1. Norwegian Involvement in RBF
Ingvar Theo Olsen, Norad

2. Agenda
1. World Bank Trust Fund HRIG
2. Bilateral MDG 4 and 5 program m e
3. GAVI
4. Global Fund for AIDS, TB and Malaria (
GFATM)
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3. Results-based financing can be used at any level but it
must trickle down to the point of contact between the
provider and household to impact results
D ono r
s
N a tiona l
G o vernm
ent S ub-
na tiona l
Results Based Aid
R eg ion/D is tr
ic t
Results Based
Budgeting and Financing
Results Based
Financing
CCP,
CCT, RB
Providers Households
bonuses
Health Centers
or Individuals
Side/Page 3 Hospitals
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4. World Bank Multi Donor Trust Fund
Health Result Innovation Grant
• Established in 2007, focusing on MDG 4, 5 and 1 c
• Im prove health results through strengthening health system s
• Explore value of RBF as a tool
• Norwegian support NOK 580 m illion over 5 years
• Norway so far the only donor, AUSAID interested
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5. W orld B a nk Afghanistan Eritrea
H R IG
• Health system barely functioning - Under utilization of reproductive and
Problem/
context after Taliban child health services
• Govt started contracting with
NGOs to deliver basic package of
health care
Supply side Contracting to NGOs: Performance incentives for:
• Performance-linked bonus to • Regional health authorities for MCH
deliver basic package of health targets
• MOH based on national MCH targets
services
• Complementary bonus for
hospitals for maternal and child
services
• Incentives for pregnant women (transp.,
Demand side
food in del. waiting rooms, etc.)
• Fin. incentives for immunization, growth
monitoring, check-ups, absence of FGM
• Ann. lottery for those fulfilling the above
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6. W orld B a nk Rwanda Zambia
H R IG
• One of the highest rates of IMR • Progress on reducing IMR/U5MR slow,
Problem/ and U5MR MMR increasing
context • Current RBF program on supply- • Coverage low due to human resources,
side, limited impact on deliveries, absenteeism, etc. and barriers to
not covering demand utilization
• Incentives for female health Target based performance incentives for
Supply side
workers to work in rural areas DHMT, facility teams, CHW, TBAs
• Incentives for pregnant w. to use • League table competition for Comm.
Demand side
MCH Health Committees non-financial
• Community incentives to do awards
• Combined transport subsidy and non-
interventions for MDG4, incl.
family planning financial incentives to promote inst.
deliveries and post-natal visits
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7. RBF in the Norwegian bilateral MDG 4&5 initiative:
• Initiative by Prime Minister Jens Stoltenberg to contribute towards the millennium
development goals for health
• Global efforts
– Global Leaders’ Network
– Sherpa group
• Country efforts in 4-5 countries based on potentials for major impact on MDG 4 & 5:
Tanzania: Sector Wide Apporach programme (SWAp) with Government and DPs
India: Support to National Rural Health Mission (NRHM) in five states
Pakistan: Support to 10 districts in a province in the North
Nigeria: Support to programmes in 3-4 states in North, channelled through DFID
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8. Tanzania (NTPI)
P ro blem :
MMR 578/1 00,000 live births, high newborn MR
Low percentage of assisted births ( health facility)
Poor quality services, poorly m otivated staff
S upply s ide R B F
• Bonuses for health facilities ( health workers)at different levels
for
(dispensary, health centres, hospitals, CHMT, RHMT)
• Based on achievem ents at institution på m åloppnåelse for institusjonen
• National universal targets for five indicators: OPV 0, DPT 3, IPT 2, facility
deliveries, HMIS com plete and subm itted in tim e
O bjec tive:
To m otivate health workers to im prove quality of services related to
m aternal and child health in order to attract m ore pregnant wom en
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9. ... Tanzania (NTPI)
• Owned by MOHSW, funds channelled through SWAp basket
arrangem ent
• Monthly reporting directly to president Kikwete
• Full national rollout without pilot!
• Many actors/stakeholders in the SWAp and basket
• Different com ponents ( training, m anagem ent, data validation,
HMIS strengthening, process evaluation, im pact evaluation)
• Final phases of program m e developm ent – im plem entation
starting
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10. India (NIPI)
Problem:
High m aternal-and newborn m ortality, low share delivering in
health centres/hospitals ( ajor changes taking place)
m ...
Supply side (NIPI)
• Bonus for voluntary fem ale health workers with low training (ASHA
og YASHODA)
• Focus on infant and child health ( well as m aternal)
as
Demand side (NRHM) :
• Cash incentives for wom en to deliver in facilities (
etc.)
