Nigeria , January 2010

Petra VergeerHealth Specialist, RBF Team

Ensuring Focus on Outputs-Results-Based Financing “Transfer of money or material goods

conditional on taking a measurable health related action or achieving a predetermined performance target.” - Eichler and Levine

An increasingly common approach in Africa to improving performance, particularly in HF’s

HF’s are provided payments based on the amount of services they actually deliver

Rwanda Health Center RBF/ Performance-Based Financing (PBF)

1. Supply Side Intervention2. Demand-side phenomena3. Targeting Health Facilities that

are made more autonomous4. Regular, significant incentives

reach front line health workers5. District Support Functions

incentivized (monitoring volume and quality: internal controls)

6. District PBF Steering Committee incentivized

7. Central MOH PBF-support department incentivized

G. Fritsche-Real World Implementation Challenges: Scaling up Performance-Based Financing in Rwanda 2006-2008

Presented at Interagency Working Group on Results Based Financing, 23 Nov 09 Oslo Meeting

How to motivate health workers to improve performance?

Pharmacy, Phoebe Hospital Liberia,

February 2009

An Example of RBF

Service Number Provided

Unit Price

Amount Earned

Fully Immunized Child 100 $5 $500

HF Delivery 20 $10 $200

Out-patient Visit <5 1,000 $0.5 $500

TOTAL $1,200

Quality Correction 60% $720

What Can Health Facility do with the $720? 70% ($504) split among staff:

◦ Physician ◦ Nurses◦ Cleaner

30% ($216) goes for inputs into facility◦ Drugs ◦ Stationary◦ Minor repairs◦ Demand side incentives

Quantitative Supervisory Checklist to look at Quality of care A reduced version of a health facility

assessment Objectively assesses a variety of indicators

to come up with total score. Takes about 2-3 hours to complete A copy of results left in the health facility,

easy to track progress QSC is both a management intervention and

tool for M&E

Example of a Quantitative Supervisory Checklist

Date of Visit 5/12 7/19 8/11 10/21

Availability of Drugs (0-15) 5 7 9 12

Presence of staff (0-10) 7 8 8 10

HMIS implementation (0-10) 6 7 7 8

TB Records and Follow-up (0-15)

8 10 11 13

EPI inputs & plans(0-20) 12 12 15 15

Quality of care in OPDs (0-20) 8 10 14 15

Quality of Deliveries (0-10) 3 4 6 8

TOTAL SCORE (out of 100) 49 56 70 81

Supervisor’s signature

HF in-charge signature

Performance framework (purchase contract) -defining rules of the game of PBF

Focus on public health and preventative services through FFS conditional on quality

Regular, significant incentives for improved performance to reach health worker

Autonomy to manage for results (i.e. use funds, resource allocation)

Health mgt committee (incl. community) to oversee transparent use of funds

The Hourglass Paradigm®Inputs: the salaries, equipment, consumables such as FP products also number of clients presenting to health facility (demand)

The ‘neck’: or ‘bottleneck’; human resources (quantity, quality, motivation –intrinsic and extrinsic-, working hours, opening hours, etc)

The outputs: services delivered; quantity and quality

Performance contract focusing on support tasks (i.e. health system issues & PBF implementation) ->

Regular, significant incentives for results Transparent governance set up to verify

performance – i.e. district level PBF steering committees (with local govt and quorum of CSOs)

Regular verification of performance (quantity and quality) at HF level, linked to incentives

Intense, dedicated TA coordinated to implement PBF (i.e. TOT) and improve HFs performance (i.e. identify non-performers for support, business plans, etc.)

Verification

PBF Policy commitment (i.e. PBF payments, into HF bank accounts, autonomy, decentralization, promote results based management approach)

Sufficient budget to pay significant incentives and additional TA

Availability of inputs i.e. sufficient drugs/ supplies (or can purchase at appropriate quality & price)

MIS system able to capture and feedback data efficiently (preferably web-based)

PBF implementation unit with dedicated TA (i.e. for IT support, MIS training, TA coordination)

Donor coordination (leverage TA, buy in, sustainability)

Management Information System- Data entry is easy

Quarterly district invoices