1. RBF Approach Results Based Financing in Ghana: About getting started Rita Tetteh-Quarshie Rtetteh-quarshie@snvworld.org

2. Presentation Background of health situation (MCH) in Ghana Planned pilot and implementation of PBF in Ghana by WB The Wapuli case Way forward

3. Health spending did increase… Recently, Ghana reached a middle income status In Ghana health financing is close to reach Abuja Target for health spending (=15% of total government expenditure) The per capita expenditure on health has grown from a level of $6.7 in 1996 to $13.5 in 2005 and $27 in 2008 Around 93% of the government contribution is used to pay for salaries, limiting funding available for services and infrastructure This is a result of the 2006 salary increase – about triplication - which was not performance based

4. But performance is off track… U-5 mortality is 80 deaths per 1,000 live births, with 90 in rural and 75 in urban areas. Infant mortality rate is 49 per 1,000 live births in urban and 56 in rural areas. The ’08 Ghana Maternal Health Survey estimates maternal death (MMR) at 451 per 100.000 live births. Health indicators in Ghana appear off track and this affects particularly poor and rural households; i.e.

5. Northern 27% Volta 54% Ashanti 73% Brong Ahafo 66% Western 62% Eastern 61% Upper West 46% Central 54% Upper East 47% Greater Accra 84% Deliveries attended by Skilled Provider – by Region Delivery by Skilled Provider by Region Ghana: 59%

6. Use of Modern FP Methods by Region Northern 6% Volta 21% Ashanti 16% Brong Ahafo 22% Western 13% Eastern 17% Upper West 21% Central 17% Upper East 14% Greater Accra 22% Ghana: 17% 35% unmet need among currently married women

7. Maternal Health- Problems Accessing Health Care

8. Reforming the Health System of Ghana? Overall consensus: “no copy & pasting of the Rwanda model”  Governance institutions and “rules of the game” do exist  Governance structure is complex, preferably no new institutions  Existing funding channels, etc So, adapting to the existing Ghanaian context – but how? Hesitation at Central level to kick-off:  Agree on the principles – but how to implement them in Ghana?  Sustainability: macro-economic implications?  Again top-up of salaries health staff through RBF?  We have already an ex-post provider payment mechanism, NHIS  Again another reform?  Assisted delivery is already free of charge

9. Opportunities and threats to start-up RBF Opportunity: existing, functioning governance structures  Like NHIA: already a purchaser with a verification function (quantity and quality of services)  Most facilities already accredited (Q/C)  District Assembly is already (by law) in charge of health Threat: the same existing governance structures  Resistance to change the “enterprise culture” and power relations in institutions as well as in individuals  Changing the “rules of the game” will not be easily  Actually no clear-cut functional split of functions existing  Deconcentrated system – complicating checks & balances

10. National RBF program (MOH/ WB)) Preparatory activities: Aide Memoire and Concept Note ready to be signed (March) Pre-pilot (2011) to inform pilot (2012 - 2013) in Eastern and Northern Regions Pre-pilot (500 K): regional program to prepare actors  Supply-side and demand-side incentives  Situational analysis, legal and financial-amin issues,  Bottleneck studies household, facility, Local Govt  Instrument development  testing payments in 1 district (ER, E Akim), 1 in NR? Pilot (11,5 Mio + 1 Mio for Impact Evaluation):  All districts in NR and ER: 240 Facilities

11. Institutional Framework in Ghana – hypothesis WB

12. Operational research: How to introduce RBF in Ghana (SNV/KIT experiences) Step 1: Regional workshops to identify need and common vision Step 2: Situational analysis on baselines Step 3: Workshops to identify and match priorities from medical and non- medical actors to agree on institutional framework (to be tested) Step 4: Assist health facilities to develop results-based action plans on identified priorities Step 5: Negotiation on contract (and agree on incentives, which may come out of existing funds) Step 6: Implementation (3 months cycle), evaluation and learning, payment of incentives, renegotiation of contract step 6 : Performance Based Financing step 5: contracting approach step 4 : develop results-based action plans at health centres & community level step 3: Identify matching priorities step 2 : situational analysis and training non-medical partners to anlyse data step 1 : joint understanding of need to develop alternative institutional performance framework

