Performance based financing in low income countries
A panorama of existing performance based financing schemes
AEDES www.aedes.be
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Nicolas de Borman AEDES
Objective : provide an overview of PBF interventions and main trends
Which countries? For how long ? How do the schemes function? (contracting agent,
fundholder) How large ? Main trends
Haiti : “Pay for Performance”Context :
Low performance of public health system Strong NGO and FBO health facilities
Intervention Started in 1999 Performance based payments
Size : Entire country. No particular geographic coverage 500.000 target population in 1999 2,8 million today. ~30% of total population
Supply side intervention
MSH (NGO)
Contracting entity Fundholder Technical assistance
USAID Funding
27 NGOs Private Service Providers
~ 100 health facilities : Hospitals Health centersdispensaries
Health system
Contract : Yearly contract Only NGO and FBO Agreement on output targets
(BHP) Agreement on yearly subsidy
needed to achieve target
Payment : Fixed tranche : 95% of budget Variable tranche : 0 – 10 % of
budget, based on achievement of output target and process indicators
Maximum 105 % of budget allocated
Cambodia : Performance incentivesContext :
Inefficient public health system Private practice and under table
payments Intervention
Started in 1999. Performance incentives. Basic health services (health center
& hospital) Different phases and systems Part of a larger health system reform
(equity funds) Coverage:
20 / 77 Health District
Supply side intervention
Demand side intervention
International NGO
Fundholder Contracting agencyTechnical assistance
Funding: Multi donor
Health Centers and dispensaries
Hospital
Health Equity Funds
NGO managedDonor funded
OperationalDistrict
Contract : Contract of health center and
hospital Key element : staff behaviour Limited involvement of
regulation
Payment : Mix of process and output
indicators Output, different systems :
Flat rate subsidy per service provided
Target + ceiling
Rwanda: PBFContext :
Post conflict reconstruction Public and faith based facilities
Intervention Started in 2001 Performance based financing Preventive and curative (incl. HIV) Health Center & Ref. hospital
Coverage: Entire country (~9 million people) ~450 health facilities
Supply side intervention
Demand side intervention
Ministry of financeFundholder
Funding : Governement of Rwanda & donor (HIV)
Health Centers and dispensaries
Hospital Health insurance
AdministrativeDistrict
Contracting entity
Contract : District (decentralized entity of
MOPH) contracts service providers. Contract with Steering Committee Public and FBO contracted. But
private can be subcontracted by facilities
Payment: Payment made by MOF and
donors Flat rate subsidy per service
provided. Example: 1$/fully immunized children.
No ceiling Bonus for quality
• Separation of functions. Purchaser – provider – regulation – controller split
• Success of integrating public, non-for profit and private facilities
• Not only about staff incentives, but PBF is a systemic health financing tool
• First scheme to be fully institutionalized
Key achievements in Rwanda
Burundi : regional dissemination (1)Context :
Post conflict situation. Weaker government than in Rwanda
Free health services (woman & U5) Intervention
Since 2006 Similar setting as in Rwanda
Coverage: ~2.000.000 people. ~25% of the population
Difference with Rwanda : Provincial Funds (vs. national) Provincial fundholder and contracting
agency is NGO/Project Cordaid (yellow) Swiss cooperation (Red) HNI (blue)
DRC : Regional dissemination (2)
Context : War, weak government, transport
problems Limited health sector resources
available
Interventions Started in 2006 & 2007
Fonds d’Achat de Service (blue and yellow). Third payer.
Agence d’Achat Sud Kivu (red)
Size : 4 provinces. ~14 million people
Specificities : Fundholder & contracting agency :
Etablissement d’Utilité Publique. Joint donor and government agency. One per province.
Funding from EC
Payment : First phase : in drugs (yellow area) Second phase : in cash (blue area)
Fonds d’Achat de Service de Santé
Coverage : Idjwi, Katana & Shabunda: 605.000 hab
Specificities : Local NGO acts as fundholder and
contracting agency Multisector PBF in Shabunda (health,
education and road)
South Kivu
• Expansion of schemes similar to Rwanda : – Within the region : DRC & Burundi, but also : Central African
Republic, Sudan, Zambia, Tanzania,…– Elsewhere : Afghanistan, Indonesia, Cambodia,…
• But also other output based financing schemes : – Voucher systems : Kenya, Uganda, Bengladesh, India,
cambodia,… – targeted interventions : HIV, TB, maternal health.
2 examples. Kenya and Madagascar
Current trend
Kenya : voucher for maternal health Intervention
Started in 2006 Voucher for maternal health
& family planningCoverage:
3 districts + 2 slums in Nairobi 1,7 million people in rural districts
Contracted service providers 54 Public, FBO, NGO & private
Demand side intervention
Health Centers and dispensaries
Hospital
Autonomous gov. agency (NACPD)
FundholderContracting body
KFW funding
Provincial /District
regulator
Funding
Fund
ing
Voucher distributor
FP or Safe Delivery Voucher
Poor Woman
Contract & control: Agency contracts Voucher
distributors Marketing & management of
scheme Public, FBO and private Specific role for national
insurance : accreditation and quality control
Payment: Cash, on reception of the
voucher
MadagascarIntervention
Started in 2008 “Système tiers payant” Emergency obstetric and paediatric
careCoverage:
2 regions 4 public hospitals
Supply side intervention
2 national NGOs
FundholderContracting agency
World Bank funding
Health Centers and dispensaries
Hospital
Provincial /District
regulator
Contract National NGO contracts
Hospitals Public hospitals only Free healthcare for patients
Payment: Lump sum cost based subsidy
per intervention
Transfer to health facilities $/yr/hab
% health facility incomes coming from PBF
Cambodia 0,25 - 0,5 5 - 25% Rwanda ~1,8 15 - 35% Burundi 0,7 - 2 30 - 35%
DRC 0,3 - 1,8 30 - 70%
Kenya ~1,7 > 50% Madagascar 0,25 ~25%
How important for providers?
Scaling up Phase 1 :
NGO or project initiativeSingle donor
Phase 2 : Multi donor
On plan (SWAP)
Phase 3 : Institutionalized
Gov & donor On plan, on budget
Initial phase : Initiative. key role played by NGOs and projects Second phase : Strengthening. Need to broaden the financial
basis. Gradual improvement of system. Key role played by development partners and bi-laterals.
Third phase : Institutionalization. Key role played by the government. Ownership and support from other stakeholders.
Need an institution to be able to monitor contracts and organize control. Flexibility is needed.
Rationale of having independent contracting entities : private (NGOs, health insurance,…) or public (decentralized government entities, independent gov. agencies). Not a single answer.
But : Reluctance of MOPH to see large share of budget going to INGOs Reluctance of MOF to see large share of budget going to external
independent agencies (even governmental).
Who is the fundholder?
Conclusion
Performance based financing has proved to be successful and adaptable in different environments
Not a single model, but flexible and evolutive approach
PBF, a trend that is growing rapidly. Key challenge : scale up and institutionalization
Thank you for your attention
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