Family planning included as a performance indicator in results-based financing initiatives

Definition:

Family planning (FP) is included as a performance indicator in a county’s results-based financing (RBF) initiative. RBF includes a range of financing mechanisms (performance-based incentives, pay for performance, and demand-side initiatives like vouchers) where financing is linked and provided after the delivery of pre-agreed and verified results (World Bank, ND).

Data Requirement:

Evidence that FP is included in the list of indicators tracked under a country’s RBF initiative

Data Sources:

Health financing strategies or by consulting with health financing experts in-country, including staff from the planning department in the country’s ministry of health and development partners

Indicator Type:

Yes/No

Purpose:

RBF is one aspect of health financing that a country can use to increase FP uptake. This is one of the indicators in the FP Financing Roadmap, which was discontinued in July 2024, that tracks health reforms.

RBF has emerged as a promising strategy to strengthen FP provision and provide quality health services. The financing approach transfers incentives to either clients, when they take health-related actions, or to healthcare providers, when they achieve performance targets focused on health service results (such as increasing the number of couples receiving FP counseling or aggregate new users of modern methods), rather than inputs (such as the construction of health centers and training of staff); thus more tightly linking financing to results (Chowdhury et. al., 2013). Most RBF initiatives focus on payments to providers or to a health system.

By including FP in RBF programs, the intention is to increase the provision and subsequently the use of voluntary FP services and address the conditions that hamper or promote quality FP services. They also aim to foster informed choice by ensuring the continuous availability of a wide range of FP methods.

Issues:

Because this is a yes/no indicator, it does not provide any information on the extent to which FP may be included in RBF initiatives or how it is being implemented or monitored.

There are ethical concerns related to FP incentives, which should be considered during the design, implementation, and evaluation of RBF schemes. Chowdhury et al. (2013) cautioned that RBF programs have the potential to limit client autonomy, contradict the values of clients or providers, lead to a focus on quantity over quality, displace providers’ intrinsic motivations, reduce trust in client-provider relationships, and erode client privacy and confidentiality. Eichler et al. (2018) warned that poorly designed RBF programs may result in excessive attention to increasing FP use, cause providers to focus on rewarded services and neglect other important services, and promote FP methods that pay higher fees. The additional potential risks to RBF mechanisms identified by Ugaz, Jha, and Correa (2022) are providers focusing more on FP services and commodities that are part of the incentive structure or scheme, concentrating on reaching targets like the number of new users of FP to the detriment of other FP clients, and undermining informed decision-making by prioritize increasing contraceptive prevalence more than improving the quality of counseling.

References

Chowdhury S, Vergeer P, Schmidt H, Barroyd H, Bishaie D, and Halpern S. 2013. “Economics and Ethics of Results-Based Financing for Family Planning: Evidence and Policy Implications”. Health, Nutrition, and Population (HNP) Discussion Paper. World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/625701468337214381/economics-and-ethics-of-results-based-financing-for-family-planning-evidence-and-policy-implications

Eichler, Rena, Jenna Wright, Ben Bellows, Marie Cole, Victoria Boydell and Karen Hardee. 2018. Strategic purchasing to support voluntarism, informed choice, quality and accountability in family planning: Lessons from results-based financing. Rockville, MD: Health Finance & Governance Project, Abt Associates Inc.

World Bank, Global Partnership for Results-Based Approaches. Results-Based Financing. Accessed September 6, 2024. https://www.gprba.org/who-we-are/results-based-financing

Ugaz, J., A. Jha, and K. Correa. 2022. Potential Impacts of Provider Payment Methods on Rights-Based Attributes of Family Planning Programs: An Updated Framework. Washington, DC: Palladium, Health Policy Plus.