The 70^thperformance-based financing (PBF) course took place from Monday, May 28 to Friday, June 8, 2018, in Mombasa, Kenya. Thirty-one participants attended the course: 16 participants from Nigeria, 6 from Zambia, 5 from Ethiopia, 3 from The Gambia, and 1 from the USA.

Here is the detailed course report

The groups analyzed their health systems and produced detailed action plans on how to advance PBF in their respective countries, states, and regions. Thirty participants conducted the final exam and achieved an average score of 70%, including three distinctions.

Daily evaluations produced scores comparable to previous English spoken courses. The final evaluation indicated that participants felt the course content related well to their regular professional activities. Participants were also satisfied with the methodology and organization. Participants rated the course modules much higher than previous courses. Some participants commented that facilitators should acknowledge the importance of context-specific issues. The importance of respecting country-specific characteristics is fully recognized. At the same time, we value open, comparative debate in an international forum, which stimulates out-of-the-box thinking and is also a vital characteristic of the course.

The course was organized around a strong core of ‘developing individual and country action plans’. This conscious focus began a few years ago, and with each course, we give more attention to the action plans. We plan to advance this approach to the course, deepen the quality of individual or group action plans each time, and build the 17-course modules around this core task.

Country recommendations of the May 2018 Mombasa course

Nigeria NPHCDA

The Nigerian government, with financial support from the World Bank, started its RBF program in 2011 to test the innovative RBF approach in response to poor national health indicators. By the end of 2018, NSHIP was supposed to cover approximately 13 million inhabitants. The RBF approach has seen encouraging results in Nigeria. Yet several key concerns remain about its design and sustainability.

Problems

• So far, the World Bank has almost entirely financed the RBF approach, and this project funding ends in 2020. The approach’s sustainability is therefore a challenge.
• The PBF Unit sits outside the MOH hierarchy, making it difficult to sustain the PBF approach, with little MoH buy-in and equally low interest from the hospital sector and Hospital Management Board agencies.
• The WB-supported Save One Million Lives initiative and the PBF program also lack coordination, even though both are World Bank-supported. Both are output-based, but the SOML only puts the States under contract, leaving it to them to meet the Disbursement Linked Indicator targets.
• The impact study that began with a baseline in 2012 proposed a research arm of the program, which would simply give money to health facilities without conditions, the so-called DFF approach, for comparison. This created problems with transparency, contamination, and crossover, which ‘spoiled’ that academic design. Firm conclusions are therefore hard to draw from the practical execution of this research.
• The administrative costs of the PBF approach in Nigeria are too high, with a multitude of actors; this while the regulatory and CDV agencies (in the NSHIP–AF states) are not yet under performance contracts;
• Quality Improvement Bonuses are absent in the Nigeria design, while this is a crucial design feature in other World Bank-supported countries to improve support rehabilitation, making available equipment and human resources, as well as restarting health facilities affected by instability
• In the current NSHIP and AF-NSHIP design, the SPHCDA has a dual role: it is the regulator (responsible for oversight of all primary facilities in a state) and the unit that signs purchase contracts with health facilities (both primary and secondary). This confuses roles, and in practice, because of its specific positioning in the NPHCDA and SPHCDAs, the PBF unit (called PIU in Nigeria) may not have the clout it needs to coordinate reform efforts.
• Overall, the feasibility scan score for most Nigerian teams under the current design is only 60%, while the proposed minimum is 80%. Design improvements are therefore necessary.

Recommendations :

• For new States wishing to start PBF, an institutional set-up is proposed that can be found in the course report
• The positioning of the PIU at both National and State level within the MOH at an appropriate level, e.g. under the PS;
• Advocate for the CMVAs (CDV Agency) to take on the role of signing and coaching of the health facility contracts rather than the SPHCDA ;
• Finalize proposal on Community PBF to ensure that other incentives exist for the community ;
• Remove the Ward Development Committee (WDC) chairman (and another community representative) from the health facility bank account ;
• Advocate with the World Bank to introduce the Quality Improvement Bonuses. The project documents may also emphasize that health facilities can use other funds for infrastructure, while PBF subsidies should focus more on small rehabilitations, improving equipment, and, in general, quality improvements.

