1. REPUBLIQUE DU BENIN------------Fraternité- Justice- Travail------------ MINISTERE DE LA SANTE Performance-Based Financing in Benin: status and perspectives Workshop « West-Africa» organised by Performance-Based Financing Community of Practice Sénégal 18th and 19th March 2011 Alphonse AKPAMOLI, focal point Bénin Maud JUQUOIS, World Bank

2. Country specific constraints • Benin context: political stability for nearly 20 years • Health sector context • Inputs globaly adequate (geographical accessibility and availability of health workers). No major cultural barrier to access health services: rate of assited delivery very high (80% in 2006, DHS) • Availability of drugs and equipment remains insufficient and high prices. • Neonatal and maternal mortalities (MM: 397/1000 in 2006) decrease slowly • Weak quality of care seems to be the main barrier

3. Human Resources for Health environment • Revenues of health workers seems low in Benin, even if it’s possible that bonuses compensate this situation and that salary structure is adequate. • Bonuses scheme is not linked to performance • Accountability mechanisms of health workers are very weak (lack of governance): absenteeism, corruption, drug pilfering, dual job holding and unresponsiveness to patient needs.

4. Salaryatbeginning and end of carrier in 4 countries Source: séminaire RHS de Cotonou (2008)

5. How to improve efficiency, accountability and governance? • Solutions to improve health system performance: • Give more power to patients/clients  • Strengthen health workers motivation • Increase revenues and autonomy of health facilities

6. Benin contracting experience: are they payment for results? • Three experiences: • Performance contracts with 3 health districts (Banikoara, Aplahoué, sakété): • Agreement on PTA and commitment from MoH to pay some expenditures and train actors on results • Problems to tranfer the funds and actors’ motivation • Experience with Ménontin: • Public-private partnership, • But not result-based payments. • Ongoing experience in health district of Come (CTB)

7. RBF pilot scheme: main features • Supply strengthen with focus on quality and utilization (equity) of health services (specifically maternal and child services) • With a community component for monitoring • Capacity building with international expertise, with an independent control role • Implement the reform in 8 pilot health districts (out 34), WB grant.

9. Benin RBF pilot scheme (1/5) • To continue contracting experience with health districts: • Contracts between MoH and HF in the 8 pilot health districts : all public and private not for profit HF, health centres and hospitals. • Fees for health services (18 indicators) focused on maternal and child health , and quality adjustment (checklist), quaterly payments • RBF unit to pilot the process inside MoH • International Technical Assistance for training and data control with capacity transfer, and 1 technical assistant in each RBF health district.

10. Benin RBF pilot scheme(2/5) A propice environment for Result-based management : • An increased autonomy for stakeholders: facilities (CSA, HZ, CHD) free to buy drugs and small equipments • An appropriate flow of funds • An intensecommunication with health staff and population

11. Benin RBF pilot scheme (3/5) Control and verification mechanisms:

12. ACTIVITES 6. Allocation du ACTIVITE SEMESTRIELLE crédit FBR 5. Paiement du crédit FBR 8. Contre-vérification qualité 7. Dépenses sur 4. le crédit FBR Détermination du montant du ACTIVITES ANNUELLES crédit FBR ANNUELLES 9. Audit comptable des 3. Mesure et dépenses FBR vérification des résultats FBR 1. Négociation 2. du contrat FBR Communication sur les contrats FBR Benin RBF pilot scheme(4/5) Activités trimestrielles

13. Benin RBF pilot scheme (5/5) Motivating rewards • Significant amount • around 200 millions FCFA (3.8 MioUSD) by district by year • Depending on results • Some freedom to use RBF credit, but without creating individualism • A part of the credit is for staff incentives, the other part to buy small equipments, drugs, IEC activities… • Staff bonus is proportional to the worker index (with a weighting in favor of small salaries)

14. Impact evaluation of RBF Benin pilot scheme • Research questions: RBF or additional budget unconditionned with results? Importance of health facilities’ management autonomy • Thus, two interventions in cross-design: • 4 groups of HF(T1-2-3 et C1) and an additional control group(C2), without additional budget. • Identification in the 8 districts, with random allocation of facilities between the 4 groups • Baseline survey : health facility survey, staff survey, households survey, with diversified tools.

15. Impact Evaluation Design ADDITIONAL FUNDING FOR HEALTH FACILITIES ? YES CONDITIONAL ON RESULTS (RBF) YES BUT NOT CONDITIONAL ON RESULTS NO MANAGEMENT AUTONOMY FOR HEALTH FACILITIES ? YES T1 (500 HH and 50 HF) T2 (500 HH and 50 HF) NO T3 (500 HH and 50 HF) C1 (500 HH and 50 HF) C2 (500 HH and 50 HF)

16. Project Causal chain

17. Implementation agenda/Work plan • Impact Evaluation: • Baseline survey: Dec 2010-Mach 2011 • Questionnaires tested • Surveyors trained (began 1st Nov) • Follow-up survey No.1: Oct-Dec 2011 • Follow-up survey No.2: Oct-Dec 2012 • Cost effectiveness analysis (2011) • RBF Program : • Effectiveness : 31 March 2011 • Launch: April 2011

18. RBF Perspectives in Benin • RBF Norway and World Bank(4 years ) • Norway: 11 millions USD • World Bank: 7 millions USD • Technical partnership • World Bank(8ZS), CTB (5 ZS), 4 ZS with GAVI and 17 ZS with GF, so 34ZS/34ZS covered with experience sharing (tools et results) • World Bank and UNICEF: traning support, drugs and equipements (Agreement letter between partners) • Complement with other partners (GAVI, GF) • Benin State

19. Questions • Technical sustainability: How can it be effectively ensured through knowledge transfer activities (transfer with progressive reduction of TA)? • Could RBF Financial sustainability be reached when donors will stop their support? (RBF cost will be US$1.3/hab; for the government, it would represent 10.1% health budget) • How to ensure effective monitoring with a local NGO?

20. Ensemble nos pays, avec la communauté internationale, le rêve sera une réalité