Recommendations for Mali, IC and DRC

Les participants de Cotonou

The participants of Cotonou

A PBF course was held in Cotonou from the 25th of April to the 6th May 2016 with seventeen participants from Mali, and one from respectively the DRC and Ivory Coast. The course was organised by SINA Health and BEST-SD Bénin and we thank the Benin MOH for their warm cooperation.

The atmosphere of the course was excellent and the participants left Cotonou with a strong desire to improve the health system in their respective countries. They concluded that Mali and the DRC still needs improvements in their PBF design. Three participants (all from Mali) obtained distinctions.

MALI

Autorités de village

Autorités de village

The design of the new PBF project and the process to start PBF in Mali could benefit from the following:

  • Prepare a report and organise feed back meetings with the aim to have the same views for the central level authorities, technical and financial partners as well as for the authorities at regional and district levels;
  • Advocate for the implementation of PBF during an enlarged meeting with the Cabinet of the MOH;
  • Harmonise the PBF documents and improve in particular the institutional set up;
  • Arrange 1 or 2 training sessions for decision-makers from the central in Mali on PBF with the support of external consultants;
  • Organise a study tours for health high decision  makers to countries that have advanced with PBF;
  • Involve participants of this course and the October 2014 course to advance with PBF in Mali;
  • Organise training sessions in those districts that will start PBF;
  • Conduct a baseline study;
  • Review the PBF project budget to ensure that financial resources are sufficient to start the project. It takes around 4 dollars per year per inhabitant to provide the full health packages at primary and hospital levels;
  • Transfer GAVI funds now available for a project that seeks to accredit health facilites towards PBF;
  • The current project has 16 indicators while an average of 25 to 35 would be desired. We propose to include more indicators to assure that holistic health packages can be provided at health facility level instead of only limiting them to reproductive health and immunisation indicators.
  • Liberalise the market for the distribution of essential medicines. Promote the development of multiple distributors operating in competition while the government strengthens its regulatory capacity to assure the quality among those distributors. This requires an accreditation system for all public and private distribution centres;
  • Develop a document that explains the role and autonomy of the in-charges of health facilities.

Ivory Coast

Meilleur participant de la journée

Best participant of the day in cotonou

The population contributes 56% of total health expenditure in Ivory Coast while the government only contributes 18% of in total USD 60 per person per year. Maternal mortality with 614 deaths per 100,000 live births is high.

Recommendations Ivory Coast

  • Give PBF health facilities the legal authority (for example in a projet memorandum of understanding) to formalize their autonomy and thereby to be able to apply the PBF best practices. This document should also include the roles for the Regional Health Directorates, District Health Teams and Regional CDV Agencies;
  • Break the monopoly and exclusivity of suppliers and provide an opportunity for health facilities to purchase drugs at public and private distributors operating in competition but accredited by government;
  • Ensure that private providers can be integrated in the PBF system;
  • Provide a training program so that public and private health facilities gain more knowledge, skills to implement PBF;
  • Discuss with the Ministry, through the Directorate General and the DPPEIS in partnership with other partners such as the Global Fund, USAID and the World Bank, the possibility of combining in health districts the MSH Development Program in Leadership and Governance with PBF.

DEMOCRATIC REPUBLIC OF CONGO

Porte de non retour Ouidah

Porte de non retour Ouidah

There are concerns about the PBF pilot project funded by UNICEF. We propose the following recommendations:

  • The government may liberalise the drug sector and cancel the Regional Distribution Center monopoly system. Yet, this also requires that government and the partners ensure effective quality control of the distributors through an accreditation system;
  • UNICEF may take into account and assure the financing of all indicators in the primary and hospital health packages;
  • UNICEF should assure that the Family Kits approach is also assured with its specific PBF targets;
  • UNICEF may transform, if possible, the budget for the inputs of the family kits into PBF subsidies directly to providers, and create a supply system with accredited distributors;
  • UNICEF may transform the subsidies allocated to the districts into PBF;
  • That the contract development and verification agency (CDV) convinces the religious authorities to entrust the payment function to an independent structure.

 

 

 

Recommendations for Kenya, Lesotho, Liberia and Nigeria

Group 51 Mombasa

The 29 participants

On Friday the 11th of December 2015, the 51st SINA Health PBF course ended in Mombasa with 29 participants: from Nigeria (13x), Kenya (7x), Liberia (5x), Lesotho (3x) and Switzerland (1x).

