World Bank jargon won’t deliver Rwanda-style health care
As 2013 came to a close, reports emerged of a new development in efforts by African governments and donors to improve the delivery of healthcare services.
Reported in this newspaper on December 28, they focus on ways of financing health services. The idea is that it should take on new characteristics in addition to the standard approach where resources are simply channelled into the sector to pay for inputs in the expectation that it will make a difference.
The approach will entail paying health care providers for delivering pre-agreed results whose achievement will be subject to independent verification.
The name for the approach is captured in special jargon: “Results-based financing” or “RBF.” Its advocates claim it will “increase impact” and assure donors that their taxpayers’ money is being put to good use.
Countries already using RBF are reported, in rather imprecise terms, to have made important strides. According to the claims, they “can get 20 per cent more healthcare for the same amount of money with a higher quality of care.”
As is often the case with new-fangled theories about how to deliver public goods or do development, leading the sales pitch is the World Bank.
Through a multi-donor Health Results Innovation Trust Fund under its management, the Bank is already supporting 36 RBF programmes in 31 countries to the tune of $404 million.
Its president, Jim Yong Kim, has sung praises of this approach: “Evidence shows that results-based financing has a significant impact — saving lives and expanding access to quality, essential health services for the poorest women and children in developing countries.” A number of African countries are cited as successful implementers of the approach: Zimbabwe, Cameroon, Zambia, Rwanda, Burundi, Tanzania, and Nigeria.
The news of these developments coincided with a revisiting in sections of the Uganda print media, of a familiar debate about what do to uplift the dismal standards of service delivery in the country’s health sector.
Over the past 40 years or so, the quality of state-provided health care in Uganda has been on a downhill trend. As of now, it is hardly an exaggeration to say that, with the exception of “islands of excellence,” mainly in the private-for-profit sub-sector, service delivery is generally shambolic.
Key attributes of the sector include corruption; understaffing and staff absenteeism; blockages and inconsistencies in the supply of drugs and equipment; wastage of resources; weak regulation, supervision and inspection; and policy incoherence linked to political manoeuvring and shifts in thinking by international experts who can be well-meaning but also misguided.
The debate in Uganda has long been about what, given all this, ought to be done to raise the standards of delivery. Recent media discussions have involved two experienced health professionals — a serving civil servant and a former junior minister in the sector. One decried the poor remuneration of health professionals and called for higher pay and improved working conditions as the starting point for improving delivery.
The other touted the importance of health insurance, which the government recognised 10 years ago as evidenced at the time, by “a lot of preparatory work” to introduce it in the country. The outcome was a Cabinet paper whose fate is easily discernible from a question the former minister posed in an article for a local daily: “When will Uganda introduce health insurance for all income earners?”
Perhaps Uganda and other countries in pursuit of improved delivery can borrow a leaf from successful implementers of RBF and follow suit? It is fairly easy to arrive at a quick answer if one considers the example given, of Rwanda.
“In Rwanda,” the reports goes, “the government decided to implement a national RBF scheme, paying incentives for the delivery of quality maternal and child health services.” Consequently, “the programme improved both the coverage as well as the quality of health services.” To seize on this and say, “Let’s go for RBF,” however, would be excessively optimistic.
It is indeed true that Rwanda, whose local version of RBF is called PBF (performance-based financing) has made significant gains in the quality of service delivery in the health sector and also in health outcomes for the ordinary Rwandan.
Evidence for this can be seen in, among other outcomes, drastic falls in both maternal and infant mortality rates, and in malaria prevalence and rises in the number of women using state-provided services to access family planning and antenatal as well as birthing facilities.
The secret behind these advances, however, is not simply PBF, vast financial resources, or remarkably high salaries for health workers.
Rather, it is a combination of factors including robust vertical and horizontal co-ordination, intense performance pressures on frontline health personnel and public servants generally, and most important, exceptional political commitment to addressing the needs of the ordinary citizen. These drivers of change are not easily transferable. Without them, RBF counts for very little.
Frederick Golooba-Mutebi is a Kampala- and Kigali-based researcher and writer on politics and public affairs. E-mail: [email protected]
