Table 3 Summary of key findings
| Â | Â | DRC | Zimbabwe | Uganda |
|---|---|---|---|---|
Key strategic purchasing actions by government | Establish clear frameworks for purchaser(s) and providers | - Weak regulatory capacity - RBF contracts provided clearer rules and regulations, though re. RBF funding only | - Strong regulatory frameworks (e.g., Results Based Management since 2005), but resource-starved. - Only primary level and some indicators covered | - RBF did not radically change regulatory frameworks - Some changes only for providers/services covered by RBF |
Ensure accountability of purchaser(s) | - EUPs have stronger accountability links with MoH compared to NGO projects - In practice, government/MOH did not exercise their oversight role | - Parallel system with external purchasers - Accountability of purchasers to funders as well as to government - Non-RBF funding through different channels | - RBF operating in parallel - Plans for a national scheme under MoH leadership is being used in the current RBF model. | |
Ensure adequate resources mobilised | - Out of pocket payments main source of funding - RBF mobilised additional resources to decrease user fees - Limited success of EUPs in raising/pooling funds | - RBF provided modest but partially additional funds, still significant for primary care providers - Focus on MCH indicators - Donor dependent | - RBF donor funded, with donors working in silos even within the same region - Discussions of a virtual pool but not realised yet | |
Fill service delivery infrastructure gaps | - Assessments carried out by RBF projects and bonus provided in some cases | - RBF provided some upfront investment, but no major revision of infrastructure planning in relation to needs | - District teams remain responsible for identifying service delivery infrastructure gaps | |
Key strategic purchasing actions in relation to citizens/population served | Assess needs, preferences, values of the population to specify benefits | - Norms on activity packages existed and RBF worked within them, covering some services in the packages - EUPs allowed to revise RBF package – but rarely done in practice | - No consultations on needs, values and preferences - Package defined nationally with no scope for variation at local level | - No direct consultation with communities - Needs determined using routine data and national surveys and indicators - RBF includes services from the minimum package |
Inform the population of entitlements Establish mechanisms for complaints and feedback Publicly report on use of resources and performance | - RBF requires price list to be made public on the facility wall - RBF aimed at improving community participation by strengthening Health Management Committees - Community verification, but delays in data collection and no/little analysis and feedback - IT portal to report performance, but only for RBF indicators and no community verification scores | - RBF requires price list to be made public on the facility wall - RBF helped revive Health Centre Committees: variable results and capacity | - Pre-existing mechanisms for feedback (barazas, suggestion boxes, Health Unit Management Committees) - Client satisfaction surveys in some RBF programmes | |
Key strategic purchasing actions in relation to providers | Select (accredit) providers | - Done by health authorities/ regulator, EUPs have limited power in deciding which facilities to contract (limited to type of contract or sub-contracts) and to enforce sanctions | - RBF did not change existing accreditation system - RBF required facilities to meet minimum criteria, including developing an operational plan, having a bank account and a functioning HCC | - Accreditation bodies preexisted and RBF did not change this. - A few schemes have provided start-up capital to enable more providers to get accreditation requirements. |
Establish service agreements/contracts | - RBF introduced contracts – but rarely enforceable with limited room for sanctions - Contracting done by EUPs, and limited to RBF services/facilities | - RBF introduced contracts – but rarely enforceable with limited room for sanctions - Contracts are limited to services and facilities covered by RBF | (As in Zimbabwe) | |
Design, implement, modify provider payment methods to encourage efficiency and quality | - Very little public funding other than (some) salaries - RBF provided additional performance-based funding, but did not alter public/other donors’ funding - Some evidence of quality improvements | - Mixed picture in terms of outputs and quality improvements - Focus on MCH services, including some for which coverage is high - Some quality improvements (e.g., drugs availability) | - Little quality improvements given broader structural challenges such as workforce shortages and insufficient medicines distributed from the center. - Private facilities have more flexibility to improve service inputs. | |
Establish provider payment rates Pay providers regularly | - RBF introduced payment rates for services (not the practice before) - Rates are additional to user fees - Rates defined at provincial level, depending on funds available and donors’ preferences (FED) - Rates defined centrally and included in Project Manual (PDSS) - Delays in paying providers | - RBF introduced payment rates for services (not the practice before) - Rates defined centrally, focus on MCH and low coverage indicators - Concerns over sustainability of payments (rates have been reduced over time) | - RBF introduced payment rates for services (not the practice before) - Payment methods complex and not well understood - Different schemes have different indicators and rates, depending on funders‘preferences and budget - Frequent unilateral decisions by fund-holders, often poorly communicated to provider and local governments | |
Allocate resources equitably Strategies to promote equitable access Monitor user payment policies | - Bonus to compensate remote facilities - Extra funds to cover services provided to the very poor (Equity Funds), but only for hospital services (FED) and for few services (PDSS) - Support to reduce user fees and introduce flat fees to cross-subsidise between patients - Community verification to monitor user fee payments | - Remoteness bonus, but considered too small and failed to compensate facilities with small catchment areas - RBF aimed to remove user fees for the services it covered. However, no difference in out of pocket payments between control/intervention areas (in impact evaluation) | - No bonus in payment calculation but some initial bonus to remote facilities. - Facilities/districts often chosen as easier to work with, adding to the fragmentation and inequity - Reduction of user fees (in PNFP facilities) as a precondition for RBF support | |
Develop, manage and use information systems to monitor/audit performance and protect against fraud Supervise providers | - RBF information system is parallel to HMIS. Plans to ensure integration in the future - Zonal/Provincial teams contracted to ensure supervision | - RBF used HMIS data after having verified and corrected it - Providers have multiple data reporting requirements - RBF brought greater focus on data quality - Little evidence of false claim, risk based verification - Pre-existing well developed and integrated supervision system to which RBF provided funding | - Similar issues of multiple data streams, but HMIS remains main one - Supervision system only partially affected/funded by RBF |