From day one, the group has been engaged in lively discussions and nice exchanges at the border of the Indian Ocean. The chief aim of the course remains of course to learn from each other and for everyone to incorporate as much as possible the rapid new developments in PBF of the last few months into everybody’s country design.

COUNTRY SPECIFIC RECOMMENDATIONS

  1. KENYA
Mombasa sunrise

Mombasa sunrise

Despite the fact that health expenditures has considerably increased between 2001 and 2014 the funds allocated to health care remain inadequate with 6% of total government expenditure against the Abuja norm of 15%. Yet funding may not be the main problem in Kenya but rather the distribution of those funds among the primary, secondary and tertiary level and the cost-effective use of the funding in general. Following the new Constitution, Kenya is engaged in an administrative devolution process of services towards a novel system with 47 autonomous Counties. Lessons learned and mistakes committed are gradually becoming available. The World Bank supported RBF program runs out by the end of 2016 with the idea to scale up RBF to 20 more counties from 2016 onwards. A new program with the World Bank and JAICA is currently being negotiated. The Kenya participants to the PBF course conducted the PBF feasibility scan, which produced the low score of 22%.

The Kenya recommendations are the following:

  • On the march

    On the march

    Advocate for change in the funding to comply with at least 3 USD per capita for the new RBF program of 2017 onwards.

  • Collaborate with NGO’s to initiate community verification in all the counties.
  • Advocate that facilities participating in PBF have autonomy as PBF best practice.
  • To advocate that facilities have right to purchase inputs from any accredited supplier and not only from KEMSA.
  • PBF unit to have further discussions with the County Departments of Health on the need for CDV Agency.
  • Lessons learned from Samburu indicated that it is best conduct supervision and quality verification together with support of development partners at each county.
  • Inclusion of CDV Agencies at the Counties in the budget in the proposed PBF project.
  • Increase the number of RBF indicators at basic health package level from the current vertical ten towards a more horizontal package of at least twenty.
  • Facility managers should be allowed to buy their inputs from accredited distributers instead of receiving drugs from the central medical stores (KEMSA).
  • Assess how much funding may be available in the various programs post 2016 (2017-2022), notably the new 150 million US$ program currently discussed with the World Bank and the further funding from the Japanese government for health systems improvement.
  • To cost out the required budget for a multi-annual RBF program on fully-fledged PBF program for example in 4 counties to be followed gradually by the other of the 21 selected counties.
  • To organize a senior-level workshop for the key policy makers (CS, PS, CMS, Head Policy, Planning and Finance and their staff) in which the potential of a mature RBF program would be discussed.

2. Lesotho

Group work

Multi country exchanges

The country allocates 14.5% of its public budget to health. Together with the out-of-pocket payments and donor contributions the total per capita health expenditure is a considerable USD 123.4 per capita per year. The main health problem in Lesotho is HIV/AIDS with a prevalence of 23%, also being the main cause of mortality. The maternal mortality rate is equally high with over 1000 deaths per 100,000 live births.

The Lesotho team identified the following bottlenecks for the implementation of PBF:

  • Delays in financial flows and management towards health facilities
  • Government health facilities are not allowed to open own bank accounts at facility level, with long delays in funds reaching the facilities.
  • Lack of a systemic approach of the village health workers system in Lesotho. There are no formal indicators for incentivising VHWs, even though a division: 40% – facility improvement, 30% – personal bonuses and 30% – Village health workers has been proposed. There are the unusually high number of around 100 VHWs per facility.
  • The hospital Lesotho PBF scheme is still limited by only financing the MCH indicators and not allowing individual performance payments to staff. In addition hospital indicators are a mix of primary care and secondary level ones and several go unreported.

Lesotho recommendations

  • Negotiate opening HF bank accounts, by proposing an experiment to the Accountant General with opening bank accounts and funds being transferred directly. Fro this the in-charges require to improve their basic financial management skils.
  • Develop SMART indicators for VHW program. The HF in-charge should select the adequate number of active VHWs to use.
  • A new PBF hospital design is proposed to pay against quality of care measured by departments and paid against a fixed overall cap allocated per hospital.

3. Liberia

Shimba Hills Park

On the watch for new ideas

The PBF feasibility scan conducted by the Liberia team showed a score of 42%.

