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Table 3 Summary of key findings

From: (How) does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo

   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