The 59th performance-based financing (PBF) took place in Mombasa, Kenya from Monday May 22 to Friday June 2, 2017.
Hereby the detailed course report.
The next English PBF course will take place also in Mombasa from November 20 to December 2.
The next open French PBF course will take place in Cotonou, Benin from August 21 to September 1, 2017.
In general, the PBF course in Mombasa was a success. All participants passed the final exam and the seven country groups produced impressive action plans (see below). The Sai Rock Hotel at the Mombasa beach is an attractive venue to learn and to think about how to improve health systems in the respective countries represented. The main lessons learned concerning the course were that we should continue to condense the course content with key messages, that we should further discipline the debates, make the PowerPoint presentations shorter and to allow for more group work.
The PBF course welcomed participants from seven countries Cameroon, Ethiopia, Lesotho PBF program, Nigeria, South Sudan, Uganda and Zimbabwe. The facilitation team consisted of Godelieve van Heteren, Fanen Verinumbe, Claire Rwiyereka and Robert Soeters. We also welcomed Nicolas de Norman, the director of BlueSquare, who enlightened us with his very spirited vision about the data collection and the integration of PBF within the DHIS2 system. Throughout the two weeks of the course, the country teams engaged in drafting and improving their action plans on how to implement and advance PBF in their countries.
The daily evaluations resulted in above average scores compared to previous courses. The methods and facilitation and participation and time keeping was above average, while the Hotel services this time was below average.
PBF course content and program materials have expanded considerably since the first course in 2007. Our aim has always been to cover all modules during the 12-days course, but this has become increasingly unrealistic with the new developments and instruments in PBF. The starting level of each participant is also different: some are novice in PBF while other’s have already PBF knowledge and come to the course with specific objectives. Therefore, we try progressively to condense the messages in order to gain time and to tailor the content of the course as much as possible to the needs of each participant. The weight of the exam has considerably increased since 2015. As a result, 11% of the participants during the last 9 courses in 2015-2016 did not pass the threshold of 55% compared to 5% during the previous 8 courses in 2014-2015. Yet, in this Mombasa course all participants manged to pass the exam for which we present our congratulations.
Cameroun started PBF first in the East Region with the Catholic Church and Cordaid in 2006, followed by a World Bank financed pilot programme in 2011 in four Regions. The government has in 2016 declared PBF as their national policy and also as the approach to reach the Universal Health Coverage objectives. During 2017, the government is scaling up PBF from 25% of the country to cover 50% of the population and aims in particular to roll out PBF in the three Northern Regions, which were recently affected by instability due to Boko Haram. The three participants from Cameroun came from the South West Region.
- Advocate for the MOH technical PBF unit that HF should be truly autonomous and are allowed to use their own revenues.
- Concerning the Quality Improvement Bonuses: (a) Advocate with the national technical PBF unit that funds should be made available for its implementation and that reimbursement is smooth; (b) The CDVA should recruit an engineer to verify and coach health facilities in the use of the QIBs.
- The CDVA should be empowered to raise the ceiling per health facility for the number of vulnerable to be exempted from 10% to higher levels per HFs according to need. It should be left to the district validation committee to which level they can increase the ceiling per health facility as long as the overall number of vulnerable exempted per district remains below the ceiling of 10%.
Ethiopia has started a small Cordaid-initiated pilot in four districts with 126,000 inhabitants in Oromia State. The representative of Ethiopia presented several implementation problems concerning the Cordaid pilot programme, including the change in strategy that was required as the result of the prolonged dry season. Another problem presented is the slow uptake of the PBF subsidies by the health facilities. The latter problem points to a more systemic problem with the design of the PBF program.
The Cordaid representative in Mombasa recommends support for the PBF health facilities, in terms of more robust verification and coaching. Another line of recommendations is to better inform the relevant authorities about PBF with the aim to scale up the pilot to other areas of the region and the country.
The development- and health indictors are poor with notably the very high maternal mortality rate of 1,024 per 100,000 live births. The HIV prevalence rate among adults is one of the highest in the world with 23%. Considerable investments in the health sector have been done, but they have not yielded the desired results. In response, the government started since 2014 testing PBF with the aim to reduce inefficiencies and to obtain better results first in two districts and later in six districts covering around 50% of the population. The feasibility score conducted by the Lesotho participants in Mombasa show a score of 50%. This implies that improvements in the design are still required.
- The PBF Unit should be brought directly under the Principal Secretary of the MoH;
- There should be a higher PBF budget of above USD 4 per capita. This does not need to be done by asking for more funding but can be done by reallocating already existing budget lines for inputs;
- Increase the number of PBF output indicators, including for equity, community PBF and the investment units;
- Establish a more robust national Contract Development and Verification Agency with branches at regional level;
- The PBF Unit should advocate for more autonomy at health facility level for the use of cost-sharing revenues and buying inputs from accredited distributors;
- Accredit pharmaceutical suppliers and train pharmacies in standard protocols
- Integrate PBF data in web based application of DHIS2.
- Train District Quality Assessment Teams
The health system has three levels – primary, secondary and tertiary – with no clear role definitions in the responsibility of each tier. Nigeria has sub-optimal health services and the maternal mortality rate is high with 576 per 100 000 live births with a very unequal distribution over the States and unfavourable for the States in the North-East such as Borno, Yobe and Bauchi. There is weak donor coordination and monitoring systems. Health is seen by many states as a social good with inefficient free medical services.
