Why The Concept of Result-Based Management (RBM) Has Become Imperative for Strengthening Health Systems.

RBM is a management strategy where all departments actively work towards achieving set targets and results. This is done by ensuring all their processes, products and services contribute to the achievement of desired results (Bester, 2012). During the planning and designing of the RBM, each department is expected to state its processes and services, clearly highlighting how they will contribute to the desired results being pursued. The results are then used to measure the performance of the company and each department and are used for future planning (Da Cunha, 2020). In brief, it involves planning, managing, monitoring and evaluation with the main focus on the results being worked towards.

RBM has 3 main principles that govern it (UNPF, 2019),

·        Goal-orientedness: This includes setting clear goals and results. Providing targets and indicators to assess whether a change has occurred.

·        Causality: various inputs and activities leading logically to outputs, outcomes and impact should be highlighted. This is called the results chain. It clearly shows the results that are generated from the inputs and the activities they require (UNDP, 2009). It begins with inputs such as funds, technical assistance and other types of resources mobilized to carry out activities and produce specific outputs. Outputs can be defined as what results from the completion of activities. They lead to outcomes that are the intended short-term effects of an intervention’s outputs, usually requiring the collective effort of partners. Lastly, the chain ends with impacts, which as the long-term positive or negative effects at the population level. It is hoped that these will help bring about a set of outcomes that will eventually contribute to the desired impacts (INTRAC, 2017).

·        Continuous improvement: periodically measuring results provide the basis for adjustment (tactical and strategic shifts) to keep programs on track and maximise their outcomes.

There are several key elements and stages to the achievement of RBM (Hailey and Sorgenfrei, 2004; Bakewell and Garbutt, 2005; Mango, 2014), they include;

1.     Setting specific, clear and measurable objectives.

2.     Establishing indicators to measure the achievement of the objectives.

3.     The setting of targets based on the objectives and their indicators.

4.     Establishing a monitoring and evaluation system to assess if the results are being achieved according to the objectives.

5.     The use of performance information for internal management accountability, learning and decision-making, as well as for reporting to external stakeholders and partners.

This can be expressed in a cyclic diagram as illustrated below, starting with planning, which includes setting the vision and defining the results framework. Implementation follows and monitoring becomes important to ensure results are being achieved. Finally, monitoring and evaluation provide information for decision-making and lessons learned for the future (UNDG, 2011).

 Fig 1: RBM Cyclic Approach. Source: UNDP (2009).

Previously, several health projects and systems have been implemented without clarity on if they achieved their intended results (UN Women, 2015).

At the national level, RBM offers country health implementers and managers’ means to apply systematic management at all levels, proper planning, setting of result-oriented objectives and targets, improve accountability, promote the development of evidence base and strengthen the commitment to health outcomes (Cordova-Pazo et Al., 2018).

The heath sector gains tremendously from result-based management. Through RBM, health officials exercise control and proper execution of the results chain. Inputs needed and used by the health sectors can be identified, budgeted for, sourced, and utilized to achieve the desired health outcomes and impacts. These inputs can be financial resources, human resources, medical equipment, ICT or information and knowledge. It is also used as an effective accountability mechanism to ensure that the appropriate use of inputs (Cordova-Pazo et Al., 2018). Also, RBM is used to list activities put in place to achieve the stipulated health outputs and outcomes such as procurement of health equipment and machinery, training, seminars and workshops, capacity building, and recruitment of health practitioners. (UNDG, 2011).

Application of concept of result-based management (RBM) in strengthening health systems

RBM in Planning

Integrating RBM into strategic planning is essential to being able to achieve and demonstrate results later in the life of a programme. This requires beginning with a grounded understanding of the situation you wish to change and strategic prioritization of the issues you will address (UNICEF, 2017). RBM has been most used in the planning phase by organizations for their strategic frameworks, programmes and projects. A number of tools are used in the planning phase: results matrix, monitoring and evaluation plan, and risk mitigation strategy (UNDG WGPI, 2010). several bilateral organizations, as well as United Nations’ programs, have taken up the Results-Based Management to achieve effectiveness and accountability from the planning stage to the completion of a project (Bester, 2015; UN Women, 2015). Throughout project or programme planning and design, stakeholder participation is always important; however, the level of participation must be considered strategically in the light of limited funds. The processes of vision setting and theory of change development may benefit from the active engagement of a large and diverse audience of both men and women, because different inputs and viewpoints will help build a nuanced and robust understanding of, among other things, the given context, how change happens and how the project will catalyse change (UNODC, 2018).

According to United Nations Children’s Fund (UNICEF), 2017 the following steps can be followed:

1.     Step 1. Understand the situation

2.     Step 2. Prioritize issues for action

3.     Step 3. Devise a theory of change

4.     Step 4. Define desired results

5.     Step 5. Align results, strategies and funding

6.     Step 6. Assess assumptions and risks

7.     Step 7. Draw it all together in a results framework and a theory of change narrative

8.     Step 8. Develop a monitoring plan

9.     Step 9. Assess the evaluability of the programme

RBM in Management

The “M” in RBM is often overlooked yet without good management it is unlikely that you will be able to achieve your results. Managing effectively for results requires the flexibility to change your strategies and activities to better achieve your results better. It also means using a team-based approach to ensure that all stakeholders concur with any proposed changes or actions. Results matrices can be updated once a year with the agreement of all stakeholders (UNDG WGPI, 2010). Five management pillars for the RBM system are; Strategic management: vision and strategic framework, Operational management: strategic planning and resource management, Accountability and learning management, Change management: internal culture of results, Responsibility management: partnerships (Rabindra N, 2020).

