The 74th International RBF course was held in Coyah in Guinea from the 10th to the 22nd of September 2018. There were 43 government participants from the central, regional and district levels, three representatives of partners organizations and one representative from the private sector.

The impact of the 74th RBF course has been reflected in the good quality of the group action plans (see rapport). The average pretest score was 32% and the post-test score was 62%  which means a 30% improvement. Three participants obtained a favorable mention for their final test with a score of 83% : Dr. Ahmed Sekou Tidiane BARRY of the Ministry of Health – DNESH ; Dr Moussa SOUMAH                                 of the Ministry of Health – SNAS and ; Dr. Houssainatou BAH from the District Health Directorate Dubreka.

Context

To meet the health needs of the population, the Ministry of Health has experimented in the past with several approaches to improve the quality and efficiency of the health services. Despite these efforts the analysis of the health care situation reveals that severe quality and efficiency problems continue.

Poor quality and inefficiency was therefore placed at the center of concerns in the National Health Development Plan 2015 – 2024 and the Ministry of Health identified results-based financing prominently as an important reform approach. The first experience in Guinea with RBF was implemented in the Mamou’s region during the 2016-2018 pre-pilot project that covered 19 health facilities. It was supported by various partner organizations, including the NGO Health Focus, KIT Amsterdam, HDP Rwanda, World Bank, and GIZ. The results were encouraging with a. A substantial increase in the number of primary curative consultations in the RBF health facilities compared to the period before; b. A significant increase in the number of referral and counter-referrals between health centers and the regional hospital and; c. A considerable improvement in the quality score of the health facilities.

On the basis of these results and also the promising results in other countries such as Burundi, Rwanda, Cameroun, Zimbabwe and DRC, the government is moving towards a more robust pilot phase in four regions covering in total around 2-4 million inhabitants. During this pilot phase, it will be decided on how far RBF will become the national policy in Guinea.

It is in this context that the Ministry of Health in collaboration with its partners the World Bank, KfW and GIZ have organized the first international RBF course in Guinea.

Aim and objectives of the RBF course

The aim of the course is to contribute to improving the health status of the population by offering health packages of good quality in an efficient way that is also (financially) accessible to the population.

The objectives of the course

• Understand what health markets do well, but also where health markets fail and how to correct them by applying market-based instruments ;
• Reach a critical mass of actors who adhere to the RBF reforms and who understand the limitations of the traditional input system ;
• Master the RBF theories, best practices and the tools for its implementation;
• Develop the right skills and attitudes to promote change.

Participant’s analysis of the strengths for introducing FBR in Guinea

• The Ministry of Health has developed initiatives to develop a unique RBF approach under their leadership ;
• There is a favorable political climate for the adoption of the RBF approach as a priority intervention of the National Health Development Plan (PNDS) 2015-2024. This willingness was clearly illustrated by the presence of the Minister of State of Health Dr. Edouard Niankoye LAMA at the closure of the 74th FBR course on September 22, 2018, in Coyah. He was seconded by the Secretary-General of the Ministry of Health, Dr. Sekou CONDE and the WHO Representative Dr. Georges Alfred KI-ZERBO;
• There exists a unique interest in the development partners to promote RBF ;

Participants’ analysis of the problems of the health system in Guinea

• The national PBF Unit has not yet been put into place ;
• Private health facilities are not yet been integrated into the national health system and do not receive the same support compared to government health facilities ;
• There is not yet the separation of functions, in particular of the regulatory authorities from health provision, contract development and verification, payment and consumer voice empowerment ;
• The central input planning and distribution system are still in place.
• There is an inefficient monopolist system for the purchase of inputs by government and partners through the Central Medical Stores of Guinea to the detriment of other suppliers ;
• There is still limited autonomy of government health facilities of where to buy inputs, human resource management and the setting of tariffs ;
• The RBF funding for the KfW and Bank financed RBF program is too low compared to the intended target population with less than $ 4 per person per year ;
• There is the centralized recruitment of government health facility staff leading to an unequal distribution of qualified staff to rural areas ;
• There are several initiatives of generalized free health care that are not effective instead of applying the targeted RBF free healthcare instruments.

The above problems resulted that the participants from the central level during the course found that in the current situation the RBF feasibility score was only 28% or 14 points out of 50. The desired score for a successful RBF program should be 80% or more. The participants, therefore, concluded that significant improvements must still be implemented in the design of the new RBF pilot program in Guinea.

Recommendations of the course

For the Ministry of Health

• Change the paradigm of the centralized paying for “inputs” towards the paradigm of paying for “outputs” or “performance”.
• Inject at least 70% of the public budget available from the government and partners directly into the decentralized structures (health centers, hospitals, and communities). This approach is more efficient as the result of the superior knowledge of the local economic actors of supply on their needs. Injecting money in the periphery will also create economic multiplier effects of economic growth and the creation of the employment. This paradigm shift is to reverse the trend of centralizing resource allocation decisions.