Liberia recommendations

  • Hold a meeting with the Deputy Minister for considering PBF in program activities also for public health emergencies.
  • Advocate with Senior Management Team (SMT) to utilize PBF mechanisms to allot PBF budgets to facilities, to present to them the documentary evidence for facility autonomy and to present documentary evidence of facility autonomy to procure drugs.
  • Assess the feasibility of introducing CDV agencies approach with involvement of private and faith-based institutions
  • Advocate with donor agencies through the SMT to better coordinate financing flows and adopt performance financing
  • Reinforce the setting up of indicators with the focus on quality, equity and efficiency. Strengthen collaboration with MOH relevant units, including Quality Management Unit to define PBF quality indicators
  • Conduct a mapping exercise to identify PBF partners at other government and MOH agencies and establish a national PBF taskforce
  • PBF steering committee to engage community members for selecting organisations to conduct client satisfaction surveys
  • Discuss with key stakeholders at MOH to conduct the evaluation household and quality studies. Work with Research Unit to design protocol to conduct baseline survey for PBF at selected hospitals
  • Meet with key management staff to clearly define the chain of communication at primary and hospital level PBF
  • Facilities on a contractual basis to develop business plans
  • Work with key stakeholders to introduce equity bonus into the PBF program to capture hard-to-reach areas
  • Organize a two-weeks training orientation meeting for political buy-in to PBF concepts for key stakeholders on PBF.

4. Nigeria

PBF started in 2011 in Ondo, Nasarawa and Adamawa States in Nigeria with a loan of the World Bank and administrative support of the National PHC Development Agency (NPHCDA). The program was scaled up in 2015 to 50% of the Local Government Authorities (LGA) in these three states. Yet the other 50% control LGA’s still maintain the DFF study approach. The PBF program considerably improved output and quality of the services and there is great enthusiasm. Once fully rolled out the main problems that PBF could potentially reduce the inequalities between the Northern and the Southern States in Nigeria. Moreover it could reduce maternal mortality, which is high by global standards. With the recent political changes in Nigeria, PBF could also become a major instrument for the new government to enhance transparency in the social services and to assure that public resources indeed reach the beneficiaries. PBF may also provide the instruments to strengthen and rehabilitate health facilities in Nigerian directly affected by political turmoil in the Northern States. The NPHCDA proposes to extend the PBF program to some of the Northern and North-eastern states of Nigeria, and for this the World Bank loan program “Save-One-Million-Lives” of 500 Million USD funds may be pledged.

Ondo State

Village chief Taiwo

The famous waterfalls for eternal life

Ondo State has very positive experiences with PBF since 2011. The PBF feasibility scan conducted by the Ondo participants showed a high score of 94%. Yet, the private and religious health facilities are not yet included in the PBF program. Moreover, there is poor quality and quantity of services at Decentralized Facility Financing (DFF) facilities. These DFF facilities were meant as a study arm of the World Bank impact study, produced according to all observers’ significantly less promising results, but are  still maintained.

Ondo State recommendations

  • Introduce an urban PBF approach in the cities
  • Survey all public / private / faith based health facilities (accredited or not)
  • Validate the data collected at the LGA authorities and create consensus on existence of facilities and their accreditation
  • Define the population served in each catchment area and service package offered.
  • Organise workshop with all private facilities to obtain final consensus and approval of the health facility survey data and the selection of primary and secondary contract holders
  • Conduct PBF training for retained health facilities
  • Negotiation and signing of contracts
  • Transfer all DFF health facilities into the PBF approach.
  • Discussion with the national PIU/WB
  • Categorization into main and secondary contract holders

Northern States in Nigeria

Group 51 for eternal life

Entertain and come back refreshed

The Northern States were requested by the NPHCDA to propose action plans on how to start PBF. For this reason, we welcomed 9 participants from 4 States in Mombasa.

The main recommendations for introducing PBF in the Northern States are:

  • Assure sufficient funding for the new PBF pilots in each State and target for achieving adequate economies of scale a population of between 300,000 and 700,000 per State. The costing for these pilots would then be approximately USD 1 – 2 million per year per State.
  • Target and pilot PBF in 2-3 Local Government Authorities in each State with all health facilities at primary and hospital level. This would include the regulatory authorities and the CDV Agencies at State and LGA levels.
  • Negotiate sufficient funding with Federal level not only from the “Safe 1 Million Lives” project but also from any other Nigerian State or Federal level budget lines.

