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CordaidPBF experiences in Sub

Saharan Africa

Piet VroegSector Health and Wellbeingpiet.vroeg@cordaid.nl

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Profile

• 80 years of emergency and development aid experience;

• Almost 1000 partners in 36 countries;

• Annual budget 170 million;– 65% from Dutch Government (Ministry of Foreign Affairs)– 25% from Private donors (members, business, lotteries) – 10% from International Donors (EU, World Bank, Global Funds)

• Principles rooted in the values of Catholic Social thinking.– Subsidiary (Empowerment)– Solidarity – Bonum Commune (Common good)– Human dignity

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Aim

OverallReducing poverty by changing power relations

HealthImproving the access and quality of health services for people in low income countries, with emphasis on the poor and vulnerable.

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Problem

Investments in health systems do not bring the expected results in terms of:

– Equity (not reaching the poor)– Effectiveness (poor quantity and quality)– Efficiency (high delivery costs)

“The system was able to absorb but not to produce”

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Solution

Change from:Input financing of health care based on percieved needs.

to:Output financing of health care based on achieved results

Introduction of Performance Based Financing “putting the horse before the cart”

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PBF – more than just a contract• Payment in cash on Outcomes (production and quality)• Separation of Purchaser, Provider and Regulator• Purchaser as Multi-stakeholder non-profit organisation• Autonomous Management Health Facilities• Free choice for consumer• Use of market mechanisms and negotiation• User pays (but free at point of entry stays possible)• Incorporation of private sector (non-profit AND for-profit)• Strong verification systems. (purchaser, regulator, consumer)

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PBF – Why Cordaid?• Strong link to Cordaid's basic values

Subsidiary, Solidarity, Common Good and Human Dignity– Empowerment– Public Private Partnerships– Equity

• Strong link to Cordaid’s overall aimReduction of poverty by changing power relations;

– Autonomous management health facilities– Payments in cash– Community participation at various levels in delivery system– Consumer choice

• Contribution to Cordaid’s professional aims– Efficiency– Effectiveness

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PBF – Cordaid’s activities

• Rwanda 2003• RDC 2005• Tanzania 2006• Zambia 2007• Burundi 2007• CAR 2009• Cameroon ?

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Expectations

• More production (better financing)• Higher quality (better conditions)• More efficient (market mechanisms and negotiation)• More effective (stronger consumer participation)• More inclusion (lower user fees and equity funds)

• Less Morbidity

• Better Health

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Challenges

• Access for the most vulnerable (inclusiveness)• Sustainability (long-term financing and results)• Quality Control• Scaling up (integrity) • How to adapt to different contexts (flexibility)• Relation with vertical programs, input financing and health

insurance (complementation)• Community Participation

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Lessons Learned - Context

• Post conflict states tend to be more receptive to PBF approaches but initiatives risk to be fragmented with weak links to central governmental structures (DRC)

• The most important results of PBF seem to be in post conflict states (Rwanda/Burundi/DRC).

• In more stable states building on existing structures is vital (Tanzania/Zambia). This existing institutional framework and practices represents a challenge to the introduction of PBF.

• Attribution of results to PBF is difficult due to con-founding factors (input financing, free access, mutuelles, security, economic factors)

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Lessons Learned - Sustainability

• Most PBF pilots are relatively young. It is unclear if results are lasting on the longer term

• It is also unclear what the effects of an eventual up-scale will have on the results achieved in pilot projects.– Re-centralisation reflex– Piloting effect (islands of exellence, focussed attention)

• Pilots have short financial horizons (most projects have contract periods of 2-3 years)

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Lessons Learned – financial access

• Where bonuses are linked to productivity health managers tend to lower fees, to attract more patients, increasing financial access (DRC/Burundi).

• Most PBF pilot projects work with some kind of equity fund for people who are unable to pay, such as reemboursement schemes or an extra bonus. However, it is too early to determine the effects of these (different) equity approaches.

• There are indications (household studies) that the poor are not excluded or that access even increased. However, this needs to be confirmed.

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Lessons Learned – Quality• Where bonuses are linked to productivity health managers tend

to invest in equipment, infrastructure and human resources creating an enabling environment and conditions for quality of care (DRC/Burundi).

• However, most monitoring systems focus on whether conditions for quality of care are met (equipment, infrastructure, hygiene, sanitation) There is a need for a system that directly monitors if quality of care.

The main motivations to deliver quality of care seem to be;• Increased ownership of staff (autonomous management of facility)• Clear norms, active monitoring and direct consequences (bonus or

not)

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Lessons Learned – Civil participation

• Community involvement partly explains a higher responsiveness from services (Burundi/Kasai)

• The design for PBF looks promising for community involvement but the results in real involvement are still weak which has consequences during scale up. (Rwanda)

• Community involvement is not (yet) well conceptualized in PBF. Often it is limited to co-financing and monitoring. Involvement in priority setting, decision making and planning is still low.

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Lessons Learned - Scaling Up

During up-scaling there is the risk of a re-centralization reflex (Rwanda) as a result important PBF principals risk being lost:– Clear split between provider and verifier– Community participation (monitoring and decisionmaking)– Negotiation of contracts and service packages (more regulation and

national norms)

• The existence of a central policy level combined with a highly decentralized approach seems successful (Burundi)

• Ownerschip at central level should be present to make a constructive link between pilot projects and national policy (DRC)

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Lessons Learned – Performance• Some areas do better than others and inside these areas some

facilities do better than others.• Some indicators are doing exceptionally well such as; assisted

births, family planning, small surgery, antenatal care, vaccinations, hospital referrals.

• Providers and clients percieve that the quality of care is improved.

• Where community involvement has been organized the services prove to be more responsive (Kasai/Burundi).

• Where providers and clients where not involved in contracting process results were nill (Tanzanai/Zambia)

• PBF strengthens HMIS it stimulates investments, proper verification of data and therefore better quality information.

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Future Focus

• Continue to contribute to the development of PBF systems by distilling best practises from pilot projects. (Learning)

• Connecting other finance systems such as; input financing, mutuelles, disease programs with PBF (Linking).

• Promoting best practises and lessons learned at national and international policy development arena's (Lobby)

• Conceptualization of civil participation at different levels (financing, decision making, priority setting M&E) and prove its added value (Public Private Partnership)

• Development of instruments that guarantee the inclusion of the poor in PBF systems (Equity).

• Assist in the development of PBF intruments and training material and actively train policy makers and PBF practitioners (Capacity bulding)

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Thank you for your attention!

Piet VroegSector Health and Wellbeingpiet.vroeg@cordaid.nl