The most important element of RBM is ensuring that interventions lead to effective development and a positive change in people’s lives. This requires that managers manage better, ensuring that their resources are commensurate with the results they hope to achieve. Results-based decision making is a key dimension of RBM that should not be overlooked. Identifying, developing and managing the capabilities (people, systems, resources, structures, culture, leadership and relationships) are essential for managers to plan for, deliver and assess results (UNDG, 2011).

RBM in Monitoring and evaluation

Monitoring and evaluation, are the foundation of results-based management. Monitoring indicates whether an activity is on track to achieve its intended objectives. Through employing RBM in the health sector, monitoring is strengthened in response to resource accountability and forming a clear basis for informed decision-making. Monitoring through RBM provides the health systems stakeholders with early indications of progress towards achieving results and objectives. It also ensures that all partners and donors are informed of the system's results (UNDG, 2011). To adequately carry out monitoring, it is imperative to identify the information that is needed and how it will be used to identify if the results are being achieved. Another important aspect to consider in monitoring is how the data will be collected, analysed and presented to conclude. Evaluation of the health systems through RBM indicates whether the entire intervention is on the right track and what lessons can be drawn from its implementation. In health systems, Evaluation informs planning, programming, budgeting, implementation and reporting, and can contribute to evidence-based policymaking. Learning is a core feature of results-based management. After monitoring and evaluation, learning allows for reflection on what has worked and what has not. It provides a chance to work on the strategy to achieve the intended results in the healthcare system (UNEG, 2016).

RBM in Reporting

Results-based reporting is one of the key challenges to reporting on results achieved. All too often, reports do not adequately tell the story of the effects that their development interventions are having. Results-based reporting seeks to shift attention away from activities to communicating important results that your programme or project has achieved. An effective results-based report communicates and demonstrates the effectiveness of your intervention and makes the case to stakeholders and funders for continued support and resources (UNDG WGPI, 2010). RBM is now an accepted norm and has gained focus during these times where there is growing pressure on governments and private sectors for transparency and accountability in the use of resources such as expenditure on the health systems in place (UNODC, 2018); RBM is, therefore, the desired approach to raising the standards of performance in health systems.

RBM for Learning, Adjusting & Decision-making

As all management systems for planning, monitoring and evaluation become more results based, it is expected that the process of implementation will lead to greater learning, adjustment and decision-making (UNDG WGPI, 2010). Some evaluations mention progress in the use of results for direction and learning (Janet Vähämäki, 2018)

Managing for results is an iterative management approach. There is constant feedback to the planning and management process as results are assessed. Based on constant feedback of performance information from; audits, management reviews, performance measurement activities and evaluations, the inputs and activities can be modified and other implementation adjustments made. This corresponds to the two management functions of continuous performance measurement and iterative implementation. These two management functions are represented above by the nested feedback/action loops representing the collection of performance information and the management decisions based on the analysis of this information. By managing for results, all of the development intervention partners can contribute to organizational learning and improved management (Werner Meier, 2003).

Evaluation is an important contributor to building knowledge and to organizational learning. Knowledge generated through evaluations provides input for future decision-making. In addition, evaluations inform key country programme milestones such as mid-term reviews, new country programme development, and strategic moments of reflection. Understanding what works and what does not work and ensuring that lessons learned and emerging good practice are well disseminated helps accelerate learning (UNICEF, 2017).

Progress in reporting and using results for domestic accountability purposes

Reports help us demonstrate the effectiveness of an intervention (UNICEF, 2017). Most evaluations report progress on results reporting. Some see this progress as the most important achievement of RBM. The UN evaluation for example states that: “the most significant contribution of results-based management for United Nations system organisations is in providing a structure for reporting evidence of results to their respective governance bodies. Many evaluations argue that accountability has been the principal driver of RBM(Janet Vähämäki, 2018).

Conclusion

According to Aly Wael (2015) by adopting a result based management framework in the health systems it will be possible to;

1.     Manage for results instead of focusing on inputs, processes and compliance;

2.     Focus on creating value for available resources instead of spending available resources;

3.     Budget for results (outputs/outcomes), not inputs;

4.     Shift accountability for inputs to outcomes or results;

5.     Manage total economic resources not cash flows and cash balances;

6.     Measure the operational performance in terms of the three ES (efficiency, effectiveness and economy), not compliance with rules, regulations and procedures;

7.     Audit the performance of government not the legality and regularity of disbursement;  

8.     Report on total economic resources and performance of government instead of reporting on monetary position of government;

9.     foster closer link between strategic planning, policies, budgeting, financial management, performance management systems;

10. Realize the centralization of objectives and decentralization of management. (Example Government needs to centralize in order to decentralize.)  

11. Encourage collaboration between and within departments.

12. Link resources with results to improve budgeting decisions

In conclusion, the healthcare system benefits immensely from result based management. Its integration into most, if not all, health systems will bring about positive and desired health outcomes though result based goals, planning, monitoring and evaluation as well as learning.

References

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