Eléments essentielles et complémentaires du design du modèle: PBF Centre de Santé Séminaire Régional sur le Financement Base Sur La Performance dans le Secteur de la Santé Bujumbura, Burundi, 3 au 6 Fév György Fritsche/HDNHE-BM

Messages clés PBF (cartoon de le New Yorker, Janv. 2010)

PBF type ‘paiement a l’acte’ par l'intermédiaire du secteur de la santé publique dans les pays à faible revenu Plus de 8 années d’expérience accumulée sur les meilleures pratiques des dessins des modèles PBF en Afrique subsaharienne (Rwanda, Burundi, RDC, RCA et Cameroun); Paiement a l’acte (pour les services preventives) avec un impact de la Qualité c’est le ‘state-of-the-art’ ‘Public’ meaning all health facilities, either ‘government- managed or managed by a non-governmental agency. In quite a few PBF schemes private for profit facilities are sub-contracted by primary recipients for certain services, for instance curative care, or family planning services

Fee-For-Service Results-Based Financing (FFS- RBF)/Performance-Based Financing (PBF) through the public health sector in low-income countries Essential Design Elements: these elements are considered crucial for a national PBF system, managed by the government, through internal contracting arrangements Complementary Design Elements: these elements are considered complementary to a national PBF system. They are judged as having potential to augment the impact of PBF on health services delivered.

Conceptual Framework: Essential Design Elements at three levels 1. Health Center level 2. District Level 3. Central Level

Health Center Level; Essential (i) Performance Framework Targeting Health Facilities (as opposed to individual health workers); Significant financial incentives reaching frontline health workers (transparent rules/process); Health Center Bank account Regular bonus payments for health workers, preferably monthly, but at least once per quarter Autonomy (management and administrative/financial autonomy) to manage resources and to make decisions)

Health Center Level; Essential (ii) Health Management Committee (includes community representatives and health center with overall management oversight, 4-5 persons). Purpose: transparent use of performance funds and other decision-making Purchase contract/agreement (between the Health Management Committee and a higher level authority, e.g. decentralized government). Purpose: this defines the rules of the game/responsibilities of the PBF system

Health Center Level; Essential (iii) Services that are purchased need to be ‘PBF- SMART’ Conduct Routine Data Quality Audit Purpose: to ensure the consistency and accuracy of reporting of services delivered –monthly Conduct Routine Household Visits Purpose: to validate that services were actually delivered and get feedback on services delivered (community client surveys)

Health Center Level; Essential (iv) Conduct Routine Quality Checks Comprehensive Quantitative Checklist. Purpose: objectively verify conditions to provide quality care and or quality of actual care provided, with strong impact on performance payments Regular Audit of the quality measure

HC Level; Complementary (i) Try to diversify sources of revenue for the health center (don’t only depend on PBF). E.g. for introducing risk pooling mechanisms such as CBHI, one needs a price signal; Decentralized Funding for Government Staff paid into health facility bank accounts; Once per quarter facility performance payment can be converted in monthly bonus installments

HC Level; Complementary (ii) Transparent rules can be emphasized through so- called ‘motivation contracts/agreement’; (contracts/agreements between health facilities and the individual health workers); ‘Business plan approach’; Using grassroots organizations in carrying out these community client surveys

District level: Essential (i) Significant financial incentives through performance framework for District Health Management Teams and District Hospitals. Purpose: performance frameworks targeting the support tasks of these institutions Separation of Functions: (i) creation of a quasi-market through internal contracts (sufficient separation between purchaser, provider and controller); (ii) transparent district level PBF governance mechanism and (iii) as much as possible separate ‘quantity audit’ from ‘quality supervisory function’ (separate teams). Purpose: to lessen conflict of interest situation

District level: Essential (ii) Intense dedicated TA during introduction and subsequently making operational and refining PBF system; District level PBF steering committee. Formalized through a contract/agreement with higher level authorities. Partaking District Director of Health (chair typically), Hospital Director, representatives from Public and Faith-based Organization Health Centers, district aids commission, PBF NGOs etc. Purpose: overall governance of PBF in all its aspects of performance improvements at the district level, including approval of performance invoices (i.e. governing board for PBF at the district level).

District level: Essential (iii) Civil Society/NGOs: (i) participation in data verification and (ii) participation in district level PBF steering committee (NGO is part of a quorum)

District level: Complementary (i) Decentralized management of PBF budgets; Performance framework for decentralized governance of PBF

Central level: Essential (i) PBF included in national policy and strategy documents; Dedicated Project Implementation Unit/MOH department; Dedicated additional TA for program; coordination of technical assistance; communication; MIS; training and IT support Leveraging TA with in-country available resources; Strong national technical coordination platform dedicated to PBF (degrees of freedom; secretariat)

Central level: Essential (ii) Strong technical coordination platform dedicated to providing TA on PBF to districts (‘bridging the gap between policy and implementation’); Ministry of Finance line-item for ‘PBF payments’; MOF: ensure PBF budget is available/protected to pay performance; Sufficient budget for PBF: estimated ‘output-only budget’ at about $3/capita/year (70% HC and 30% DH); Sustainability for PBF funding: donor coordination;

Central level: Essential (iii) Decision on ‘kick starting’ the payment cycle (4-5 months lag of first payment as it is output-based); Administrative system able to capture and feedback data efficiently and effectively (web-based solution advisable); Drugs and medical supplies: ensure access to sufficient supply at a reasonable quality and price through any mechanism or combination of mechanisms; Rigorous evaluations (formal third party and formative multi- donor mission type); Performance payments directly from central to health facility bank accounts;

INSERT GRAPHIC TO ADD MAP MAP IS 6.17” TALL

Quarterly district invoices

Central level: Complementary (i) Demand side interventions: conditional cash or in-kind transfer programs; Significant financial incentives through performance frameworks for central MOH departments; Issues of Equity and rural hardship compensation frameworks (analysis of financial inflows per capita per province/district/health facility, and build compensatory mechanisms through PBF payments; but this is hard);