Objective:
• To m otivate voluntary health workers to im prove quality and follow-
up of m aternal-and child health services
• Encourage wom en to utilize health services
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11. India (NIPI)
• NIPI supports NRHM in 5 states with 60% of India’s under five
m ortality
• NIPI offers flexible financing – m oney that can be used in
catalytic, strategic or innovative ways
• The funds are channelled through thre UN agencies: UNOPS,
UNICEF & WHO
• RBF m uch used in NRHM:
– supply and dem and based
– Institutional deliveries
– PPP – engaging obstetrics
– Im prove health services for infants ( NIPI – Yashoda and
ASHA)
• Need for form al evaluations
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12. Pakistan (NPPI)
P ro blem :
• High m aternal-and newborn m ortality, poor quality and access to
health services resulting in low utilization rates
S upply s ide R B F:
• Increased access to MCH services through result based contracts
(PPPs)
• Im proved governance and result based m anagem ent
D em a nd s ide:
• Incentives/vouchers to pregnant wom en to deliver at facility
O bjec tives :
• Im prove em powerm ent of wom en ( increase awareness/choice re
own health)
• Increase access to and quality of MNCH services
• Increase adm inistrative capacity and quality of health care system s
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13. Pakistan (NPPI)
• Sindh province – 1 0 rural districts
• Strategic and catalytic support to achieve MDG 4&5
• Via UN (”One UN” country)
• RBF schem e to increase access, quality, dem and for im proved
MNCH services
• Voucher initiative:
– rem ove econom ic barriers
– pilot and eventually scale- up
• How can perverse incentives be avoided
– anti corruption, good governance and m gt capacity
– Strengthen HMIS, evaluation m echanism s and research
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14. GAVI
G A V I boa rd
T he V a c c ine Fund
(M ultila tera l, bila tera le do no rs , res ea rc h ins t.,
fund raising, advocacy,
va c c ine indus try, c ivil s oc iety) additional resources to countries
I ndependent
Immu
R eview C o m m ittee
niza tio
N ew S a fety H ea lth
review of country proposals,
n
monitoring reports va c c in s uppli s ys te
S ys te
es es ms
m
(I S S )
P ro po s a ls
Technical support -
from partners M o nitoring
(WHO, UNICEF R eports
etc.)
National systems
Preparing applications, implementation, monitoring and evaluation
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15. GAVI ISS - (Result based Aid)
• N o rw eg ia n s uppo rt N O K 500 m illio n per yea r
• A pplic a tio n ba s ed
– Countries with GDP per capita below US$1 000 are eligible for ISS funding
from GAVI in a five year perspective ( R es ult-ba s ed A id)
i.e.
• I nves tm ent
– The two first years a country receives support as an investm ent calculated
as num ber of additional children to be vaccinated, with baseline current
year
• R ew a rds
– The third year countries receive support based on actual achievem ents
– $20 per additional vaccinated child over the baseline in the application
• R es ult indic a to r
– # children > 1 year that have been vaccinated with DPT3
• E x terna l va lida tio n o f da ta
– Validation of data through Data Quality Audits ( DQA)carried out by audit
firm s
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16. Results
• 36 o f 51 c ountries w ith a ppro ved a pplic a tio ns qua lified fo r
rew a rds
• Qualification depending on:
– achievem ents re num ber of children vaccinated
– that country reports on results are accepted in an external data
validation test
• Most of the countries that did not receive the reward did not pass the data quality
test, whereas others did not vaccinate enough children
• V a c c ina tio n c o vera g e m ea s ured by D T P 3 in G A V I c o untries ha s
inc rea s ed
– DTP3 – from 64% to 71 %
• P o verty o rienta tio n a nd reduc ed inequities
– poor countries and countries with poor coverage have received a larger
proportion of GAVI funds
– urban/rural inequity has been reduced
– 1 5.01 .09 inequities have been reduced
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gender

17. Conclusion: Findings from the evaluation could not conclude that the
positive results can be attributed to the result based aspects of the
GAVI ISS
– Flexibility of funds m ay in itself be attributable
– Countries with good results had strong partners that provided
sound technical support, etc.
– Population growth in itself was the basis for the m ajor share of the
num ber of children vaccinated
Latest:
Recent Lancet article by Chris Murray indicates data fraud with
routine data reporting for GAVI ISS. Survey data model indicates over
reporting from countries, linking this to result based financing.
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18. GFATM - RBF
• Norwegian support 2008: NOK 375 m illion
• Application based ( reviewed by independent panel and approved
by Board)
• Support for 2 years – followed by phase 2 application ( total 5
years)
• Local Fund Agent ( audit firm )reviews and validates invoices
intl.
and report the results back to GFATM
• Results end in recom m endation to the Board: ”go”, ”conditional
go”, ”no go”
• The system is basically flexible, based on local conditions, the
harm onization agenda and existing best practices
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