Recommendations 50th PBF course in Cotonou

Les participants du cours PBF de Benin

The 39 course participants of the Cotonou course

The 50th PBF course was held in Cotonou from October 12 to 23, 2015 with thirty-nine participants from Chad (16) Niger (10x), Haiti (4x) Cameroon (3x), DRC (2), Comoros (2x), Ivory Coast (1x) and Benin (1x).

There were six participants, who obtained a certificate of distinction with a score of 90% or more:

  • Dr Adama OUEDRAOGOU of Benin; Christina DAURISCA from Haiti; Koulthoume Maoulana from the Comoros; Dr Charles Kambo Sanza from DRC; Dr Pascal BEMADJINGAR from Chad; Dr. Francis SIMO Peumo from Cameroon;
  • Christian WOLLO KLA from Ivory Coast obtained a Mention with 87%.

COUNTRY RECOMMENDATIONS

Cameroon

  • Advocate for derogations for the PBF structures and regulatory authorities.
  • Recruit more quality staff for the Regional CDV Agencies
  • Advocate for the inclusion of bonuses for vulnerable regions
Les sculptures de Benin

The sculptures of Benin

Comoros

  • Conduct a feed back meeting within the MOH on the PBF training
  • Conduct a restitution with the other stakeholders such as the Ministry of Finance, AFD, GAVI, UNICEF, UNFPA, CCM, Ministry of Education, FENAMUSAC, MAEECHA, etc.
  • Organize the external review of the current pilot PBF Project
  • Implement the recommendations of this review
  • Mobilise additional resources
  • Scale up the PBF program

Ivory Coast

Cote d’Ivoire is scaling up PBF, which is considered an effective instrument to improve the performance of the health system and a precursor for radical reforms of the health system. There is already ownership by the Ministry and other stakeholder’s buy in.

Niger

  • Assign staff to the PBF unit required for its operation
  • Organize a round table of partners to mobilize funds to ensure PBF
  • Advocate for the opening of a PBF line in the national budget
  • Integrate private health facilities in PBF
  • Train and supervise community workers on the PBF indicator “Household Visit”

Chad

  • Organize meetings at national and regional levels on the 50th PBF course
  • Organize a high-level advocacy meeting and training on PBF
  • Establish a pool of trainers in PBF
  • Advocate within the MSP for more autonomy at health facility level to procure essential drugs at accredited wholesale organizations outside central medical stores;
  • Provide a budget line for the PBF investment units at health facility level
  • Conduct the rationalization of the health facilities in the PBF project area

Haiti

  • Le voyage PBF sous supervision du chef de villageInclude 3 indicators on HIV / AIDS, malaria and tuberculosis in the PBF package;
  • Brief the contracting team responsible for the implementation of the International Strategy on the PBF course;
  • Revise the indicators;
  • Propose the insertion of the Investment Units.

 

Democratic Republic of Congo

Difficulties

  • Low budget allocated to the health sector;
  • Strong centralization of the health system resources;
  • Poor management of resources: corruption, lack of accountability;
  • BF is necessary in DRC to address these issues.

Benin

Strategies to strengthen the health system and the FBR in Benin:

  • PBF promotes the achievement of the Sustainable Development Goals.
  • Integrate other MOH departments in the consultation about the PBF;
  • Obtain the government’s commitment to maintain an appropriate level of governance to ensure the success of the PBF, including progress towards decentralization;
  • Ensure, that health facilities have sufficient equipment and personnel;
  • Ensure that the innovative initiatives (community PBF, quality assurance, involvement of the private health sector, …) are not diverted into vertical programs, but retain their cross-cutting nature;
  • UNICEF, through its mission to the realization of rights of children in accordance with the Convention of Rights of the Child (CRC) is part of this process in Benin not only to strengthen the acquired high impact package at community level but also at health facility level to the fight against child, maternal, and neonatal mortality.

 

The Douala 47th strategic PBF course finished

 

Cours PBF 47 DoualaThe 47th PBF course finished the 26th of June 2015 in Makepe Palace Hotel in Douala.

The 47 participants all came from Cameroon and among them 34 from the Ministry of Health in Yaoundé, 5 from UNFPA and 1 from UNICEF and HGOPY.

There were 6 distinctions which implies a score of 90% or higher in the final test.

Chef de village avec meilleur participantOverall, the International PBF Course Douala was a great success. Also, should we congratulate the 8 groups of participants for the quality of the recommendations.

