Nigeria, January 2010 Petra Vergeer Health Specialist, RBF Team

 “Transfer of money or material goods conditional on taking a measurable health related action or achieving a predetermined performance target.” - Eichler and Levine  An increasingly common approach in Africa to improving performance, particularly in HF’s  HF’s are provided payments based on the amount of services they actually deliver

Rwanda Health Center RBF/ Performance-Based Financing (PBF) 1. Supply Side Intervention 2. Demand-side phenomena 3. Targeting Health Facilities that are made more autonomous 4. Regular, significant incentives reach front line health workers 5. District Support Functions incentivized (monitoring volume and quality: internal controls) 6. District PBF Steering Committee incentivized 7. Central MOH PBF-support department incentivized G. Fritsche-Real World Implementation Challenges: Scaling up Performance-Based Financing in Rwanda Presented at Interagency Working Group on Results Based Financing, 23 Nov 09 Oslo Meeting

How to motivate health workers to improve performance? Pharmacy, Phoebe Hospital Liberia, February 2009

An Example of RBF ServiceNumber Provided Unit Price Amount Earned Fully Immunized Child100$5$500 HF Delivery20$10$200 Out-patient Visit <51,000$0.5$500 TOTAL$1,200 Quality Correction60%$720

 70% ($504) split among staff: ◦ Physician ◦ Nurses ◦ Cleaner  30% ($216) goes for inputs into facility ◦ Drugs ◦ Stationary ◦ Minor repairs ◦ Demand side incentives

 A reduced version of a health facility assessment  Objectively assesses a variety of indicators to come up with total score.  Takes about 2-3 hours to complete  A copy of results left in the health facility, easy to track progress  QSC is both a management intervention and tool for M&E

Example of a Quantitative Supervisory Checklist Date of Visit 5/127/1 9 8/1 1 10/21 Availability of Drugs (0-15)57912 Presence of staff (0-10)78810 HMIS implementation (0-10)6778 TB Records and Follow-up (0- 15) EPI inputs & plans(0-20)12 15 Quality of care in OPDs (0-20) Quality of Deliveries (0-10)3468 TOTAL SCORE (out of 100) Supervisor’s signature HF in-charge signature

 Performance framework (purchase contract) - defining rules of the game of PBF  Focus on public health and preventative services through FFS conditional on quality  Regular, significant incentives for improved performance to reach health worker  Autonomy to manage for results ( i.e. use funds, resource allocation)  Health mgt committee (incl. community) to oversee transparent use of funds

The Hourglass Paradigm® Inputs: the salaries, equipment, consumables such as FP products also number of clients presenting to health facility (demand) The ‘neck’: or ‘bottleneck’; human resources (quantity, quality, motivation –intrinsic and extrinsic-, working hours, opening hours, etc) The outputs: services delivered; quantity and quality

 Performance contract focusing on support tasks (i.e. health system issues & PBF implementation) ->  Regular, significant incentives for results  Transparent governance set up to verify performance – i.e. district level PBF steering committees (with local govt and quorum of CSOs)  Regular verification of performance (quantity and quality) at HF level, linked to incentives  Intense, dedicated TA coordinated to implement PBF (i.e. TOT) and improve HFs performance ( i.e. identify non-performers for support, business plans, etc.)

 PBF Policy commitment (i.e. PBF payments, into HF bank accounts, autonomy, decentralization, promote results based management approach)  Sufficient budget to pay significant incentives and additional TA  Availability of inputs i.e. sufficient drugs/ supplies ( or can purchase at appropriate quality & price)  MIS system able to capture and feedback data efficiently (preferably web-based)  PBF implementation unit with dedicated TA (i.e. for IT support, MIS training, TA coordination)  Donor coordination (leverage TA, buy in, sustainability)

Management Information System- Data entry is easy

Quarterly district invoices