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Jhpiego’s collaboration with the Elizabeth Glaser Pediatric AIDS Foundation - EGPAF

PBF initiative

Performance-based Finance (PBF) in Mozambique

Edgar Necochea, Director Health Systems DevelopmentJhpiego - an Affiliate of Johns Hopkins University

• Implemented by the Elizabeth Glaser Pediatric AIDS Foundation with funding from CDC/PEPFAR (AIDS funds)

• Started in 2009 with cost reimbursement and PBF component in 2010

• Includes approximately 27 districts and 2 provincial directorates of health

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The EGPAF PBF initiative in Mozambique

• Jhpiego has collaborated with EGPAF providing tools for the assessment of the quality component of the PBF initiative in Mozambique in two areas: infection prevention and control and maternal health

• Jhpiego is improving quality of care in these areas in the country using its Standards-based Management and Recognition (SBM-R) approach

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SBM-R in Mozambique

• Infection Prevention and Control (IPC): implemented nationally in all hospitals of the country (45) and 82 health centers, with CDC support

• Model Maternities: implemented in 34 facilities planned expansion to 122 by 2014, with USAID support

• Others: Model wards, pre-service education• Adopted by the Mozambican MOH, key part of

the MOH national quality strategy4

Mozambican MOH Quality Strategy

1. Promote and guarantee the dissemination and adoption of evidence-based health practices and standardize healthcare processes with base on these practices:

a. Update service delivery norms and guidelines working with the professional and specialty associations.b. Continue and expand the implementation of the SBM-R approach currently used in IPC and Model Wards and Maternities.c. Promote the use of the WHO check-lists as job aids that reinforce the adoption of evidence-based practices in areas such as safe surgery and patient safety.

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The SBM-R approach

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• There is significant amount of evidence on what works in healthcare, but…

• Many countries are not implementing even the basic standards of care in their facilities

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• 12 cities in the U.S., 6,712 patients• 439 performance standards for 30 acute and

chronic conditions and preventive care• Clinical records review plus phone interviews• Average: 54.9% recommended care (acute:

53.5%, chronic: 56.1%, preventive: 54.9%)• Range: between 78.8 (cataracts) and 10.5%

(alcohol dependency)• Gap between best care based on evidence and

average care

Rand Corporation study, 2003

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The critical gap

Between:

What is known

What is done

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The reality in many low resource settings

• Few health workers for service provision• Staff overburdened by workload• Poor working conditions, lack of resources• Low motivation of staff• Weak pre-service education, often staff lack

basic knowledge and skills• Dysfunctional management systems, including

patient records and information

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What we were looking for

Less emphasis on problem analysis andmore focus on providing a solution that is:

• Practical• User-friendly• Informative• Challenging• Fun

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Systematic reviews of the evidence (Scientific basis)

Guidelines(Synthesis of the evidence)

From evidence to action

Standards(Care maps, check-lists)

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The Standards-Based Management and Recognition Approach

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Area: Pregnancy Care

Perf. Standard Verification Criteria Y, N, NA Comments

1. The facility conducts a routine rapid assessment of pregnant women

Sample performance standard for EOC

Observe in the reception area or waiting room if the person who receives the pregnant woman:• Asks if she has or has had:- Vaginal bleeding- Headache or visual changes - Breathing difficulty- Severe abdominal pain- Fever

• Immediately notifies the health provider if any of these conditions are present

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Area: Operating Room

Criteria Verification Means Y, N, N/A Comments

1. The cleaning equipment is processed before reuse or storage

Observe if the mops, buckets, brushes and cleaning cloths are:• Decontaminated by soaking for 10 minutes in 0.5% chlorine solution or other approved disinfectant.• Washed in detergent and water.• Rinsed in clean water.• Dried completely before reuse or storage.

Sample performance standard for IP

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Sample summary form of assessment tool for MNH - hospital

AREAS STANDARDSCare for pregnancy-related complications 17Labor, delivery, immediate postpartum and newborn care

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Support services (lab., blood bank, pharmacy) 28Infection prevention 11Information, education and community participation

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Human, physical and material resources 27Management systems 14Total 139

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Assessment tool areas for HIV/AIDS ART

AREAS STANDARDSART treatment readiness assessment (adults) 7ART treatment commencement (adults) 9ART treatment follow-up (adults) 24ART treatment readiness assessment (pediatric) 8ART treatment commencement (pediatric) 13ART treatment follow-up (pediatric) 24Laboratory 9Pharmacy 17Medical records and information systems 16IEC and community participation 7Human and physical resources 23Management systems 16Total 173

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100%

0%

60%

Scientific (evaluation)

Managerial

Optimizing

Satisficing

Level of Certainty

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Types and uses of measurement

METHOD STRENGTHS LIMITATIONS

Measurements using the Assessment Tool

Simple, data readily available Limited to process, level of certainty relatively low

Tracking of selected result indicators using routinely collected data

Data often available, relatively simple, gives information on results achieved

Data may not be complete, may take staff time for data collection and analysis, may require some training, results may not be completely accurate

Tracking of selected result indicators using specially collected data

Data is more reliable, gives more accurate information on results

Usually requires a system and training for data recording, collection, and analysis, requires more staff time and dedication

