PERFORMANCE BASED FINANCING IN BURUNDI

By Dr BASENYA OlivierPresident of the PBF Steering Committee in BURUNDI

Director General of the National Institute of Public Health

OUTLINE OF THE PRESENTATION

• INTRODUCTION• WHY PBF IN BURUNDI?• IMPLEMENTATION PROCESS OF PBF IN BURUNDI• ROLE OF THE REGULATION IN PBF• MAIN RESULTS• FUTURE PERSPECTIVES • KEY CHALLENGES• CONCLUSION

INTRODUCTION • In 2004, MoH organised “General States of Health» that underlined

key weaknesses of the health sector• After the diagnosis of health sector, The MoH elaborated key

documents:– National Health Policy 2005-2015 – National Health Developpement Plan (PNDS) 2006-20102006-2010 with a

four-fold objective:• Reduce maternal mortality• Reduce under five mortality • Fight against transmissible and non transmissible diseases• Strenghten the performance of the national health system

INTRODUCTION • The fourth Objective of PNDS recommends the

reinforcement of the national health system through contracting strategy among others;

• Contractual approach should allow: –Quality improvement of health care and services at

different levels– Improvement of health care management and

organisation–motivation and stabilization of health personnel – Population’ views taken into account in managing

health system problems

WHY PBF IN BURUNDI?• The PBF was implemented in BURUNDI in order to deal

with main health system challenges such us :– quantitative and qualitative lack of health personnel,

especially at peripheric areas: 50% of nurses and 80% of Medical Doctors work in Bujumbura

– Instability and lack of motivation of health personnel– Low quality of care provided to population– Weaknesses in organisation and management of health

care system– Low financial accessibility of populations to health care

WHY PBF IN BURUNDI? • Facing such challenges, the governement decide to

implement some reforms and strategies :– decentralisation of health system by setting up

operationnal health districts– Output Financing health system based on performance– Elaboration of human ressources development plan– Initiate a common framework Committee for health and

Development with partners (Cadre de concertation et de Partenariat pour la Santé et le Développement (CPSD)

WHY PBF IN BURUNDI? • PBF was adopted in order to : – Motivate and stabilize health personnel– Encourage health personnel to work in peripheric areas– Improve quality of health care – Reinforce autonomy, organisation and management of

health care facilities– Take into account population views in resolving health

problems

IMPLEMENTATION PROCESS OF PBF• Preleminary missions for key staff of MOPH in countries with PBF

were conducted• The MoH support NGOs (Cordaid and HNTPO) in implementing PBF in

three pilot zones • In order to monitor the process, the MOPH set up a National Steering

Committee in charge to elaborate a National Contracting Policy. This Committee includes staff from MoH, Other Ministries, Non for Profit Private sector, health partners with a technical support of WHO

• The National Contracting Policy has been adopted in February 2007

by the Government, after technical approval by health sector

stakeholders. – The National Contracting Policy document is a reference document that

provide guidelines in terms of contractual arrangements in the health sector.

• PBF is one of contracting strategies outlined in this document, among others.

IMPLEMENTATION PROCESS OF PBF

• PBF pilots experiences have started in November 2006

in 3 provinces : Bubanza and Cankuzo (CORDAID) and

the Health District of Kibuye in Gitega’s province

(HealthNet TPO)

INSTITUTIONAL SET UP OF PBF• The set up of PBF respects the principle of

separation of functions : – The regulation and stewardship function is the

responsability of the Ministry of Health and provincial health authorities (Health Provincial Offices, Health Districts)

– The function of funding (channeling of funds) : is endorsed by Performance Purchase Agencies « Agences d’Achat des Performances »

– The function of service provision is endorsed by the health facilities

– The voice of the population is part of the system through Health Comities and the local associations

INSTITUTIONAL SETUP OF PBF

• At central level of MOPH, there is 2 main Organs:– a Technical Support Unit which has the role of:

– Follow up and monitoring PBF implementation– provide a technical support to stakeholders

involved in PBF. – a Steering Committee : Its role is to follow up the

implementation of National Contracting Policy, and advocate for the contractual approach.

MAIN RESULTS OF PBF• Improvement of Health Indicators • Improvement in Health services quality • Motivation and stability of health staff• Availability of personnel and drugs even in remote health facilities • The voice of the population is taken into account in the management

of health services• Development of initiative and entrepeneurship among health facility

managers, progressively improving health services : i.e. – Purchase of beds, sheets, and matrasses for patients – Purchase of solar panels for health center – Maintenance of facility (water adduction, doors, walls)– Painting of several health centers – Purchase of matterial for the cleaning – Construction of incinerators

MAIN RESULTS OF PBF

• Comparison of Zones with PBF and zones without PBF was made in 2008 by CORDAID: – 22 out of 27 indicators are significatively higher in PBF

zones than in « input based financing » zones. • Positive results in pilot areas has lead other actors to

implement PBF in other provinces • Currently, 9 Provinces out of 17 have adopted PBF:– Bubanza, Cankuzo, Makamba, Bururi (DS Rumonge),

Rutana, Ruyigi, Karuzi (CORDAID, Union Européenne)– Gitega (HealthNet TPO)– Ngozi (Coopération suisse)

FUTURE PERSPECTIVES• The Ministry of Health target the scale up of PBF in

the whole country in 2009• The Governement has voted a budget of 2,5

millions usd for PBF in 2009 • Several partners are committed to support the

governement in the scale up of the system – The World Bank (in the entire country)– The European Commission – Bilateral partners

FUTURE PERSPECTIVES (2)• The training of a critical mass of actors in terms of PBF : – 2 international courses of 14 days on PBF have been

organized at the National Institute of Public Health (INSP) with the support of Cordaid• 60 health staff from Burundi, DRC, Cameroun and RCA have

been trained

– The INSP, with the support of the MoPH is planning to organize a yearly course on PBF for service providers and health staff, and a short training (3 days) for Policy makers

MAIN CHALLENGES• The future institutionalization of PBF in health sector: The

factors in favor of PBF are numerous : – The positive results observed in the zones with PBF– A political will (PNDS and PNC)– The involvement of partners – The sector wide approach: A Medium term Expenditure

Framework (MTEF) and a common monitoring and evaluation framework are being designed.

MAIN CHALLENGES • Instutionalization of fundholders and separation of

functions – So far : the fundholder is a Performance Purchase

Agency dependent on NGOs and Projects

– In the future: the fundholders could become • Non for profit organization from civil society? (asbl)• Autonomous public agencies?

• A large debate will be initiated by the MoPH in order to achieve a common ground with stakeholders

CONCLUSION• PBF in Burundi is the result of a close collaboration

between MoPH and external partners• The MOPH remains in charge of its mission of public

service• The PBF has shown positive results, hence the

decision by MoPH to scale up the approach in the whole country

• The institutional framework of PBF in a medium term remains a challenge

Thank you