CARE. ACT. SHARE. LIKE CORDAID.

PBF IN THE

REPUBLIC OF

THE CONGO

DIFFERENT CONTEXT, SAME BUILDING BLOCKS

CARE. ACT. SHARE. LIKE CORDAID.

COOPERATION BETWEEN DIFFERENT ACTORS

PBF IN THE

REPUBLIC OF THE

CONGO

Ministère de la Santé

et de la Population

Programme de Développement

des Services de Santé - PDSS

CORDAID RBF

2 JULI 2013

Technical assistance, pilots or implementation in 13 countries

• Cameroun (impl.)

• Congo Brazzaville (impl.)

• Zimbabwe (impl.)

• South Sudan (impl.)

• RDC (pilot)

• Central African Republic (pilot)

• Uganda (pilot)

• Malawi (pilot)

• Burundi (TA)

• Sierra Leone (TA)

• Rwanda, Burundi and Congo SRH (impl.)

• Afghanistan

• Haiti

PROGRAM BACKGROUND

2 JULI 2013

• Start in January 2012 • Information meetings

• Manuel de produres (AAP)

• Opening of bank accounts

• First contracts in May 2012

• Startup grant paid

• Interruption from June to September 2012 • Facilities and regulator stopt using PBF instruments

• Cordaid temporarily closed sattelite offices

PROGRAM BACKGROUND

2 JULI 2013

• Restarted in October 2012 • New contracts signed

• First operational training

• Verification and validation

• Retrospective payments in November/December (also for Jan –May 2012)

CONTEXT

2 JULI 2013

• 3 regions (départements), 3 districts per region

• 73 Health Centers (CSI)

• 7 Hospitals

• 9 Circonscriptions Socio-Sanitaire (CSS)

• 3 Directions Départementales de la Santé (DDS)

• Sparsely populated

• Low utilization of services (average number of new consultations is

0,1 per capita)

SIX DIMENSIONS OF RBF

2 JULI 2013

Linking Payment

and results (indicators)

Contracting

Cycle from business

plan to verification

Autonomy (cash,

hire and fire etc)

Segregation of functions

Community

empowerment

(feedback, satisfaction)

Equity measures

LINKING PAYMENT AND RESULTS

2 JULI 2013

Shift from input to output, indicators, targets

• Target setting (163% coverage for vitamin A)

› Population correct? Calculation correct (10% of population in a setting with

much malnutrition)?

• Relatively good salaries for health staff.

› Doctors receive 1,000 USD per month

› Does the bonus payment of 60 USD make a difference?

• Some indicators (pregnant women completely vaccinated and distribution of

mosquito nets) deleted from the list because badly operationalized or

activities not performed

SEGREGATION OF FUNCTIONS

2 JULI 2013

Client

Agent

Principal

Problem

• Strong asymmetry

• Principle is not the client

• Property rights delegated to agent

• Agent prone to pursue self-interest

SEGREGATION OF FUNCTIONS

2 JULI 2013

Service Provider

Purchaser

Budget Principal

Qualit

y c

ontr

ol

Regulator

Client

SEGREGATION OF FUNCTIONS

2 JULI 2013

Challenges in Congo

• Regulator not capacitated to do supportive supervision (transport, knowledge, no medical staff trained in public health)

• Limited availability of trained staff also a problem for setting up purchasing agency. Specifically provide external technical assistance in startup phase (procurement, training, manuals etc)

• Crucial that purchaser is present at the lowest possible level (Satellite in Dolisie)

• Steering committee and technical committee at national level as well as a steering committee at department level; more regular meeting at national level necessary

• More reliable supervision, but still challenges in quality (organizational aspects, medical training, documentation)

• Peer evaluation

SEGREGATION OF FNCTIONS

2 JULI 2013

CONTRACTING

2 JULI 2013

From business plan to verification

• Clarifies, roles, responsibilities and expectations

• Not enough verification officers to accompany contracting cycles and do

supportive verification

• Low capacities (low number of staff with public health training)

• Capacities to apply operational instruments still limited

• Also, intensive support needed to understand procedures

• Continuous training necessary; people change jobs

COMMUNITY EMPOWERMENT

2 JULI 2013

Feedback, satisfaction surveys

• Community based organizations are contracted to verify existence of patients

• Challenges because of sparse population

• Patient satisfaction

AUTONOMY

2 JULI 2013

Cash payments, hire and fire, decentralised procurement

• Facilities paid “tax” to regulator. Has been abandoned and replaced by a

contract between the purchaser and the regulator for supervision

• Facilities in sparsely populated areas (2000/3000/4000 catchment area)

receive small RBF payments and have little room for improvement; bonus for

staff is lower as a result

• Facilities not allowed to hire staff. Distribution of staff not efficient. Now hired

informally and PBF payments used for this

• Limited availability of drugs (local stores not functioning; specifically HIV and

FP)

AUTONOMY

2 JULI 2013

AUTONOMY

2 JULI 2013

Cash payments, hire and fire, decentralised procurement

• Facilities not able to provide some services (only 3% of CSI offered TB

testing in 2012); more emphasis on training

• Limited operational knowledge regarding PBF: how to use instruments, do

planning, set priorities and write a business plan. For example, how to

calculate staff incentives?

• What has been done with subsidies?

• Incentives for staff

• Infrastructure (latrines etc)

• Medicines

• Motorcycles

EQUITY

2 JULI 2013

Isolation bonus, equity fund, vouchers

• A general 5% equity bonus is given to facilities

• Do facilities indeed setup equity funds? What is the role of the

COSA’s?

• Now one indicator for consultation for indigents

• How are indigents identified?

RESULTS

2 JULI 2013

Facilities offer more services

RESULTS

2 JULI 2013

Number of new consultations increased

3.827

5.810

6.823

9.418

7.521

8.403

-

1.000

2.000

3.000

4.000

5.000

6.000

7.000

8.000

9.000

10.000

DDS NIARI DDS PLATEAUX DDS POOL

Consultations Curatives 1er

Trimestre (oct.-déc. 2012)

Consultations Curatives 2ème

Trimestre (janv.-mars 2013)

RESULTS

2 JULI 2013

Number of children vaccinated

806

559 524

1057

736

1177

0

200

400

600

800

1000

1200

1400

DDS NIARI DDS PLATEAUX DDS POOL

Enfants complètement vaccinés

1er Trimestre (oct.-déc. 2012)

Enfants complètement vaccinés

2ème Trimestre (janv.-mars

2013)

RESULTS

2 JULI 2013

Number of deliveries in health centers increased

394

685

430

525

779

461

0

100

200

300

400

500

600

700

800

900

DDS NIARI DDS PLATEAUX DDS POOL

Accouchement eutocique assisté

1er Trimestre (oct.-déc. 2012)

Accouchement eutocique assisté

2ème Trimestre (janv.-mars 2013)

RESULTS

2 JULI 2013

Reliability of data improved (example inpatient days)

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

TRIM.1 de la 2ème Phase TRIM. 2 de la 2ème Phase

5520

9053

7119

9086

Données Vérifiées

Données Déclarées

RESULTS

2 JULI 2013

Number of supervision visits improved

RESULTS

2 JULI 2013

Quality score Pool

CARE. ACT. SHARE. LIKE

CORDAID.