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

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

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

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

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 1. What are the leading causes of death? 2. Are there particular interventions/programs that are weak or is everything weak? 3. Geographically, where are the problems? 4. What are the institutional issues?

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

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

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

Differences between provinces – DPT3 Coverage in Cameroon

4. What are the institutional issues? M anagement: Quality of management at provincial and district level? M otivation of health workers? Absenteeism? M easurement: Are results measured? Is there accountability for results? M ilieu:What has been tried in the past? e.g. What has been done with confessional NGOs? Any performance bonuses in MOH?

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

Step 2: Objectives and Recipients Possible Objectives Possible Recipients 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 Demand: Mothers, TBA Increase Supply: TBA, Service provider Supply: DHMT, NGOs, private providers, public sector providers Service provider (NGO, public, private)

Example 1: CCT for Institutional Delivery 1. Objective: Increase institutional deliveries as means for reducing MMR 2. Recipient: Mother 3. Measurement: Mother actually in facility 4. Payment Terms: Mother receives cash 5. Use: Mother can spend cash as she likes 6. Manager: NGO or MOH or Social Welfare Ministry

Example 2: Contracting – In Management for Poorly Performing District 1. Objective: Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, index of quality of care, consultations by bottom income quintile 2. Recipient:NGO, firm, or individual that manages a health district 3. Measurement:Health Facility Survey (HFS), Household survey (HHS), HMIS, 4. Payment Terms: Bonuses for good performance, termination/embarrassment if it’s poor 5. Use: Bonuses can be used to increase pay to managers or staff, carry out other development activities, seperate from budget for service delivery 6. Manager: MOH, or Procurement/Management Firm

Example 3: Contracting for LLIN Distribution and Use 1. Objective: Increase % of childen/mothers sleeping under LLINs last night, especially among the poor 2. Recipient:NGO or firm or DHMT 3. Measurement:Household survey (HHS) 4. Payment terms: Bonuses for high LLIN use rates, or payment for each child user; termination or embarrassment if rates are low 5. Use: Bonuses can be used to pay managers or carry out other development activities 6. Manager: MOH or Procurement/Management Firm

Example 4: Internal Contracts 1. Objective: Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, index of quality of care, consultations by bottom income quintile 2. Recipient:District Health Management Team 3. Measurement:Health Facility Survey (HFS), Household survey (HHS), HMIS, 4. Payment Terms: a) commendation; b) budget increase; c) cash bonus to DHMT; d) cash bonuses to health workers 5. Uses: Also complicated 6. Manager: PHD, MOH