Post on 05-Jan-2016
description
transcript
04/20/23 Performance Based Financing1
Performance Based Financing
Principles and Practices
Piet VroegProgram OfficerDepartment of Health and Well beingT: +31(0) 703136522F: +31(0) 703136511 piet.vroeg@cordaid.nl
CordaidPostal Box 16440,2500 BK The HagueLutherse Burgwal 10 2512 CB The Hague Netherlandswww.cordaid.nl
04/20/23 Performance Based Financing2
Our Profile
• Dutch development organisation• 80 years emergency aid and structural development;• Almost 1000 partners in 36 countries in Africa, Asia, Latin America,
Central and Eastern Europe ;• Annual budget 170 million Euro;• Solid base in the Netherlands: 370.000 contributors,• Rooted in the catholic missionary tradition (Caritas, Medicus Mundi).
04/20/23 Performance Based Financing3
1. Why PBF?
2. Principles
3. Rwanda Pilot
4. Scaling Up
5. Expectations
6. Challenges
04/20/23 Performance Based Financing4
2002 Traditional Financing
INPUT
2003 Performance Based Financing OUTPUT
DIFFERENCE
2003 / 2002
External Consultations 1140 3900 242% Major Surgical Interventions 60 180 200%
Complicated deliveries 336 456 36% Cesarien sections 264 288 9%
Total number of acts 1800 4824 168% Occupation rate (beds) 45% 63% 38%
External Financing by Cordaid $52,000 $17,685 - 66%
Adverage subsidy per act $28.89 $3.67 - 87%
Improvement of Cost effectiveness in 2003 in relation to 2002 = $28.89 : $ 3.67 = 8 fold
We found an 8 fold increase of output with Performance Based Financing
Hospital Miblizi Rwanda
04/20/23 Performance Based Financing5
Why PBF?
Rwanda 2002 :
Despite huge investments in the Health Sector;
Health Indicators did not improve.
“The system was able to absorb but not to produce”
Response: Introduction of Performance Based Financing
04/20/23 Performance Based Financing6
Principles
04/20/23 Performance Based Financing7
The Principles
More than a contract:
• Separation of Functions• Inclusion of the Private sector (non-profit and for-profit)• Community Participation and Verification
04/20/23 Performance Based Financing8
Separation of Functions
Purchaser
Consumer
Provider
Regulator
Legislation
Negotiation
Supervision
04/20/23 Performance Based Financing9
Separation of Functions
• The regulator controls for the quality of the inputs and processes
• The purchaser verifies the outputs and pays a fee for service; • Autonomous provider some key decision rights;
- Incentives to staff- Hiring and Firing- Procurement of Medicaments and Material- Investment in Infrastructure
04/20/23 Performance Based Financing10
Inclusion of Private Sector
All capable providers should have access to a performance contract either directly or with a subcontract
• Increase geographical access• Separation of the good from the bad• Increase competition between health facilities
Think about: Private Practitioners, Village Health Workers, Traditional Birth Attendants, NGO’s (hiv/aids)
04/20/23 Performance Based Financing11
Community Participation
High level of community participation contracting:
Health Committees (co-management)• To increase transparency• To increase access for the most vulnerable
Local Associations (audits and feedback)
• To increase accountability• To increase relevance/satisfaction
04/20/23 Performance Based Financing12
Rwanda Pilot
04/20/23 Performance Based Financing13
Pilot Profile (1)
• The pilot started in 2003 in four health districts of the former Cyangugu province (now Western Province) and was taken over by MoH on 1st January 2006
• Initially funded by the Dutch Ministry of Foreign Affairs
• Catchment area 630.000 people
• Total Investment 3,000,000 USD
• Investment pppy 1.65 USD
• Transaction costs 25% in 2005
04/20/23 Performance Based Financing14
Pilot Profile (2)
• Purchaser contracted:
– 4 Hospitals
– 24 Health Centers
– 4 District Health Teams
– 24 Local associations
• Health Centers sub-contracted:
– 20 Private Dispensaries
and initiated
– 14 Health Posts
04/20/23 Performance Based Financing15
Monitoring and Evaluation
• Monthly Monitoring of Utilization (purchaser)
• Quarterly Monitoring of Quality HC (regulator)
• Quality Review System Hospitals (peers)
• Quarterly Verification and Satisfaction Surveys
(local community associations contracted by purchaser)
• Household Surveys (2003 and 2005) (project consultant)
• End of Project Evaluation (external consultants)
04/20/23 Performance Based Financing16
Results (Utilization)
Service 2002 2005 increase target % of target
OPD visits in HC p/person p/year 0.32 0.77 141% 0.7 110%
Beddays in HC /pop 1/2349 1/1929 22% 1/1000 52%
Occupancy Rate of beds in HC 40% 53% 33% 100% 53%
Fully vaccinated children 73% 78% 7% 90% 87%
ANC (new cases) 88% 93% 6% 100% 93%
ANC (4 visits=tous standards) 28% 39% 39% 100% 39%
Tetanus toxoid vaccinations as % of pregnant women 42% 63% 50% 80% 79%
Institutional deliveries in HC + hospitals/all deliveries 26% 40% 54% 50% 80%
Contraceptive prevalence in HC (couples) 0.5% 7% 1300% 22% 32%
Referrals to hosp as % of OPD visits 1.6% 2.4% 50% 0.5% 480%
Sale of mosquito nets/100 inhabitants 0 5 30 17%
OPD/MD visits in hosp as % of pop 2.2% 5.8% 163% 5% 116%
Occupancy rate for beds in hospitals 54% 66% 22% 100% 66%
