Overview of RBF Indicator Compendium

The Results-based Financing Indicator Compendium for RMNCAH Initiatives is a list of indicators that may be used to design and implement programs that provide incentives to healthcare providers for good performance. You may also find indicators that will be useful for the monitoring and evaluation of a results-based financing program for RMNCAH. 

Results-based financing (RBF) refers to the provision of incentives (money or goods) on the condition that a measurable action is taken or a predetermined performance target is reached.[1] RBF health programs transfer incentives to either clients, when they take health-related actions (such as having their children immunized), or to healthcare providers, when they achieve performance targets (such as immunizing a certain percentage of children in a given area).[2] Traditional health programs finance inputs, such as medical supplies, training, and providers' salaries, with the expectation that those inputs will produce good services and positive outcomes for patients. RBF health programs provide payments based on the outputs or outcomes that result from the resources.[3]

RBF programs focus on either the supply of or demand for services. Performance-based incentive programs are designed to influence the supply side of the healthcare system, aiming to improve the quality or efficiency of service provision. Performance-based incentive programs provide facility-level incentives or bonuses to healthcare teams contingent on reaching a set of performance targets. A second example of supply-side RBF is performance-based contracting, which provides incremental funding conditional on program performance and is arranged at a higher level than the healthcare team. Conditional cash transfer programs are designed to influence the demand side of the healthcare system, aiming to motivate patients to use needed services by paying them to do so.

This indicator compendium provides a list of output and outcome indicators from which to choose when selecting indicators to measure facility-level or administrative-level results. For RBF programs to work well, predetermined results must be independently verified, which requires investment in strong infrastructure and intensive administration practices. This makes it difficult to isolate and understand the role of the incentives versus the investment in infrastructure. However, it has been demonstrated that small, highly targeted incentives can change client and provider behavior in order to achieve positive results. Long-term and unintended effects on clients and the healthcare system should be monitored and evaluated.[4] We provide a broad set of reproductive, maternal, newborn, child, and adolescent health (RMNACH) indicators in the compendium, with the intention that users may also consider using some of those listed to monitor and evaluate the wider and long-term effects of RBF programs.

The purpose of the RBF Indicator Compendium is to provide you with a list of indicators that have been systematically identified from expert resources and organize them in an easy-to-use, up-to-date platform. After a technical review of several comprehensive lists of indicators used in RBF programs all over the world, this compendium includes indicators that meet the following criteria:

• Relevant to RMNCAH
• Focused on measurable results—either outputs or outcomes
• Global standards or commonly used in RBF programs
• Fully defined
• Contribute to a balanced set of indicators to design, monitor, or evaluate RBF for RMNCAH programs.

The principal resources for the compendium are indicator manuals published by the World Health Organization and case studies conducted by the World Bank. The RBF Indicator Compendium is organized into four collections: (1) structural; (2) quality of services; (3) service use and intervention coverage; and (4) health outcomes and impact.

1. The structural collection includes indicators that measure facility management, such as availability of physical and human resources, physical accessibility of health services, the existence of facility systems, and the capacity of the workforce to provide services.
2. The quality of services collection includes indicators that measure process of care, reaching standards of care, and client satisfaction. Quality checklists are not included in the indicator compendium.
3. The service use and intervention coverage collection includes indicators that track the number of people using a service, and proportions of people who need a service who are using the service.
4. The health outcomes and impact collection includes indicators that monitor change in the health status of an individual, group, or population, which is attributable to a planned intervention or series of interventions, regardless of whether such an intervention was intended to change health status. This collection includes measures of morbidity and mortality.

During the design, implementation, and evaluation of an RBF program, it is important to consider that data will be collected internally (by the healthcare providers) and externally (by a third party).[5] Routine data collection by healthcare providers should include both process of care (documentation of diagnosis and treatment) and outcomes of interest (cure rate),[6] and a combination of those indicators are used to set performance targets. Depending on the RBF program goals, indicators may be chosen to measure progress on structural improvements, standard care provision, patient or provider satisfaction, service use, intervention coverage, or health outcomes. Frequencies, proportions, rates, and scores are used to calculate indicators included in this compendium, whereas checklists that cannot be scored and are intended to be used as qualitative tools are not included in this indicator compendium. Quality checklists can be found at http://www.tractionproject.org/resources/results-based-management-performance-based-incentives-quality-care/multi-country. Just as it is important to plan out which indicators will be collected internally and externally, it is also important to consider quantitative and qualitative methods to provide a strong understanding of the measurable results.

See the following publication for a literature review of relevant materials: Evaluation Research on Results-Based Financing: An Annotated Bibliography of Health Science Literature on RBF Indicators for Reproductive, Maternal, Newborn, Child, and Adolescent Health