13. RBF-institutional framework, hypothesis SNV/KIT Area Council verification facility negotiation Community Representatives patient s Provision of care - curative, - prevention, - promotion MoHealth policies, norms & standards, resource allocation Regulation/ DHMT - quality ass/ accreditation - respect norms & standards - training and supervision MoFinanc e Donor s Fund Holder DMHIS/ payer Funds NHIA Steering Cttee Regional Coord Council Perform: productivity & quality CSO, NGO, Universities verification household Distr Ass Contractin g

14. Distribution of Roles & Responsibilities

15. Regions where PBF is being piloted by SNV Northern Volta Ashanti Brong Ahafo Western Eastern Upper West Central Upper East Greater Accra

16. Intervention methodology Lessons learning from experiences elsewhere Define the building blocks for CA/ PBF in other contexts; Site-visits to develop and adapt the working hypothesis with future local contracting partners at the operational level; defining the institutional framework for the CA/PBF; development of instruments – contextualizing those developed for elsewhere (Rwanda, Mali, ….) Supporting Local Capacity Builders ( NGOs) to support local actors to take up their future contracting roles; Negotiation between contracting actors Developing results-based action plans

17. The case of Wapuli sub-district Understanding performance and quality management, current theory and global practice PBF Introductory workshop at Saboba District: DA,CSOs, NHIS,DHMT, Providers Health baseline data was presented to stakeholders, put into result chain Issues prioritized for the sub-district health team to work on were: -Skill delivery -ANC4+ attendance -Family planning. -Malnutrition Issues were confirmed at a community durbar at a health sub-district.

18. Some results (process) Training SNV health advisors and LCB Institutional framework for RBF developed:  Who will purchase, verify, etc? Measures taken by the clinic to increase outputs:  Formation of steering committee by the community to help in educating other community  A system for compensating TBAs for bringing referring pregnant women to the clinic for delivery (instant and annual)  The clinic now opens everyday for ANC and FP activities and the staff work beyond their working hours.  Though slow but the traditional leaders are taken measures to release pregnant women to the clinics.

19. Results MonthsANC RegistrationANC AttendanceDelivery 200820092010200820092010200820092010 September5983872691942791513 October86625625311822291320 November756686260207246147 December3389901812032845714 January 11 7723915

20. Next steps…. Further training of NGOs to support actors Preparing non-medical actors: holding providers to account on results Preparing medical actors: being creative and innovative to achieve results (enterprise culture) Tools development (like verification: mHealth?)

21. The approach leaves ‘room’ to address some known challenges during the process Potential challengeHow these are mitigated, if RBF is applied as an approach Perverse effects – providers have a financial incentive to deliver excess on targeted services Quality scoring on total package of activities Keep contracting cycles short (so excesses can be identified soon) Equity/ inclusivenss – how to ensure access for the most vulnerable Women, PWD etc, should be included. Sustainability (financial)Understanding the national context. In Ghana using RBFincentives to top-up already high salaries would not be sustainable Carrot and stick Future policy making: make part of actual salary performance based. Integration of vertical programs Local priority setting Quantity indicators selective, quality indicators comprehensive Community involvement Decisive in local priority setting to make providers responsive to local needs and demand, in agreeing on payments Need to prepare the non-medical actors, Resilience of the system Flexibility If outputs truly answer to local needs and wants of the population So, not a model, but approach Technical sustainability…. Social sustainability… are health workers prepared for more demand Assisting clinics in developing ‘results-based action plans)

22. Questions to the audience…. How to finance scaling-up to national level ?!? Assessing cost-benefit of increased transaction-costs? Pay for results: to top-up of salaries – or to invest in conditions quality of care and « indirect costs »? Ho to avoid the “vertical” and “centralistic” approach of RBF (focusing on MDG4,5)