Tracking of selected result indicators using randomly selected case and control sites

Level of certainty of results of evaluation is high

Requires special and careful design, a data collection and analysis system and infrastructure, trained staff, more costly, requires more time

ACTION

EVIDENCE

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Some results for the Model Maternitie

s

 PROVINCE

 HEALTH FACILITY

BASELINE(JANUARY - JUNE 2010)

FOLLOW-UP ASSESSMENT(SEPTEMBER - DECEMBER 2010)

STANDARDS ASSESSED

STANDARDS ATTAINED STANDARDS ASSESSED

STANDARDS ATTAINED

No. No. % No. No. %

Maputo City

Maputo Central Hospital73 11 15.1 76 34 44.7

José Macamo General Hospital77 19 24.7

Mavalane General Hospital65 5 7.7

Chamanculo General Hospital69 15 22.2 77 29 37.7

Maputo Province

Manhiça Health Center77 29 28.7

Matola II Health Center77 21 27.0

Boane Health Center77 35 49.5

Gaza

Xai Xai Provincial Hospital61 15 24.6 59 22 37.3

Manjacaze Rural Hospital77 32 41.6

Chicumbane Rural Hospital66 20 30.3

Inhambane

Inhambane Provincial Hospital44 8 18.2

Chicuque Rural Hospital39 6 15.4

Homoine Health Center77 29 37.7

Sofala

Beira Cental Hospital66 12 18.2 65 34 52.3

Buzi Rural Hospital 42 16 38.1

Macurrungo Health Center72 24 33.3 75 45 60.0

Manica

Chimoio Provincial Hospital60 19 31.7

1st of May Health Center79 14 17.7

Catandica Rural Hospital79 10 12.7

Tete

Tete Provincial Hospital65 16 24.6

Songo Rural Hospital74 22 29.7

Matundo Health Center76 27 35.5

Zambézia

Quelimane Provincial Hospital73 58 79.5 63 49 77.8

Mocuba Rural Hospital76 42 55.3 79 34 43.0

Gurué Rural Hospital

75 27 36.0 79 51 64.6

Nampula

Nampula Central Hospital*

62 18 29.0 63 33 52.4

Monapo Rural Hospital*

70 21 30.0 59 45 76.3

Nacala Porto General Hospital*

74 31 41.9 48 26 54.2

Niassa

Lichinga Provincial Hospital

62 22 35.5 65 27 41.5

Cuamba Rural Hospital

62 24 38.7 62 23 37.1

Chihualua Health Center

57 11 19.3 48 9 18.8

Cabo Delgado

Pemba Provincial Hospital

56 13 23.2 79 47 59.5

Montepuez Rural Hospital

73 18 24.7 66 21 31.8

Natite Health Center

72 10 13.9 79 53 67.1

* initial evaluation redone, June 2010

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Some results for the Model Maternities

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Some results for the Model Maternities

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Some results for the Model Maternities

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Motivation

• Empowerment• Challenge• Growth• Achievement• Healthy competition• Fun

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Recognition as an incentive

• Feedback• Social recognition• Material recognition

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The EGPAF PBF initiative

Components

• Cost-reimbursement (input-based): provider receives funds based on budget line items, submits justifications to EGPAF (without receipts, no payment); approximately 60% of budget

• Performance-based (output-based): provider is paid for services delivered (without service, no payment); approximately 40% of budget

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Functions and entities

• Regulator/Provincial health directorate: monitors quantity and quality of services, establishes procedures for usage of PBF funds

• Purchaser/EGPAF: verifies and pays• Provider/Health facility & District health

department: provides services• Consumer/civil society: utilizes services, controls

results, and measures client satisfaction

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Quantity indicators

• HIV indicators (50%): PMTCT (4), Pediatric HIV (5), Care and treatment program (6)

• Non-HIV indicators (50%): MCH program/TB/Primary health (6)

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PBF model

EGPAF –Mozambique PBF model is similar to the Rwanda model based on price for service

• HIV indicators taken from PEPFAR indicators, with comparatively robust M&E system.

• Additional components are the quality tools (IMQ, MM and PCI) approved by MOH.

• Equity bonus (for remote districts)• Patient satisfaction bonus (based on independent patient

satisfaction survey)

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Equity and quality indicators

• Equity factor: 0.20 or 0.25• HIV Quality Index (QI): 0.25• Infection Prevention and Control QI: 0.125• Model Maternity QI: 0.125• Client Satisfaction Index: 0.05

These are percentages of the total amount for quantity (quality represents 75% of the amount for quantity.)

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Reporting and verification

• Quarterly and semi-annual reports from beneficiaries

• Verification: Quality tools: quarterly for HIV(IMQ); Infection Prevention and Control and Model maternities: semi-annual

• When targets are met for a particular quantity indicator, it will receive a 4% bonus (of the total amount for the specific indicator)

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Community verification

• Independent verification of quantity service data reported by the health facility

• Independent assessment of client satisfaction

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Equity factor

• For districts that face greater obstacles in service delivery (lack of investment, resources, or other constraints)

• Amount to 20 or 25% of the total amount for quantity x Price(Basis for payment)

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Use of funds

• A minimum of 60% of funds should be used for health staff incentives

• A maximum of 40% for other activities like reinvestment in the HF.

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