Based on the result so far since 2011 in the three pilot States, the Nigerian team felt that PBF has the potential to significantly improve health outcomes by moving away from input financing and focusing on results in terms of quality and outputs.
General recommendations Nigeria
- The team in Mombasa proposes for Nigeria the slogan: “Performance Based Financing for Universal Health Coverage – PBF4UHC”.
- Integrate PBF into ongoing activities in the health sector and make it a strategic health reform program that should be included in the National Strategic Health Development Plan;
- Ensure improved coordination and ownership for the PBF Program by government at all levels
- Increase funds for the PBF program budget through re-allocation of existing funds and government budget lines
- Mobilize funds from the private sector to complement Government budgets
Specific recommendations Nigeria
- Send the report of the Mombasa PBF course with recommendations to the Federal Minister of Health;
- Organize a coordination meeting between all the PBF actors at the national level with the FMOH, World Bank, technical assistants and the PIU NPHCDA;
- Convene a technical working group meeting with the NSHIP actors to discuss the health reform approach, its challenges and develop a plan for the inclusion of PBF in the National Strategic Health Development Plan II;
- Align and harmonize the indicator sets used in tracking the NSHIP interventions with the national indicator sets in the DHIS2
- Integrate the RBF platform with DHIS2 platform
- Provide appropriate support to the NSHIP Additional Financing States.
After two relatively calm years of peace after its independence in 2011, the country has descended since 2013 in internal and external strive. As a result, the population suffers from displacement, and there is limited access to food and social services. Cordaid is currently working in several States in South Sudan, but so far mostly with classical input oriented health programs. Yet, Cordaid also appreciates the importance of performance based systems and decided to send a four-member team to Mombasa to analyze what can be done. South Sudan has poor health impact indicators such as the very high maternal mortality rate of 789 per 100,000 live births. The health system is extremely donor-driven and implemented by International NGOs with at least 90% of public health expenses financed by external sources. There is a vibrant local – mostly informal – private sector, but which is being ignored by government and development partners. The distribution system in South Sudan is input oriented and supply (“push”) driven and does not allow for competition. Stimulating and regulating fair competition among the South Sudanese private sector is not yet a government priority. As a result, stock outs are frequent and there are doubts about the quality of drugs brought in the country. The ‘zero cash policy’, only allows for inputs in kind to health facilities. This is a de facto pure centralised planning approach with an inefficient and ineffective input policy;
Recommendations South Sudan
- Conduct high level advocacy with government and donors on the need for output-based programs. An important partner for this is the World Bank, which is in negotiation with the government along the same lines;
- Develop a well-designed PBF pilot in areas where Cordaid has a large presence, especially where it is the lead partner for its implementation. For this, the Mombasa team propose a full package and with sufficient funding;
- Consolidate funds to provide the comprehensive health packages;
- Start with a selected set of manageable indicators, but not less than 20;
- Introduce also the community PBF indicators to reachable (secure) populations;
- Health facility managers should have the right to decide where to buy their inputs;
- Introduce the management tools of the business plan and the indices management tool for facilitating autonomous health facility management;
- Establish independent CDV Agencies with the objective to sign contracts with facility managers, conduct verification and coaching. As an intermediate solution, Cordaid could propose that the payment function is done by the central Juba office, while the CDV role is played by the Cordaid field offices;
- Negotiate with the SMOH to respect decisions made by facility managers
- Introduce investment unit or quality improvement bonuses for infrastructure improvements
- Introduce equity bonuses for vulnerable people but also allow health facilities to charge user fees from those patients who can afford.
The Uganda health system is facing major challenges and the government tries to find a proper RBF/PBF design to tackle them. Since abut 15 years there have been experiments with smaller RBF / PBF pilots, which provided useful lessons. A new framework has been developed for the implementation of RBF in two third of the country. Yet the team in Mombasa scored the feasibility of the current design with only 42% and they identified several points for improvement.
Given the discrepancies between the PBF best practices and the currently proposed RBF National Framework design, the Uganda team proposes:
- To review the current RBF design and notably: (1) review the budget and the scope of indicators; (2) review and change the CDV function from the regulatory DHT function
- Adoption of the free market system for facility commodities
- Digitalize RBF data management system.
The Zimbabwe government made RBF its national policy several years ago with the objective to improve the health services in terms of efficiency, equity and to enhance check and balances and transparency. Its medium-term financing strategy aims to enhance the institutionalization of RBF and minimizing user fees while also respecting the core tenets of the results based management approach.
The problem analysis according to medium-term financing strategy document concerns: (1) The government feels it has a limited role in executing key RBF functions; (2) The accounting systems lies outside the public management system; (3) There is declining development partner funding.
Problem analysis and recommendations Zimbabwe
- Provide feedback on the PBF Training in Mombasa to the top management team of the Ministry
- The standard feasibility scan of the current PBF design in Zimbabwe showed a low score of 52% and the team concluded that there is a need to revise the Project Implementation Manuel;
- The team felt that the Ministry need to consider separating the two roles of the PBF-PCU Unit and therefore proposes to have a relook at the implementation arrangements with special emphasis on separating the functions of contract development and verification from the regulatory role.
- Come up with a strategy for a deeper public-private partnership that will share the burden of health service provision
- Mobilise additional resources from partners and re-direct available resources meant for input financing activities to cover the gap to meet the minimum PBF per capita requirement currently estimated at USD 2,44 to reach at least USD 4.00 per capita per year