Nigeria State Health Investment Project (NSHIP ...siteresources.worldbank.org/EXTPBFTOOLKIT/Resources/7364043... · Minimum Package of Activities ... NSHIP Nigeria State Health Investment

Federal Ministry of Health

Ondo, Nasarawa and Adamawa State Ministries of Health

National Primary Health Care Development Agency

Ondo State Primary Health Care Development Board;

Nasarawa and Adamawa State Primary Health Care Development Agencies

Nigeria State Health Investment Project (NSHIP)

Performance-Based Financing User Manual

Final version 14 December 2013

NPHCDA: Plot 681/682 Port Harcourt Crescent, Off Gimbiya Street, Area 11, Garki, Abuja. Tel: +234 802 345 6789, +234 01 2345678, http://nphcda.org/

FMOH: New Federal Secretariat Complex, Phase III, Ahmadu Bello Way, Central Business District, Abuja FCT Nigeria, Tel: +234-9-5238 362, Fax: +234-9-5234590, http://www.health.gov.ng/

PBF portal: https://nphcda.thenewtechs.com/

http://nphcda.org/

http://www.health.gov.ng/

NSHIP Performance-Based Financing User Manual

Version 131214_pbf_usermanual_ng-final Page 2

TABLE OF CONTENTS

TABLE OF FIGURES .................................................................................................................................. 4

TABLE OF TABLES ................................................................................................................................... 5

FOREWORD ................................................................................................................................................ 8

BACKGROUND .......................................................................................................................................... 9

NSHIP- PBF APPROACH ......................................................................................................................... 10

PBF- PRE PILOT EXPERIENCE .............................................................................................................. 13

DEFINITIONS ............................................................................................................................................ 17

SERVICES AND FEE VALUES ............................................................................................................... 22

Health Service Packages: MPA and CPA ............................................................................................... 22

Fee setting for services: Determining the Subsidies ............................................................................... 23

Household visit........................................................................................................................................ 25

Service Protocol Reference Guide .......................................................................................................... 27

The Quality Checklists for Health Facilities ........................................................................................... 27

The Performance Framework for the Local Government PHC Department .......................................... 30

Subsidized Care for the Indigents ........................................................................................................... 30

CONTRACTS ............................................................................................................................................. 33

Contract 1: Multilateral Contract for the LGA RBF Steering Committee .............................................. 33

Contract 2: Purchase Contract between the SPHCDA and the Health Provider ................................... 34

Contract 3: Motivation Contract between the Health Center Management and the Individual Health Worker .................................................................................................................................................... 35

Contract 4: Contract between the SPHCDA and the LGA PHC Department ........................................ 36

Contract 5: Sub-Contract between the Health Provider and a Secondary Health Provider .................. 36

PERFORMANCE MANAGEMENT AT THE HEALTH FACILITY ...................................................... 37

Business Plan .......................................................................................................................................... 37



Indice Tool .............................................................................................................................................. 38

Framework for Individual Performance Evaluation............................................................................... 38

MONITORING AND EVALUATION ...................................................................................................... 39

FRAUD: PREVENTIVE MEASURES AND PENALTIES ..................................................................... 42

Possible Fraud ........................................................................................................................................ 42

Fraud prevention .................................................................................................................................... 42

Penalties for Fraud ................................................................................................................................. 43

DATABASE ............................................................................................................................................... 46

PAYMENT CYCLE ................................................................................................................................... 48

Rules of Use of the PBF Income ............................................................................................................. 49

Invoices ................................................................................................................................................... 49

CAPACITY BUILDING ............................................................................................................................ 49

COORDINATION ...................................................................................................................................... 50

ANNEXES .................................................................................................................................................. 52

Annex 1: Multilateral Contract for the LGA RBF Steering Committee .................................................. 52

Annex 2: Purchase Contract between the SPHCDA and the Health Provider ....................................... 60

Annex 3: Motivation Contract between the Health Center Management and the Individual Health Worker .................................................................................................................................................... 76

Annex 4: Contract between the SPHCDA and the LGA PHC Department ............................................ 80

Annex 5: Sub-Contract between the Health Provider and a Secondary Health Provider ...................... 85

Annex 6: MPA and CPA ......................................................................................................................... 87

Annex 7: Service Protocol Reference Guides ......................................................................................... 89

Minimum Package of Activities ......................................................................................................... 89

Complementary Package of Activities ................................................................................................ 93

Annex 8: Quarterly Quality Supervisory Checklist for Health Centers .................................................. 98

Annex 9: Quarterly Quality Supervisory Checklist for General Hospitals ........................................... 117



Annex 10: Monthly Health Facility Invoice .......................................................................................... 139

Health Center .................................................................................................................................... 139

General Hospital ............................................................................................................................... 141

Annex 11: Quarterly Consolidated LGA Invoice .................................................................................. 143

Annex 12: Performance Framework for the LGA PHC department ..................................................... 145

Annex 13: Business Plan for Health Centers ........................................................................................ 149

Annex 14: Indice Tool for Health Centers ............................................................................................ 161

Annex 15: Individual Performance Evaluation Template ..................................................................... 165

Annex 16: Column Headers for PBF Registers .................................................................................... 170

Annex 17: Terms of Reference for the Health Center Health Committee/General Hospital Governing Board .................................................................................................................................................... 171

Health Center: ................................................................................................................................... 171

General Hospital: .............................................................................................................................. 173

Annex 18: Terms of Reference for the Indigent Committee .................................................................. 175

Annex 19: Indicative Indice Values for Health Center Staff ................................................................. 178

Annex 20: Terms of Reference for the Health Center and General Hospital Internal Management Committee ............................................................................................................................................. 179

TABLE OF FIGURES

Figure 1: The Nigeria PBF Administrative Approach ................................................................................ 13

Figure 2: Purchaser-Provider Split in the NSHIP-PBF Approach .............................................................. 21

Figure 3: Image of the public frontend of the PBF web-enabled application ............................................. 47



TABLE OF TABLES

Table 1: An important note for the reader ..................................................................................................... 9

Table 2: December 2012 SWOT analysis for the PBF pre-pilot ................................................................ 14

Table 3: An example of the application of a rural hardship weighting ....................................................... 24

Table 4: Changing the weight for content of care ....................................................................................... 28

Table 5: Weighting for the 15 Health Center Services in the 2014 Quality Checklist ............................... 29

Table 6: Weighting for the 15 General Hospital Services in the 2014 Quality Checklist .......................... 29

Table 7: Evaluations: ex-ante and ex-post .................................................................................................. 39

Table 8: Penalties in case of more than 5% (up to 10%) untraceable clients ............................................. 43

Table 9: Penalties in case of more than 10% untraceable clients................................................................ 44

Table 10: Penalties in case of more than 10% unexplained discrepant results in quality counter-verification of health centers ....................................................................................................................... 45



ACRONYMS

AFB Acid Fast Bacillus AIDS Acquired Immunodeficiency Syndrome CPA Complementary Package of Activities DFF Decentralized Facility Financing DLI Disbursement Linked Indicator DOTS Directly Observed Therapy for Tuberculosis DPM Director of Personnel Management DRF Drug Revolving Fund EDL Essential Drug List EDM Essential Drug Management FMOH Federal Ministry of Health HCWM Health Care Waste Management HMIS Health Management Information System HIV Human Immunodeficiency Virus HRITF Health Results Innovation Trust Fund MDG Millennium Development Goal M&E Monitoring and Evaluation MySQL My Structured Query Language NAFDAC National Agency for Food and Drug Administration and Control NSHIP Nigeria State Health Investment Project MPA Minimum Package of Activities NPHCDA National Primary Health Care Development Agency IBRD International Bank for Reconstruction and Development IC Indigent Committee IDA International Development Association LGA Local Government Authority PBF Performance-Based Financing PFMU Project Finance Management Unit PIM Project Implementation Manual PBF-TSU PBF Technical Support Unit, unit of the SPHCDA PCN Pharmaceutical Council of Nigeria



PFMU Project Financial Management Unit PHC Primary Health Care PHP Hypertext pre-processor PTB Pulmonary Tuberculosis RBF Results-Based Financing RBF-TA Results-Based Financing Technical Assistance Agency; staffing the PBF-TSU SMOF State Ministry of Finance SMOH State Ministry of Health SPHCDA State Primary Health Care Development Agency SPHCDB State Primary Health Care Development Board (Ondo State) SURE-P Subsidy Reinvestment & Empowerment Program USD United States Dollar WB The World Bank



FOREWORD

[Executive Director NPHCDA]



BACKGROUND

Performance-Based Financing (PBF) for health services has been introduced in many developing countries over the past decade: for instance in Cambodia, Haiti, Afghanistan, Democratic Republic of Congo, Rwanda, Burundi, Cameroun, Central African Republic and Indonesia.1 The approaches in various contexts differ; but they all aim at increasing the efficiency, effectiveness, quality and equity of health services offered to the population.

The PBF approach generates interest from Ministries of Health who are looking for ways to reach the health-related Millennium Development Goals 1, 4, 5 and 6. Reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases are high on the agenda. PBF approaches have been especially successful in improving access to curative services,2 and increasing the uptake of preventive services such as vaccination in children and pregnant mothers, voluntary counseling and testing for HIV, institutional deliveries and the use of modern family planning methods. While increasing the volume of services, PBF also increased considerably the quality of these services.3

Table 1: An important note for the reader

1 By the end of 2013, there were over 32 countries planning, designing or implementing such PBF approaches. 2 Especially in areas where there were dysfunctional health services, see for instance: SOETERS, R., PEERENBOOM, P.-B., MUSHAGALUSA, P. & KIMANUKA, C. (2011) Performance Based Health Financing Experiment Improves Care in a Failed State. Health Affairs, 30, 1518-1527, or where there are dysfunctional free health care systems see for instance: MEESSEN, B., SOUCAT, A. & SEKABARAGA, C. (2011) Performance-based financing: just a donor fad or a catalyst towards comprehensive health care reform? Bulletin of the World Health Organization, 89, 153-156. 3 BASINGA, P., GERTLER, P., BINAGWAHO, A., SOUCAT, A., STURDY, J. & VERMEERSCH, C. (2011) Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. The Lancet, 377, 1421-28.

This is a long manual with a lot of information. We hope that managers and health workers will find it useful. We understand that managers and health workers will have to explain and teach difficult PBF concepts to their colleagues who might be too busy to study all details in this manual. To facilitate their task, we will create a separate ‘executive summary’ which will attempt to explain in easy language the 10 most important issues from this manual.



Although PBF approaches differ, they tend to have certain elements in common, they:

• increase managerial autonomy and decision making rights on resources; • use non-governmental agencies for a purchaser role and management support; • introduce a purchaser-provider split; • Enhance monitoring and evaluation and data use; • Use a fee-for-service-conditional-on-quality provider payment mechanism; • Introduce performance frameworks at various levels of the health administration; • Strengthen the community voice by requesting feedback from users and creating new

governance mechanisms while strengthening existing ones.

PBF usually starts with pilot projects after which scaling up to the national level is attempted. Such has been the case in Rwanda, where successful PBF pilot projects which were started in 2002 covering by 2005 about 40% of the health delivery network, which convinced the Ministry of Health of their effectiveness, after which PBF was scaled up to national level during 2006. Burundi was a similar case: pilot projects were started in 2006, expanded to cover 40% of the country by 2009, which were scaled up nationwide in April 2010.

Conceptually, the Nigeria State PBF approach is a ‘contracting in’ approach. Government, with technical and financial support from development partners, contracts-in technical assistance to purchase health services from public, and faith based health institutions. An internal market is created in which government purchases services from public, and private non-for profit and private for profit health providers.

In this innovative PBF approach, the State Primary Health Care Development Agency (SPHCDA) is the purchaser of services. The SPHCDA contracts-in a technical agency – the Results-based Financing Technical Assistance Agency (RBF-TA) - to carry out the purchasing function. The State Ministry of Health (SMOH) is the regulator. The Local Government Authority Primary Health Care Department is contracted to execute the quality supervisory function. The government through the State Ministry of Finance/Project Financial Management Unit (SMOF/PFMU) is the fund holder. This PBF approach allows multiple fund holders to purchase performance: they can be billed their share and pay facilities for performance directly.

NSHIP- PBF APPROACH The Nigerian State Health Investment Project (NSHIP) is a USD$171million five-year program which will be implemented in Ondo, Nasarawa and Adamawa States. Of this amount $20M is a grant from the Health Results Innovation Trust Fund (HRITF), in addition to a $1M grant for an impact evaluation. The NSHIP has a 100% Results-Based Financing (RBF) focus.



Various Results-Based Financing components of this program aim at changing the incentive environment and the accountability and governance mechanisms at State level, at the Local Government Authority level, and at the health facility level.

The NSHIP largely consists of the introduction of Performance-Based Financing (PBF) in the three States. This PBF manual details the institutional arrangements for the PBF approach. The operational details for the larger NSHIP can be accessed through the NSHIP Project Implementation Manual (PIM). This PBF manual is an integral part of the PIM.

A PBF pre-pilot has been introduced in one select LGA in each State. This was done before scaling up in half of the LGAs in each State. Building local capacity for PBF and to adapt PBF to local realities was its purpose. See the next section for a summary of the experience so far.

Rather than being a ‘contracting-out’ model (an approach in which non-state actors are contracted to provide certain services), the NSHIP- PBF is a hybrid approach with a ‘contracting-in’ in which contracted-in non-state actors and co-opted civil society strengthen Government services.

This PBF approach effectively creates an internal market though which the SPHCDA purchases health services from public, private and faith based organization-managed health facilities.

Performance-contracts are writing throughout the system. Performance frameworks exist for the Health Facilities, for the community client surveyors, and for the Local Government Authority (LGA) Health Team.4

Figure 1 shows the administrative arrangements for PBF.

• Decentralized governance for PBF is done at the local government level through a formal steering committee.

• A purchaser-provider split: contracting and verification/counter-verification is done through a specific purchasing unit (with an embedded RBF-TA) from the SPHCDA.

• The LGA- PHC department verifies the quality at the health centers using a quantified quality checklist.5

• The SPCHDA through its purchasing unit through a defined protocol carries out community client satisfaction surveys.

• The SPHCDA organizes through a defined protocol regular counter-verifications of the reported quality of health centers and general hospitals.

4 Performance contracting is considered for the NPHCDA PBF-unit, and for the SPHCDA. 5 In Adamawa State the LGA-PHC department is directly managed by the SPHCDA.



• Technical assistance, coordinated through state level extended team mechanisms is systematically provided.

• The community has a voice through the community client satisfaction surveys.



Figure 1: The Nigeria PBF Administrative Approach

PBF- PRE PILOT EXPERIENCE The PBF pilots were started Dec 1st, 2011 in three LGAs: Ondo-East LGA in Ondo State; Wamba LGA in Nasarwa State and Fufore LGA in Adamawa State. In June 2011, a two-week intense PBF training was held in Enugu. From June onward, three international PBF consultants were posted in the three LGAs – one in each LGA, the tools were designed, fieldtested and adapted, and an intense training was provided towards the end of June 2011 on location in the three States. In December 2012, a review was done of the experience so far, using a SWOT approach see table 1.



Table 2: December 2012 SWOT analysis for the PBF pre-pilot

Strengths Availability of drugs First quarter payment was done BP financing was done Commitment from the health workers (experienced) consultants were present all the time (in the field) Early impressive achievements in two states Community participation (ward health committees; local leaders) Health facility autonomy & fund availability High level political commitment Improved health infrastructure/equipment (due to availability of cash) Intense supervision (part of PBF intervention) Availability of champions in two States Pooling of staff in the intervention health facility (HR interventions) Web-application functional http://nphcda.thenewtechs.com/

Weaknesses Payment for performance for Q2-3 has not been done in two states, and Q1-3 was never paid in the third state Shortage of qualified staff in some facilities [absence of money led also to difficulties for verification; supervision and coaching] Overstaffing and wrong cadres Relative high salaries Nigerian health workers (and therefore low impact of the incentives through PBF) Administrative weakness (e.g. HRITF and PPF funds available for 1.5 years but not utilized) Absence of champions in one State Institutional structures are not yet established in the States (various steering committees and working groups)

Opportunities Get the message out wider as there are results to be shared UN agencies and development partners would be supportive if they can see how it works Attract more support Engage civil society to strengthen accountability SURE-P program Saving one millions lives program Active media engagement

Threats Program needs to be scaled-up quickly Entrenched interests (e.g. central procurement of drugs) Centralized control Bottlenecks in disbursements can kill the program Lack of political will Transfer of staff Lack of understanding of PBF principles

The pre-pilot PBF program showed remarkable results. Quantity and quality enhancements were quick and significant: https://nphcda.thenewtechs.com/. The PBF pre-pilot has importantly shown that PBF as a concept works very well in Nigeria. There is room for even better

http://nphcda.thenewtechs.com/

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performance, and the SWOT analysis in table 1 brings out the lessons learned and some pointers at future system strengthening activities. Some things worked well, and some things less well:

Things that worked very well:

• Introduction of the business plans and the investment units and thereby a rapid increase in quality across the board;

• Introduction of drug revolving funds (suggested during the training and picked up by all) and transparent pricing mechanisms led to an immediate access to essential reasonably priced drugs;

• Decentralized purchasing of drugs and medical consumables by health facilities themselves and thereby a rapid availabity of reasonsable quality drugs;

• Staff motivation and client receptiveness leading to much higher utilization of services by the community and quality of services provided;

• Counter-verification of the quantity and the quality was done and showed a very high level of correlation with reported results and this finding is important for the credibility of the much enhanced results.

Things that worked less well:

• Fee-exemptions for the indigents were not implemented. The review after one year indicated that program managers were unsure of the post-identification mechanism (they had not implemented it), and did not see the need for it either. Protecting the poorest requires thinking and talking about how we can protect the poorest against high health expenditures, and to test and implement novel approaches that target the poorest.

• The service ‘new latrine constructed’ did not take off, and it was stopped. • The service ‘impregnated mosquito net sold’ did not work well as there was interference

by nationwide mosquito net distribution campaigns, it was stopped. • Monthly and quarterly income-expense statements in the indice tool proved difficult for

health facility managers and more effort would need to be put into capacity building and coaching for this essential management tool to ensure a more effective use of this indispensable management tool.

• Payments were delayed significantly in all three states (over nine months), and although payments were carried out in full eventually, it led to a drop in confidence by the health facilities (and a corresponding drop in results). Regular performance payments are a condition sine qua non of PBF.

Areas of future system strengthening include and are not limited to:



Human resources for health will need radical reform. Whereas the total amount of health staff is probably sufficient, they are wrongly distributed and some lower cadres are in excess. Management of human resources would need to be decentralized to the health facility levels, which should be able to hire the staff they need (only).

Demand side barriers to health service utilization need to be tackled to maximize utilization. Targets for such demand-side interventions are: (i) enhanced information campaign on patient rights; (ii) conditional cash transfer program (such as planned through the SURE-P); (iii) transport vouchers for maternal health services; (iv) enhanced output budget which would allow excempting the poorest of the poor to access essential services.

Management of health facilities needs strengthening. The introduction of cash management, activity planning through business plans and investment units, individual performance evaluations and formal collaboration with the community has brought out weaknesses (and sometimes unexpected strengths). There is need for interventions such as (i) a professional stream of ‘health facility managers’ who are selected and trained, and rewarded for their management of inputs and results; (ii) benchmarking of health facility managers; (iii) rewarding managers for good performance and (iv) intense coaching for the application of novel strategies to boost demand and supply of health services.

The PBF output budget needs increasing. The PBF output budget which is around $2.7 per capita per year is too meager for the Nigerian context. States would do well by planning a higher amount (double to triple the current amount) for this output budget. A higher output budget combined with other reforms – most notably comprehensive HRH reforms- would maximize results and Nigeria can afford it.

The private-for-profit sector in urban areas needs engaging. Urban areas in the project States, just like in the rest of Nigeria house about half the population. Whereas in rural areas public providers are virtually the only qualified providers, in urban areas there is a booming private sector. The public service delivery network is insufficient to cater for the population in urban areas, and this is why it is important to engage with select private providers in urban areas to offer equitable access to health services for Nigerians.

The poorest of the poor need protection. Whereas putting in place a post-identification mechanism has never been done before in Nigeria (but has been done successfully elsewhere)6, this cannot be an excuse for not doing it. Until the time has come when a civil registration system works well, and a the poorest of the poor are pre-identified so

6 In many small PBF pilots there is experience with applying post-identification mechanisms. Increasingly, such post-identification mechanisms are built into large pilots, some with a specific research component to study its effect such as Burkina Faso and Congo.



that they can be exempted or charged a lesser fee when using health facilities, other mechanisms to reach the poorest have to be used. A post-identification mechanism is a reasonable method to do just that.

DEFINITIONS Definition of PBF: services are purchased through Performance-Based Financing. The transaction is based on a purchase contract. Both service quantity and service qualities are rewarded. Services purchased are of a limited number (which typically are 15-24), while the quality consist of hundreds of data elements. The quality measure, through a quantified quality checklist, or ‘balanced score card’ leads to a single composite quality value.

A working definition of Performance-Based Financing (PBF) was elaborated in 2010 by the community of practitioners and knowledge institutions in the forefront of PBF development7:

“Performance-Based Financing is a health systems approach with an orientation on results defined as quantity and quality of service outputs. This approach entails making health facilities autonomous agencies that work for the benefit of health related goals and their staff. It is also characterized by multiple performance frameworks for the regulatory functions, the performance purchasing agency and community empowerment. Performance-Based Financing applies market forces but seeks to correct market failures to attain health gains. PBF at the same time aims at cost-containment and a sustainable mix of revenues from cost-recovery, government and international contributions. PBF is a flexible approach that continuously seeks to improve through empirical research and rigorous impact evaluations which lead to best practices (see footnote).8”

Definition of Results-Based Financing: Results-Based Financing (RBF) is a term which encompasses the entire family of incentive approaches, both on the supply-side, and on the demand-side. PBF is a sub-set of RBF, and is classified as a specific RBF strategy.9

7 As discussed on the PBF googlegroups forum, a discussion forum of the African PBF Community of Practice, final consensus working definition as of 17 August 2010. 8 PBF draws from micro-economic, systems analysis, public choice and new institutional economics theories. The effectiveness can be enhanced by demand-side interventions such as equity funds; conditional cash transfer programs, vouchers schemes and obligatory community based health insurance programs. Definition discussed and accepted on the African PBF community of practice discussion group, August 2010. 9 Musgrove, P. (2010). Financial and Other Rewards for Good Performance or Results: A Guided Tour of Concepts and Terms and a Short Glossary. Washington DC.



Definition of Decentralized Facility Financing (DFF): in decentralized facility financing or DFF in short, health facilities receive enhanced autonomy and once per quarter lump-sum cash transfer into their health facility bank accounts. All LGAs in the three project states have been randomly assigned to either ‘DFF’ or ‘PBF’. This random assignment is part of an impact evaluation in which the Government of Nigeria is testing the effectiveness of PBF and DFF. The DFF facilities will get on average 50% of the cash that PBF facilities have earned. PBF facilities can use up to 50% of their income for paying performance bonuses, however DFF facilities cannot use their income for performance bonuses, only for spending on items and activities to increase quality or increase service production. DFF facilities will also get at least once per quarter a supervision from the LGA – PHC department, where the LGA- PHC department will apply the quality checklist. The score of the quality checklist will not influence the earnings. Based on the results of the impact evaluation, DFF – LGAs might transit to become full fledged PBF – LGAs.

Definition of the Provider: the provider is an institution contracted to supply services. Providers are health centers and general hospitals; public, quasi-public and private. Main PBF contract holders are allowed to sub-contract certain services. Sub-contracted Health providers can be public, private non-for-profit or private-for-profit. Sub-contracting is a strategy that is negotiated between the purchaser and the provider, through the business plan.

Definition of the Regulator: the regulator is the State Ministry of Health. The SMOH has multiple levels of regulatory functions related to PBF.

First, the SMOH participates in the design and continuous development of the quantified quality checklists:

• Quality checklists reflect the priority norms of the SMOH (such as for instance adherence to the national waste disposal guidelines);

• Priority norms are made operational through quality checklists; • The regulatory role is made operational through performance contracting of the LGA

PHC department by the SPHCDA; • Quality supervisory checklists - applied by the local government health teams once per

quarter to the PBF health centers - are based on National Health Service deliver norms. Quality checklists contribute to a quality bonus of a maximum of 25% on top of the quantity earnings of health centers.

Second, the SMOH is closely involved in the peer-evaluations of the general hospitals;



• General Hospitals are subject to a quality checklist once per quarter, using a transparent peer-review mechanism. Here also, a 25% quality bonus is at stake.

Third, the SMOH is part of a tripartite quorum for the LGA RBF Steering Committee meetings:

• Without SMOH presence such steering committee meetings are unable to validate performance pay for the contracted health facilities.

Fourth, the SMOH participates in the extended team mechanism. This is an implementation oriented coordination mechanism. Policy and strategy oriented coordination mechanisms are the State RBF steering committee and the RBF Technical Working Group.

• The SMOH, in close collaboration with the SPHCDA and partner agencies drafts policy and strategy related to PBF.

Fifth, the SMOH’s technical collaboration with the State office of the National Agency for Food and Drug Administration and Control (NAFDAC), the State office of the Pharmaceutical Council of Nigeria (PCN) and the SPHCDA on drugs and medical consumables:

• The State NAFDAC and the State PCN will work closely with the SMOH and the SPHCDA to certify three to four distributors in the State for selling generic drugs to PBF contracted facilities;

• PBF facilities are contractually obliged - guided by availability and best quality/price - to procure their inputs from one of these certified distributors and to stock generic drugs only;

• Compliance is checked – and rewarded- through quarterly quality reviews; • Providers paid through public funds will need good guidance on market prices and

relative quality of drugs.

Definition of the Purchaser: the Purchaser is the SPHCDA. The SPHCDA deploys verifiers, about 1 to 2 per local government authority. The SPHCDA roles are:

• Performance contracting of health facilities, both public and private; • Negotiating targets and strategies through business plans; • Contract management and strategic purchasing; • Carrying out monthly or bi-monthly verification on the services produced; • Once per quarter, the SPHCDA - through select members from grass root organizations-

carries out community client surveys to: a. find out whether the clients have actually received the service (to avoid the

‘phantom patient phenomenon’);



b. to get feedback from clients on their satisfaction and on their perception of the quality of care;

c. Other information such as for instance how much money the clients paid; • Assessing whether the local government health department deliverables have been met.

This makes the SPHCDA a controller for an internal SMOH function (the correct execution of the regulatory function on behalf of the SMOH);

• In consultation with other stakeholders get agreement on the content of the service packages;

• Due diligence on validation procedures of the LGA RBF Steering Committees; • Printing the quarterly invoice from the web-application and sending to the PFMU and

eventual other fund holders for payment; • Coordination and capacity building for PBF; • Coaching of health facilities in enhancing performance.

Definition of the Separation of Functions: separation of functions is a core concept of PBF. In the Nigerian PBF approach it is:

• primarily a separation of the purchaser from the provider; • secondly, a separation between the regulator and the purchaser; • Thirdly, a separation between the purchaser/verifier and the fundholder.

An important concept is the purchaser-provider split. The purpose of this split is to avoid or reduce situations of conflict of interest or collusion. The SPHCDA is a para-statal, with its chief executive reporting to the Health Commissioner.

A special purchasing unit will be created within the SPHCDA to reinforce this separation of functions. This Performance-Based Financing Technical Support Unit (PBF-TSU) will be staffed by a contracted-in technical assistance agency. The verifiers will be on the PBF-TSU pay-roll, including some key technical support staff. Direct line management of this unit - including several technical and support functions- will be through SPHCDA staff. The entire unit will be under a performance framework. This approach has been applied successfully in the Rwanda and Burundi PBF technical support units.

When products/outputs/performance needs to be assessed, and are linked contractually to money, having an independent verifier, and credible checks and balances becomes important. See figure 2 below:



Figure 2: Purchaser-Provider Split in the NSHIP-PBF Approach

Definition of the Purchaser-Provider Split: the purchaser-provider split is a concept which indicates that the purchaser (the SPHCDA) is not providing the services itself. Implicit in this definition is that the provider is not verifying itself but that the provider is verified by the purchaser, or by an agent hired by the purchaser.

Description of the role of the Contracts: five contracts are used in the Nigerian PBF approach. These contracts are described in the section ‘contracts’ and are annexed in full to this manual.

Contracts are meant to clarify expected performance and to establish the new rules of PBF. It is vital that all working in PBF understand these contracts to a sufficient extent. Clarity in expected roles, and expected performance and transparency of control procedures and clear communication of results to all will contribute to lowering the risks, and implementation costs of PBF.

A strong initial effort in rolling out PBF through well-designed training modules, and continued strong support to local government RBF steering committees, although costly and time-consuming, will bear fruit in the mid to long term.



Definition of the Business Plans:10 business plans in the Nigerian PBF approach are an integral part of the purchase contract between the SPHCDA and the health facility. Business plans are unlike action plans: action plans have a tendency to present overinflated targets which are never met. Business plans on the contrary are carefully negotiated between the SPHCDA and the health facility and are tied to the purchase contract. The health facilities have to indicate how they propose to get from A to B, and what interventions, and physical resources will be used to reach those targets.

Definition of Investment Units: investments units, also called quality improvement units, are pre-defined lump sums of money which are part of the business plan approach. Investment units form part of the start-up of the PBF approach, and if necessary, will be used six-monthly during re-negotiations of the business plans. Health facilities, based on an approved business plan, can use their autonomy to implement their strategies using these investment units.

SERVICES AND FEE VALUES Performance-Based Financing uses a mix of quantity and quality indicators to define the level of performance of a health institution. Performance frameworks are also applied to the health administration and contain process indicators.

For PBF facilities the quantity performance is measured monthly or bi-monthly and the quality performance is measured once per quarter. Each defined service has a unit fee/subsidy and the quality carries a bonus up to 25% of the earnings.

We will discuss in turn:

1. Health service packages; 2. Fee setting for services; 3. Quality checklists for health facilities; 4. Performance framework for the LGA health department; 5. The purchase of home visits; 6. Subsidized care for the indigents.

Health Service Packages: MPA and CPA The PBF health service packages are carefully designed to respond to health problems facing the Nigerian population. The PBF service packages are based on 14 years of incremental experience gained on purchasing services through PBF. The services chosen have the highest potential to

10 Also called ‘management plans’



contribute to meeting the health related Millennium Development Goals. There are two types of health service packages:

1. Minimum Package of Activities (MPA): for the health center and community level, 2. Complementary Package of Activities (CPA): for the first level referral hospital.

The MPA and CPA are listed in annex 6. Each defined service carries a variable unit fee.

Fee setting for services: Determining the Subsidies The fees were modeled using a financial risk forecasting method commonly used in PBF projects.11 Baseline data were drawn from the 2008 Demographic and Health Survey. As the three States have radically different baselines for the same services, the set of fees for each of the three States will differ over time.

It is important to note the difference between a PBF fee, and a traditional fee-for-service provider payment mechanism. In PBF systems it is assumed that the costs for the services are already met (human resources; building; equipment and various recurrent expenses for vertical programs). However, these services do ‘not move’; there is low output and a general lack of coverage for important public health services. Therefore in PBF we talk about ‘subsidies’.

The PBF ‘fee’ for a ‘new outpatient consultation’ is not meant to pay for the cost of delivering this consultation. It is a subsidy for this service. Depending on local context, total subsidies for curative care can be around 20-30% of available PBF budget, the rest are subsidies for preventive services. The level of these PBF subsidies can change, depending on certain equity adjustments, local priorities and available budget. These variables are discussed below.

The combined subsidies for all services are modeled at $1.8 per capita per year for the MPA and $0.9 per capita per year for the CPA. Within a State, policy makers can decide to allocate a certain equity weighting for local governments. Such weighting can be based on for instance:

1. distance in travel time to the State capital; 2. health worker population density; 3. Relative poverty measure. Such measures can thus lead to the allocation of a slightly

higher per capita PBF output budget to certain local governments which are scoring lower on these measures.

11 Fritsche, G., Soeters, R., Meessen, B., Ndizeye, C., Bredenkamp, C., Heteren, van, G. – (2014). PBF toolkit, Chapter 4: Setting the unit price and costing. The World Bank, Washington DC



Within a given local government area, the purchaser can allocate an ‘equity weighting’ for relative destituteness of a facility (‘rural hardship’). Contracted facilities are categorized in five categories 1 – 5; with a maximum difference in subsidy levels for individual services of 40%. See figure 3 below: the unit fees are illustrative only. The Cat3 column represents the average fee for that LGA.

Table 3: An example of the application of a rural hardship weighting

An equity calculator has been developed to assist in this calculation. However, the actual fee/subsidy setting will be done through the web-enabled application (the ‘cloud computing’ see the section on the database).

The local government health department will have to assist in categorizing its health facilities in these five categories. The health facility closest to the LGA administrative center would typically be a ‘Category 1’ health facility, while the health facility with the longest travel time to the administrative center, the furthest from the main road and some other metrics, would typically fall in a ‘Category 5’ category. The idea is that if one health facility is categorized as a ‘Category 5’ (+10% fee), that the health planners will have to find another facility to categorize as a ‘Category 1’ (-10%). Namely: the average fee for the LGA is the Cat3 column.



Higher subsidies for services in the most remote and destitute health facility are a way of providing that facility with the means to attract and retain qualified staff, and to compensate it for the higher costs of delivering quality health services in general.

Fees/subsidies can be negotiated quarterly, if need be, depending on level of achievement/performance, and locally and communally perceived needs and targets; this requires a process of negotiation between the health facility and the purchaser.

Household visit Performance-based financing (PBF) programs have, over the years, tried to engage with community-based activities. The basic purpose of these engagements was social marketing (attracting clients for services); the dissemination and use of Insecticide Treated Bed nets and the construction of Latrines. In rare cases, such engagements have led to innovative attempts to engage community health workers directly or indirectly through PBF approaches (Rwanda; Mali).

In Ondo, Nasarawa and Adamawa states, some targeted community activities have also been tried in the PBF pre-pilot LGAs but to not much avail. Paying for distributing bed nets, in a context where large vertical programs already pay for these bed nets, including their distribution, or in a context where Ventilated Pit Latrines are not very common (rural remote Nigeria) such measures do not lead to an outright effect, or lead to perverse effects such as claiming the community based distribution of bed nets for payment. This early Nigerian experience is similar to those of a growing number of countries with such PBF programs, and the consensus is that something else needs to be done at the community level.

There is an increasing tendency for mixing Results-based financing approaches which work on both the supply and the demand side. As an example: PBF programs combined with Conditional cash transfer programs (planned for Senegal; Nigeria; Republic of Congo); PBF programs combined with voucher schemes (planned for Yemen).

In Cameroun, in the context of a PBF program in Littoral, there is an ongoing experimentation with the purchase of a ‘house hold visit’. This intervention is also planned in Burkina Faso and the Republic of Congo. This novel community based intervention is described below.



The purchase of a house-hold visit12

In essence, the purchase of ‘a house-hold visit’ is a demand-generating activity and a public health intervention at the same time. It is a paid visit, by a team of community health workers, or a grassroots organization, of a household, using a protocol.

This protocol consists of the following:

• How does the household dispose of household waste? • Do household members regularly wash their hands? • What is the family planning status and reproductive choice of women aged 15-49 in the

house hold? • Are children exclusively breastfed until 6 months? • Is the latrine or toilet available, clean and utilized? • Is the house hold using insecticide treated bed nets? • Does the household have access to clean water?

The process is as follows:

• 1st, 2nd and 3rd house hold visit, according to protocol, each visit paid separately (in Burkina Faso for instance @ $2.40 per visit which in Burkina involves 16% of the total budget for PBF)

• During the first household visit the baseline situation in the household is reviewed, and recorded in a standard register. The team then discusses with the household on the specific actions to be taken during a 2 month period respectively by the household members, the health center staff and the local administrative authorities.

• The second household visit will be planned to monitor the actions and recommendations. Some recommendations such as on child vaccinations or family planning are voluntary while others are more binding such as that authorities will insist that the household must have a hygienic toilet or latrine in the house. The medical person may discuss behavioral changes while the person for household hygiene indicators provides more binding recommendations including in extreme cases penalties. If the results during the second household visit are satisfactory, this ends the inspection of that particular household.

• IF there are still problems during the second household visit, a third visit may be proposed.

12 This information was kindly provided by Dr Robert Soeters



Service Protocol Reference Guide Service protocol reference guides define further the PBF services and list the primary and secondary data collection tools. They are meant to be used by the health facility, the local government health authority and the purchaser.

PBF uses defined primary registers for each service, and also has defined secondary registers. Primary registers are the ones in which the verifiers will be ‘counting the services’. Secondary registers are meant for deeper verifications in case of discrepancies, or when there is a ‘counter-verification’ exercise.

Signing a purchase contract obliges the health facility contractually to use these defined primary and secondary data collection tools, according to their set formats. The formats for the column headers are listed in annex 16. If the primary and secondary data collection tools are not filled in completely and legibly, then in that case the service concerned will not be remunerated.

Each PBF service line has, apart from identifying information and medical data, a column for the mobile phone number. If this column is not filled in- just like any other identifying information - the service provider will not get paid for that service. Clients will provide their personal mobile phone number and in case they do not have such, a number of a neighbor, a family member who lives close, or the village chief.13

In the rare instance in which clients cannot provide a mobile phone number, they will have to sign next to the mobile phone column header.

The service protocol reference guides can be found in annex 7.

The Quality Checklists for Health Facilities The quality checklists for health facilities consist of a checklist for the health center, and a different one for the General hospital. These checklists have been developed from existing checklists in successful PBF projects, and adapted to the Nigerian context. The purpose of these checklists is to guide the health facility in delivering services according to prevailing norms. The focus of these checklists is predominantly on structural quality, although clinical processes (rational drug prescribing patterns and adherence to defined treatment protocols) are also measured and rewarded.

13 In Wamba LGA in Nasarawa State, the LGA decided to enumerate all households in the LGA. The household number was then used in case the client did not have a mobile phone number.



These checklists attempt to be as objectively verifiable as possible. Different people measuring the same thing ought to lead to the same scores. The health center quality checklist will be applied by the local government health authority once per quarter to each contracted facility.

The local government health authority will be under a performance contract to carry out this important function timely and correctly. The local government authority PHC department performance framework can be found in annex 12.

There will be a third-party counter-verification mechanism set up for this quality checklist: through a defined protocol, the scores provided by the local government authority will be counter-verified. The health center quality checklist can be found in annex 8.

The General hospital will also be subjected to a quality checklist, once per quarter. A peer-evaluation mechanism will be set up, whereby key technical and administrative staff from other hospitals, with representatives from the SMOH, SPHCDA and civil society, will peer-evaluate each other’s performance. Also, a transparent counter-verification mechanism will be set-up. The General hospital quality checklist can be found in annex 9.

Quality has various dimensions, and the PBF checklists can only measure some dimensions. Lessons from other PBF projects point at the importance of regular – typically once per year - review of the quality checklists. New norms and guidelines can thus be incorporated as they come available. Feedback from the end users can inform the design. The quality bar can be put progressively higher.

Table 4: Changing the weight for content of care

The quality checklists have been modified since the 2011 pre-pilot experience and the revised checklists are included in this manual. The checklists have been changed to put a significantly larger weighting on actual content of care. Indicators that directly measure content of care, such as file reviews, provider knowledge on TB danger signs or observations of actual patient – provider interactions, received a weighting of 25.6% (84/324) in the MPA and 38.4% (218/567) in the CPA.



Table 5: Weighting for the 15 Health Center Services in the 2014 Quality Checklist

Nr MPA Service (2014) Points Weight_% 1 General Management 21 6.5% 2 Business Plan 9 2.8% 3 Finance 15 4.6% 4 Indigent Committee 2 0.6%

5 Hygiene and medical waste disposal 31 9.6%

6 OPD 97 29.9% 7 Family Planning 22 6.8% 8 Laboratory 17 5.2% 9 Inpatient Wards 6 1.9%

10 Essential Drugs Management 20 6.2%

11 Tracer Drugs 20 6.2% 12 Maternity 24 7.4% 13 EPI 20 6.2% 14 ANC 12 3.7% 15 HIV/TB 8 2.5%

324 100.0%

Table 6: Weighting for the 15 General Hospital Services in the 2014 Quality Checklist

Nr CPA Service Points Weight_% 1 General Management 24 4.2% 2 Business Plan 8 1.4% 3 Finance 42 7.4% 4 Indigent Committee 4 0.7%

5 Hygiene & Medical Waste Disposal 42 7.4%

6 OPD 103 18.2% 7 Family Planning 31 5.5% 8 Laboratory 12 2.1% 9 Inpatient Wards 155 27.3%

10 Essential Drugs Management 20 3.5%

11 Tracer Drugs 30 5.3%



Nr CPA Service Points Weight_% 12 Maternity 26 4.6% 13 ANC 7 1.2% 14 HIV/TB 8 1.4% 15 Surgery 55 9.7%

567 100.0%

The Performance Framework for the Local Government PHC Department The local Government Health Authority has important functions related to the LGA PBF system. These functions are: (a) regular supervision of its health facilities; (b) application of the quality supervisory checklists once per quarter to each of the PBF health centers; (c) a capacity building role; (d) managing the HMIS; and (e) being the secretariat for the local government RBF steering committee.

The local government PHC department is under a performance contract with the SPHCDA for its PBF supportive role. The SPHCDA Verifier will apply the performance framework, and present the results in the local government RBF steering committee. The performance framework can be found in annex 12.

Subsidized Care for the Indigents The poorest of the poor face real problems accessing care. Free health care or selective free health care is not an option for Nigeria as available public funding is insufficient to pay for good quality and accessible basic health services.

However, selective free health care could theoretically be subsidized through the PBF provider-payment mechanism, such as has been done for the Burundian SFHC/PBF mechanism.14 Additional funding would have to be made available by the State to reimburse providers for such selective free health care.

For improving access to health care by the poorest of the poor PBF will introduce a specific category called ‘new consultation for an indigent patient’. The poorest of the poor - the indigents- will be able to access curative and preventive services, without paying at the point of service.

14 Meessen, B., A. Soucat, et al. (2011). "Performance-based financing: just a donor fad or a catalyst towards comprehensive health care reform?" Bulletin of the World Health Organization 89: 153-156.



We will first discuss the Drug Revolving Fund concept, and then the quality checklist. After this we will explain subsidized care for the indigents through PBF.

A Drug Revolving Fund (DRF) will be introduced together with the PBF intervention.

Rates for the drugs and medical consumables of the DRF are determined by the type of the drug, the source of the drug and the markup. The new rules for these Drugs are:

• They should be generic type; • Figure on the Essential Drug List (EDL); • They should be procured from the 3-4 certified distributors at the State level; • Prescriptions should be used for all drugs and medical consumables, and prescriptions

should be kept in the pharmacy; • Modern pharmacy stock control measures will have to be implemented (‘first in first

out’; use of individual stock control cards, etc); • Retail rates will have to be negotiated between the health facility management, the

Health Facility RBF committee (its oversight committee); • These negotiated rates will have to figure on the public bulletin board for clients to see.

As a condition of the purchase contract all drugs and medical consumables sold from the health facility ought to be through this formal DRF. Informal DRFs or prescribing from private pharmacies will not be permitted. If the PBF facility breaks this rule it stands to get cautioned, receive a penalty or lose its purchase contract.

The PBF intervention will be working closely with grassroots organizations to conduct client satisfaction surveys. Mobile phone technology will be used intensively, including testing a citizen’s reporting through sms functions. The average costs of a prescription will therefore be known. Quality issues such as stock outs of drugs, or being sent to private pharmacies to buy drugs, will also be obvious.

The quality checklists will be monitoring, and rewarding rational drug prescribing practices.

The above measures are expected to bring down considerably the average variable cost of a curative consultation. However, these costs might still be too high for the indigents: the poorest of the poor.

We will introduce a system of subsidized care for the indigents. This system will be piloted on a small scale so that we can see if it works. We will introduce a single case-based remuneration category, called ‘new outpatient consultation for the indigent patient’ (MPA) and ‘new outpatient consultation by a Doctor of an indigent patient’ (CPA). Basic rules are (see also annex 18):



• Up to 5% of the total number of new outpatient visits can be claimed under this category the following month;

• There should be created an ‘indigent committee’, with members drawn from the Facility RBF committee and involving other community representatives appointed by the RBF committee (see annex 18 for its terms of reference);

• This indigent committee is responsible for verifying the accuracy of the application of the indigent category, especially related to perceived poverty;

• The health facility is encouraged to devise innovative methods to ensure accurate targeting. Such methods will be evaluated through focus group discussions.

The PBF purchase contracts will make the care for the indigents an integral part of the MPA and CPA and therefore, just as for each of the individual services, adherence to the rules (such as the correct application of guidelines and procedures, and correct reporting), are a condition for continuing the purchase contracts.

Purchase contracts are writing with one select health facility in each LGA, whereas there are more such health facilities in each LGA, and therefore, there is an element of contestability in each contract. The PBF contracts are not a right, but are conditional on continued good performance. The various strategies related to each of the services, including the care for the indigents, are negotiated in the business plans of each contracted facility.

The financial risk forecasting model is set up to make an informed choice, within a given budget, a given baseline and hundreds of target assumptions, of the actual fee/subsidy paid for each category. These fees/subsidies can be renegotiated depending on target achievements or when certain services are overproduced whereas others are under produced (moral hazard).

PBF uses the principle of cross subsidies; it is assumed that the case-based payment reimburses providers for the average variable cost of a curative treatment. In case the cost for an individual surpasses the actual reimbursement it is assumed that the health facility will cross-subsidize the actual variable costs through its other PBF earnings.

In fact, curative care is the gateway for preventive services: one curative care case, such as an indigent, can lead to additional earnings for mother and child care services and other incentivized services. It should be quickly understood by health facility managers that attracting more patients (through offering good quality curative care and available drugs), leads to an opportunity to earn more through offering additional preventive services.

Health facility managers in PBF projects frequently decrease the level of user charges in order to attract clients after which additional income can be gained through preventive care subsidies.



CONTRACTS

Five contracts govern the Nigerian PBF approach. These contracts form the new rules and regulations of the PBF system. Its linked technical documents (quality checklists; performance frameworks and technical manuals) are part of these new rules and regulations. These contracts are:

1. A Multilateral Contract for the LGA RBF Steering Committee 2. A Purchase Contract between the SPHCDA and the Provider (health facility) 3. A Motivation Contract between the Health Center Management and the Individual

Health Worker 4. A Contract between the SPHCDA and the Local Government Health Department 5. A sub-Contract between the primary contract holder and a secondary health provider

The contracts are described shortly below, and are annexed to this guide for more elaborate reference.

Contract 1: Multilateral Contract for the LGA RBF Steering Committee The LGA-RBF steering committee is a core institutional aspect of the Nigerian PBF approach. It contains a formalized set of rules, in the form of a multilateral agreement between the members of the LGA RBF Steering Committee, and the LGA Chairman.

The following organizations and position holders are members of this steering committee:

• The LGA Supervisory Councilor for Health • The Primary Health Care (PHC) Coordinator • The representative of the State Ministry of Health • The Chief Medical Officer of the LGA General Hospital • The representative of Health Facilities • The representative of the SPHCDA • The representative of Non-Governmental Organizations active in the LGA • The Director for Local Government Administration (DLG) where available or Director of

Personnel Management (DPM) or his/her representative • The Pharmacy Officer

The quorum is formed by (a) the LGA PHC Coordinator (or his/her deputy); (b) the representative of the SMOH and (c) the representative of the SPHCDA. If any one of these three position holders is not present then in that case the RBF steering committee meeting cannot be held, or when held, is not authorized to make any decisions.



Minutes of the steering committee meeting, together with a signed copy of the consolidated LGA PBF invoice for MPA and CPA, will need to be submitted to the SPHCDA prior to the 10th of the fifth month.15 Without these deliverables the SPHCDA and the PFMU cannot process the performance payments.

The steering committee meets at least once per quarter and underscores the decentralized nature of PBF management. It is at the LGA level where the local actors know their health system best. It is here where performance data are submitted for scrutiny and validation and for subsequent action.

The local government RBF steering committee contract is in annex 1.

Contract 2: Purchase Contract between the SPHCDA and the Health Provider The SPHCDA – who is the PBF purchaser - writes purchase contracts with select health facilities for the delivery of the MPA and the CPA. These purchase contracts are conditional on reaching an agreement on the business plan for each facility. See annex 13 for the business plan.

The purchase contracts are writing for the duration of 12 months. They are conditional on continued satisfying performance which is defined as: (a) good performance and (b) continued good performance and (c) agreement on the strategies as laid out in the business plan.

Purchase contracts can be writing with public facilities, with private non-for-profit facilities, with religious facilities and with private for profit facilities on a basis of non-discrimination. In principle, one main health facility per ward is contracted. For urban areas, other ratios might apply.

Sub-contracting of other facilities by the main contract holder is allowed pending agreement on this strategy in the business plan.

The fees/subsidies agreed in the purchase contract are valid for each 3 month period. They can be renegotiated by the SPHCDA in case: (a) the production is higher than expected; (b) the production is lower than expected; and (c) certain services are overproduced while others are under produced.

15 Months 1-3 are the performance months; by the end of month four latest the LGA RBF Steering Committee has to convene. The deliverables (minutes of this meeting; consolidated MPA and CPA performance data) have to arrive in original hard copy, carrying the appropriate signatures, at the SPHCDA prior to the 10th day of the fifth month.



In case the SPHCDA does not issue a new amendment prior to the last working day of the quarter, the past quarter’s fees/subsidies are automatically continued for a second 3- month period.

Purchase contracts are not a right or an entitlement. The purchase contract can be found in annex 2.

Contract 3: Motivation Contract between the Health Center Management and the Individual Health Worker The health facility management writes a motivation contract with each health worker in its facility. These motivation contracts indicate the rights and obligations of each health worker. It indicates the number of points the health worker is entitled to, when the health worker has carried out his/her job description and when his/her performance is 100% according to the individual performance evaluation (see annex 15).

The management decides each quarter, based on the financial position of the health facility and the budget for the following quarter, which part of the budget will be allocated to ‘performance bonuses’.

The budget for the following quarter is structured around procurement of drugs and medical consumables, maintenance of facilities/equipment and facility/equipment upgrade, payment of contracted medical staff, payment of sub-contracts, and performance bonuses.

Performance bonuses cannot be more than 50% of PBF earnings of the facility. However, a lesser percentage can be allocated to performance bonuses if the facility decides to invest in its facilities first (to earn a higher performance score on the quality for instance, or to invest in equipment or infrastructure in order to provide more services).

The performance bonus budget is then divided by the total number of points. The total number of points are the sum total of all points in all motivation contracts. Each health worker is thus entitled to its number of points * point value for that quarter (these point values can differ, depending on the health facility performance and the investment decisions taken by the management) * individual performance assessment %. The performance bonuses are paid once per month.16

Motivation contracts are primarily meant to assist in the provision of good quality MPA and CPA services. In case of a mismatch between staff, for instance an overabundance of non-

16 Although the health facility is paid once per quarter, the management is expected to plan for monthly bonus payments to staff.



medical staff, and a shortage of medical staff, the health facility management is free to judge how much points it should allocate to non-medical staff as compared to medical staff. If for instance a health facility has 20 sweepers but only five medical staff, then it seems appropriate that the management considers how many sweepers and other non-medical staff it actually needs to ensure good hygiene and waste disposal and good patient registration.

An internal health facility committee oversees the allocation of the performance budgets and ensures that the results of the performance evaluations are applied.

Health workers, who are no longer working at the health facility, are not entitled to performance payments.

See annex 3 for the motivation contract.

Contract 4: Contract between the SPHCDA and the LGA PHC Department The SPHCDA writes a performance contract with the local government health department. This contract is meant to support the PHC department in its vital functions related to the LGA PBF system.

The contract is an output-based contract with a performance framework linked to it. The SPHCDA Verifier will apply the framework once per quarter and present the findings in the quarterly LGA RBF Steering Committee meeting.

In the LGAs which are classified as DFF, an adapted contract and framework will be introduced.

The contract can be found in annex 4, and the performance framework can be found in annex 12.

Contract 5: Sub-Contract between the Health Provider and a Secondary Health Provider The main PBF contract holder can sub-contract other facilities present in its ward, to provide some MPA services. Such a sub-contracting strategy should be indicated in the business plan and negotiated with and approved by the SPHCDA. It is assumed that such business plans are also vetted by the Facility RBF Committee and the local government health department.

Sub-contracted facilities can be public, private non-for-profit, religious and private-for-profit facilities.

The main contract holder is required to assure (a) adequate supervision; (b) quality norms related to the sub-contracted services; and (c) to ensure that the primary and secondary data collection tools are used for these sub-contracted services.



Typical services that can be sub-contracted include (a) curative services; (b) immunization services; (c) family planning services; (d) growth monitoring services, and (e) household visit as per protocol.

The primary data collection tools ought to be present in the main PBF facility during the verification by the SPHCDA. The SPHCDA will also conduct community client satisfaction surveys under the sub-contractors.

The primary contract holder will claim all services from the SPHCDA, merging his own production with the sub-contracted facility’s production. The primary contract holder is entitled to a management fee of up to 25% of the sub-contracted PBF earnings.

Other arrangements can include for instance remunerating traditional birth attendants to accompany women to deliver in the main PBF facility, or community health workers to ensure DOTS for TB patients. Such arrangements do not need a sub-contract and are typically managed through a tacit agreement between the PBF facility and the individual community health workers.

See annex 5 for the sub-contract template.

PERFORMANCE MANAGEMENT AT THE HEALTH FACILITY

Performance Management is at the core of PBF systems.

There are various levels to performance management. There is: (i) higher level performance management (strategic purchasing and coaching by the SPHCDA); (ii) performance management through supportive action by the local government health authority, and (iii) guidance through the LGA RBF Steering Committee.

However, here, we explain shortly the three tools used in the facility level performance management. These tools are meant as an aid for the health facility management to focus their problem solving skills on the required quantity and quality performance. The first tool is the business plan; the second the Indice tool, and the third the framework for individual performance evaluation.

Business Plan The business plan is used by the health facility management to explain the various targets and strategies it has devised to improve the coverage of good quality services. Close collaboration with the Facility’s RBF Committee (drawn from key members of the Ward Development Committee) is required in its design. A valid business plan is necessary for the purchase contract



to take effect. It is also an integral part of the purchase contract: if the health facility does not do what it has set out to do, it faces a re-negotiation of its purchase contract. It might when poor performance continues lose its purchase contract.

The business plan template can be found in annex 13.

Indice Tool The indice tool is available in two forms; one is an excel spreadsheet for use in the General hospital, where there is IT equipment available. The other is a paper-based tool meant for use in health centers.

The purpose of the indice tool is to manage health facility income in a holistic fashion. Cash income for the health facility is from:

• The Drug Revolving Fund (DRF); • Eventual other charges (as determined by the health facility RBF committee); • Income from PBF; • Income from sub-contracting; • Cash subsidies from the Government.

The health facility will need to manage this income from various sources to pay for its expenses:

• Purchase of NAFDAC certified generic drugs and medical consumables from select certified distributors;

• Purchase of equipment; • Rehabilitation of facilities; • Pay contracted health staff; • Pay sub-contractors; • Pay community health workers (on a case by case basis when involved in PBF

strategies); • Pay performance bonuses to staff; • Ensure a reasonable cash buffer.

The paper based indice tool can be found in annex 14.

Framework for Individual Performance Evaluation Health facility managers will use an individual performance evaluation framework, to distribute the performance bonus budget while managing individual effort. An example of such a performance evaluation framework is provided in annex 15. Health facilities are invited to expand this framework according to their local insights.



MONITORING AND EVALUATION

Monitoring and Evaluation (M&E) permeate PBF approaches. PBF has a ‘super M&E’, in which data are monitored throughout the system and validated at various levels. Most importantly data are validated at the source (systematic Data Quality Audit) but also at other levels. In addition data are used intensively at all levels: at the health center level; LGA level; State level, and at the Federal level. In all, six levels of control/monitoring can be distinguished in the Nigerian PBF approach.

Each of these six levels contributes to the reliability of the data and the subsequent performance payments. PBF systems are extremely thorough in the sense that each Naira paid for a service can be followed to the patient who received that service.

Table 7: Evaluations: ex-ante and ex-post

Structure Ex-ante Ex-post Frequency

Health Center Quantity Quantity verification: Technical Support Unit (TSU)- SPHCDA

As per protocol Community Client Satisfaction Surveys: CBOs

Quantity verification: monthly

Community client satisfaction surveys: sampling once per quarter

Health Center Quality PHC-unit of the LGA As per protocol TSU-SPHCDA

Quality verification: once per quarter

Quality counter-verification: sampling once per quarter

General Hospital Quantity Quantity verification: Technical Support Unit- SPHCDA

As per protocol Community Client Satisfaction Surveys: CBOs

Quantity verification: monthly

Community client satisfaction surveys: sampling once per quarter

General Hospital Quality Multi-agency organized by TSU-SPHCDA with Hospital Board and

As per protocol: Multi-agency

Quality evaluation: once per quarter



Structure Ex-ante Ex-post Frequency

technical partners Quality counter-verification: sampling once per six months

LGA – PHC department TSU- SPHCDA As per protocol: Multi-agency

Performance framework: once per quarter

Performance framework: sampling once per six-months

The first level of control is the purchase contract & its linked business plan. This purchase contract lays down the rules and regulations that govern PBF and include clauses that deal with fraud. This contract is writing between the health center management & its RBF committee and the SPHCDA. This first level of control ensures that data submitted in the monthly invoice (see annex 10) are true. These performance data have been compiled by the one responsible for the service department and have been signed off by the head of the health facility and also by the president of the Facility RBF committee. Health facilities already count their performance data many times prior to claiming them. Quality checklists are extensively utilized by the health facility management to measure progress on the various quality dimensions and to make clear what they expect from their staff.

The second level of control consists of the monthly or bimonthly (depending on local circumstances) quantity control by the SPHCDA. The SPHCDA has a purchasing unit (the PBF-TSU), which employs its own Verifiers and has as task to verify health facility productivity. Verifiers count every single entry in the designated primary registers and sign off on the monthly invoice. Also, data elements that are the same for PBF and for the national HMIS system are triangulated during this process, thereby enhancing the reliability of key HMIS data at the source.

The third level of control consists of community client satisfaction surveys. These community client satisfaction surveys are organized by the SPHCDA who selects grassroots organizations and selects and trains suitable surveyors among its members. These surveys are meant to answer



three questions: (a) is the client known in the community; (b) has the client actually received the service, and (c) what was the opinion of the client on the service received. The community client satisfaction surveys will also judge the reliability of the post-identification methods for the ‘new outpatient consultation for an indigent patient’ category.

The program will also experiment with mHealth (mobile phone technology through the sms function), to get qualitative feedback by community groups, which will be published on the RBF website.

The fourth level of control consists of the local government health department carrying out the quarterly quality supervision using the designated checklist (see annex 8). Once per quarter, 15 service areas are checked in each health center. For the General hospital, a different quality checklist is used (see annex 9), and applied through a different mechanism. The summary data for each service are entered in the database. A maximum quality bonus of 25% of the quarterly earnings can be earned.

The fifth level of control consists of the quarterly LGA RBF Steering Committee meetings. In these meetings, the monthly invoices are compared with the quarterly consolidated LGA PBF invoice (see annex 11), printed from the web-enabled database. The reason for comparing these two sets of invoices is to intercept data entry errors while at the same time having local stakeholders have a close look at the results. Furthermore, the quality score of the health centers is discussed and also the progress on the business plans. Results from the community client surveys are discussed and plans are drawn up to provide feedback to the authorities, health centers, and the communities. Minutes of these proceedings are sent to the SPHCDA, together with the approved quarterly consolidated LGA PBF invoice.

The sixth level of control consists of the SPHCDA doing ‘due diligence’ on procedures; the received minutes of the LGA RBF Steering Committee proceedings and the signed and approved consolidated LGA PBF invoices (for both MPA and CPA). Data are triangulated with data from the database. If all is found well a payment order is printed from the web-enabled database signed by the head of the PBF-TSU and his/her supervisor and sent to the PFMU (and eventual other fund holders). The PFMU will execute the payments to the contracted health facilities and the LGA PHC departments.

Approved and executed payment orders will be published on the PBF website of the NPHCDA.



FRAUD: PREVENTIVE MEASURES AND PENALTIES

Possible Fraud The introduction of PBF increases the risk for fraud as some providers or administrators inflate results to earn more money.

Verification and counter-verification procedures mitigate the risk for fraud through measuring the difference between claimed (& paid for) performance and actual performance. This requires special attention to measures to detect fraud and to penalties applied in case of certified fraud.

Fraud in PBF systems can be either intentional, or non-intentional. Intentional fraud relates to falsifying documents related to a service activity, falsifying register information, claiming services that had not been delivered, referring to acts of care that the user did not benefit from etc. Unintentional fraud (which is a rare occurrence) can be an error made by a verifier – due to lack of comprehension of the indicators- on a quality checklist or it can be a misinterpretation of indicators by different verifiers (an effect known as ‘inter-observer variability’).

To avoid fraud - intentional or unintentional - there is need for incentives for good behavior, correct reporting and scoring, and disincentives for fraud. In all cases, possible fraud need to be substantiated quantitatively (the numbers and facts) but also qualitatively (a writing explanation as to what actual happened) as sometimes a case of non-intentional fraud can be based on a mis-interpretation of an element of the quality checklist due for instance to a different sampling of a patient file, or be caused by different interpretations of the same event by different verifiers. However, once fraud is established based on quantitative proof, and supported by qualitative elements, strong actions needs to be implemented to discourage future fraudulent behavior.

Fraud prevention The following preventive measures are implemented to decrease the risk of fraud, intentional or unintentional:

• Separation of functions, which helps to minimize fraud by avoiding conflicts of interest; • Good quality ex-ante verification both of the quantity (SPHCDA) and quality (LGA-PHC

departments); • A clear manual, clear contracts and good training in the rules of the game; • An effective reward and punishment system (and application of punishments in case of

certified fraud); • Good governance for PBF at the LGA level; • Regular community client satisfaction surveys with feedback of the results at all levels.



If rules are transparent and known to all and actions are taken swiftly when fraud is detected while communicating such fraud and its consequences to all stakeholders, then the likelihood of fraud will be minimized.

Penalties for Fraud When fraud is certified, the following actions are taken: Related to ex-post verification of the quantity (community client satisfaction surveys):

• If more than 5% (up to 10%) of the sample cannot be traced back in the community. This means that either the client exists but did not receive the service OR that the client does not exist. Verification is done through mobile phones and/or through household visits with certification that client does or does not exist – as confirmed by the village head:

o First offence: retention of 20% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website;

o Second offence: retention of 50% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website;

o Third offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA).

Table 8: Penalties in case of more than 5% (up to 10%) untraceable clients

• If more than 10% of the sample cannot be traced back in the community:

First offence: retention of 20% of PBF earnings, no performance bonuses staff and repeat counter-verification

Second offence: retention of 50% of PBF earnings, no performance bonuses staff and repeat counter-verification

Third offence: stop the purchase contract, replace head of health facility.



o First offence: retention of 50% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website;

o Second offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA).

Table 9: Penalties in case of more than 10% untraceable clients

Related to ex-post verification of the quality for health centers (quality counter-verification of HC): both the LGA – PHC department and the health facility are penalized as follows:

• If the discrepancy is larger than 10% and no qualitative explanation can be given for this discrepancy (average across the sampled services according to the protocol):

o First offence: related to the LGA-PHC department: retention of 50% of LGA-PHC

department performance earnings while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification. Writing warning to the responsible verifier;

related to the health facility: retention of 20% of the total earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman.

o Second offence: related to the LGA-PHC department: retention of retention of 50% of

LGA-PHC department performance earnings while remaining earnings cannot be spent on individual performance bonuses PLUS warning in


Second offence: stop the purchase contract, replace head of health facility



writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification PLUS exclusion of responsible verifier from performance bonuses and from quality checklist assessments for a period of one year;


o Third offence: Related to the LGA-PHC department: stop of the performance contract for

the duration of one year (or until - for the SPHCDA - a satisfactory solution has been found) PLUS offering of quality supervision contract to another PHC pending resolution of the conflict.

Related to the health facility: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA).

Table 10: Penalties in case of more than 10% unexplained discrepant results in quality counter-verification of health centers

The ex-ante verification for the hospital quality is done by a multi-organizational team led by the SPHCDA, consisting of Hospital Board staff, third-party hospital staff and technical partner

First offence: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification. Health facility: retention of 20% of performance earnings, nil bonuses staff.

Second offence: LGA-PHC department: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification plus exclusion of offending verifier from pool of verifiers. Health facility: retention of 30% of performance earnings, nil bonuses staff.

Third offence: LGA-PHC department: stop the performance contract for the duration of one year. Health facility: stop the purchase contract.



agencies. The actual scoring for results is done by the SPHCDA with the others in observer status (i.e. not responsible for the actual scoring).

DATABASE

A web-enabled application forms the backbone of the Nigerian PBF administrative system. This time-tested solution has led to the successful scaling up of PBF nationwide in Rwanda and Burundi with near 100% data completeness, a high degree of timeliness, a very high level of data reliability and widely available data which are used at all levels of the health system.17

A website will form the portal to the database. This website will also figure news, events, documents, information related to actors such as their contacts and websites and so on. The software used for this IT solution, WordPress, MySQL and PHP, are all open source. The database will offer preconfigured reports, such as the important consolidated quarterly LGA PBF invoices, but also interactive graphs and tables.

A health facility table of all contracted Nigerian health facilities will be used, in which figures information such as their bank accounts. The health facilities will use unique identifiers which will enable them to be linked to other databases such as the HMIS.18 The health facility table will also be updatable through the web application, for select administrators. The database can also be accessed through exporting data in Excel, and analyzing trends using the Excel Pivot or Graph option. Drawback from this approach is the limited internet connectivity in LGAs.

However, SPHCDA staff which will be responsible for data entry will have fast internet access in its main and also zonal offices. LGA health staffs can use either internet cafes, or mobile 3G or 4G networks where available to access the web-enabled database. All performance information is accessible through the public frontend through ready-made graphs, and also through MS Excel tables that can be downloaded from the public frontend through the data-tab.

17 Similar systems have been designed for Zambia, and are in preparation for Chad, and DRC.

18 A DHMIS web-enabled platform is planned for Nigeria. Performance data can thus be linked ‘in the cloud’.



Figure 3: Image of the public frontend of the PBF web-enabled application19

The database will have administrator, author, and editor and guest accounts. The SPHCDA will have various ‘author’ accounts for its verifiers attached to each LGA (1-2 per LGA). These authors can only enter and modify data for their own LGA. Data from all health facilities are visible through not only the back-end, but also the public frontend.

There will be select ‘editor’ accounts for technical assistants from developing partners providing TA to the national PBF system and for certain core SPHCDA/PBF-TSU staff. These editor accounts allow for a larger range of editorial functions.

19 https://nphcda.thenewtechs.com/ (accessed 5 December, 2013)

https://nphcda.thenewtechs.com/



A few select users will have ‘administrator’ accounts which confer the highest level of user account in which users can be added or modified, including their passwords. The administrators also have access to a log in which mutations in the database are recorded.

Finally, all performance information is publicly visible, and allows website visitors to view dashboard information and to download data and carry out additional analysis without the ability to make changes in the database.

PAYMENT CYCLE

The payment cycle will be once per quarter. The following steps can be distinguished:

(1) monthly health facility invoices are controlled and signed off by the verifier and brought to the SPHCDA where the data will be entered in the web-enabled application;20

(2) The last such monthly invoices will arrive at the SPHCDA during month four prior to the end of week three (month one to three representing the quarter). The quarterly quality checklists are finalized for the health centers and the information will reach the SPHCDA latest by the end of the third week of month four;

(3) Data entry through the web-application and printing of the provisory quarterly consolidated LGA- PBF invoice (one for the MPA; one for the CPA for each LGA);

(4) The quarterly LGA- RBF Steering Committee meeting is held in which the quarterly

consolidated LGA- PBF invoice is approved (or amended if necessary). During this process the original monthly invoices are compared with the quarterly consolidated LGA PBF invoice which has been printed from the database. After approval, the approved invoice together with the LGA RBF Steering Committee meeting minutes are sent as original hardcopies to the SPHCDA for which the LGA will receive a writing proof. All required documents ought to reach the SPHCDA/PBF-TSU latest the 10th of the fifth month (months one to three being the quarter under consideration);

(5) The SPHCDA has seven days to do its due diligence after which it produces a payment order

(the payment order is generated through the web-application). The payment order is signed

20 Or for that matter entered through any functioning internet connection, which could be an internet café, or the personal 3G/4G mobile internet connection of the Verifier.



by the head of the PBF-TSU, by the SPHCDA supervisor of the PBF-TSU and sent to the PFMU;

(6) The PFMU will process the payments within 14 days (i.e. before the end of the fifth month)

and transfer the performance payments to the health facility bank accounts;

(7) The payment orders will be published on the NPHCDA- PBF website.

Rules of Use of the PBF Income PBF earnings are supposed to be used in a holistic manner taking into consideration all cash-income of the PBF facility from all combined sources. As a rule of thumb: a maximum of 50% can be allocated to staff performance bonuses from the PBF earnings.

Invoices See annex 10 for a sample of the monthly Health Facility Invoice, and annex 11 for a sample of the quarterly consolidated LGA PBF invoice.

CAPACITY BUILDING

Capacity building and system strengthening are vital to a successful PBF program. Health Facilities need to be equipped with basic equipment and rehabilitated to a reasonable extent to level the playing field for service provision and to offer quality health services equitably.

This will partially be achieved by introducing the business plan concept linked to retroactive financing. This will enable health facilities to upgrade themselves.

A PBF training program will be devised. The institutional framework of the Nigerian PBF approach will be explained ending with the contract signing ceremonies. All actors at Federal, State, LGA, and health facility level will need to be trained. This is a major effort which will need excellent coordination between the FMOH, NPHCDA, SMOH, SPHCDA and development partners and operational and financial support from all to make this a reality.

The level of effort required is much larger than any one single agency could undertake (administration; operations support and so on), therefore, such trainings will need to be decentralized to the different agencies that have operational capacity to do so. The PBF-TSU/SPHCDA will form the core of this coordination effort through its extended team mechanism.

The following State level training strategy is proposed:



1. Employ a qualified international level master trainer;

2. Select a team of trainers from various agencies (SMOH, SPHCDA and development partners), a team of about 20- 30 per State would be necessary (cost born by partners for their staff);

3. Train the trainers in modern andragogic methods and approaches;

4. Create the training modules for the various target groups, with the trainers, create a manual for trainers;

5. Train (the first training can be a try-out, then the trainings can be simultaneous and in parallel);

6. Follow up.

Creating a technical team, which collaborates horizontally to achieve the same mission (the implementation of the Nigerian PBF approach), tied to the SPHCDA/PBF-TSU (whose members are also part of this larger technical team) is deemed necessary. This is the so-called ‘extended team approach’.

A window of opportunity opens by assembling a team of dedicated State level PBF trainers from various agencies. This extended team can also become part of the State technical resource pool which can and should be mobilized to offer technical support to the LGA RBF Steering Committees (where required) and the health facilities, to make PBF a reality (see below under ‘coordination’).

COORDINATION

Coordination is of utmost importance for the successful introduction of the Nigerian PBF approach. Organizing technical assistants from all concerned State agencies and development partners engaged in the State PBF roll-out is most essential to a successful implementation. Such a team can be organized through the PBF-TSU/SPHCDA, and will contribute to a successful top-down policy implementation.

The State RBF steering committee and Technical Working Group are the governing organs of PBF at the State level and double as an important forum for coordination and policy guidance related to PBF.



The web-enabled application and the website will contribute to making information accessible for all.



ANNEXES

Annex 1: Multilateral Contract for the LGA RBF Steering Committee

(………………..) State Ministry of Health

(……………..) State Primary Health Care Development Agency

AGREEMENT ON THE FUNCTIONS OF THE LOCAL GOVERNMENT RESULTS BASED FINANCING STEERING COMMITTEE

THIS AGREEMENT is dated [……………] 201X BETWEEN:

[…………………………………], the LGA Chairman, representing [……………………] LGA

Dr. /Mrs. /Mr. ________________________________________________

And



The Members of the _________________ Local Government Authority Results-Based Financing (RBF) Steering Committee

• The LGA Supervisory Councilor for Health • The Primary Health Care (PHC) Coordinator • The representative of the State Ministry of Health • The Chief Medical Officer of the LGA General Hospital • The representative of Health Facilities • The representative of the SPHCDA • The representative of Non-Governmental Organizations active in the LGA • The Director for Local Government Administration (DLG) where available or Director of

Personnel Management (DPM) or his/her representative • The Pharmacy Officer

IT IS AGREED as follows:

Purpose of the Agreement

1.1 The present Agreement aims at establishing the institutional framework and rules that govern the implementation of the Performance Based Financing (PBF) program at Local Government Level.

1.2 The Performance Based Financing strategy emanates from National Public Health policy. The Performance Based Financing User Manual (as published by FMOH/NPHCDA) serves as the principal reference document for all mechanisms agreed to herein and shall be referred to for further details and interpretation.

2. State Level Management of PBF : a Joint Responsibility of Key Stakeholders

2.1 The Statewide regulation of PBF shall be under the authorities of the State Ministry of Health (SMOH) and the State Primary Health Care Development Agency, in close collaboration with development partners and international agencies.

2.2 The SMOH will set up a State RBF Steering Committee that will review the implementation of PBF at state level, and provide general policy direction. The general objectives of the PBF program will be informed through collaboration with concerned Federal and International Institutions. The SPHCDA will provide the secretariat for this State level RBF Steering Committee.



3. State Level Management of PBF: The State Primary Health Care Development Agency (SPHCDA)

3.1 The day-to-day management of the PBF program shall be carried out by the SPHCDA. The SPHCDA shall be responsible for the following:

(a) Facilitate the integration of other Statewide or LGA-wide health programs with PBF; (b) Purchase the minimum package of activities (MPA), and complementary package of

activities (CPA) through direct purchase contracts with select public, faith-based institution, or non-for profit Health Facilities (one principal contracted health facility per ward; based on the principle of non-discrimination and best performance);

(c) In collaboration with the local government health department, negotiate the business plan contents with the PBF facilities;

(d) In collaboration with the local government health department, classify all contracted facilities in ‘Categories 1 to 5’ depending on the perceived rural hardship grading of these facilities (the health center closest to the LGA administrative centre will typically be categorized as a ‘Category 1’);

(e) Do strategic purchasing of the MPA and CPA services. Define the subsidies for MPA and CPA services based on (i) results obtained; (ii) observed moral hazard and (iii) within the boundaries of a given PBF output budget;

(f) Contract the local government health department for the quarterly quality supervision of the health centers;

(g) Verify the monthly quantity production of the MPA and CPA services; (h) Verify the quarterly performance grid of the local government health authority; (i) Enter the MPA, CPA and quality checklist data in the PBF web-enabled database and

produce the consolidated quarterly LGA PBF invoice for discussion in the LGA RBF Steering Committee;

(j) Organize community client satisfaction surveys through local grassroots organizations using a defined protocol;

(k) Perform due diligence on all quarterly LGA RBF Steering Committee deliverables (minutes of meetings; approved consolidated performance invoices), and facilitate the payment for performance without ado by the with the SMOH Project Finance Management Unit (PFMU);

(l) Execute any contractual sanctions imposed by the PBF purchase contracts in case of non compliance or irregularities on the health facilities.

3.2 The SPHCDA may delegate some of these responsibilities through a writing agreement with a local government entity such as the Primary Health Care unit or to an external third party organization active at local government level.



4. Local government level management of PBF: The LGA RBF Steering Committee

4.1 The present agreement establishes a Local Government Results- Based Financing Steering Committee with the signatories as its members.

4.2 The LGA RBF Steering Committee shall ensure coordination of the PBF program and ensure that the applicable monitoring, control and sanction mechanisms are implemented within the geographical of jurisdiction of the LGA. The LGA RBF Steering Committee shall also be entrusted with devising local strategies to improve access and quality of care at the LGA health facilities.

5. Members of the PBF LGA Steering Committee

5.1 The Steering Committee is chaired by the LGA Supervisory Councilor for Health of the LGA, or his or her designated deputy.

5.2 Other members of the steering committee are the following: (a) the Primary Health Care (PHC) Coordinator; (c) the Representative of the State Ministry of Health ; (d) the Chief Medical Officer of the General Hospital, or his deputy; (e) one elected representative of the contracted health facilities; (f) The representative of the SPHCDA; (g) The representative of Non-Governmental Organizations active in the LGA (h) The Human Resources Management Officer; (i) The Pharmacy Officer

5.3 The Steering Committee chairman may propose additional members by writing request to the SPHCDA. Any additional members should be chosen for their active involvement in public health in the LGA and its communities. Non response or non-objection from the SPHCDA to a proposal from the Steering Committee chairman to add to the above listed members, within a month of the receipt of the request, shall be considered as a tacit approval.

6. Functioning of the LGA RBF Steering Committee

6.1 The Steering Committee shall meet at least once every quarter upon invitation to its members by the Committee chairperson. The Steering Committee shall validly meet and take resolutions if the minimum tripartite quorum of LGA leadership and representative from SMOH and representative of the SPHCDA are present. If any or all of these three parties are absent, the steering committee meeting will be invalid and any decisions or approvals taken in this meeting, notably: the approval of the monthly and quarterly performance figures will be invalid. The PHC coordinator shall act as the committee’s secretary.



6.2 The chairman shall invite participants with at least 14 days notice, and will ensure that the next quarter’s meeting will be planned during a current meeting.

6.3 The quarterly RBF Steering Committee meetings shall be held in the last week of the fourth month.

6.4 The minutes of the RBF Steering Committee meeting, signed by the chairman, and the consolidated quarterly LGA invoice, shall be sent in hardcopy to the SPHCDA. These deliverables ought to be received by the SPHCDA before the 10th of the fifth month.

6.5 The minutes of the meeting should conform to the norms related to Agenda content and reporting format (see PBF user manual).

6.6 The Committee meetings shall have on their agenda at least the following areas of discussion:

(a) PBF strategy: To present and discuss the data and information related to the PBF health facilities including activity level, quality of care level and other relevant information; to review the different strategies in place for the improvement of results and follow-up on previous decisions of the committee.

(b) PBF dialogue: To give opportunity to every member of the committee and representatives of the health facilities to express any challenges or difficulties in implementing the program or their own strategies; to address disputes that are referred to it by members or stakeholders.

(c) PBF invoice validation: To review, discuss and eventually approve the final consolidated quarterly invoices of PBF health facilities prior to transmission to the SPHCDA. This validation process needs to ratify every single original monthly PBF invoice, and all the quality scores, with the consolidated quarterly LGA PBF invoice. The latter invoice is drawn from the PBF web-enabled application: verifying whether the data match (the ‘physical evidence’ with the data in the database) is an important validation function.

(d) PBF management support/evaluation: To review and discuss the performance of the LGA PHC department: the LGA PHC department is under a performance contract to carry out certain functions related to the well-functioning of the PBF system, in a timely and correct manner. The SPHCDA Verifier has scored the performance using the performance evaluation tool. The results are discussed in the plenary.

(e) Care for the indigents: curative care for the indigents is introduced as a pilot mechanism. The steering committee is required to follow up on the functioning and appropriateness of the developing targeting mechanisms– whether they target the poorest of the poor and the near poor -, and to ensure the Indigent committees are functioning appropriately.



6.7 Monitoring of the LGA RBF Steering Committee

6.8 The SPHCDA shall monitor the Steering Committee and is authorized to access the committee’s minutes and any other relevant documents related to committee’s activities.

6.9 Receiving the steering committee minutes, created according to strict guidelines, conjointly with the quarterly consolidated LGA PBF invoice, is a pre-condition for the SPHCDA and the PFMU to process the performance payments.

6.10 The SMOH, upon advise from the SPHCDA, may review the modalities of the Committee’s operations and/or dissolve it appears that irregularities may have compromised the PBF system in the LGA.

7. Role of the Heath Facilities’ representative The LGA’s PBF health facilities are represented by one of the Health Facilities heads. He/She has been elected by the in-charges of the other facilities, during a plenary meeting. She/he shall have responsible with bringing to the committee’s attention the concerns of the different facilities’ managers. She/he shall also responsible to inform accurately to the other heads of facilities about the decisions of the Committee. His/her tenure is 12 months, with the possibility of one times re-election.

8. Role of Chief Medical Officer of the General Hospital The Chief Medical Officer of the General Hospital will be part of the RBF Steering Committee. The first level referral hospital has important functions related to (i) the referral system; and (ii) training and capacity building.

9. Role of the LGA PHC Department The LGA PHC Department, hereby represented by its coordinator, shall be responsible of the following:

(a) General supervision of health facilities within the LGA to ensure that the PBF program is being implemented according to agreed strategies and policies;

(b) Apply the quality checklist to each PBF health facility, once per quarter and submit these checklists to the SPHCDA Verifier linked to the LGA, prior to the 20th of the third month;

(c) Organize the quarterly LGA RBF Steering Committee meetings prior to the end of the fourth month. Invite members at the least 15 days prior to the steering committee meeting. The LGA PHC department will function as the secretariat of this steering



committee. Agenda setting will need to be agreed between the SPHCDA designed LGA Verifier and the local government health director or his designated PBF coordinator;

(d) Manage financial and human resources diligently towards the achievement of the recommendations and strategies set by the LGA Steering Committee, the SPHCDA and the SMOH.

(e) All other functions normally attributed to the department as part of its day-to-day mission in the LGA.

10. Role of the NGO representative The NGO representative represents civil society. The NGO representative is chosen among civil society organizations active in the health or social protection sectors in the local government area.

11. Dispute resolution

11.1 In the case of dispute relating to the interpretation of the present contract, both parties agree to refer to the current Performance Based Financing User Manual.

11.2 In case of unclarity of certain PBF system elements, the Steering Committee might request higher level SPHCDA technical support for clarifying certain matters.

11.3 In the case of dispute relating to the implementation of the present contract, both parties agree to refer to the matter to the arbitration of the State RBF Steering Committee which acts as the regulator of the PBF system in the State. The arbitration decision in the matter shall be final and binding towards all parties.

11.4 The SPHCDA is under no obligation to write a purchase contract for MPA or CPA with any health institute. Its primary drivers for contracting are (a) good performance and (b) continued good performance. Past performance budgets or performance fees/subsidies are no guarantee for future fees/subsidies.

12. Duration of the Contract The present contract is signed on (_________) for a period of 12 months until (__________). It shall be renewed tacitly for an additional 12 subject to the terms stipulated in section 1 of the present contract.

SIGNED BY



[………………….] LGA, hereby represented by the Chairman of [……………….] LGA

Dr. /Mrs. /Mr __________________________

Signature __________________________

And

The Members of the _________________Local Government Authority Performance Based Financing (PBF) Steering Committee

1. The LGA Health Director ______________________

2. The Primary Health Care (PHC) Coordinator ______________________

3. The Representative of the State Ministry of Health ______________________

4. The Chief Medical Officer of the LGA General Hospital ______________________

5. The representative of Health Facilities ______________________

6. The representative of the SPHCDA ______________________

7. The representative of Non-Governmental Organizations active in the LGA ______________________

8. The Director for Local Government Administration (DLG) where available or Director of Personnel Management (DPM) or his/her representative ______________________

9. The Pharmacy Officer ______________________



Annex 2: Purchase Contract between the SPHCDA and the Health Provider

(……………………) State Primary Health Care Development Agency

PERFORMANCE BASED FINANCING (PBF) CONTRACT FOR THE PURCHASE OF HEALTH SERVICES

No ______________

THIS CONTRACT is dated [……………] BETWEEN: The State Primary Health Care Agency (“SPHCDA”) represented by its Executive Chairman Dr. /Mrs. /Mr.…………………………………………: And […………………………….] Health Centre, herein referred to as the “facility” or “HF” Represented by: Mrs. / Mr. [……………………] Head of […………………] Health Centre

Mrs. / Mr.: […………….] Chair [………...] Facility RBF Committee



IT IS AGREED as follows: 1. Principles of Performance Based Financing 1.1 The present contract is a performance contract between the SPHCDA and the Health

Facility in the context of the State Performance Based Financing (PBF) program. 1.2 The goal of PBF is to increase the provision of quality Basic Health Services to the

population by increasing health facilities’ decisional rights on the management of their own operations.

1.3 The Performance Based Financing strategy emanates from National Strategic Health Development Plan and NEEDS and Vision 20/20/20. The SPHCDA reserves the right to amend the applicable policies that serve as the basis of its support to the health centres prior to the expiry of the present contract.

1.4 The Performance Based Financing User Manual (as published by FMOH/NPHCDA) serves as the principle reference document for all mechanisms agreed to herein and shall be referred to for further details and interpretation.

2. Duration of the Contract 2.1 This purchase contract is valid from [……………….] for a period of [12] months until

[…………………]. 2.2 This contract may be revoked by the SPHCDA unilaterally at anytime, in case of fraud,

or continued underperformance. The annexes and Business Plan (as stipulated in Section 13 herein) form an integral part of the present contract.

2.3 The SPHCDA reserves the right to re-negotiate the service fees each 3 month period, however, the SPHCDA can also decide to keep the fees at their current levels. If such amendment is not produced on the last working day of the end of the quarter, the current fee set will be used for the following quarter. After re-negotiation, an amendment with a new set of negotiated fees will be produced, including a new business plan.

3. Purpose of the Contract This contract defines the rights and obligations of both parties within the context of the PBF system: The Health Facility, as the provider of health services and the SPHCDA, the purchaser of Health Services.



4. Performance Payments

4.1 The SPHCDA shall make Performance payments to the HF according to a fee –for –

service / case based provider payment mechanism, which is also conditioned on the quality of care. The services that are purchased and corresponding unit fees are listed in Annex 1.

4.2 The payments received by the Health Facility under these terms may be used as incentives in the form of salary bonuses to its staff members and as reinvestments in activities, equipments, commodities or infrastructure that contribute directly to the attainment of improved performance targets and enhanced quality of care to the population.

4.3 The maximum that the HF may budget for worker’s bonuses is 50% of its profits. Violation of this basic rule may lead to the termination of the present contract by the SPHCDA.

4.4 Any bonus payments by the facility to its workers shall be spread over a period of three months, in the sense that each entitlement is received monthly by the workers.

4.5 In consideration of the fact that non-medical staff are in general over-supply, and essential medical staff in undersupply, it is agreed that it is up to the HF management, and its Facility RBF committee, to decide on how many of the non-medical staff it needs to incentivize to keep basic hygiene, the waste disposal according to applicable norms, and cleanliness of the premises.

4.6 The HF may decide to forfeit bonuses for a limited period and to invest in its infrastructure or equipment. The HF may choose to invest part of its earnings in expanding its health workforce through local labor contracts, and invest also in fringe benefits to attract and retain qualified health staff.

5. Organs of the Health Center 5.1 The Health Facility shall be jointly represented by the Head of the Facility and the

Chairman of the Facility RBF Committee. 5.2 The Health Center in-charge shall put in place an Internal Management Committee to

review individual staff performance and distribution of the funds generated through PBF and the present contract. This Internal Management Committee shall use (a) the indice tool for integrated financial management and performance bonus payments; (b) a motivation contract writing with each employee in which its ‘part’ (proportion) of each quarterly bonus budget is indicated; and (c) minutes to document its proceedings. See the latest PBF manual for further details.



6. Mission of the Health Facility 6.1 The Health Facility must ensure that funds generated through PBF are managed in the

general interest of the health centre and, in general, contribute to the improvement of public health in the community.

6.2 In doing so, the health facility (HF) hereby commits to undertake the following: • Develop strategies designed to achieve the overall goals of Performance Based Financing

at HF and community level; • Avoid any activities in contradiction with national health policies and/or accepted

medical ethics; • Inform the Primary Health Care (PHC) Department at the Local Government Authority

of any change in HF personnel, technical skills and equipment at the facility that which could hamper its capability to render the Services remunerated by the present PBF contract;

• Ensure the permanent availability of all data recording registers and all management tools at the HF, and ensure that such documents are accessible to the SPHCDA, LGA PHC department and research companies during the execution of the present contract;

• Report in writing any case of fraud or attempted fraud committed by HF staff members to the SPHCDA and the PHC Department;

• Ensure complete transparency and access to information relating to the use of funds generated through PBF and all others sources;

• Distribute part of the revenues generated through PBF and the present contract its staff in the form of “bonuses” and in accordance with set guidelines. The indice tool will assist to direct resources to core essential medical staff;

• Allocate part of the revenues generated through PBF and the present contract to operational expenditure (other than personnel remuneration and trainings).

7. Procurement and Prescription of Drugs and Medical Consumables 7.1 The Heath Facility shall procure all drugs and medical consumables with PBF - Certified

Distributors. The State Agency of the Pharmaceutical Council of Nigeria (PCN), in collaboration with the SMOH will issue a list of 3 to 4 PBF - Certified Distributors in the State. The HF shall, at all times, be expected to conform to the list of Certified Distributors as updated from time to time by the State PCN. In choosing the distributors, availability of drugs, best price and quality should be the guiding principles.

7.2 The facility shall only procure essential drugs (as listed in the approved essential drug list) and medical consumables in generic form. Procurement of non-essential (not listed in the essential drugs list) of non-generic drugs (expensive brands drugs while cheaper



generic drugs are available) is not allowed. Non-compliance with this obligation may lead to the termination of the present contract by the SPHCDA.

7.3 Procurement of drugs and or medical consumables from non- PCN/PBF - Certified Distributors will be considered a violation of the purchase contract and may lead to immediate termination of the present contract by the SPHCDA.

7.4 The facility shall keep records of drugs and consumables procurement accessible at the pharmacy, and in-depth audits will need to show a match of stock-in and stock-out.

7.5 The facility shall ensure that all drugs and medical consumables prescribed in the HF are prescribed through a prescription, which shall be maintained and accessible at all times for control at the pharmacy. Prescriptions should indicate (a) the name and age of the patient; (b) the date; (c) clearly legible listed generic drugs with quantities; (d) name and signature of the prescriber. Prescription of drugs should strictly follow protocols (types of generics and recommended quantities) as mentioned in the treatment guidelines. Irrational use of drugs leads to a high cost to the population. Systematic non-adherence to these treatment guidelines could therefore lead to loss of this purchase contract.

7.6 Drugs and medical consumables available at the health facility should be clearly listed and accessible at the public notice board and at the pharmacy and should: (a) list the unit price; (b) list the number of items for a typical course, and (c) the unit price (the ‘retail price’) should not exceed the whole sale price + a reasonable markup as negotiated with the community and ratified by the Facility RBF Committee.

7.7 The existence of informal drug schemes managed by the facility or by its staff is strictly forbidden under this contract and it may lead to immediate termination of the contract by the SPHCDA.

8. Quantity audits and provisional PBF invoices The SPHCDA verification teams shall conduct monthly or bi-monthly Quantity audits by reviewing all entries made in the designated registers. They will compare their review with the provisory monthly invoice as prepared by the HF management (see annex 2). Such monthly quantity control shall be conducted not later than the 15th day of each month, or in some instances bi-monthly depending on local conditions. 9. Data Collection Registers 9.1 For the purpose of the present contract, each PBF Data Collection Register and its

contents/entries register constitute a financial records document and will be treated as such. Non-adherence to strict registration norms herein, non-completeness or non-



legibility of the data in the columns, will lead to non-remuneration of the concerned services.

9.2 The Facility shall adhere to the norms for Primary and Secondary Register Column Headers as described in the applicable Performance Based Financing Manual. In the event pre-printed PBF registers are not available, the health facility shall design hand-writing registers using the available office stationery according to the above mentioned norms. .

9.3 All numbering, in all registers, from the first day of the PBF contracting, shall start with a ‘1’, and continue for the remainder of the calendar year. The following calendar year, the numbering should start with a new ‘1’, etc. The end of the month should be clearly indicated through a line. The numbering should continue into the following month, until the end the calendar year.

9.4 Routine Health Management Information System (HMIS) data shall align with data from the PBF registers.

10. Quality audits 10.1 In order to ensure that the services performed by the HF meet satisfactory quality

standards, specific Quality Indicators (as described in the latest PBF manual) will be assessed every quarter by the LGA PHC department.

10.2 The results of these Quality Audits will be factored in the calculation of the overall performance of the HF and the final PBF invoice as follows:

a. 25% of the total claimed earnings over the preceding months shall be added as

“quality bonus” if the quality score for that quarter is 100%. b. If the HF’s quality score is 49% or less, the quality bonus is automatically ‘0’ for

the evaluated quarter. c. A quality score between 50% and 99% will be prorated as follows: Quality

Bonus = % Quality Score * (total earnings for all contracted services over the past three months).

10.3 The quality audits shall be counter-verified regularly by an independent third party to be

determined by the SPHCDA. If fraud is detected with the quality score, the present purchase contract may be terminated immediately by the SPHCDA.

11. Validation of the Quarterly Consolidated PBF invoices



11.1 The LGA PBF Steering Committee shall, on a quarterly basis, validate the Health Facility’s monthly PBF invoices and the quality score obtained.

11.2 The LGA PBF Steering Committee shall determine the amount earned by the Health Facility on the basis of the scores obtained in both the quality and quantity controls conducted respectively by the LGA PHC Department and the SPHCDA verification teams as described in Section 9 herein.

12. Terms of payment The amount of each Quarterly Validated final PBF invoice shall be paid into the Health Facility bank account not later than 60 days after the quarter in which they were earned. For that purpose, the Health Facility shall operate autonomously its own bank account in which the funds will be transferred. Guidance on the management of the bank account is available in the PBF manual. 13. Utilization of funds received through PBF, and through all other sources 13.1 The utilization of funds earned through PBF, and through all other sources, and the

present contract shall be at the discretion of the Health Center Management Committee within the limits fixed in Section 4 of this contract.

13.2 Against this background the health center, shall ensure that all documents are well secured. All payments made to staff and other beneficiaries should be clearly signed or thumb printed. Fraud in financial management will be dealt with according to applicable State Laws. Fraud in financial management may lead to immediate termination of the present contract by the SPHCDA.

14. External Counter-verification and Misreporting 14.1 A third party organization shall be contracted by the SPHCDA to conduct random

counter-verifications at community level (the so-called community client satisfaction surveys) on a periodic basis in order to confirm the Facilities results. In that event, the Health Facility hereby agrees to grant full access to the relevant records as may be required.

14.2 In case of any irregularities discovered in the course of such counter-verification (including, but not limited to, inaccurate reporting and “ghost” patients), the Health Facility shall be subject to the penalties as detailed in the PBF user manual and annex 3 of this contract.



15. Business Plan Within three months upon the signature of the present contract, the HF shall submit a Business Plan for the following twelve months of activities (see format in the PBF manual). The Business plan will outline the strategies considered in order to increase the quantity and the quality of its services. The Business Plan shall then be reviewed and approved by the SPHCDA and form an integral part of the present contract. The absence of Business Plan or the non-compliance with its strategies may lead to the termination of the present contract by the SPHDCA. 16. Care for the Indigents 16.1 The Health Facility may allocate a maximum number of 5% of the curative consultations

of the previous month under the reimbursement-category ‘new outpatient consultation for an indigent patient’ for the current month. When allocated to this category the patient shall not pay any fee. Patients allocated under the ‘new outpatient consultation for an indigent patient’ cannot be allocated under ‘new outpatient consultation’ (see annex 1).

16.2 The monthly sum of the number of ‘new outpatient consultations’ and the number of ‘new outpatient consultations for an indigent patient’ shall form the monthly new outpatient consultations provided by the Health Facility. However, a ‘new outpatient consultation for an indigent patient’ client or ‘new outpatient consultation’ client can consume other PBF services. In this case, the additional service shall also be counted under the additional PBF service.

16.3 The reimbursement for a ‘new outpatient consultation for an indigent patient’ category is based on the cost of an average curative care consultation in the Nigerian context according to modern treatment guidelines. The reimbursement is also based on the principle of cross-subsidization: this means that in case the treatment for the indigent client surpasses the actual treatment costs incurred by the HF, that the HF ‘cross subsidizes’ this treatment from other sources of income.

16.4 The ‘new outpatient consultation for an indigent patient’ category is meant for indigents, the poorest of the poor. This category shall be recorded using a separate register, and any other such tools that the facility management, its Facility RBF committee, or its indigent committee have put in place.

16.5 The appropriate use of the ‘new outpatient consultation for an indigent patient’ category will be verified through the routine verification and through the community client satisfaction surveys.

16.6 A specially designated Indigent Committee shall meet regularly to review the appropriateness of the post-identification mechanisms. This indigent committee is drawn



from three members of the Facility RBF Committee and select members of the community not related to any of the health facility staff. This indigent committee reviews each month the appropriateness of the allocations (ref PBF user manual).

17. Sub-contracting for defined services in the minimum service package 17.1 The Facility may sub-contract with select providers for defined services in the MPA will

be allowed. The sub-contracts – including the proposed services - will need to be proposed in the business plan, vetted by the LGA PHC department and approved by the SPHCDA. Sub-contracting can be with public, private non for profit and private for profit providers.

17.2 All sub-contracted services shall be verified by the SPHDA verification teams, and counter-verified by an independent agency through community client satisfaction surveys in the same manner as non sub-contracted services. The Health Facility, as principle contract holder, shall use the approved sub-contracting template (see PBF manual), shall be responsible for the filing and accessibility of all signed sub-contracts, and ensure secondary registers are in conformity with applicable norms in the same manner as the primary registers.

17.3 The Facility, as principal contract holder, is responsible for the appropriate quality standards of care in the sub-contracted facility which is under its direct supervision. It may use up to 25% of the earnings of its sub-contracted facility for its own administration costs provided that it is agreed upon in the sub-contract document between both facilities.

Done at …………………………….. On …………./…………/201.. For The State Primary Health Care Agency Mrs. / Mr. ______________________________ Signed ______________________________ And Chairman of the Ward Health Committee Head of the Health Facility Mrs. /Mr./Dr _____________________ Mrs/Mr/Dr_____________________ Signed ______________________ Signed ______________________



Annex 1: list of Minimum Package of Health Services for the PBF purchase contract. Note: fees are valid for the first three months only and subject to possible re-adjustment by the SPHCDA. Previous fee/subsidy levels are not a guarantee for future fee levels. No

MPA Service Fee (Naira)

1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital 5 Completely Vaccinated Child 6 Growth monitoring visit Child 7 2 - 5 Tetanus Vaccination of Pregnant Woman 8 Postnatal consultation 9 First ANC consultation before four months pregnancy 10 ANC standard visit (2-4) 11 Second dose of SP provided to a pregnant woman 12 Institutional Delivery 13 FP: total of new users of modern FP methods 14 FP: implants and IUDs 15 VCT/PMTCT/PIT test 16 PMTCT: HIV+ mothers and children born to are treated according to

protocol

17 STD treated 18 New AFB+ PTB patient 19 PTB patient completed treatment and cured 20 Household visit per protocol



Annex 2: Provisory Monthly PBF Invoice

Provisory Monthly Invoice for MPA Services

LGA: Month: Health Center: Year:

Service

Quantity Produced

Unit Fee

Sub-Total Naira

1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital 5 Completely Vaccinated Child 6 Growth monitoring visit Child 7 2 - 5 Tetanus Vaccination of Pregnant Woman 8 Postnatal consultation 9 First ANC consultation before four months pregnancy 10 ANC standard visit (2-4) 11 Second dose of SP provided to a pregnant woman 12 Institutional Delivery 13 FP: total of new users of modern FP methods 14 FP: implants and IUDs 15 VCT/PMTCT/PIT test 16 PMTCT: HIV+ mothers and children born to are treated

according to protocol

17 STD treated 18 New AFB+ PTB patient 19 PTB patient completed treatment and cured 20 Household visit per protocol

Grand Total for the month

The current invoice for the month of …………… of ………………………..Health Center is totaled at [………………………………………………] Naira Date…………. Health Center RBF Committee Members: The HC in charge: 1…………………………………………. 2…………………………………………. 3…………………………………………. 4…………………………………………. 5………………………………………… The verifier:



Annex 3: Fraud

FRAUD: PREVENTIVE MEASURES AND PENALTIES

Possible Fraud The introduction of PBF increases the risk for fraud as some providers or administrators inflate results to earn more money.

Verification and counter-verification procedures mitigate the risk for fraud through measuring the difference between claimed (& paid for) performance and actual performance. This requires special attention to measures to detect fraud and to penalties applied in case of certified fraud.

Fraud in PBF systems can be either intentional, or non-intentional. Intentional fraud relates to falsifying documents related to a service activity, falsifying register information, claiming services that had not been delivered, referring to acts of care that the user did not benefit from etc. Unintentional fraud (which is a rare occurrence) can be an error made by a verifier – due to lack of comprehension of the indicators- on a quality checklist or it can be a misinterpretation of indicators by different verifiers (an effect known as ‘inter-observer variability’).

To avoid fraud - intentional or unintentional - there is need for incentives for good behavior, correct reporting and scoring, and disincentives for fraud. In all cases, possible fraud need to be substantiated quantitatively (the numbers and facts) but also qualitatively (a writing explanation as to what actual happened) as sometimes a case of non-intentional fraud can be based on a mis-interpretation of an element of the quality checklist due for instance to a different sampling of a patient file, or be caused by different interpretations of the same event by different verifiers. However, once fraud is established based on quantitative proof, and supported by qualitative elements, strong actions needs to be implemented to discourage future fraudulent behavior.

Fraud prevention The following preventive measures are implemented to decrease the risk of fraud, intentional or unintentional:

• Separation of functions, which helps to minimize fraud by avoiding conflicts of interest; • Good quality ex-ante verification both of the quantity (SPHCDA) and quality (LGA-PHC

departments); • A clear manual, clear contracts and good training in the rules of the game; • An effective reward and punishment system (and application of punishments in case of

certified fraud); • Good governance for PBF at the LGA level;



• Regular community client satisfaction surveys with feedback of the results at all levels.

If rules are transparent and known to all and actions are taken swiftly when fraud is detected while communicating such fraud and its consequences to all stakeholders, then the likelihood of fraud will be minimized.

Penalties for Fraud When fraud is certified, the following actions are taken: Related to ex-post verification of the quantity (community client satisfaction surveys):

• If more than 5% (up to 10%) of the sample cannot be traced back in the community. This means that either the client exists but did not receive the service OR that the client does not exist. Verification is done through mobile phones and/or through household visits with certification that client does or does not exist – as confirmed by the village head:

o First offence: retention of 20% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website;

o Second offence: retention of 50% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website;

o Third offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA).

Box 1: Penalties in case of more than 5% (up to 10%) untraceable clients


Second offence: retention of 50% of PBF earnings, no performance bonuses staff and repeat counter-verification

Third offence: stop the purchase contract, replace head of health facility.



• If more than 10% of the sample cannot be traced back in the community: o First offence: retention of 50% of total PBF earnings from a next payment while

remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website;

o Second offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA).

Box 2: Penalties in case of more than 10% untraceable clients

Related to ex-post verification of the quality for health centers (quality counter-verification of HC): both the LGA – PHC department and the health facility are penalized as follows:

• If the discrepancy is larger than 10% and no qualitative explanation can be given for this discrepancy (average across the sampled services according to the protocol):

o First offence: related to the LGA-PHC department: retention of 50% of LGA-PHC

department performance earnings while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification. Writing warning to the responsible verifier;


o Second offence: related to the LGA-PHC department: retention of retention of 50% of

LGA-PHC department performance earnings while remaining earnings


Second offence: stop the purchase contract, replace head of health facility



cannot be spent on individual performance bonuses PLUS warning in writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification PLUS exclusion of responsible verifier from performance bonuses and from quality checklist assessments for a period of one year;


o Third offence: Related to the LGA-PHC department: stop of the performance contract for

the duration of one year (or until - for the SPHCDA - a satisfactory solution has been found) PLUS offering of quality supervision contract to another PHC pending resolution of the conflict.

Related to the health facility: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA).

Box 3: Penalties in case of more than 10% unexplained discrepant results in quality counter-verification of health centers

The ex-ante verification for the hospital quality is done by a multi-organizational team led by the SPHCDA, consisting of Hospital Board staff, third-party hospital staff and technical partner

First offence: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification. Health facility: retention of 20% of performance earnings, nil bonuses staff.

Second offence: LGA-PHC department: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification plus exclusion of offending verifier from pool of verifiers. Health facility: retention of 30% of performance earnings, nil bonuses staff.

Third offence: LGA-PHC department: stop the performance contract for the duration of one year. Health facility: stop the purchase contract.



agencies. The actual scoring for results is done by the SPHCDA with the others in observer status (i.e. not responsible for the actual scoring).



Annex 3: Motivation Contract between the Health Center Management and the Individual Health Worker

This Contract is dated [………………] 2011 Between: (Official name) Health Centre, herein referred as the “facility” or “HF” Represented by: Ms/Mrs. / Mr. [………………….] Head of [………….………..] Health

Centre, and Mrs. / Mr.: […………….………………….] Chair person of the […………………….] Facility RBF Committee

And Dr/Ms/Mrs/Mr [names of HF worker], [Job title] herein referred as the “worker”

IT IS AGREED as follows: 1. Principles of Performance Based Financing 1.1 The present contract is entered between the worker and the facility within the context of

the Performance Based Financing (PBF) program and the Performance Based Financing Contract for the Purchase of Health Services signed between the facility and the State Primary Health Development Agency (SPHCDA).

1.2 The payment of workers motivation bonuses emanates from National Public Health policies and as such the Government reserves the right to unilaterally amend applicable policies prior to the expiry of the present contract.

Health Facility Worker Motivation Contract



1.3 The motivation contract institutes a mode of additional remuneration to the worker, by way of individual bonuses according to his or her personal work performance with respect to his or her Job Profile.

2. Validity of the contract: Motivation contract and employment contract

2.1 The Job Profile of the worker (in annex 1) including the details of his/her tasks at the

Facility form integral part of the present contract. 2.2 The motivation contract does not supersede or replace the existing worker’s employment

contract. In the event the worker’s employment contract is terminated, the present motivation contract shall automatically be terminated without notice.

3. Validity of the contract : Motivation Contract and PBF contract The existence of this contract is strictly subordinated to the existence and the duration of the PBF Purchase Contract between the facility and the State Primary Health Development Agency (SPHCDA). In the event the PBF Purchase Contract is terminated for any reasons, the present motivation contract shall automatically be terminated without notice. 4. Covenants of the parties

4.1 The Facility worker

4.1.1 The worker shall use reasonable effort in promoting access of the population to better

quality Health Care, working in collaboration with other facility workers. 4.1.2 The worker commits his/herself to safeguarding the transparency and veracity of

information regarding the Facility’s operations. 4.1.3 The worker agrees to be held accountable for fraud or negligence committed by him/her

during the execution of his/her duties.

4.2 The Health Facility

a) The Facility management commits itself to evaluate monthly, in an objective and transparent way, the performance of the worker in light of his Job Profile and tasks which were assigned to him.

b) The Facility management commits itself to pay to the worker a performance bonus on a monthly basis, if the general financial position and the performance income permit, and according to the terms of the present contract. Performance bonuses are the result of a mix of productivity and quality of the health facility. If this productivity is low, there will



be less money available for performance bonuses. The health facility management and the RBF Health Committee might propose, to invest in upgrading the physical infrastructure and the equipment first, to gain more performance payments in the future. Such a strategy will be communicated to the staff. Therefore, the performance bonuses might be forfeited by management, to invest in the health services offered to the population, but which might, in the middle term, lead to higher performance rewards by the health facility and its workers.

c) The Facility management commits itself to put all reasonable effort in providing the worker with the resources necessary for the successful completion of the tasks assigned to her/him and within the limits of the resources available to the facility.

5. Amount and Calculation of Salary Bonuses 5.1 The payment of individual bonuses shall be approved by the RBF Committee upon

proposal from the Facility Internal Management Committee (IMC) using the result of Monthly Individual Evaluation and the index corresponding to his/her professional category as determined by the IMC.

5.2 Important: the management of the health facility, in conjunction with the RBF Committee, may decide to forfeit part or all of the bonus payments for a given quarter, in order to invest in increasing the quantity and quality of care. Individual performance bonuses might, therefore, fluctuate considerably each quarter.

5.3 The amount payable to the worker shall be calculated as follows: The Indice value corresponding to his/her professional position, which is hereby fixed at _____________________ points.

5.4 The individual performance award is calculated by multiplying the individual indice value with the monthly point value with the individual performance evaluation. The proportion of the Facility’s profits allocated to the payment of facility worker’s bonuses is determined quarterly by the Facility’s RBF Committee. See the PBF manual and the indice tool for further guidance.

6. Payment of PBF workers bonuses

The PBF bonuses shall be paid to the workers retrospectively on a monthly basis. 7. Individual performance evaluation

The Internal Management Committee of the HF shall, on a monthly basis, evaluate the worker’s performance in accordance with the tasks assigned to him. The IMC shall keep individual



performance score cards that will record the worker’s performance. These individual score cards shall be kept accessible for transparency and audit purposes. 8. Temporary suspension of the motivation bonuses

In the event of fraud, record falsification, or any other serious irregularity, the RBF Committee may decide to suspend salary bonuses of all HF Workers for a maximum period of three (3) months. 9. Resolution of disputes

In the event of any disputes relating to execution of the present contract, either party may resort to the arbitration of the Facility RBF Committee. All parties hereby agree that such arbitration shall be final and binding towards all parties. 10. Duration and amendment of the contract The present contract is valid from [………………] for a period of [….] month until [..………….] and it shall be tacitly renewed for as long as the worker’s employment contract remains in force. Done at …………………………….. On …………./…………/201… The Worker Ms/Mrs. / Mr. ______________________________ Signed ______________________________ And Chairman of the RBF Committee Head of the Health Facility Ms/Mrs. /Mr. _____________________ Ms/Mrs./Mr. __________________ Signed _____________________ Signed _______________________

Annex 1: Job Profile



Annex 4: Contract between the SPHCDA and the LGA PHC Department

(…) State Primary Health Care Development Agency

PERFORMANCE BASED FINANCING (PBF) CONTRACT FOR THE QUALITY SUPERVISION OF HEALTH SERVICES

No _________________

THIS CONTRACT is dated [……..] 2011 BETWEEN: The State Primary Health Care Agency (“SPHCDA”) represented by its Executive Director Dr. /Mrs. /Mr.…………………………………………: And The [………………….] Local Government Authority Primary Health Care Department Represented by: Mrs. / Mr.: [………………………………] Primary Health Care Department Coordinator Mrs. / Mr.: [……………………………….] Chairperson of […………] Local Government



IT IS AGREED as follows: 1. Principles of Performance Based Financing 1.1 The present contract is a performance contract between the SPHCDA and the Local

Government Authority Primary Health Care Department (PHCD) in the context of the State’s Performance Based Financing (PBF) program.

1.2 The goal of PBF is to increase the provision of quality Basic Health Services to the population by increasing financial incentives for health workers and by increasing health facilities’ decisional rights on the management of their own operations.

1.3 The Performance Based Financing strategy emanates from National Public Health and Poverty Reduction policies. The SPHCDA reserves the right to amend the applicable policies that serve as the basis of its support to the PHCD prior to the expiry of the present contract.

2. Purpose of the Contract 2.1 The purpose of this contract is to establish a performance contract for the LGA PHCD to

undertake Supervision of the Quality of Care at the LGA’s PBF contracted Health Facilities based on the applicable Performance Framework (see attached in annex 1).

2.2 Part of the payments received under these terms may be used by the PHCD department to pay for incremental expenses directly related to the Supervision and Control Activities, including, but not limited to, per-diem for supervision team members, office equipments and consumables, maintenance and repair of vehicles and communication costs.

2.3 Part of the payments received under this performance contract may be used to pay performance bonuses to staff involved in the supervisory activities.

3. Mission of the PHCD within the PBF System 3.1 The Primary Health Care Department (PHCD) shall ensure that Health Facilities in the

LGA provide adequate quality health care services in the general interest of improvement of public health in the community.

3.2 In doing so, the PHCDA hereby commits to undertake the following:

• Conduct timely quarterly quality supervisions of the Health Facilities contracted through PBF contracts with the SPHCDA (as stipulated in Section 4 herein);

• Investigate at facility level any activities in contradiction with national health policies and/or accepted medical ethics and solve these, and bring these to the attention of the LGA RBF Steering Committee if necessary;



• Supervise the Health Facilities regularly (as stipulated in Section 4 herein), investigate and document for the LGA RBF Steering Committee any change in HF personnel, technical skills and equipment at the facility that which could hamper its capability to render the Services remunerated by the present PBF contract;

• Investigate and Report in writing any case of fraud or attempted fraud committed by HF staff members to the SPHCDA and the LGA RBF steering committee;

• Ensure complete transparency and access to information relating to the use of funds received from the SPHCDA in relation to the present contract.

4. Quality audits of the PBF contracted Health Facilities 4.1 For the purpose of this contract, the term ‘PBF facilities’ shall refer to all health facilities

that are contracted and remunerated by the SPHCDA through PBF purchase contracts; 4.2 The PHCD verification teams shall conduct Quarterly Control audits by applying the

applicable PBF Quality supervisory checklist (see template in annex 2). This checklist is updated regularly, typically annually, and the PHCD should use the latest version as developed and approved by the NPHCDA/SPHCDA;

4.3 Such Quarterly Quality supervision shall be conducted at all PBF facilities no later than the 15th of the fourth month following the quarter and must contain all quality scores for review and validation by the LGA RBF Steering Committee;

4.4 The original of all quality supervisory checklists shall be sent to the SPHCDA, and arrive there no later than the 20th of the fourth month (the month following the quarter).

5. Business Plans 5.1 The PHCD shall review on a quarterly basis the level of implementation of the Business

plans developed by the HFs and part of their PBF purchase contracts. The Business Plans evaluation shall form part of the PBF Quality Verification checklist as described in annex 2;

5.2 The PHCD may, as a result of the review, suggest changes to the business plans in close collaboration with the Facility RBF Committees and Heads of facilities. The PHCDA has an important technical supportive and advisory and capacity strengthening role in this aspect;

5.3 In relation to 5.2, it is ultimately the SPHCDA which will have to agree on the proposed business plan contents, and which consists of a negotiation between the health facility management and the SPHCDA directly.

6. Performance Remuneration of the PHCD



6.1 The budget ceiling for this contract is Naira … (N…). The level of remuneration shall be directly proportional to the score obtained by the PHCD in accordance with the performance framework tool (as detailed in Annex 1 of the present contract);

6.2 For instance, if the PHCD obtains 75% score in a given quarter, the PHCD shall receive 75 % of the total available performance budget for that quarter.

7. Evaluation of the PHCD Performance 7.1 The SPHCDA Verifier shall evaluate the PHCD’s performance every quarter, not later

than the 15th day of the month immediately following each concerned quarter and using the Performance Assessment Framework;

7.2 The SPHCDA Verifier shall sign 1 original of the quarterly performance assessment, the original will go to the SPHCDA HQ for filing and entry in the web-enabled application; a copy will remain at the PHCD and will be presented during the following RBF steering committee meeting;

7.3 In case of systematic underperformance, such as not carrying out the quality supervision in a timely and complete manner, or in the case of fraud with the quality assessments, the SPHCDA retains the right to unilaterally stop this contract, and to provide this contract to another party.

8. Terms of payment 8.1 The SPHCDA shall directly pay the PHCD by way of bank transfer in the designated

PHCD bank account in quarterly installments; 8.2 Payments will be executed along with the performance payments for health facilities, and

will follow the same system of validation, due diligence and approvals (validation in the LGA RBF Steering Committee; submission of minutes of the meeting and invoices to the SPHCDA; due diligence of the SPHCDA on the deliverables; payment for performance by the PFMU);

8.3 It is hereby agreed, as a critical pre-condition to the present contract, that the PHCD shall have direct access and control of the designated bank account.

9. Dispute resolution 9.1 In the case of dispute relating to the interpretation of the present contract, both parties

agree to refer to the most current applicable Performance Based Financing User Manual, and attempt to resolve the issue in the LGA RBF Steering Committee meeting;



9.2 In the case of dispute relating to the implementation of the present contract, both parties agree to refer to the matter to the arbitration of the State RBF steering committee which acts as the regulator of the PBF system in the State. The arbitration decision in the matter shall be final and binding towards all parties.

9.3 However, in case of systematic underperformance, as documented in section 7.3, the SPHCDA retains the right to stop the current contract unilaterally and to contract with another party.

10. Duration of the Contract The present contract is signed on [date] for a period of 12 months. It shall be renewed tacitly for an additional 12 months subject to the terms stipulated in section 1 of the present contract. Done at …………………………….. On ……/………/2010 For The State Primary Health Care Agency Mrs. / Mr. ______________________________ Signed ______________________________ And Chairperson of the Local Government Authority LGA PHCD Coordinator Mrs. /Mr. _____________________ Mrs. /Mr._____________________ Signed ______________________ Signed ______________________ Annex 1: LGA – PHC Department performance framework

Annex 2: Quality Supervisory Checklist for Health Centers



Annex 5: Sub-Contract between the Health Provider and a Secondary Health Provider

PERFORMANCE BASED FINANCING (PBF) SUBCONTRACT

Subcontract No.

Between __________________________________ Health Center (Principal Facility) in [……………….] State; [……………….] Ward, [……………………] LGA And __________________________________Health Center/Health Post (Subcontractor) 1. Purpose of the contract The present contract is a performance contract between the Principal Facility and the Subcontractor for the remuneration of health services provided by the subcontractor on a case based payment basis. 2. Services delivered The Health Services provided by the subcontractor and their remuneration are as follows:

No Service Fee 1 New Outpatient Consultation 2 Fully Vaccinated Child 3 FP new or existing user of modern FP methods 4 Growth monitoring visit child 5 Household visit as per protocol

The Fee has been adjusted to reflect the administrative overheads that the principal PBF contractor is allowed to levy on each service of the sub-contractee. This administrative overhead is meant to pay for the efforts of the main PBF contractor to (a) manage the sub contracting



process; (b) ensure quality services delivered by the sub-contractor; (c) coaching on the use of registers; (d) coaching in the use of advanced strategies employed to boost productivity. The administrative overheads can be up to a maximum of 25% of the Fee value claimed by the main PBF contractor, from the SPHCDA. It can be a lesser percentage, but not a higher percentage. 3. Principal contract The existence of this contract is subordinated to the existence and the duration a Principal PBF Purchase Contract between the Principal Facility and the State Primary Health Development Agency (SPHCDA). In the event the Principal Contract is terminated for any reasons, the present subcontract may automatically be terminated without notice. 4. Interpretation and reference Both parties agree to refer to the most current applicable Performance Based Financing User Manual and the Principal PBF Contract between the Principal Facility and the State Primary Health Development Agency (SPHCDA) for any matter relating to the interpretation and execution of obligations inferred by the present contract. 5. Duration, validity and termination The present contract is valid for a period of [……] months from [Date ………….] to [Date ……………] subject to satisfaction of both parties. Either party may terminate the contract at any time. It shall be renewed automatically for additional 12 months periods in the absence of writing notice to the contrary emanating from one of the party prior to the end date. 6. Dispute resolution Both parties agree to refer any dispute relating to the present contract to the Facility RBF Committee. In case of unresolved conflict, the issue will be referred to the LGA RBF steering committee, whose decision will be final. SIGNED on ________________ By Head of ______________Health Center And Head of _______Health Center/Post ________________________________ ______________________________ Contractor Sub-contractor



Annex 6: MPA and CPA

1. Minimum Package of Activities (MPA)

No MPA Service 1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital 5 Completely Vaccinated Child 6 Growth monitoring visit Child 7 2 - 5 Tetanus Vaccination of Pregnant Woman 8 Postnatal consultation 9 First ANC consultation before four months pregnancy 10 ANC standard visit (2-4) 11 Second dose of SP provided to a pregnant woman 12 Institutional Delivery 13 FP: total of new users of modern FP methods 14 FP: implants and IUDs 15 VCT/PMTCT/PIT test 16 PMTCT: HIV+ mothers and children born to are treated according to protocol 17 STD treated 18 New AFB+ PTB patient 19 PTB patient completed treatment and cured 20 Household visit per protocol



2. Complementary Package of Activities (CPA)

No CPA Service 1 New outpatient consultation by a Doctor 2 New outpatient consultation by a Doctor of an indigent patient 3 Counter-referral slip arrived at the Health Center 4 Minor Surgery 5 Major Surgery (ex CS) 6 Normal delivery 7 Assisted Delivery 8 CS 9 Inpatient Day 10 Inpatient Day for an indigent patient 11 Postnatal consultation 12 First ANC consultation before four months pregnancy 13 ANC standard visit (2-4) 14 FP: total of new users of modern FP methods 15 FP: implants and IUDs 16 FP: vasectomy and bilateral tuba ligation 17 VCT/PMTCT/PIT test 18 PMTCT: HIV+ pregnant mothers and children born to are treated according to

protocol 19 STD treated 20 New Client put under ARV treatment 21 New AFB+ PTB patient 22 PTB patient completed treatment and cured

Annex 7: Service Protocol Reference Guides

Minimum Package of Activities

No Name MPA Service Description Primary Data Collection Tools21

Secondary Data Collection Tools22

1 New outpatient consultation

Any new curative care visit during the past month

Curative Care Register Original prescription for drugs dispensed kept at the pharmacy which includes cost of drugs. Drugs register and stock cards conform.

2 New outpatient consultation of an indigent patient

During the past month, indigents who have been consulted as an outpatients. Indigents are locally identified. Maximum of 5% of all new curative consultations during the previous month.

Indigent outpatient register Proceedings indigent committee Community Client Satisfaction Survey: post-identification questionnaire application

3 Minor Surgery

Any new minor surgical intervention during the past month. Minor Surgery defined as (i) Suture; (ii) incision and drainage; (iii) minor excisions.

Minor Surgery Register Original prescription for drugs and medical consumables dispensed kept at the pharmacy which

21 See Annex ‘Primary Data Collection Tool Column Headers’. These registers ought to be well-legible with filled all columns filled in. The PBF column header formats are mandatory. If information is lacking, automatically this service is not remunerated/validated. The Verifier can use a red pen to cross out the service and or to make annotations. If the mobile phone number is not recorded, the service risks not being remunerated. In case of absence of mobile phone number the client can provide any number, i.e. from a family member, the neighbor, or the village chief. But a recorded number is mandatory. In the unlikely case that the client has no number at all to provide, the patient will need to sign the register’s column header.

22 The secondary data collection tools can be partially at the health facility, partially with the client. They can be subject to scrutiny during either the routine data verification exercises, and or during the community client satisfaction surveys. In case there is no trace of such services rendered in the secondary data collection tools, then the service might be considered ‘not rendered’ ex-post, and sanctions will be applied as per contract.





includes cost of drugs/consumables. Drugs register and stock cards conform.

4 Referred patient arrived at the General Hospital

Counter-referral slip available at the Health Center. Fully filled in by the MD. The number of valid counter-referral slips is counted.

Original of counter-referral slip available at the Health Center.

Copy of the counter-referral slip available at the General Hospital. Referred patient registered in the outpatient’s department register.

5 Completely Vaccinated Child

Child less than 12 months old which has received all vaccines according to the national protocol (BCG; DTP3; Measles)

Vaccination Register Under-five card with vaccination records, held by the mother.

6 Growth monitoring visit Child

Any new quarterly growth monitoring visit of a child less than five years old during the past month. These growth monitoring visits ought to be monthly according to the protocol, however, here, a quarterly visit is remunerated.

Under-five clinic/Nutrition Register

Under-five card with growth curve plotted, held by the mother

7 2 - 5 Tetanus Vaccination of Pregnant Woman

Each second to fifth TT vaccination of a pregnant woman during the past month

ANC register Individual Card kept at the HF

ANC card held by the mother Vaccination register

8 Postnatal consultation

A post natal consultation held within 48 hours after giving birth, during the past month.

Delivery register Partogram or inpatient form

9 First ANC consultation before four months pregnancy

A first ANC consultation occurs before 4 month’s pregnancy, during the past month.


ANC card held by the mother

10 ANC standard visit (2-4) Any 2-4th standard visit according to the ANC register ANC card held by the





focused antenatal care visit schedule and approach. Second visit between 24-28 weeks; third visit at 32 weeks and the fourth visit at 36 weeks. During the past month.

Individual Card kept at the HF

mother Medical prescriptions for Ferrosulphate, Vermox and SP kept at the pharmacy. Drugs register and stock cards conform.

11 Second dose of SP provided to a pregnant woman

The second dose of SP (IPTp), according to the protocol, during the past month.


ANC card held by the mother; medical prescription for SP kept at the pharmacy. Drugs register and stock card conform.

12 Normal delivery

A delivery attended by a trained attendant at the health facility during the past month.

Delivery Register Partogram; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

13 FP: total of new and existing users of modern FP methods

Any new or existing user of injectable contraceptive or oral contraceptive pills, during the past month. An injection represents three month’s protection and a FP visit for OAC should provide three month’s worth of pills.

FP register Individual Card kept at the HF

Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

14 FP: implants and IUDs

Any new user of implant or IUD, during the past month.

FP register Individual Card kept at the HF

Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs





register and stock cards conform.

15 VCT/PMTCT test

Any new VCT or PMTCT test carried out during the past month.

VCT register Laboratory register; stock records

16 PMTCT: HIV+ mothers and children born to are treated according to protocol

Any new HIV+ mother and newborn child treated according to the PMTCT protocol, during the past month.

ARV register; delivery room register

PMTCT register; laboratory register; stock records.

17 STD treated

Any new STD treated according to syndromic treatment protocol, during the past month

Curative Care Register Drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

18 New AFB+ PTB patient

A new AFB sputum positive Pulmonary Tuberculosis patient diagnosed, at the facility, during the past month.

Tuberculosis register Laboratory register. Slides kept for counter-verification/quality assurance.

19 PTB patient completed treatment and cured

A former AFB+ PTB patient completed DOTS, and cured after treatment proven by negative sputum examinations, during the past month.

Tuberculosis register Laboratory register. Slides kept for counter-verification/quality assurance. Drugs register.

20 Household visit per protocol A household visit as per protocol, using a defined list of questions/issues and ending with a business plan for each household related to water&sanitation; FP/RH; vaccinations and growthmonitoring visits.

Household visit register



Complementary Package of Activities

No Name CPA Service Description Primary Data Collection Tools23


1 New outpatient consultation by a doctor

Any new curative care OPD visit attended by a Doctor during the evaluated month

Curative Care Register Original prescription for drugs dispensed kept at the pharmacy which includes cost of drugs. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams.

2 New outpatient consultation by a doctor of an indigent patient

Any new curative care OPD visit by an indigent patient attended by a Doctor during the evaluated month. Indigents identified according to local norms. Maximum of 20% of all new curative consultations and or admissions during

Indigent register Proceedings Indigent committee Community Client Satisfaction Survey

23 See Annex ‘Primary Data Collection Tool Column Headers’. These registers ought to be well-legible with filled all columns filled in. The PBF column header formats are mandatory. If information is lacking, automatically this service is not remunerated/validated. The Verifier can use a red pen to cross out the service and or to make annotations. If the mobile phone number is not recorded, the service risks not being remunerated. In case of absence of mobile phone number the client can provide any number, i.e. from a family member, the neighbor, or the village chief. But a recorded number is mandatory. In the unlikely case that the client has no number at all to provide, the patient will need to sign the register’s column header.

24 The secondary data collection tools can be partially at the health facility, partially with the client. They can be subject to scrutiny during either the routine data verification exercises, and or during the community client satisfaction surveys. In case there is no trace of such services rendered in the secondary data collection tools, then the service might be considered ‘not rendered’ ex-post, and sanctions will be applied as per contract.





the previous month. 3 Counter-referral slip arrived at

the Health Center A counter-referral note filled by the MD, sent to the health center, during the evaluated month. The feedback must at least mention the diagnosis and treatment received. The carbon copy of the referral note is only remunerated when it is accompanied by a short note with name, date and signature of the health center in-charge.

Carbon copy of the original referral slip, filled in by the MD.

Original prescription for drugs and medical consumables dispensed kept at the pharmacy which includes cost of drugs/consumables. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams. Original referral slip available at the Health Center

4 Minor Surgery Any new minor surgical intervention during the evaluated month. Minor Surgery defined as (i) Suture; (ii) Herniotomy; (iii) Subcutaneous cyst removal; (iv) I&D; (v) amputation of a finger/toe

Minor Surgery Register Original prescription for drugs and medical consumables dispensed kept at the pharmacy which includes cost of drugs/consumables. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams.

5 Major Surgery (ex CS) Any new major surgical intervention during the evaluated month. Major surgical intervention defined as a laparatomy for any cause (bar CS), or amputation of a large limb.

Theater register Original prescription for drugs and medical consumables dispensed kept at the pharmacy which includes cost of





drugs/consumables. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams.

6 Normal delivery A normal delivery attended by a trained attendant in this facility, during the evaluated month.

Delivery register Partogram and inpatient file; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

7 Assisted delivery An assisted delivery attended by a Doctor in this facility, during the evaluated month.

Delivery register Partogram and inpatient file; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

8 CS A CS carried out at this facility during the evaluated month.

Delivery register or theater register

Partogram and inpatient file; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register

9 Inpatient Day One day admission of an admission of a minimum of three days duration and discharged alive, during the past month.

General admission register for each department

In patient form kept at the health facility





10 Postnatal consultation A post natal consultation held within 48 hours after giving birth, during the past month.

ANC register ANC card kept at the health facility

11 First ANC consultation before four months pregnancy

A first ANC consultation occurs before 4 month’s pregnancy, during the evaluated month.

ANC register ANC card kept at the health facility.

12 ANC standard visit (2-4) Any 2-4th standard visit according to the focused antenatal care visit schedule and approach. Second visit between 24-28 weeks; third visit at 32 weeks and the fourth visit at 36 weeks. During the evaluated month.

ANC register ANC card kept at the health facility. Medical prescriptions for Ferrosulphate, Mebendazole and Fansidar kept at the pharmacy. Drugs register and stock cards conform.

13 FP: total of new users of modern FP methods

Any new or existing user of injectable contraceptive or oral contraceptive pills, during the past month. An injection represents three month’s protection and a FP visit for OAC should provide three month’s worth of pills.

FP register Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

14 FP: implants and IUDs Any new user of implant or IUD, during the evaluated month.

FP register Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

15 FP: vasectomy and bilateral tuba ligation

A vasectomy and bilateral tuba ligation carried out at this facility, during the evaluated month

Theater register Family Planning Register





16 VCT/PMTCT/PIT test Any new VCT or PMTCT or PIT test carried out during the evaluated month.

VCT/PMTC register Laboratory register; stock records

17 PMTCT: HIV+ pregnant mothers and children born to are treated according to protocol

Any new HIV+ mother and newborn child treated according to the PMTCT protocol, during the evaluated month.

ARV register; delivery room register

PMTCT register; laboratory register; stock records.

18 STD treated Any new STD treated according to the syndromic treatment protocol, during the evaluated month

Curative Care Register Drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform.

19 New Client put under ARV treatment

Any new patient (pediatric or adult) HIV positive who started ARV (Antiretroviral therapy), including transferred in, during the evaluated month.

ART Register Patient files

20 New AFB+ PTB patient A new AFB sputum positive Pulmonary Tuberculosis patient diagnosed, at the facility, during the past month.

Tuberculosis register Laboratory register: Slides kept for counter-verification/quality assurance.

21 PTB patient completed treatment and cured

A former AFB+ PTB patient completed DOTS, and cured after treatment proven by negative sputum examinations, during the past month.

Tuberculosis register Laboratory register: Slides kept for counter-verification/quality assurance. Drugs register.

Annex 8: Quarterly Quality Supervisory Checklist for Health Centers

[………..…...] MOH/[…..………..] PHCDA Quarterly Quality Review of Health Centers

version 14 December, 2013 Date: Name Supervisor: LGA: Ward: Medical Staff Total: HF: Population: Non-Medical Staff Total:

1 General Management [max 21 points] YES NO

1.1 Presence of map of health facility catchment area 1 0

1.1.1 Health map of the health area available and on the notice board of the health facility showing villages, main roads, natural barriers, special points and distance

1.2 HMIS reports - business plan - minutes of meetings and patient cards (OPD, ANC, Partographs, FP and Bed head tickets) well stored 4 0

1.2.1 In cupboard and in box files and accessible by the duty manager

1.3 Staff duty roster available and well displayed up to date for current month and visible for staff and patients

1 0

1.4 Technical meetings with staff conducted monthly and minutes available

3 0; 1;2 1.4.1

Each monthly minutes contains at least: (i) date of the meeting; (ii) signed list of participants; (iii) follow-up of decisions taken during the previous meeting; (iv) there is a list of developed recommendations or decisions taken; (v) each month the monthly financial balance is discussed; (vi) minutes of the meeting are signed by the chair. For every meeting report that contains the above = 2 p. (max 3 reports)

1.5 Standard Sheets for referral available 1 0

1.5.1 At least 10 standard sheets are present during the evaluation

1.6 Availability of communication radio or dedicated mobile phone for communication between health facility and general hospital

1 0 1.6.1

Radio or mobile phone functional with batteries and/or call credit and contact details on the phone (e. g: Medical Director CH, HF Staff, LGA PBF HFs OICs, PHC Dept. PBF Team and SPHCD PBF Team, etc.)

1.7 HMIS reports are filled, updated and transmitted to the LGA on schedule 5 0



1.7.1 Transmission of HMIS report is after verification of the SPHCDA of the monthly MPA invoice (including those of subcontracted HFs if applicable) and a signed receipt of acknowledgement is available

1.8 HMIS data analysis report for the quarter being assessed concerning priority problems

2 0 1.8.1 Five priority health problems are followed each quarter and data have been updated up to

the month prior to the supervisor's visit (all or nothing)

1.9 Health Facility RBF Committee meetings conducted monthly and minutes available

3 (0; 1; 2) 1.9.1

Each monthly minutes contain: (i) date of the meeting; (ii) signed list of participants; (iii) follow-up of decisions taken during the previous meeting; (iv) there is a list of developed recommendations or decisions taken; (v) each month the monthly financial balance is discussed; (vi) minutes of the meeting are signed by the chair. Each report according to norms = 1 p (maximum 3 points)

Total Points (21) ../21 Remark

s Date:

Name of Supervisor: Signature of the supervisor:

2 Business Plan [max 9 points] YES NO

2.1 Quarterly business plan for the current period made and accessible 2 0

2.1.1 Valid and renegotiated for the current quarter

(Section 2: Business Plan) 2.2 Business plan prepared with key stakeholders

2 0 2.2.1 Facility RBF Committee Members involved (Chairman (president) signed off on the plan)

2.2.2 Representative (s) of subcontracted private clinics or health posts involved (if applicable)

2.3 Business plan contains convincing geographic coverage plan

1 0 2.3.1 Strategies for sub-contracts (e.g. villages at more than one hour by foot) are elaborated

2.3.2 Mobile strategies (EPI, FP; ANC, household visits per protocol) are used and planned

2.4 Business plan analyses presence of untrained informal practitioners in catchment area 1 0

2.4.1 HF treats this subject in the BP, and suggests a strategy for dealing with informal practitioners

2.5 Business plan analyses presence of trained practitioners operating without any permission 1 0



2.5.1 BP may suggest to include them or to discourage if quality conditions are not met

2.6 Business plan shows a plan to assure financial accessibility for the population

2 0 2.6.1 Business plan shows negotiated rates between HF, committee and community

2.6.2 Business plan shows planning for care for the indigents

Total Points (9) ../9 Remarks Date:


3 Finance [max 15 points] YES NO 3.1 Financial and accounting documents available and well kept

5 0 3.1.1 Monthly financial report available and correctly filled 3.1.2 Theoretical balance of cash-book corresponds to liquidity in cash

3.2 Document available (Indice Tool) to show that quarterly calculation of incomes, running costs, investments and variable performance subsidies are done

4 0 3.2.1 This document guarantees running costs: = salaries, purchase of drugs and equipment, subcontracts, petty cash from small expenditures, social marketing, maintenance and rehabilitation

3.2.2 This document calculates the performance bonus according to the formula: performance bonuses = income of the quarter - running costs

3.3 Contract salaries and benefits + performance bonuses do not exceed 50% of total HF income through PBF 2 0

3.4 Existence of monthly performance bonus system is known by staff 4 0

3.4.1 Take a random staff member and ask what the performance bonus was last month, and what his or her individual performance % was. If both are explained then 4 points.

Total Points (15) ../15



Remarks Date:


4 Care for the Indigents [max 4 points] YES NO 4.1 Planning for Care for the Indigents expenditures

1 0 4.1.1 5% of curative consultations of the previous month: documented quantity in monthly

management meetings

4.2 Indigent committee meets monthly

3 0; 1; 2 4.2.1

The Indigent committee meets monthly to review the Care for the Indigent Category use. Each monthly minutes contain: (i) date of the meeting; (ii) signed list of participants; (iii) follow-up of decisions taken during the previous meeting; (iv) there is a list of developed recommendations or decisions taken; (v) each month the monthly financial balance is discussed; (vi) minutes of the meeting are signed by the chairman. Each report according to norms = 1 p



5 Hygiene and Sterilization [max 31 points] YES NO 5.1 Fence health facility available and well-maintained 1 0

5.1.1 Fence exists, can be closed at night and there are no holes

5.2 Availability of a garbage bin in the courtyard 1 0

5.2.1 Bin with lid accessible to clients which is not full

5.3 Presence of sufficient latrines/toilets which are well-maintained 5.3.1 At least two functional latrines/toilets 1 0



5.3.2 Floor without fissures with single hole and lid 0.5 0 5.3.3 Recently cleaned without visible fecal matter 0.5 0 5.3.4 Door lockable from the inside, super structure with roofing, without flies and no smell 0.5 0 5.3.5 Smells of disinfectant 0.5 0 5.4 Presence of sufficient showers which are well-maintained

5.4.1 At least one bathing facility (with floor without fissures, Door lockable from the inside, super structure with roofing) 1 0

5.4.2 Bathing facility with running water, or container with at the least 20 L of water 0.5 0 5.4.3 Evacuation of the waste water in a sanitation pit 0.5 0 5.5 Waste pit for Health Care Waste is available and according to the norms

5.5.1 Waste disposal pit minimum 2 meters deep, lined with clay, concrete or brick or plastic, it is fenced and has a bright flag.

12 0 5.5.2 The waste pit is a minimum of 15 meters from the health facility, minimum of 50 meters

from a household, and 100 meters from a water source

5.5.3 Health Care Waste is not visible (covered by at the least 10 cm of soil or lime)

5.5.4 The health facility maintains a register indicating the date of the creation of the pit(s), and the location (s)

5.6 Courtyard clean 1 0 5.6.1 No waste or medical waste in the courtyard

5.7 Sterilization according to norms using a pressure sterilizer

3 0 5.7.1 Sterilizer functional

5.7.2 Sterilization protocol available and utilized (medical personnel present can explain the protocol or demonstrate the process)

5.9 Hygienic conditions assured during wound dressing and injections

2 0

5.9.1 Yellow and Red Bins for medical waste with lid and foot pedal, lined with bag

5.9.2 Security box for needles well positioned, and used (and not full)

(Section 5: Hygiene)

5.9.3 Needle cutter available and used

5.9.4 Container/bowl with lid containing disinfectant used for putting used instruments

5.10 Disposal of Health Care Waste according to National Norms

6 0 5.10.1 Waste disposal of non-contaminated waste in Black Bin with lid and foot pedal, lined

5.10.2 Waste disposal of contaminated HCW in Yellow Bins with lid and foot pedal, lined

5.10.3 Waste disposal of organically HCW in Red Bins with lid and foot pedal, lined

5.10.4 Protective gear for personnel managing HCW available; boots, plastic shorts, thick plastic/rubber gloves

Total Points (31) ../31 Remarks



Date:


6 Curative Consultations [max 97 points] YES NO 6.1 Good conditions in waiting area

1 0 6.1.1 Sufficient benches and or chairs protected against sun and rain and waiting area is not

inside the consultation room

6.2 Unit fees of drugs displayed to the public

1 0 6.2.1 Easily visible in the consultation room waiting area, updated, with (i) unit price per item; (ii) price for a standard treatment of the drug

6.2.2 Drugs are all generics

6.3 Existence and use of waiting card system with numbers 1 0 6.4 Consultation room in good condition

5 0

6.4.1 Walls with durable materials well painted, floor paved with cement without fissures, undamaged ceiling

6.4.2 Consultation room and waiting space separated assuring confidentiality

6.4.3 Windows with curtains

6.4.4 Functional door with functional lock

6.4.5 Running water (tap or water dispenser) with soap and clean towel available and used between patients

6.5 Consultation room (where emergencies are received) has 24/7 light 1 0 6.5.1 Electricity or solar light or functioning high pressure kerosene light present

6.6 Consultations are done by skilled staff 2 0

6.6.1 Identification of consulting staff in register (names, rank and signature)

6.7 Consulting staff is well-dressed 1 0

6.7.1 Clean blouse and footwear

6.8 Correct numbering of registers 1 0

6.8.1 Correct numbering and closed at the end of the month

6.9 Service availability 7/7 1 0

6.9.1 Supervisor verifies entries in register for the last three Sundays

6.10 Malaria protocol put on wall and accessible for staff 1 0

6.10.1 National protocol for diagnosis and treatment of simple and severe malaria



6.11 Simple malaria correctly treated 5 0

6.11.1 Register see last five cases of simple malaria and review treatment acc protocol (one point for each correct treatment according to protocol: max 5 points)

6.12 WHO flow diagram for ARI put on wall and accessible for staff 1 0 6.13 ARI protocol applied

5 0 6.13.1

See last five cases of ARI and review treatment acc protocol; register mentions Temp; RR; cough yes/no; diagnosis (one point for each correct treatment according to protocol: max 5 points)

6.14 WHO protocol for Diarrhea put on wall and accessible for staff 1 0 6.15 Diarrhea protocol applied

5 0 6.15.1 See last five cases of Diarrhea and review treatment acc protocol (each correct treatment

one point; max 5 points)

6.16 Proportion of consultations treated with antibiotics <30% 4 0

6.16.1 See last 100 cases in register, check diagnosis and calculate the rate (< 30 cases)

(Section 6: OPD) 6.17 Treatment guidelines available in consultation room 1 0 6.18 Knowledge of tuberculosis danger signs and criteria for referral

5 0 6.18.1 Select any available qualified medical staff, and ask the question on TB dangers signs

6.18.2 Answer must contain at least 4 of the following signs: (i) weight loss; (ii) loss of appetite; (iii) fever; (iv) cough of more than 15 days duration; (v) night sweating

6.19 Stethoscope and BP machine available and functional 1 0

6.19.1 Let nurse check BP and review measure

6.20 Thermometer available and functional 1 0 6.21 Otoscope available and functional 1 0 6.22 Examination bed available with mattress

1 0 6.22.1 Non-torn, plastic cover, specific for the OPD consultations only

6.23 Weighing scale available and functional 1 0

6.23.1 Inspect in comparison with known weight of supervisor: after weighing, the balance should return to zero

6.24 Integrated Management of Childhood Illnesses strategy is applied

2 0 6.24.1 Protocol is available in the consultation room

6.24.2 The last five IMCI cases are traced in the register and comply with the IMCI strategy (all five)

6.25 Determination of nutritional status

6.25.1 Determination of nutritional status of all children under 5 who come for consultation (check ten children under five through a random sampling method: take a random number between 1 and 3 and using this sampling interval check five consultations)

2 0



6.25.2 Determination of nutritional status of all women with a sick child under 6 months of age (as above) 2 0

6.25.3 Screening record of nutritional status available, up to date and properly filled out 2 0

6.26 Direct observation of three consecutive children under five (each child maximum 14 points; max 42 points)

6.26.1 Ask about fever and IF FEVER ask about (i) since when; (ii) persistent or intermittent 2 0 6.26.2 Ask about cough and IF COUGH ask about since when 2 0 6.26.3 Ask for diarrhea IF DIARRHOEA then ask (i) since when; (ii) how often per day; (iii)

consistency - water or mucus or bloody; (iv) vomiting 2 0 6.26.4 GENERAL IMPRESSION: awake or tired? 2 0 6.26.5 FIRST - COUNT RESPIRATION RATE (observe before touching child!!!) 2 0 6.26.6 Temperature (measure) 2 0 6.26.7 Skin pinch (in case of diarrhea) OR chest auscultation (in case of cough) 2 0


Date:


7 Family Planning [max 22 points] YES NO 7.1 At least one qualified staff trained in Family Planning 2 0 7.2 Confidentiality in consultancy room assured

2 0 7.2.1 Room with closed doors, curtains at windows or non-transparent glass

7.3 Family planning methods available and visible in demonstration box for potential users

2 0 7.3.1 Condoms; OAC; Injectable; Implant; IUD; are available in the demonstration box (all five items)

7.3.2 Penis model available on the desk; box with condoms available with at the least 50 condoms

7.4 Staff correctly calculates number of clients expected monthly for oral and injectable contraceptives

1 0 7.4.1

For example for 10.000 population (target is entire ward catchment pop) = 10.000 * 22.5% * 25%/12 * 4 * 90% (assuming 25% unmet need; 22.5% target population; 90% of oral/inject AC at HC level. Ask any medical personnel involved in care for clients to



explain this target calculation.

7.5 Business plan contains strategy to achieve FP targets

3 0 (Section 7: FP)

7.5.1 Collaboration with public sector, private sector and social marketing, mobile strategies, advocacy among local leaders etc (explicit mention in the BP)

7.5.2 Involvement of HF staff in strategies (explicit mention of this in the BP)

7.6 Stock of oral and injectable contraceptives in adequate 2 0

7.6.1 for example for 10.0000 pop 72 doses of oral (3 month cycles) and injectable methods combined

7.7 IUD available and staff trained to use it 3 0

7.7.1 at least five IUDs and at the least one staff trained to use it

7.8 Implant method available and staff trained to use it 3 0

7.8.1 at least five implants available and staff trained to use it

7.9 Strategies available for transfer of persons to hospital seeking permanent FP methods 2 0

7.9.1 Referral system worked out - strategy to reduce prices; mobile strategy for surgery?

7.10 FP individual cards available and filled according to the format 2 0

7.10.1 Check at least five cards for BP, hepatomegaly, varicose veins, weight (all cards; all elements checked)



8 Laboratory [max 17 points] YES NO 8.1 Laboratory technician or technologist available 1 0 8.2 Laboratory is open every day of the week

1 0 8.2.1 Supervisor verifies the last 4 Sundays in laboratory register

8.3 List of laboratory examinations visible for the public with fees 1 0



8.4 Results recorded correctly in laboratory register and match with results in inpatient sheets or OPD examination cards 3 0

8.4.1 Supervisor verifies last five results

8.5 Availability of parasites demonstrations

1 0 8.5.1 On plastic paper, in a color book, or put on wall

8.5.2 Blood smear: Vivax, Ovale, Falciparum and Malariae

8.5.3 Stools: Ascaris, entamoeba, ankylostoma and schistosome

8.6 Microscope available and functional 2 0 8.6.1 functional objectives; immersion oil available, mirror or electricity

8.6.2 blades, cover glass, GIEMSA available

8.7 Malaria rapid tests available 2 0

8.7.1 At the least 20 tests available in the laboratory; non-expired

8.8 Centrifuge available and functional 1 0 8.9 Waste evacuation correctly carried out

2 0 8.9.1 Organic waste in a bin with lid with disinfectant

8.9.2 Security box for sharp objects available and destroyed according to waste disposal guidelines

8.10 Personnel adequately washes dirty pipettes in containers with disinfectant 1 0

8.11 Laboratory equipment for testing for PTB

2 0 8.11.1

Reagents for AAFB testing; stock control car for reagents is available and lists stock; at the least 30 non-recycled slides available for testing

8.11.2 External Quality assurance protocol for PTB testing available and implemented: slides sampled and sent for quality control according to protocol, and latest report, as per protocol, is available and shows results as per cut-off point of the protocol

Total Points (17) ../17 Remarks (Laboratory)

Date:


9 In-patient Wards [max 6 points] YES NO 9.1 Guard duty roster clearly visible for staff and followed up 0.5 0

9.1.1 Supervisor verifies guard duty's report - names and signatures match



9.2 Furniture available and in good state 1 0

9.2.1 Each bed has a (i) non-torn plastic covered mattress, (ii) mosquito net, (iii) clean sheets, (iv) night table

9.3 Patient comfort and hygiene 9.3.1 The wards are clean: no debris on the floor; and wards smell of disinfectant 0.5 0 9.3.2 Space between the beds is at the least one meter 0.25 0 9.3.3 Each ward has access to drinking water 0.25 0 9.3.4 Each ward has running water or water dispenser with water, soap and a clean towel 1 0 9.4 Light available in each ward 0.5 0

9.4.1 Electricity; solar light or rechargeable battery lamp

9.5 Confidentiality 0.5 0

9.5.1 Women in separate ward from men; the inside of the wards are not visible from the outside

9.6 In patient register available and is well maintained 0.5 0

9.6.1 check identity and hospital bed days

9.7 Recording forms for hospitalizations available and well filled and well stored

1 0 9.7.1 At least 10 blanks; supervisor verifies 5 filled forms

9.7.2 Weight, temperature, and eventual laboratory exams recorded

9.7.3 Treatment monitoring checked



10 Essential Drugs Management [max 20 points] YES NO

10.1 Staff maintains stock cards for ED showing security stock levels = monthly average consumption (MAC) * 2 (two months monthly average consumption) 4 0

10.1.1 Supply in register corresponds with physical supply: random sample of three essential drugs

10.2 Health facility purchases drugs, equipment and consumables from the Pharmaceutical Council of Nigeria certified distributor, approved by SMOH/SPHCDA

3 0



10.2.1 Latest Pharmaceutical Council of Nigeria certified distribution center list for the State available

10.2.2 Last procurement list is shown which shows the certified distributor which sold the drugs

10.2.3 All drugs and medical consumables are (i) NAFDAC certified and (ii) Generic

10.3 Main pharmacy store delivers drugs to health facility dispensary according to requisition

10 0 10.3.1 Supervisor verifies whether quantity requisitioned equals quantity served

10.3.2 Drugs to clients are uniquely dispensed through prescriptions. Prescriptions are stored and accessible

10.3.3 Drugs and medical consumables prescribed, are all in generic form

10.4 Drugs stored correctly 2 0 10.4.1 Clean place, well ventilated with all drugs on cupboards, labeled shelves

10.4.2 Drugs and medical consumables stored on alphabetical order, first in - first out basis

10.5 Absence of out of date drugs or drugs with unreadable labels

1 0 10.5.1 Supervisor verifies randomly three drugs and 2 consumables

10.5.2 Out of date drugs well separated from stock

10.5.3 Destruction protocol for out of date drugs available and applied


Date:


11 Tracer Drugs (min. stock = Monthly Av. Consumption times 2) [max 20 points]

YES >

MAC x 2

NO < MAC

x 2

11.1 Paracetamol 500 mg tab 1 0 11.2 Ibuprofen 200 mg caps 0.5 0 11.3 Chlorpheniramine 2 mg 1 0 11.4 Oxytocin 10IU/ml vial 1 0 11.5 Mebendazole 100 mg tab 1 0 11.6 Ferrous Sulfate 325 mg tab 1 0 11.8 Amoxicillin 500 mg caps 1 0



11.9 Amoxicillin 125 mg/5ml suspension 0.5 0 11.10 Co-trimoxazol 480 mg tab 1 0 11.11 Co-trimoxazol 40mg/200mg - 5ml susp 0.5 0 11.12 Doxycycline 100 mg caps 1 0 11.13 Erythromycin 250 mg tab 1 0 11.14 Co-artemeter 20/120 mg tab (1; 2 3 and 4) 1 0 11.15 Sulfadoxine/pyrimethamine 500 mg tab 1 0 11.16 ORS sachet 1 0 11.17 Condom 0.5 0 11.18 Metronidazol 200 mg tab 1 0 11.19 Sterile gloves 1 0 11.20 Venflon 18G

0.5 0 11.20.1 Min stock = 10; MAC applies only when higher than 10

11.21 Venflon 22G 0.5 0

11.21.1 Min stock = 10; MAC applies only when higher than 10

11.22 IV giving set 0.5 0


11.23 Ringers lactate 1L 0.5 0

11.23.1 Min stock = 5L; MAC applies only when higher than 5L

11.24 Dextrose 5% 1L 0.5 0


11.26 Syringe 5ml 0.5 0 11.27 Syringe 10ml 0.5 0 11.28 Scalp vein needle 0.5 0

Total Points (20) …./2

0 Remarks Date:


12 Maternity [max 24 points] YES NO



12.1 Sufficient water with antiseptic soap and liquid antiseptic in delivery room 2 0

12.1.1 A functioning water source or at the least 20L

12.2 Light in delivery room 24 hours 1 0

12.2.1 Electricity, solar light or rechargeable battery lamp or kerosene lamp filled with kerosene

12.3 Waste from Maternity correctly handled 1 0

12.3.1 Bin with lid and lining and safe needle disposal container, specific for the maternity room use only

12.4 Delivery room is well-maintained 12.4.1 Walls with durable materials and painted 1 0

(Section 12: Maternity) 12.4.2 Curtain between delivery bed and door 1 0 12.4.3 Delivery room smells of disinfectant 1 0 12.4.4 Floor level cement, without fissures and ceiling not damaged 1 0 12.4.5 Windows with curtains and functional door 1 0 12.5 Availability and use of the Partographs

2 0 12.5.1 At the least 10 forms available for use

12.5.2 Verify three randomly selected Partographs whether filled according to the norms

12.6 Deliveries performed by skilled personnel 2 0

12.6.1 Identification of the skilled provider from names in the register

12.7 Availability of scales for weight/length, an obstetrical stethoscope and an aspirator 12.7.1 Tape to measure length 1 0 12.7.2 Scale to measure weight (check functionality) 1 0 12.7.3 Aspirator plunged into a non-irritating disinfectant or functional manual/electric aspirator 1 0 12.8 Availability of at the least 10 pairs of sterile gloves 1 0 12.9 Availability of at the least 2 sterilized obstetrical boxes

2 0 12.9.1 Content at the least 1 pair of scissors, 2 pliers and one needle holder

12.10 Availability of at the least one episiotomy box 1 0 12.10.1 One sterilized box with needle holder, needles, 1 anatomical plier and 1 surgical plier

12.10.2 Catgut and nylon sutures; antiseptic, local anesthetics, sterile swaps

12.11 Delivery table in good state 1 0

12.11.1 Table in two parts with removable non-torn plasticized mattress and two functional leg supports

12.12 Available equipment for care of the newborn 2 0

12.12.1 Sterile tying string or clip for umbilical cord



12.12.2 1% tetracycline eye ointment non-expired

12.13 Adequate in-patient rooms 1 0 12.13.1 Mattress covered in impermeable plastic

12.13.2 Sheets, blankets and mosquito nets on each occupied bed


Date:


13 EPI and Pre-School Consultation [max 20 points] YES NO 13.1 Personnel calculates correctly target for fully vaccinated children

1 0 13.1.1 Target = population * 4.8% / 12 : asked from any medical personnel dealing with care for clients

13.1.2 The target population concerns the ward population (or the defined catchment pop in case ward has more PBF primary contract holders)

13.2 EPI fridge

4 0 13.2.1 Presence of a fridge - temp form available, filled twice a day including the day of the visit

13.2.2 Temperature remains between 2 and 8C in register sheet

13.2.4 Supervisor verifies functionality of thermometer

13.2.5 Temperature between 2 and 8C also according to the thermometer

13.3 Chemical Temperature Indicator 1 0

13.3.1 Presence of a chemical temperature indicator (this is a specific piece of paper different from the thermometer) which shows temperature acc to the norms

13.4 Appropriate storage of vaccines

1 0 13.4.1 Freezing compartment: Measles

13.4.2 Non-freezing compartment: BCG, Penta + HepB, TT, thinners

13.4.3 Absence of vaccines which are expired

13.4.4 Readable labels on all vaccines

13.5 Appropriate stock of vaccines

1 0 13.5.1 BCG, Penta, Polio, Yellow Fever, HBV, Measles, Tetanus

(Section 13: EPI)

13.5.2 Presence of stock control cards for all vaccines; concordance paper and physical stock verified



13.6 Cold Chain maintenance 1 0

13.6.1 If kerosene fridge: stock of at the least 14L Kerosene; if solar fridge: battery not damaged

13.7 Cold packs are well frozen 1 0

13.7.1 At the least 5

13.8 Syringes available 1 0

13.8.1 Auto-blocking at least 30; for dilution - at least 3

13.9 Waste collection availability of safe disposal box 1 0 13.10 Stock of U5 growth cards available

1 0 13.10.1 At the least 10

13.11 Child immunization register well maintained 1 0

13.11.1 System is capable of identifying drop outs and Fully Vaccinated Children

13.12 Conditions in waiting area for immunization services 1 0

13.12.1 Sufficient benches and or chairs, protected against sun and rain

13.13 Patients receive numbered waiting buttons according to their arrival 1 0 13.14 Baby weighing scale available and in working condition

1 0 13.14.1 Balance calibrated to zero + pants available, clean and in good condition

13.15 Group IEC/BCC

1 0 13.15.1 Group meeting held before vaccinations (check the schedule of health education sessions)

13.15.2 Existence of updated IEC report with (a) topic, (b) number of participants, © leader of activity, (d) date and (e) signature

13.16 Existence of a system to recover drop-outs 2 0

13.16.1 Schedule, record of appointments, classified invidual charts


Date:


14 Antenatal Care [max 12 points] YES NO

14.1 Business plan contains convincing strategies to effectively conduct ANC for all pregnant women in catchment area 1 0



14.1.1 Fixed strategy; and advanced strategy for distant villages: catchment area covers entire ward or defined catchment population if multiple PBF primary contract holders

14.2 Weighing scale present, functional and calibrated to zero 1 0 14.3 ANC form for HF available and well filled in: last five forms verified

3 0 14.3.1 All: Examinations: weight - BP, Uterus height, Parity, Date of last menstruation

14.3.2 All: Laboratory: albuminuria, glucose

14.3.3 All: Obstetrical examination done: Fetal heart rate, Uterine height, presentation, Fetal movement recorded

14.4 ANC form shows the administration of Ferrous Sulphate/Folic Acid and Mebendazole and SP (for the last five forms above) 2 0

14.5 ANC cards for mother available: at least 10 in stock 1 0 14.6 ANC register available and well filled in

2 0 14.6.1 Complete identity, state of vaccinations, date visit, whether high risk pregnancy or not/danger signs

14.6.2 All columns well filled including the identification of problems if any, and actions taken

14.7 ANC conducted by qualified personnel 1 0

14.7.1 Nurse; midwife CHO or CHEW, verified on ANC cards

14.8 Group IEC/BCC

1 0 14.8.1 Group meeting held before FP consultation (check the schedule of health education sessions)

14.8.2 Existence of updated IEC report with (a) topic, (b) number of participants, (c) leader of activity and (d) date and (e) signature

Total Points (12) ../12 Remarks ANC:

Date:


15 HIV/TB [max 8 points] YES NO 15.1 Well-equipped HIV counseling room ensuring privacy:

1 0

15.1.1 Plastered and painted wall of solid material

15.1.2 Smooth cement floor

15.1.3 Ceiling in good condition

15.1.4 Windows with glass and curtains

15.1.5 Doors that close



15.2 Availability of IEC/BCC material related to HIV 1 0 15.2.1 Penis model on the table

15.2.2 A box of condoms on the table which has at the least 50 condoms

15.3 Existence of a VCT/PMTCT counseling register and lab register acc norms 1 0

15.4 Staff trained in counseling 1 0 15.4.1 At the least one staff trained as a councilor

15.4.2 All counseling done by a trained councilor

15.5 Referral system and follow up for HIV clients 1 0

15.5.1 Individual client cards available; planning for CD4 cell counts

15.6 Referral system and follow up for TB patients

2 0 15.6.1 Each AAFB+ PTB patient has a person attached to him/her who supervises DOTS: proof of in register; mobile phone number of such a supervisor is registered

15.6.2 Each PTB patient has a contact address and/or phone number in both the register and the individual card

15.8 Availability of anti-tuberculosis drugs (for at least three new clients) 1 0 15.8.1 Rifampicine-isoniazide-pyrazinamide : cp120+50+300mg 15.8.3 Etambutol tabs 400 mg


Date:


Nr Service Max P % 1 General Management 21

2 Business Plan 9 3 Finance 15 4 Indigent Committee 2 5 Hygiene 31 6 OPD 97 7 Family Planning 22 8 Laboratory 17 9 Inpatient Wards 6 10 Essential Drugs Management 20 11 Tracer Drugs 20



12 Maternity 24 13 EPI 20 14 ANC 12 15 HIV/TB 8

Total 324

Name Supervisor Signature:

Name Head of Clinic/Staff Signature:

Date: Final Score:



Annex 9: Quarterly Quality Supervisory Checklist for General Hospitals

[…………...] MOH/[…..……….] PHCDA Quarterly Quality Review of General Hospitals

version 14 December 2013 Date: Name Team Leader Evaluation: LGA: Medical Staff Total: CH: Population: Non-Medical Staff Total:

1 General Management [max 24 points] YES NO

1.1 General Hospital RBF Committee meets once per month. Each complete report is worth 1.5 points; max 3 reports

1.1.1 Date of the meeting 0.1 0 1.1.2 Agenda 0.1 0 1.1.3 Signed list of participants 0.1 0 1.1.4 Follow-up of the decisions taken during the previous meeting 0.1 0 1.1.6 In each issue section there is a description of the problem 0.1 0

1.1.7 In each issue section there is a list of developed recommendations or decisions taken 0.2 0

1.1.8 In each issue section there is a deadline to solve the issue 0.1 0 1.1.9 In each issue section there is a responsible named 0.1 0 1.1.10 Each month the monthly financial balance is discussed 0.5 0

1.1.11 Minutes of the meeting are signed by the chairman (minutes should be separate documents) 0.1 0

1.2 HMIS reports - business plan - minutes of meetings well stored 1 0

1.2.1 In cupboard and in box files and accessible by the administrator

1.3 Staff duty roster 24/7 available in all units and well displayed up to date and visible for staff and

1 0



patients

1.4 Management Team Meetings conducted Monthly and minutes available. Each complete report is worth 1.5 points (max 4.5 points); max 3 reports

1.4.1 Date of the meeting 0.1 0 1.4.2 Agenda 0.1 0 1.4.3 Signed list of participants 0.1 0 1.4.4 Follow-up of the decisions taken during the previous meeting 0.1 0 1.4.6 In each issue section there is a description of the problem 0.1 0

1.4.7 In each issue section there is a list of developed recommendations or decisions taken 0.2 0

1.4.8 In each issue section there is a deadline to solve the issue 0.1 0 1.4.9 In each issue section there is a responsible named 0.1 0 1.4.10 Each month the monthly financial balance is discussed 0.5 0

1.4.11 Minutes of the meeting are signed by the chairman (minutes should be separate documents) 0.1 0

1.6 Availability of communication radio or dedicated mobile phone for communication between General Hospital and health centers

1 0 1.6.1

Radio or mobile phone functional with batteries and/or call credit and contact details of all PBF/DFF facilities (e. g: Medical Director CH, Head of Units, PBF HFs OICs, PHC Dept. PBF Team, HSMB Key Officer and SPHCD PBF Team, etc.)

1.6.2 List of phone number of health facility in-charges available and up to date

1.7 HMIS reports are filled, updated and transmitted to the HSMB/SMOH

2 0 1.7.1 After verification of the SPHCDA of the monthly CPA invoice

1.7.2 Completely filled according to the prevailing formats

1.8 HMIS data analysis report for the quarter being assessed concerning priority problems

6 0 1.8.1 Ten priority health problems are followed each quarter and data have been updated up to the month prior to the quality evaluation visit

1.8.2 Through a chart, follow up on monthly (i) average length of stay; (ii) average bed occupancy rate, (iii) Bed turnover rate and (iv) income/expenses statements

1.9 Ambulance available and functional 4 0 1.9.1 Vehicle log book available and maintained/filled



1.9.2 Vehicle maintenance register available and filled

1.9.3 Ambulance available and functional


2 Business Plan [max 8 points] YES NO

2.1 Quarterly business plan for the current period made and accessible 1 0

2.1.1 Valid and renegotiated

2.2 Business plan prepared with key stakeholders 2 0

2.2.1 Hospital RBF Committee involved

2.3 Business plan analyses Hygiene and waste management

1 0 2.4.1

HF treats this subject in the BP (toilets; showers; medical and non-medical waste disposal; safe sharps disposal practices; general cleanliness; infection prevention), and suggests a strategy for improvement

2.5 Business plan analyses Quality of Medical Care 1 0

2.5.1 BP may suggest to include them or to discourage if quality conditions are not met

(Section 2: Business plan)

2.6 Business plan shows a plan to assure financial accessibility for the population

2.6.1 Business plan shows negotiated rates between HF, Indigent Committee and community 1 0

2.6.2 Business plan shows the mechanism how the GH identifies indigents, and how it assesses eligibility, and how it deals with decision making on difficult cases

1 0

2.6.3 Business plan shows planning for the resources available for financing care for the indigents 1 0




3 Finance [max 42 points] YES NO

3.1 Financial and accounting documents available and well kept

2 0 3.1.1 Monthly report of treasury available and correctly filled 3.1.2 Theoretical balance of cash-book corresponds to liquidity in cash

3.2 Document available to show that quarterly calculation of incomes, running costs, investments and variable performance subsidies are done

3.2.1 This document guarantees that running costs: = salaries, purchase of drugs and equipment, subcontracts, petty cash for small expenditures, food for patients, maintenance and rehabilitation and financial buffer

3 0

3.2.2 This document uses the MS Excel- based 'indice tool' for its information. The 'indice tool' is shown and the calculations for the coming quarter are explained.

28 0

3.2.3 This document calculates the performance bonus according to the formula: performance bonuses = income of the quarter - running costs 3 0

3.3 Contract salaries and benefits + performance bonuses do not exceed 50% of total HF income through PBF 2 0

3.4 Existence of monthly performance bonus system is known by staff

4 0 3.4.1

Take a random staff member and ask what the performance bonus was last month, and what his or her individual performance % was. If both are explained then 4 points.

Total Points (42) ../42

Remarks (Financial Management)



4 Indigent Committee [max 4 points] YES NO 4.1 Planning for Care for the Indigent expenditures

1 0 4.1.1 5% of curative consultations of the previous month: documented

quantity in monthly management meetings

4.2 Indigent committee meets monthly

3 0 4.2.1

The Indigent committee meets monthly to review the care for the indigent category use. Each monthly minutes contain: (i) date of the meeting; (ii) signed list of participants; (iii) follow-up of decisions taken during the previous meeting; (iv) there is a list of developed recommendations or decisions taken; (v) each month the monthly financial balance is discussed; (vi) minutes of the meeting are signed by the chairman. Each report according to norms = 1 p


5 Hygiene and Medical Waste Disposal [max 42 points] YES NO 5.1 Fence health facility available and well-maintained 2 0

5.1.1 Fence exists, can be closed at night and there are no holes

5.2 Availability of a garbage bin in the courtyard 1 0

5.2.1 Bin with lid accessible to clients which is not full, one for each ward

5.3 Presence of sufficient latrines/toilets which are well-maintained

5.3.1 One toilet/latrine per 10 beds working flush or water container with sufficient water 1 0

5.3.2 Floor without fissures with single hole and lid (latrine) or lid with functioning cover (seating style toilet) 1 0

5.3.3 Recently cleaned toilet/latrine without visible fecal matter 1 0



5.3.4 Door lockable from the inside but not from the outside, super structure with roofing, without flies (mosquito screening), floor clean 1 0

5.3.5 Functional lighting 1 0 5.3.6 Water container/functioning tap and soap for hand washing available

for each toilet block 1 0

5.3.7 Cleaning schedule next to toilet, and toilet/latrine smells of disinfectant or deodorant 1 0

5.4 Presence of sufficient showers which are well-maintained 5.4.1 One shower per ten beds 1 0 5.4.2

Shower with running water, or container with at the least 20 L of water and cup for scooping 1 0

5.4.3 Door lockable from the inside but not from the outside, super structure with roofing, without flies (mosquito screening), floor clean 1 0

5.4.4 Functional lighting 1 0 5.4.5 Cleaning schedule next to shower and shower smells of disinfectant

or deodorant 1 0 (Section 5: Hygiene)

5.5 Waste pit for Health Care Waste is available and according to the norms

5.5.1 Waste disposal pit minimum 2 meters deep, lined with clay, concrete or brick or plastic, it is fenced and has a bright flag.

19 0 5.5.2

The waste pit is a minimum of 15 meters from the health facility, minimum of 50 meters from a household, and 100 meters from a water source

5.5.3 Health Care Waste is not visible (covered by at the least 10 cm of soil or lime)

5.5.4 The health facility maintains a register indicating the date of the creation of the pit(s), and the location (s)

5.6 Courtyard clean 1 0 5.6.1 No waste or medical waste in the courtyard

5.7 Hygienic conditions assured during wound dressing and injections

2 0 5.7.1 Bins for medical waste with lid and foot pedal

5.7.2 Security box for needles well positioned, and used

5.7.3 Needle cutter available and used

5.7.4 Container/bowl with lid containing disinfectant used for putting used instruments

5.8 Disposal of Health Care Waste according to National Norms

5 0 5.8.1 Waste disposal of non-contaminated waste in Black Bin with lid and foot pedal, lined

5.8.2 Waste disposal of contaminated HCW in Yellow Bins with lid and foot pedal, lined



5.8.3 Waste disposal of organically HCW in Red Bins with lid and foot pedal, lined

5.8.4 Protective gear for personnel managing HCW available; boots, plastic shorts, thick plastic/rubber gloves and a trolley to transport the HCW


6 Curative Consultations [max 103 points] YES NO 6.1 Good conditions in waiting area

1 0 6.1.1 Sufficient benches and or chairs protected against sun and rain and

waiting area is not inside the consultation room

6.2 Unit fees of drugs displayed to the public

5 0 6.2.1 Easily visible in the consultation room waiting area, updated, with (i) unit price per item; (ii) price for a standard treatment of the drug

6.2.2 Drugs are all generics

6.3 Existence of waiting card system with numbers 1 0 6.4 Consultation room in good condition

5 0

6.4.1 Walls with durable materials well painted, floor paved with cement without fissures, undamaged ceiling

6.4.2 Consultation room and waiting space separated assuring confidentiality

6.4.3 Windows with curtains

6.4.4 Functional door with functional lock

6.4.5 Running water (tap or water dispenser) with soap and clean towel available and used between patients

6.5 Consultation room (where emergencies are received) has light around the clock (24/7) 1 0

6.5.1 Electricity or solar light or functioning high pressure kerosene light present

6.6 Consultations are done by skilled staff 1 0

6.6.1 Identification of consulting staff in register

6.7 Consulting staff is well-dressed 1 0

6.7.1 Clean blouse with identification tag and shoes (no slippers)

6.8 Correct numbering of registers 1 0



6.8.1 Correct numbering and closed at the end of the year

6.9 Service availability seven out of seven days 1 0

6.9.1 Supervisor verifies entries in register for the last three Sundays

6.10 Malaria protocol put on wall and accessible for staff 1 0

6.10.1 National protocol for diagnosis and treatment of simple and severe malaria

6.11 Simple malaria correctly treated 5 0

6.11.1 Register see last five cases of simple malaria and review treatment acc protocol (one point for each correct treatment according to protocol: max 5 points)

6.11.2 Severe malaria correctly treated 3 0

6.11.2.1 Register see last three cases of severe malaria and review treatment acc protocol (one point for each correct treatment according to protocol: max 3 points)

6.12 WHO flow diagram for ARI put on wall and accessible for staff 1 0

6.13 ARI protocol applied

5 0 6.13.1

See last five cases of ARI and review treatment acc protocol; register mentions Temp; RR; cough yes/no; diagnosis (one point for each correct treatment according to protocol: max 5 points)

6.14 WHO protocol for Diarrhea put on wall and accessible for staff 1 0

6.15 Diarrhea protocol applied 5 0

6.15.1 See last five cases of Diarrhea and review treatment acc protocol (each correct treatment one point; max 5 points)

6.16 Proportion of consultations treated with antibiotics <30% 4 0

6.16.1 See last 100 cases in register, check diagnosis and calculate the rate (< 30 cases)

6.17 MSF treatment guidelines available in consultancy room 1 0

6.18 Knowledge of tuberculosis danger signs and criteria for referral

5 0 6.18.1 Select any available qualified medical staff, and ask the question on TB dangers signs

6.18.2 Answer must contain at least 4 of the following signs: (i) weight loss; (ii) loss of appetite; (iii) fever; (iv) cough of more than 15 days duration; (v) night sweating

6.19 Stethoscope and BP machine available and functional 1 0

6.19.1 Let nurse check BP and review measure



6.2 Thermometer available and functional 1 0 6.21 Otoscope available and functional 1 0 6.22 Examination bed for OPD consultations only

1 0 6.22.1 Available mattress, non-torn, plastic cover

6.23 Weighing scale available and functional 1 0

6.23.1 Inspect in comparison with known weight of supervisor: after weighing, the balance should return to zero

6.24 Integrated Management of Childhood Illnesses strategy is applied

2 0 6.24.1 Protocol is available in the consultation room

6.24.2 The last five IMCI cases are traced in the register and comply with the IMCI strategy (all five)

6.25 Determination of nutritional status

6.25.1

Determination of nutritional status of all children under 5 who come for consultation (check ten children under five through a random sampling method: take a random number between 1 and 3 and using this sampling interval check five consultations)

2 0

6.25.2 Determination of nutritional status of all women with a sick child under 6 months of age (as above) 2 0

6.25.3 Screening record of nutritional status available, up to date and properly filled out 2 0

6.26 Direct observation of three consecutive children under five (each child maximum 14 points; max 42 points)

6.26.1 Ask about fever and IF FEVER ask about (i) since when; (ii) persistent or intermittent 2 0

6.26.2 Ask about cough and IF COUGH ask about since when 2 0

6.26.3 Ask for diarrhea IF DIARRHEA then ask (i) since when; (ii) how often per day; (iii) consistency - water or mucus or bloody; (iv) vomiting

2 0

6.26.4 GENERAL IMPRESSION: awake or tired? 2 0 6.26.5 FIRST - COUNT RESPIRATION RATE (observe before touching

child!!!) 2 0 6.26.6 Temperature (measure) 2 0 6.26.7 Skin pinch (if diarrhea) OR auscultation (if coughing) 2 0




7 Family Planning [max 31 points] YES NO 7.1 At least one qualified staff trained in Family Planning 2 0 7.2 Confidentiality in consultation room assured

2 0 7.2.1 Room with closed doors, curtains at windows or non-transparent glass

7.3 Family planning methods available and visible in demonstration box for potential users

2 0 7.3.1 Condoms; OAC; Injectable; Implant; IUD are available in the demonstration box

7.3.2 Penis model available on the desk; box with condoms available with at the least 50 condoms

7.4 Staff correctly calculates number of clients expected monthly for oral and injectable contraceptives

1 0 7.4.1

For example for 100.000 population (target is entire LGA catchment pop) = 100.000 * 22.5% * 25%/12 * 4 * 10% (assuming 25% unmet need; 22.5% fertile women; 10% of oral/inject AC at hospital level)

7.5 Staff correctly calculates number of clients expected monthly implants and IUDs

1 0 7.5.1

For example for 100.000 population (target is entire LGA catchment pop) = 100.000 * 22.5% * 8%/12 * 4 * 10% (assuming 8% unmet need; 22.5% fertile women; 10% of implants/IUDs at hospital level)

7.6 Business plan contains strategy to achieve FP targets

3 0 7.6.1 Collaboration with public sector, private sector and social marketing, mobile strategies, advocacy among local leaders etc.

7.6.2 Involvement of HF staff in strategies

7.7 Stock of oral and injectable contraceptives is adequate 2 0

7.7.1 For example for 100.000 pop 100 doses of oral (3 month cycles) and injectable methods combined

7.8 IUD available and staff trained to use it (certificate available) 7 0

7.8.1 at least 20 IUDs and at the least one staff trained to use it

(Section 7: FP)

7.9 Implant method available and staff trained to use it (certificate available) 7 0

7.9.1 at least 20 implants available and staff trained to use it

7.10 FP individual cards available and filled according to the format 4 0

7.10.1 Check at least five cards for BP, hepatomegaly, varicose veins,



weight


8 Laboratory [max 12 points] YES NO 8.1 Medical laboratory scientist is available 1 0 8.2 Laboratory is open every day of the week

1 0 8.2.1 Supervisor verifies the last 2 Sundays in laboratory register

8.3 List of laboratory examinations visible for the public with fees 1 0

8.4 Results recorded correctly in laboratory register and match with results in inpatient sheets or OPD examination cards 1 0

8.4.1 Supervisor verifies last five results

8.5 Availability of parasites demonstrations

0.5 0 8.5.1 On plastic paper, in a color book, or put on wall

8.5.2 Blood smear: Vivax, Ovale, Falciparum and Malariae

8.5.3 Stools: Ascaris, entamoeba, ankylostoma and schistosome

8.6 Microscope available and functional 0.5 0 8.6.1 functional objectives; immersion oil available, mirror or electricity

8.6.2 blades, cover glass, GIEMSA available

8.7 Malaria rapid tests available 0.5 0

8.7.1 At the least 20 tests available in the laboratory; non-expired

8.8

Equipment available and functional; (i) centrifuge; (ii) electrophoresis machine; (iii) hematocentrifuge; (iv) clinical chemistry analyzer; (v) hemoglobinometer (manual or automated)

2.5 0

8.9 Waste evacuation correctly carried out

1 0 8.9.1 Organic waste in a bin with lid

8.9.2 Security box for sharp objects available and destroyed according to waste disposal guidelines



8.11 Personnel adequately washes dirty pipettes in containers with antiseptic 1 0

8.12 Laboratory equipment for testing for PTB

2 0 8.12.1

Reagents for AAFB testing; stock control car for reagents is available and lists stock; at the least 30 non-recycled slides available for testing

8.12.2

External Quality assurance protocol for PTB testing available and implemented: slides sampled and sent for quality control according to protocol, and latest report, as per protocol, is available and shows results as per cut-off point of the protocol

Total Points (12) ../12 Remarks (Laboratory)

9 In-patient Wards [max 155 points] YES NO

9.1 Guard duty roster clearly visible for staff and followed up 2 0

9.1.1 Supervisor verifies guard duty's report - names, phone numbers and signatures

9.2 Furniture available and in good state 8 0

9.2.1 Each bed has a (i) plastic covered mattress, (ii) mosquito net, (iii) clean sheets, (iv) night table

9.3 Patient comfort and hygiene

5 0 9.3.1 The wards are clean: no debris on the floor; and wards smell of

disinfectant 9.3.2 Space between the beds is at the least one meter

9.3.3 Each ward has access to drinking water on the ward

9.3.4 Each ward has running water or water dispenser with water, soap and a clean towel

9.4 Light available in each ward 2 0

9.4.1 Electricity; solar light or rechargeable battery lamp

9.5 Confidentiality 1 0

9.5.1 Women in separate ward from men; the inside of the wards are not visible from the outside

9.6 In patient register available and is well maintained 2 0

9.6.1 Check identity and hospital bed days



9.7

In-patient Care Gyn/Obs ward: systematic random sample of 5 patient files from discharged patients who have delivered from the delivery register from the last quarter. Each of the files is subject to the following criteria; (each file 11 points, max 55 points)

9.7.1

Each patient file meets key standard requirements: (i) full personal data of patient; (ii) date and time of admission; (iii) mobile phone number; (iv) date and time of first examination by midwife/Dr; (v) Anamnesis; (vi) Past history

2 0

9.7.2 Clinical examination done (blood pressure; frequency and rhythm of heartbeat; body temperature; weight; height; respiration rate frequency; assessment of obstetrical condition

2 0

9.7.3 Justification of clinical diagnosis and elaborate description of obstetrical proceedings (including post-partum hemorrhage; pre-eclampsia; premature birth etc.). Compliance with MSF 'obstetric guidelines'. 2 0

9.7.4 Notes on midwife/Dr daily examinations which include clinical examination 1 0

9.7.5

Partogram: both sides filled correctly (opening; prolapses; VE each 4 hours at the least; frequency and rhythm of heartbeat of mother and child each 30 min at the least; contractions every 30 min) 4 0

9.8

In-patient Care Pediatric ward: systematic random sample of 5 patient files from discharged patients from the admission register from the last quarter. