24 September 2013
Over the past 18 months the ministry of Health in Mali has invited KIT to support it in developing its own approach for Results Based Financing (RBF) in the Koulikoro Region of Mali. With great success: after piloting the project will be scaled up to cover the entire country and KIT’s contract has been renewed.
So, what are the results in Mali the Ministry of Health (MOH) was so enthusiastic about? For example, visits of children up to five clinics have increased by 530%, for Family Planning by 233% and for post natal care by 321%. And, providers have become more responsive to client’s needs, because the demand-side in the governance structure has been strengthened. KIT is currently verifying and validating these results.
Results Based Financing (RBF) in health?
The first experiences on RBF in Africa come from Rwanda; when Malian MOH officials visited this country in 2011 they were enthusiastic about the results – in Rwanda – but wondered ‘how can this been done in Mali, how can we develop “RBF à la Malienne” will PBF also be effective in Mali?’ They asked KIT for support.
After 18 months of developing and then piloting the RBF approach in times of political turmoil in Mali, struggling with the consequences of a coup d’état and successive war, the Steering Committee of the MOH was convinced by the results of the program. It decided to start implementing RBF country-wide, and to achive that goal will request that Parliament, the Ministry of Finances and donors increase the allocated budget for health. KIT will continue to study and advise on ‘what works why’ – to inform national policymakers on RBF.
RBF: changing the financial dynamics
RBF is an approach which (partly) replaces input-based health financing through ex ante agreements on budgets, by ex post payments based on results that have been agreed upon in an annual contract. Typically in RBF there is a contracting approach between purchaser and provider of health care, while a regulator ensures that results are produced within national norms and standards. An independent organization verifies if reported results were attained in reality. Payments come per ‘output’, so checks and balances are key, verification of results takes place at health center and household level.
Developing RBF à la Malienne
KIT previously worked in Koulikoro on solving local governance problems between different stakeholders in the health sector in Mali based on a contracting approach between local stakeholders. Building on these experiences, the Malian approach of RBF was developed ensuring that compliance and non-compliance to the contract would have serious (financial) consequences. To develop RBF in the Malian context, RBF instruments, -systems and -procedures were developed, and local actors were trained.
KIT’s approach making a difference
What makes the Malian type of RBF different from other RBF projects? Through KIT’s action-research approach, ‘generic’ RBF principles have been adapted to local context, to make them work. In typical PBF programs a newly developed RBF purchaser organization is introduced. In Mali, with an already complex health governance structure this seemed not to be appropriate and expensive. In Mali, already existing governance structures are being used and this way reinforced through RBF: here the Local Government takes up the purchaser role. Demand-side representatives are contracting partners, they finally decide on priority results and on payments. This way they have been empowered – so, there is no other way for the providers then to become responsive to the patient’s needs. Another difference is that in Mali the major aim is to pay for quality of care, rather than for number of services. But there are more differences.
Can the Malian RBF-model work anywhere?
It is not recommended to copy and paste the Mali model: RBF principles should be adapted to every national context through a process approach. The Mali approach – not the model – is now being used supported by KIT, in Ghana, with a different outcome. KIT is currently also supporting partners in Benin. Again, the local context created a different RBF-model. KIT hopes to support other countries in developing a tailor made approach to PBF too.
More on Results Based Financing and KIT
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