The report contains important recommendations in particular concerning the need of upscaling PBF in Cameroon, the restructuring of the Regional CDV Agencies and setting up of the national PBF Technical Unit in the MOH as well as proposals for the indicators at primary and hospital level and the costing.

Le dimanche social agréableThe more detailed recommendations of the 8 groups can be found in the French version of this posting.

 

 

Recommendations 46st PBF Mombasa course

Class 46

Class 46

The 46th PBF course ended the 1st of May 2015 in Mombasa.

There were 32 participants from Nigeria (11x), Kenya (8x),  Zimbabwe (6x), Malawi (5x), Rwanda (1x) and Kyrgyzstan (1x). All participants passed the final exam and there were six distinctions of 90% or more.

The next English Mombasa course will be organised from July 27th to August 7th (contact Godelieve van Heteren at sina_health@hotmail.com or robert_soeters@hotmail.com The next open French spoken PBF will be in Cotonou from October 12nd to 23rd –  contact Aoudi Ibouraima at aaoudi1@yahoo.fr

RECOMMENDATIONS OF THE PARTICIPANTS

1. NIGERIA

PBF started in 2011 in Ondo, Nasarawa and Adamawa States in Nigeria with a loan program of the World Bank and administrative support of the National PHC DA and State PHCDA. The program was scaled up to 50% of the Local Government Authorities in the three states. The PBF program considerably improved output and quality of the services and there is great enthusiasm. Yet, there are also a number of challenges, which can be tackled when there is enough technical staff trained in PBF to create a sufficient critical mass of PBF champions.

Nigeria federal level team recommendations

  • Develop an Action Plan for the Implementation of PBF in all States in Nigeria;
  • Sensitize stakeholders at the State level and create platforms for interaction between PBF implementing states and non-implementing States using the PBF alumni
  • NPHCDA should use the national health fund to create a budget line for PBF implementation in all the States
  • Conduct advocacy by visiting relevant stakeholders and present PBF at the Federal MOH TMC meeting and the different Technical Working Groups of the National Health Act – 2014 Implementation Committees to obtain their collaboration.
  • Conduct PBF presentations and Memo’s to the National Council on Health. Upon adoption of PBF by the National Council on Health, States will be encouraged to roll out business plans on how to roll out PBF.
  • Create legal backing for the implementation of PBF in line with existing structures in order to avoid duplication of activities, wastages and conflicts at all levels.
  • The team will also work further to ensure the development and operationalization of the National PBF Policy in Nigeria.

 Nigeria State level recommendations

  • The implementation of PBF in the three states should be according to the PBF best practices;
  • PBF should be scaled up to the remaining 50% LGAs in the 3 states and the DFF approach should be abolished, which was only meant as an impact study technique;
  • The key actors implementing PBF should be remunerated (regulators, CDV agency etc)
  • More policy makers should be trained as change agents in order to create a critical mass of PBF champions in Nigeria.

2. KENYA

Mombasa sunrise

Mombasa sunrise

Kenya is engaged in an administrative devolution process of services towards a system with 47 autonomous Counties. This devolution process is still young and also directly affects the health services. Lessons learned and mistakes committed are gradually becoming available.

There are the following issues and challenges:

  • The Public Finance Management Act of 2012 states that all funds should pass through the County treasury. Yet, this limits the autonomy of PBF health facilities.
  • There still seems to lack the political will and leadership to directly invest in health services. Decision makers require more knowledge about PBF.
  • Skilled health personnel are insufficient in particular in peripheral health facilities. Kenya may not have a total shortage of skilled health workers but moreover a distribution problem of lacking incentives to work in remote counties and health facilities. PBF may solve this problem;
  • Insecurity is rife in some Counties. Emergency PBF approaches may be proposed to assist the distressed populations
  • Poor infrastructure in terms of building, roads, equipment etc. Standard PBF approaches with investment units may assist health facilities to improve their infrastructure and buy equipment
  • Poor participatory planning and budgeting
  • If the facility management team can plan for user fees and is given the authority to use the revenues, this will lead to improved quality services and improved motivation;
  • PBF may be applied in public, private and FBO facilities, thus creating a more competitive environment and choice for patients;
  • PBF provide incentives to health workers that perform better in the health sector and thus contribute to better health outputs;

The feasibility based on 19 PBF criteria showed a score of 50%. The main recommendations are the following:

Kenya recommendations

  • Increase the subsidies given directly to the health facilities, which is currently far below the 70% of the national budget that PBF proposes to pay in cash performance payments directly to health facilities and community programs.
  • Increase the number of RBF indicators at basic health package level from the current ten towards at least twenty.
  • Facility managers should be allowed to buy their inputs from accredited distributers instead of receiving drugs from the central medical stores (KEMSA).
  • Create in each County a separate CDV agency for the contracting process, verification and coaching. Currently a joint verification committee, connected to the county medical teams, does the verification. There is not really a separation of functions.

