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Prioritizing Performance Problems and Choosing Recipients

Prioritizing Performance Problems and Choosing Recipients. Benjamin Loevinsohn Lead Public Health Specialist The World Bank June 2008. U5MR (per 1,000) in sub-Saharan Africa – MDG4 Target and Actual. Source: Global Monitoring Report 2008. U5MR in Afghanistan Actual and MDG4 Target.

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Prioritizing Performance Problems and Choosing Recipients

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  1. Prioritizing Performance Problems and Choosing Recipients Benjamin Loevinsohn Lead Public Health Specialist The World Bank June 2008

  2. U5MR (per 1,000) in sub-Saharan Africa – MDG4 Target and Actual Source: Global Monitoring Report 2008

  3. U5MR in Afghanistan Actual and MDG4 Target

  4. What do these graphs show? • Sub-Saharan Africa has a long way to go to achieve MDG4 • Continuing current approaches is not likely to achieve sufficient progress to meet MDG4 • There is no reason for pessimism, progress is possible • Bold actions are needed • Need to try things, evaluate, and learn

  5. A Few Messages to Start • Don’t Panic:RBF has worked in difficult situations, not everything has to be perfect, be creative! • Be Systematic: Write things down in a contract or manual or plan • The Limits of Planning: Endless planning and analysis can get in the way of action & learning • Humility:a) don’t be too sure of things b) knowledge must be larger than our experience c) give people at local levels sufficient autonomy d) keep learning, evaluating, adapting

  6. An Iterative- Learning Model for RBF • Diagnose performance problems/issues • Develop some options to test • Implement the options on a reasonable scale • Monitor and evaluate performance of the different options • Scale up successful options

  7. Step 1: Identifying the Problems - Hard Work and Work Hard • There are many issues, there’s a need for looking at lots of data critically, some of the issues are «soft » – motivation, management • What are the leading causes of death? • Are there particular interventions/programs that are weak or is everything weak? • Geographically, where are the problems? • What are the institutional issues?

  8. 1. Leading Causes of Death – Understanding U5MR: In Pakistan Neonatal Mortality Rate is Stagnant and 58% of U5MR, not Cameroon source: PDHS 1990-91 & 2006-07, DHS 2004

  9. 2. Are there particular programs that are weak? Cameroon in 2004 Afghanistan in 2003

  10. 3. Geographical Issues: 2003 Afghanistan – Rural vs. Urban

  11. Differences between provinces – DPT3 Coverage in Cameroon

  12. 4. What are the institutional issues? • Management: Quality of management at provincial and district level? • Motivation of health workers? Absenteeism? • Measurement: Are results measured? Is there accountability for results? • Milieu:What has been tried in the past? e.g. What has been done with confessional NGOs? Any performance bonuses in MOH?

  13. An Iterative- Learning Model for RBF • Diagnose performance problems/issues • Develop some options to test • Implement the options on a reasonable scale • Monitor and evaluate performance of the different options • Scale up successful options

  14. Step 2: Objectives and Recipients Possible Objectives Possible Recipients Demand: Mothers, TBA Increase Supply: TBA, Service provider Supply: DHMT, NGOs, private providers, public sector providers Service provider (NGO, public, private) Increase institutional deliveries as means for reducing MMR Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, Increase % of childen/mothers sleeping under LLINs last night, especially among the poor

  15. Example 1: CCT for Institutional Delivery • Objective: Increase institutional deliveries as means for reducing MMR • Recipient: Mother • Measurement: Mother actually in facility • Payment Terms: Mother receives cash • Use: Mother can spend cash as she likes • Manager: NGO or MOH or Social Welfare Ministry

  16. Example 2: Contracting – In Management for Poorly Performing District • Objective: Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, index of quality of care, consultations by bottom income quintile • Recipient:NGO, firm, or individual that manages a health district • Measurement:Health Facility Survey (HFS), Household survey (HHS), HMIS, • Payment Terms: Bonuses for good performance, termination/embarrassment if it’s poor • Use: Bonuses can be used to increase pay to managers or staff, carry out other development activities, seperate from budget for service delivery • Manager: MOH, or Procurement/Management Firm

  17. Example 3: Contracting for LLIN Distribution and Use • Objective: Increase % of childen/mothers sleeping under LLINs last night, especially among the poor • Recipient:NGO or firm or DHMT • Measurement:Household survey (HHS) • Payment terms: Bonuses for high LLIN use rates, or payment for each child user; termination or embarrassment if rates are low • Use: Bonuses can be used to pay managers or carry out other development activities • Manager: MOH or Procurement/Management Firm

  18. Example 4: Internal Contracts • Objective: Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, index of quality of care, consultations by bottom income quintile • Recipient:District Health Management Team • Measurement:Health Facility Survey (HFS), Household survey (HHS), HMIS, • Payment Terms: a) commendation; b) budget increase; c) cash bonus to DHMT; d) cash bonuses to health workers • Uses: Also complicated • Manager: PHD, MOH

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