery and the potential incentive-earning under the RBF model. The first scenario involves shifting some of the operational costs to the facilities, making RBF incentives necessary to fully cover the cost of operation. This approach would require facilities to take on more financial risk, but it would also provide them with more incentives to improve their performance. The second scenario involves reducing the level of funding for operational costs and using the saved funds to support RBF incentives. This approach would require facilities to reduce their operational costs, but it would also provide them with more incentives to improve their performance. The third scenario involves introducing a hybrid model that combines elements of the first two scenarios. This approach would involve shifting some of the operational costs to the facilities, but also providing them with additional funding to support RBF incentives. This approach would require facilities to take on more financial risk, but it would also provide them with more incentives to improve their performance. Overall, the scenarios presented by SSQH-CS aim to address the funding gap between the operational costs of service delivery and the potential incentive-earning under the RBF model. The scenarios propose a reasonable roll-out plan that balances cost constraints while providing facilities with more incentives to improve their performance.