Major surgery (excl CS) 798 1046 31% 1920 54%
Caesarian sections (% complicated deliveries) 898 1200 34% 30% 147%
04/20/23 Performance Based Financing17
Results (Quality)
HC Q2 Q3 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Total
Bugarama 65% 80% 60% 90% 100% 75% 90% 80% 80% 85% 80.50% Bweyeye 90% 80% 100% 75% 100% 60% 100% 35% 85% 95% 82.00% Cimerwa 100% 65% 40% 90% 90% 80% 80% 45% 95% 30% 71.50% Gihundwe 75% 90% 55% 85% 65% 90% 90% 90% 85% 90% 81.50% Hanika 60% 80% 100% 90% 90% -- 70% 45% 40% 50% 69.50% Kamonyi 75% 75% 90% 80% 75% 75% 60% 25% 70% 85% 71.00% Kibogora 90% 60% 65% 65% 80% 85% 75% 75% 45% 90% 73.00% Mashesha 55% 65% 25% 80% 75% 75% 65% 75% 90% 90% 69.50% Muyange 90% 65% 90% 55% 75% 55% 75% 40% 70% 100% 71.50% Nkungu 90% 100% 100% 85% 90% 65% 85% 90% 100% 80% 88.50% Nyabitimbo 90% 80% 90% 90% 90% 90% 100% 85% 75% 70% 86.00% Nyamasheke 75% 75% 75% 90% 65% 80% 70% 40% 85% 40% 69.50% Ruheru 55% 80% 90% 80% 80% 90% 70% 35% 40% 45% 66.50% Rusizi 55% 55% 20% 90% 65% 65% 85% 80% 65% 85% 66.50% Yove 90% 90% 90% 65% 90% 75% 60% 35% 45% 45% 68.50%
Provincial 76% 76% 72% 80% 80% 74% 74% 61% 76% 72% 74.10%
When looking at the 3-year averages, the overall total quality index for the province was 74.1%, with a range from 66% - 88.5% over the HCs. However some of the outliers are huge jumping from 20%-90%
04/20/23 Performance Based Financing18
Results (Financial Access)
Service Old price New price Decrease OPD visit 1241 440 - 64.5% Hospitalisation 2288 1182 - 22.6% Mosquito nets 1123 696 - 49.0% Deliveries 1302 784 - 39.8%
Difference in price paid for service between 1st and 10th survey by local associations (FRw)
Changes in Financial implications of illness according to Household surveys 2003-2005
Description Old New Change % HH budget spent on health 22% 7% - 214% Costs of OPD visit $2.43 $1.56 - 36% Costs of hospitalisations $12.95 $6.59 - 49% Price is problem to pay 34% 25% - 36%
04/20/23 Performance Based Financing19
Scaling Up
or Rolling Out
04/20/23 Performance Based Financing20
Pilots
Until now most PBF initiatives have started by an NGO.
There seems to be a pathway of growth
1. Small seed projects with a limited number of services financed with proper funds and executed with traditional partners
2. Pilot projects that cover one or more zones/districts/provinces with a population of minimum 300.000 people, financed by external donors such as Dutch Ministry of Foreign Affairs, European Commission, Norad and WB ).
3. National roll out of the initiative by the government with funding through a consortium of various multilateral and bilateral donors sometimes including “vertical donors” (PEPFAR, GAVI)
04/20/23 Performance Based Financing21
Overview
Rwanda 2003
RDC 2005
Tanzania 2006
Zambia 2007
Burundi 2007
CAR 2010
Cameroon 2010?
04/20/23 Performance Based Financing22
Issues
• How to institutionalize the new Purchaser?• How to timely pay the provider?• How to collect and verify information in a cost effective
manner?• In how far is civil society allowed to participate?• Is the private sector eligible?
04/20/23 Performance Based Financing23
Purchaser
The Purchaser can fulfill several crucial functions:
• Holding the contract• Verification of quantity• Control of quality• Audit• Coaching/Supervision• Payment
04/20/23 Performance Based Financing24
Rwandan Pilot
ContractPayment
VerificationCoaching
PopulationProvider
Ministry of Interior
Province
Districts
Village
Government
Provincial Hospital and Inspection
District Hospital and Inspection
Health Center
Ministry of Public Health
Insurance
TBA
VHWHealth
Committee
NGOChurch
Audit
QC
04/20/23 Performance Based Financing25
PopulationProvider
Ministry of Interior
Province
Districts
Village
Government
Provincial Hospital and Inspection
District Hospital and Inspection
Health Center
Ministry of Public Health
Insurance
TBA
VHWHealth
Committee
NGOChurch
Rwanda National System
QCSupervision
ContractVerification
Audit
MoFPayment
04/20/23 Performance Based Financing26
PopulationProvider
Ministry of Interior
Province
Districts
Village
Goverment
Provincial Hospital and Inspection
District Hospital and Inspection
Health Center
Ministry of Public Health
Insurance
TBA
VHWHealth
Committee
NGOChurch
DRCongo South Kivu Pilot
QC
Audit
ContractPayment
VerificationSupervision
04/20/23 Performance Based Financing27
PopulationProvider
Ministry of Interior
Province
Districts
Village
Government
Provincial Hospital and Inspection
District Hospital and Inspection
Health Center
Ministry of Public Health
Insurance
TBA
VHWHealth
Committee
NGOChurch
Burundi Roll Out
ContractPayment
QCSupervision
Audit
Verification
04/20/23 Performance Based Financing28
Expectations
More efficient (lower user fees)
More production
Higher Quality
Better geographical access
Stronger Consumer Participation
More inclusion
Less Morbidity
Better Health
04/20/23 Performance Based Financing29
Challenges
Access for the most vulnerable (inclusiveness)
Macro-financing (sustainability)
How to adapt to different contexts (flexibility)
How to deal with volatile situations (resilience)
Integration Vertical Programs
Community Participation
04/20/23 Performance Based Financing30
Get for what you pay