Kano State – Nigeria

Kano State, in northern Nigeria, has a population of 13.8 million. Private health facilities are concentrated in metropolitan areas. Despite years of government efforts and investments, delivering quality healthcare services remains a challenge: infrastructure is poor. Many facilities lack the required equipment or drugs to deliver basic health services. Facilities face an acute shortage of qualified manpower, and funds are insufficient to cater for basic needs. Key impact indicators such as under-5 mortality, assisted deliveries, and family planning coverage are far below the national average. The health system is unresponsive, inefficient, and inequitable. Resource leakages are mostly associated with public health services.

Recommendations:

• Kano State proposes a new reform approach, performance-based financing (PBF), starting in three LGAs covering 1 million people.
• The aim is to meet the Sustainable Development Goals (SDG) whereby health facilities provide quality care. Both public and private providers will be contracted to reach the population competitively. People entrusted with responsibility in the health system should be held accountable for their performance, work under contracts, and be compensated based on their performance.
• The pilot budget should be around 4 million USD per capita per year. With ongoing reform and strengthened health services, the State has a unique opportunity to introduce and finance PBF through the Kano Health Trust Fund Law and the Saving One Million Lives project.
• The Kano State Contributory Health Care Management Agency is proposed to serve as the contract development and verification agency.
• The State has a pool of employable, qualified health personnel that health facilities could employ through the PBF approach.
• The institutional setup is shown in the NPHCDA report above. The PBF Unit will be based in the State Ministry of Health, with a State PBF Steering Committee and LGA validation committees.
• The PBF will apply best practices where possible, including autonomous management, competition for contracts, public-private partnerships, and equity instruments.
• Other issues, such as the obligation to bank money in the Treasury Single Account, the central Medical Stores monopoly, and the procurement law for infrastructure, need analysis and action.

 Jigawa State – Nigeria

Health indices in Jigawa State are among the worst in the country due to low investment in the health sector, ineffective health systems, and poor health-seeking behavior among the populace. Different health reform initiatives for the last 10 years have unfortunately been ineffective.

The State aims to implement PBF to address these challenges.

Some key issues regarding the implementation of PBF

• The Treasury Single Account principle does not allow health facilities to control their own funds, which poses a serious problem for autonomous financial management ;
• Human resource management is too centrally controlled, and there should be more autonomous management of human resources, also for contract staff ;
• The procurement process for the inputs (drugs, consumables, equipment, etc.) is still based on central planning through the Central Medical Store. This creates frequent stock-out problems and the wasteful use of public resources ;
• The financing source for the PBF program has not yet been decided upon ;
• There are few private health facilities in the State ;
• The 2019 election process may negatively influence the reforms.

Yet, there are also opportunities such as:

• The existence of the PBF know-how in the country ;
• The committed Commissioner of Health may also promote PBF during the election process as a solution for improving health services.

Recommendations

• The Jigawa State action plan will focus on the design of a Performance-based financing pilot in 3 large LGAs, Gwaram, Kafin Hausa and Babura, covering a population of about 1 million people representing nearly 20% of the state population.
• The 1% consolidated revenue fund may be tapped into for funding PBF ;
• The existence of the SOML funding that may be tapped, which could benefit future PBF funding ;
• To conduct awareness creation meetings with various stakeholders during the 3^rdweek of June 2018
• To conduct an advocacy meeting with members of the State House of Assembly in the 4th week of June 2018
• To conduct a study tour with key stakeholders to Rwanda in July 2018.

Zamfara State – Nigeria

Zamfara State is located in north-western Nigeria and has a population of 4.8 million.

Problems

• The health system in the State is fragmented ;
• Health facility autonomy is limited without competition in the procurement of essential drugs ;
• There are few adequately skilled human resources;
• There is an unacceptably high level of maternal, neonatal, and child mortality ;
• Health funding is limited, services are poorly utilized, and health care services are centralized.

Recommendations

• The State Ministry of Health proposes to initiate Performance-based financing(PBF). The approach will be bottom-up and will be piloted in three Local Government Areas across the state (one per senatorial zone) and will cover a population of about one million people ;
• The current feasibility scan score is only 44%, and the team proposes to discuss the change issues at several levels with the aim of improving the design of the PBF approach, including where to source the funds ;
• An ambitious action plan has been presented in the detailed report.

