DR. Michael M. Amara,PRINCIPAL HEALTH ECONOMIST,

MoHS

Health Development Partners Meeting

PERFORMANCE-BASED FINANCING (PBF)

Presentation

22nd august 2012

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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

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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

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Objectives of PBF in Sierra Leone

General objective:To change the behaviour of health providers at

health facilities level for them to deliver more quality 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.

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Rationale for PBF in Sierra LeoneHigh 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.

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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.

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PBF components

1. Staff incentives: 60% of the quarterly package (Maximum)

2. Investment: 40% (Minimum)

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Processes

Technical discussions with World Bank

Joint study tour by the MoHS, MoFED and World Bank staff to Rwanda and Burundi

Developed Operational Manual

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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.

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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)

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PBF Actors and Functions

VerifierVerifies accuracy of

performance reports

ProviderDelivers health services

to beneficiaries

Beneficiary

RegulatorSets up the ‘rules’: indicators, prices,

verification process

PurchaserContracts provider to

deliver health services

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Institutional Structure and Agreements

REGULATORREGULATORFUND HOLDERFUND HOLDER SERVICE PROVIDERSERVICE PROVIDER INDEPENDENT VALIDATORINDEPENDENT VALIDATOR

MoFED: Local Govt. Finance Department

MoFED: Local Govt. Finance Department

Independent Validation

Agency Contract

Tripartite PBF Agreement

Tripartite PBF Agreement

Peripheral Health Unit or

Clinic

Peripheral Health Unit or

Clinic

Independent Validation

Agency

Independent Validation

Agency

District Health Management

Team

District Health Management

Team

Ministry of Health and Sanitation

Ministry of Health and Sanitation

PBF Supervision/ Verification Agreement

PBF Supervision/ Verification Agreement

Local CouncilLocal Council

Health Management

Committee

Health Management

Committee

Institutional Structure of PHU’s

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Institutional Structure of HospitalsFUND HOLDER:

MoFED/IPAU

PURCHASER AND REGULATOR: MoHS

PROVIDERS: PCMH & ODCH

VERIFIERS: PEER REVIEW HOSPITAL + MoHS PBF & HOSPITAL DIRECTORATE

Performance transfer payment

Performance transfer payment

Performance contract

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No. ACTIVITY MAXIMUM SCORES

SCORES OBTAINED

1 General organization 100

2 Human resources management 100

3 Financial management 100

4 Pharmacy management and

prevention of drugs stock out 150

5 Hygiene and sanitation 100

6 Customer care 100

7 Health care services 250

8 Laboratory 100

TOTAL 1000

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PBF Interventions for PHUsThe 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)

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PBF PRICES for 2011

PBF Indicator Old Price Revised Price

N1 = Number of new acceptors of modern family planning methods. 1,000 1,000

N2 = Number of pregnant women completing series of four antenatal consultations. 6,000 7,000

N3 = Number of pregnant women in labour attended by a health professional, at the facility. 10,000 15,000

N4 = Number of women completing series of three postnatal consultations 6,000 7,000

N5 = Number of children aged less than 12 months completing national EPI immunization course. 6,000 7,000

N6 = Number of outpatient visits of children under five 300 500

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PBF RESULTS

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SUMMARY OF PHUs PAID FOR 1ST AND 3RD QUARTERSQtry 1 Qtry 2 Qtry 3

No District

Existing

PHUs

PHUs

paid

PHUs

paid

PHUs

paid1 Bo 109 107 108 110

2 Bombali 95 95 97 91

3 Bonthe 51 46 41

4 Kailahun 76 76 77 77

5 Kambia 60 63 63 62

6 Kenema 117 121 121 114

7 Koinadugu 68 54 68 688 Kono 75 75 24

9 Moyamba 92 94 95 86

10 Port Loko 108 102 102 9811 Pujehun 64 63 63 61

12 Tonkolili 90 89 89 83

13 Western Area 76 70 90 83

1,081 1,055 973 998Total

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Use of the Investment Component

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Lessons learntDesigning 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.

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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

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ChallengesInadequate 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.

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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)

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Challenges contd.

Initial stock out of drugs

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MAURITANIA

MALI

SENEGAL

THE GAMBIA

GUINEA BISSAU GUINEA

SIERRA LEONE

LIBERIA

CÔTE D’IVOIRE

BURKINA FASO

GH

AN

ATOGO

BE

NIN

NIGERIA

NIGERCHAD SUDAN

CA

ME

RO

ON

CENTRAL AFRICAN REPUBLIC

ERITREA

ETHIOPIA

SOM

ALIA

KENYAUGANDA

RWANDA

BURUNDICO

NG

O

GABON

EQUATORIAL GUINEA

SAO TOME AND PRINCIPE

ANGOLA

NAMIBIABOTSWANA

ZAMBIA

TANZANIA

MALAWI

ZIMBABWE

MO

ZAM

BIQ

UE

SOUTH AFRICA

SWAZILAND

LESOTHO

MA

DA

GA

SC

AR

MAURITIUS

COMOROSMAYOTTE (Fr.)

SEYCHELLES

DEM. REP.OF CONGO

National Scale-up (3)Pilots Ongoing (12)Advanced Planning (8)

Under Discussion (8)

Impact Evaluation (8)

The RBF in South Sahara Africa

The RBF in South Sahara Africa

Conclusion and Next Steps

Next Steps

Hiring of independentagency to verify andvalidate PBF data.

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.

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Thank YouThank You

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