The Kenyan team proposed the following advocacy strategies:

  • Sensitizing the county health management teams on the PBF concepts
  • Sensitizing the county executive committee members for health & the chief officer for health on the PBF concepts and PBF’s benefits
  • Sensitizing and advocating for PBF with the county assembly committee for health
  • Pilot PBF in at least two health centres and three dispensaries in each County

3. MALAWI

In the recent past, the Malawi public services had as one of its main paradigms to provide free health services and primary education. Many people, however, now realize that what is wanted is not just providing ‘services’ but ‘quality services’.

Malawi has been implementing decentralisation reforms since the early 1990s and government is currently devolving various functions to 35 local government authorities. Providing quality services cannot merely be resolved by increasing government expenditures. It must be matched with at the same time improving the design, implementation and monitoring of the system. Moreover, there is a need to change people’s mind-set and make citizens aware that they also take the responsibility of their own destiny and reflect what they ought to do for themselves and their country. Performance based financing is an approach that supports social entrepreneurship instead of only being ideologically driven by unrealistic advocates of social justice. PBF aims at wide reforms and is, in fact, a new reform approach.

Malawi recommendations

  • Reorienting public service delivery from merely increasing access to also improving quality;
  • Providing performance incentives to public servants and thereby to improve service delivery;
  • Enhancing the collaboration among staff from various sectors
  • Enhancing the drive towards decentralization through advocacy for autonomy for public service providers at the local levels;
  • Motivating facilities (school, health, etc) to produce more and better quality services and thus receive performance bonuses. This extra income should also be used to improve working conditions and staff salaries
  • Separating functions to enhance good governance. It is a ‘purchaser – provider split’ e. a split between purchaser (at district level), regulator (ministry), inspection, provider (schools or hospitals), beneficiaries (communities).
  • Target remote facilities providing services with extra payments for the same activity.
  • Train and contract community groups to conduct satisfaction surveys (school or health). The results should be discussed with school managers and teachers, health staff or other service managers, so that they obtain feedback on their performance.

4. ZIMBABWE

Mombasa village

Mombasa village

During a couple of years Zimbabwe experienced severe socio-economic decline that weakened the social services. In 2010, the Ministry of Health received funding support from the World Bank to finance the health services through results based financing mechanism in 18 rural districts. The project supported primary health facilities and referral hospitals. Based on the encouraging results, the MOHCC and the partners decided in January 2014 to roll out RBF to the remaining 42 rural districts. The urban areas are not yet included in PBF but hopefully they will also start applying urban PBF similar to experiences such as in Cameroon.

The Zimbabwe delegation in Mombasa conducted a PBF feasibility scan which produced a 66% score indicating that there are still steps to be made towards a more pure system.

Zimbabwe recommendations

  • Expand scope of programs incorporated in PBF: TB, HIV, Malaria, NCDs
  • Expanding scope may increase indicators, and funds available for PBF per capita per year
  • Adapt a standard protocol, train personnel, and pay VHWs according to performance
  • Cost recovery mechanisms to be adopted for sustainability
  • Involve private facilities in the PBF contracts that may help government to improve quality care, reduce costs and improve HMIS reporting of all activities instead of only for government facilities.
  • Formalize some cost recovery measures whilst giving the local facility and health centre committee the task of identifying vulnerable clients for exemptions.

5. KYRKIS REPUBLIC 

a.NuristhanHealth reforms in Kyrgyzstan has achieved almost universal access to health care and increased efficiency by reducing excess hospital capacity and reallocating funds to primary health care facilities. However, the quality of care remains a problem. The WB RBF project focuses on district-level hospitals with the aim of increasing provider autonomy and accountability and improving structural aspects and clinical processes of care.

There are the following challenges that may need t be addressed:

  • The project does not pay for output indicators, but focuses exclusively on quality measured using a balanced scorecard containing about 150 indicators.