DR. Michael M. Amara, PRINCIPAL HEALTH ECONOMIST, MoHS

1. DR. Michael M. Amara,PRINCIPAL HEALTH ECONOMIST, MoHS Health Development Partners Meeting PERFORMANCE-BASED FINANCING (PBF) Presentation 22nd august 2012

2. Outline of the Presentation • PBF defined • PBF in Sierra Leone –Objectives and rationale • Some benefits of PBF • Processes • PBF Component • PBF Actors Tree • PBF in PHUs • PBF Results • Use of the investment component • Lessons Learnt • Challenges • Conclusion

3. What is PBF? • Financial mechanism which provides finances for performance (payment for output), Payment for Reward or payment for result. • It is an approach in health financing that shifts attention from inputs to output, and eventually outcomes, in health services. • Also known as Results-Based Financing

4. Objectives of PBF in Sierra Leone General objective: • To change the behaviour of health providers at health facilities level for them to deliver morequality services sustainably and thereby • to increase their productivity in the health sector. Specific objectives: • Provide financial incentives to health facilities in order to increase quality of health care services. • To improve quality of service delivery at health facilities level.

5. Rationale for PBF in Sierra Leone • High mortality and morbidity especially among young children and mothers. • Financial barriers preventing mothers and children from accessing health care are being tackled through the Free Health Care policy.

6. We can use PBF to: • Improve health services in Sierra Leone • Change the attitude of health workers • Increase health workers productivity • contribute to achieving the Millennium Development Goals.

7. PBF components • Staff incentives: 60% of the quarterly package (Maximum) 2. Investment: 40% (Minimum)

8. Processes • Technical discussions with World Bank • Joint study tour by the MoHS, MoFED and World Bank staff to Rwanda and Burundi • Developed Operational Manual

9. Developed training manual • Conducted Training of Trainers (ToT) for M&E of both DHMTs and Local Councils, District Health Sisters and some key staff. • Conducted Cascade training for all In-charges of PHUs.

10. Tripartite Agreement signed between, the Mayors/Chairmen, DMOs, and In-charges. • Tripartite Agreement signed between the Mayor, Chief Medical Officer and Hospital Superintendent of (Ola During and PCMH)

11. Verifier Verifies accuracy of performance reports Purchaser Contracts provider to deliver health services Provider Delivers health services to beneficiaries Regulator Sets up the ‘rules’: indicators, prices, verification process PBF Actors and Functions Beneficiary

12. FUND HOLDER SERVICE PROVIDER REGULATOR INDEPENDENT VALIDATOR NATIONAL LEVEL MoFED: Local Govt. Finance Department Ministry of Health and Sanitation Independent Validation Agency Contract PBF Supervision/ Verification Agreement DISTRICT LEVEL Local Council District Health Management Team Independent Validation Agency Tripartite PBF Agreement COMMUNITY LEVEL Peripheral Health Unit or Clinic Health Management Committee Institutional Structure and Agreements Institutional Structure of PHU’s

13. FUND HOLDER: MoFED/IPAU Performance transfer payment PURCHASER AND REGULATOR: MoHS Performance contract VERIFIERS: PEER REVIEW HOSPITAL + MoHS PBF & HOSPITAL DIRECTORATE PROVIDERS: PCMH & ODCH Institutional Structure of Hospitals

15. PBF Interventions for PHUs The PBF Scheme is based on six key RCH interventions: • Family planning (BPEHS 7.2) • Antenatal care of pregnant women (BPEHS 7.1.1.) • Safe childbirth deliveries (BPEHS 7.1.2) • Postnatal care of mothers and babies(BPEHS 7.1.4) • Routine immunisations for children under one (BPEHS 7.6) • Outpatient consultations for children under five (BPEHS 7.7)

17. PBF RESULTS

24. SUMMARY OF PHUs PAID FOR 1ST AND 3RD QUARTERS Qtry 1 Qtry 2 Qtry 3 Existing PHUs PHUs PHUs No District PHUs paid paid paid 1 Bo 109 107 110 108 2 Bombali 95 95 91 97 3 Bonthe 51 46 41 4 Kailahun 76 76 77 77 5 Kambia 60 63 62 63 6 Kenema 117 121 114 121 7 Koinadugu 68 54 68 68 8 Kono 75 75 24 9 Moyamba 92 94 86 95 10 Port Loko 108 102 98 102 11 Pujehun 64 63 61 63 12 Tonkolili 90 89 83 89 13 Western Area 76 70 83 90 Total 1,081 1,055 973 998

25. Use of the Investment Component

27. Lessons learnt • Designing and preparation of documents (OM, Tripartite Agreement etc)was done by the country team and has led to strong ownership of the program. • Pool of experts has being created as a result. • Improvement in quality and utilization • Competition leading to innovations for better service delivery.

28. Lessons Learnt contd. • Direct payment of incentive package into respective bank accounts of the facility. • Verification of reported data through the existing DHIS strengthens the system • We are using PBF to strengthen monitoring of health facilities especially in hard to reach areas and ensuring improvement of quality of services

29. Challenges • Inadequate human resource especially at facility level. (some facilities with one staff) • Geographic and socio-economic diversities favours some health facilities whilst others are disadvantaged. • The banking systems were not initially ready for bank to bank transfers to the smaller institutions (health centers and posts), etc.

30. Challenges contd. • Delays in submitting verified reports by DHMTs (Mentoring strategy). • Difficulties in accessing some facilities (due to poor road network, riverine areas, mountains etc) • Capacity building at facility levels (mentoring strategy)

31. Challenges contd. • Initial stock out of drugs

32. The RBF in South Sahara Africa MAURITANIA MALI NIGER ERITREA CHAD SENEGAL SUDAN THE GAMBIA BURKINA FASO GUINEA BISSAU GUINEA BENIN NIGERIA ETHIOPIA SIERRA LEONE CÔTE D’IVOIRE GHANA CENTRAL AFRICAN REPUBLIC LIBERIA CAMEROON TOGO SOMALIA The RBF in South Sahara Africa DEM. REP.OF CONGO EQUATORIAL GUINEA UGANDA KENYA SAO TOME AND PRINCIPE GABON CONGO RWANDA BURUNDI SEYCHELLES TANZANIA National Scale-up (3) MALAWI COMOROS ANGOLA MAYOTTE (Fr.) Pilots Ongoing (12) ZAMBIA MOZAMBIQUE Advanced Planning (8) ZIMBABWE MADAGASCAR Under Discussion (8) NAMIBIA MAURITIUS BOTSWANA Impact Evaluation (8) SWAZILAND SOUTH AFRICA LESOTHO

33. Conclusion and Next Steps Next Steps Conclusion PBF is being used successfully to complement the free health care and to strengthen entire health system inspite of the challenges mentioned. Does not change the existing structures of the health system, but rather strengthens it. Hiring of independent agency to verify and validate PBF data.

34. Thank You