Yobe State – Nigeria

Yobe is in the North Eastern part of Nigeria with 3.4 million people and 17 LGAs. 80% are poor subsistence farmers, and the literacy level is 35%. On average, women give birth to 7 children during their reproductive lifespan. The median age at first marriage is 16.3 years, accounting for the high rates of teenage pregnancy and associated health problems. Yobe State has unacceptable health indices with an MMR of 1200 / 100,000. The contraceptive prevalence rate is only 3%.

Yobe started PBF in 2017 and will scale it up in 2018 to 10 LGAs. However, design issues remain, and the feasibility score is only 64%.

 Problems:

• The State provides only USD 3 per capita per year for the PBF program. This needs to be around USD 6 per capita per year if the program is to successfully address problems caused by political instability, dilapidated infrastructure, lack of equipment, and a very poor population.
• The SOML DLI approach is not linked to the PBF program, so it is problematic for the State to achieve the DLI targets.
• The regulatory institutions are not yet under performance contracts ;
• There are no Quality Improvement Bonuses.

Recommendations

• Establish a PBF unit under the Office of the Hon Commissioner and establish a PBF coordinating unit in the office of the PS to sign a contract with the Directorates ;
• Create legal and policy frameworks for provider autonomy to hire and fire staff ;
• Decentralize the procurement of supplies by the health facilities from distributors operating in competition ;
• Revise the business plans to include the Quality Improvement Bonuses ;
• Review the law to allow the government to directly fund private and public health facilities on the basis of PBF principles and best practices ;
• Sensitize the decision makers to mobilize PBF resources.

Zambia

The Ministry of Health of Zambia has been engaged in RBF for several years, but it has not yet established a national PBF unit. Four RBF projects financed by the World Bank, USAID, DFID, and SIDA are managed under 4 different departments. This creates challenges for coordination and resource optimization.

This may change, however, since at the beginning of 2018 the Government announced a shift from INPUT-based planning to OUTPUT-based planning. On this basis, the Zambia team proposes lobbying to integrate and establish a professional PBF Unit directly under the Permanent Secretary to better coordinate the different vertical RBF programs.

Main challenges

PBF principles stress the need to establish a PBF Unit, preferably at the decision-making level. PBF also emphasizes efficient and effective use of funds. However, this contrasts with the current situation in the Ministry of Health, where no unit is established, and efforts are duplicated due to vertical, fragmented project implementation.

In the current situation;

• There is fragmentation of PBF interventions depending on the source of funds (no resource pooling);
• There is no standard approach to PBF.

We estimate the feasibility score of the Zambia PBF programs at 32% => for details, see report

Action points

• Debriefing of the NTLP and Partners in the concept of PBF
• Debriefing of the Permanent Secretary on the concept of PBF

One tough dimension will be convincing the PS and other stakeholders to set up a coordinated funding basket run by a central PBF Unit, rather than having project implementation units run in parallel. We also anticipate resistance from various donors in establishing a common funding basket. This could create conflict at different levels, including senior management at the Ministry of Health.

The Gambia

The Gambia is a small country on West Africa’s coast with a population of 1.9 million. The Maternal Mortality Rate is high at 433 / 100,000, and the contraceptive prevalence rate is 9%. The total fertility rate is also high at 5.6. Wasting and stunting, but at the same time, overweight problems are public health concerns.

Since 2014, The Gambia has run a World Bank-financed PBF pilot that currently covers 40% of the population. It is implemented in 5 of the 7 health regions of the country, all of which are rural.

Problems

• The current PBF setup does not yet promote full sustainability and buy-in by the Ministry of Health.
• Health facilities in urban areas are not included, nor are private and faith-based health facilities.
• Based on the report of the NaNA coordinator who attended the PBF course in 2016, the Mid Term Review of early 2018, and the report of the group that came to the June 2018 Mombasa course, it is clear that there is a need to make the PBF health reform approach more sustainable by bringing the PBF Unit within the MOH.
• The MoHSW is both the Regulator and the CDV, which is not recommended for transparency reasons ;
• NaNA also doubles its role as a fund-holder and CDV, which is not recommended for transparency reasons ;
• The Regional Health Department is contracted by both NaNA and the MoHSW.
• Health facility business plans are reviewed by three institutions: a. The Region; b. the PHC Unit in the MoHSW an; and c. the NaNA project staff. This confuses facility staff and delays contract negotiation and signing.
• Health facility user fees are paid into a central account of the Treasury Department instead of into a commercial bank account of the health facilities
• There are too few indicators at both the primary (15) and hospital (6) levels, while at least 25 are recommended for each level.

Recommendations

• Promote MoHSW buy-in for PBF and develop a strategy to institutionalize the PBF approach through a PBF Unit in the MoHSW, autonomous CDV Agencies, and QIB Officers. For the detailed set-up, see the detailed course report.
• Ask the National Nutrition Agency for their support to engage with the senior management of the Ministry of Health;
• Increase the scope of complementary health indicators in the primary and hospital packages ;
• Reduce the verification costs for community RBF ;
• Introduce the contracting of the regulator at all levels for the implementation of activities ;
• Allow health facility managers to use funds generated from user fees to improve service quality.
• Strengthen health facility autonomy through the application of the business plans and the indices management tool.

Ethiopia

Ethiopia is the second most populated country in Africa, with 102 million people. Health service delivery and indicators in Ethiopia have been improving over the last 25 years. Yet there are still important caveats, such as the fact that 1 in 3 children are chronically malnourished and that the MMR is still high, at 412 per 100,000 live births. Health service challenges are also unequal, with pastoral areas particularly lagging behind, and healthcare provision remains basic and, in many cases, of poor quality.

Therefore, the next phase of improvement will require more investment if the country wishes to move beyond basic-level primary care, largely provided by community-based health extension workers, to fully functional primary health facilities and hospitals with skilled health care providers equipped to handle life-threatening conditions, and an effective referral mechanism.

Under the Health Sector Transformation Plan, the Federal Ministry of Health addresses Universal Health Coverage (UHC) as a key component, aiming to provide coverage for all essential health services for everyone without financial hardship. As part of this strategy, the Performance-based financing (PBF) approach was adopted to improve quality.

Why apply PBF in Ethiopia?

Cordaid carried out a PBF pilot in 2015 in Borena Zone, Oromia Region, for a population of 186,000, with encouraging results. In the PBF approach, several strategies can improve service quality, and several equity instruments can be applied if resources are available. Yet, PBF also emphasizes efficiency, aiming to make better use of scarce public resources through competitive contracting, accreditation of health facilities and pharmacies, public-private partnerships, and fostering a group spirit in health facilities by sharing profits through performance bonuses. HMIS also improves through a robust PBF verification and validation system. Performance contracts are also introduced for regulatory authorities at all levels and for CDV Agencies and Community-Based Organizations.

Problems

The institutional design of the Cordaid PBF pilot is still project-based and does not yet propose a setup that involves government institutions and the national health insurance company.

 Recommendations

• Establish a PBF unit within the Federal Ministry of Health to oversee the overall implementation process of PBF initiatives in Ethiopia. For the set-up, see the course report
• For scale-up and to link PBF with the country’s health sector transformation plan, further evidence is needed. This may become a joint responsibility between the Oromia Regional Health Bureau, the Borena Zonal Health Department and the District (Woreda), and the Health Offices of Borena. The rollout is intended to include 9 districts to cover a population of around 581,000 ;
• The Oromia Regional Health Bureau must approve the scale-up financed by Cordaid and the Dutch Embassy;
• The new scaled-up project includes a zonal validation committee  ;
• The Payment Agency for the PBF project is the Addis Ababa office of Cordaid only during this pilot phase. Once PBF in the future may become national policy, other payment agencies should also start playing this role ;
• The Cordaid sub-office in Yabello town may play the Zonal Contract Development and Verification Agency role, but in the (close) future this role may be transferred to the Ethiopian Health Insurance Agency (EHIA).
• The Mombasa group’s action plan includes several workshops to advance scale-up, conduct exposure visits, and train frontline champions in PBF.