• Create urgently the national RBF Unit embedded in the Ministry of Health.
• Promote the long-term sustainability of the RBF approach through the creation of regional Contract Development and Verification (CDV) Agencies embedded in already existing organizations such as the decentralized structures of the Ministry of Territorial Administration and Decentralization (SERACCO at the regional level and the SPD at prefectural level). It should be noted that the contracts between the national RBF Unit and the Regional CDV Agencies could be done under the direct coordination of the decentralized structures such as SERACCO. Such contracts do not require international tenders that tend to delay implementation for months or even years. Such institutional arrangements will also be more acceptable for the authorities as it builds on existing organizations and they will be lower cost solutions than recruiting international organizations. However, during the discussions, it was also noted that there was already convention signed by some partners such as KfW with the government. This specific institutional set-up should be respected at the short-term while they can change gradually towards a better-harmonized approach at the mid-term.

• Integrate private sector health facilities into the RBF contracting mechanisms and make use of their comparative advantages. This is illustrated by the finding that for example in the semi-urban District of Coyah with 360 000 people, there are only six government health facilities and more than 110 private ones. The regulator should play its role of quality assurance and accreditation instead of ignoring the private sector. The regional CDV Agencies can offer performance contracts both to government and private health facilities able to deliver high quality primary and secondary health package services that meet the standards set by the Ministry of Health. Thus private providers should have the same opportunity to obtain RBF contracts as public providers.
• District regulators should map and subdivide each year the district health map into catchment areas at primary level for target populations of between 5000 (rural) and 14000 (urban) people. At first referral or hospital level, they should subdivide the health map into catchment areas of between 100 000 and 250 000 target population.
• Involve community organizations in the implementation of RBF. In the RBF reforms, this involves the funding of community indicators such as home visits following a protocol, the identification of the vulnerable, the identification of the malnourished, and identifying the dropouts for example of tuberculosis treatment, immunization.
• Allow health facilities to have a large degree of autonomy to buy their inputs, to recruit their human resources and to set their tariffs. These prerequisites for the successful implementation of RBF require that the RBF health facilities must be exempted from certain existing texts or laws.
• Ensure motivation and retention of staff especially in rural areas through district and health facility specific higher subsidies so that these health facilities can provide more attractive performance bonuses to staff willing to work in remote areas.
• Apply targeted free health care instead of generalized free healthcare by introducing the following RBF equity instruments:

1. Provide high subsidies for public goods and positive externalities, such as family planning, vaccination, prevention of TB transmission or Ebola virus disease ;
2. Provide modest subsidies for curative services with the aim to slightly reduce the tariffs for patients to be treated for common diseases such as malaria, acute respiratory infections (ARI), diarrhea, diabetes, etc. This subsidy has the effect of providing a signal towards public and private providers to lower their prices.
3. Introduce regional, and district equity bonuses that correct the differences in vulnerability between regions and districts.
4. Provide health facility specific equity bonuses that correct the differences in vulnerability between health facilities.
5. Provide individual equity bonuses with the aim to exempt vulnerable people or groups from fee paying. This allows health facilities to choose which patients to exempt from direct payments. Yet, there should be a ceiling for the proportion of patients that can be exempted.
6. Provide a higher ceiling of up to 100% for patients to be exempted from fee paying in case of humanitarian or natural emergencies. This means that health facilities will be reimbursed with a higher subsidy for each patient that was exempted.

• Develop only one national RBF manual endorsed by the Ministry of Health and not several RBF manuals produced for the different donor programs. Yet, this does not exclude that partners will develop their own manual for their specific procedures and operational aspects ;
• Transform existing government lines into RBF budget lines in the Finance Law.

For the regional and district authorities

• Find funding for the continuation of the RBF pilot experiment in the Mamou Health District (GIZ?);
• Start upon return at the office to prepare the administrative officials, local elected officials, civil society, health providers for the establishment of RBF in the regions and districts ;
• Start the process of mapping and rationalizing public and private structures in the future RBF areas ;
• Advocate for RBF at the level of the governorate / communal / community authorities and civil society organizations for their effective participation in the RBF reforms ;
• Stimulate the creation of local associations in areas that do not have them ;
• Support health districts in the process of setting up their RBF programs.

For the technical and financial partners

• Change the input-based policies toward output and results-based policies ;
• Support the extension of the implementation of results-based financing in other regions and districts in the country ;
• Reallocate all or part of the centralized infrastructure and equipment component budget towards the RBF component (KFW).

Recommendations from specific groups in the RBF Course

Hospitals group

• 

  Social outing at the 16th of September 2018

  Government and partners should allocate for the RBF pilot interventions at least USD 4 per capita per year ;

• Recruit the regional CDV Agencies ;
• Make the required institutional arrangements at the central level that includes the verification, validation and payment procedures nationwide and start negotiating that the RBF reform best practices replace existing laws and procedures in the RBF health facilities ;
• Review the hospital RBF indicators so that they are adapted to international orientations ;
• Share the main findings and recommendations of the RBF course with the district authorities and hospital staff ;
• Start using the RBF indices management tool system for the already existing hospital revenues ;
• Ensure that all revenues from user fee payment are collected at one point in the hospitals and that they are deposited into the commercial bank account of the hospitals ;
• Use the Quality Improvement Bonus or Investment Unit bonus to improve the infrastructure and equipment of the hospitals.

Central level group

• Put RBF on the agenda of the next Technical Coordinating Committee (CTC) and meetings with partners organizations ;
• Promote the adoption of the results-based financing in the Guinean health system among the relevant authorities such as the directorates of the Ministry, the cabinet council and the Minister’s cabinet meeting ;
• Develop the draft text for the establishment of the national quality assurance coordination body and update the standards for health care delivery for the quantitative and qualitative indicators. This includes to identify, validate and disseminate the care packages at primary (MPA) and first referral level (CPA) ;
• Plan the establishment of a consultation framework with the private sector ;
• Plan the integration of the structures of the lucrative and non-profit private sector in the information system and the monitoring of the quality of services
• Plan the organization of the hospital peer reviews.

Central Guinea Pharmacy (PCG)

• Prepare the course report by the Head of Human Resources Department PCG of the 74th RBF training in Coyah. Present this report to all the PCG executives ;
• Create awareness about RBF by organizing exchanges with colleagues ;
• Propose a technical team for the development of the RBF – PCG tools;
• Develop a business plan for RBF in PCG
• Make a funding plea to partners for the integration of the RBF system in the activities of the PCG and regulatory authorities for the pharmaceutical market.

KfW Group

The regions of Kindia and Boké are eligible for the KfW-funded Project “Promotion of Reproductive and Family Health”, which aims to improve the supply and the increase in demand for Reproductive Health Services. This project has three components: 1. Infrastructure (rehabilitation, extension, and equipment); 2. Results-Based Financing (RBF) and; 3. Communication, outreach and community-based distribution.

Problems :

• The KFW project has three components with different budgets. The available budget for the RBF component is only US $ 1.30 for the target population of 2.1 million and does not reach the US $ 4 per capita per year such as recommended ;
• Health facilities and authorities are not yet informed, sensitized and trained in RBF ;
• Mapping and rationalization of health facility catchment areas is not done ;
• Public-private partnership mechanisms are insufficiently built in the project design.

Recommendations:

Scenario 1: Reallocate the KfW budget component for infrastructure/equipment towards the second RBF component by change the strategy for all components from centralized input financing towards decentralized performance financing.

Scenario 2: Reduce the coverage area. Select a population in such a way that the per capita budget per year is USD 4.00. This could result in the choice of two districts in both regions.

Scenario 3 : Develop a common basket approach by allying government and different donors in assuring that in the RBF areas all indicators will be incentivized and that the budget reaches at least USD 4,00 per person per year. Take into account all output indicators of the Minimum  Health Package and Complementary Health Package instead of only concentrating on reproductive health. This to avoid that the KfW project becomes a vertical program at the detriment of the non-incentivized indicators. This would require to create a structure that integrates the contribution of all donors (national RBF Unit). Put at the level of SERACCO a sustainable state structure, the CDV agency instead of the AGFA.

Evaluation of the RBF course in Coyah by the participants

The daily evaluations of the course had an average score of 78%. The scores for “facilitation”, “participation” and “timekeeping” were higher than the 41 previous francophone courses, with respectively 4.5%, 8.4%, and 12.8%. The preparation and methodology of the course were considered by the participants as very good. As for the duration of the course, it was considered too short by half of the participants and especially the time for the working groups was considered too short such as for the indices management tool. For the next course, more attention should be paid to the participants of the Ministry of Territorial Administration and Decentralization.

The organization was evaluated extremely poor by the participants with only 43%, which is 31% below the average of the previous francophone courses. This poor evaluation was due to the inadequate accommodation of the participants in the four hotels, multiple problems with meals and in general the poor quality of hotel services. The hotel managers were not open to suggestions for improvement and we could therefore not improve the services during the course. Several participants advised us to look for another hotel in case there will be another course in Guinea in 2019.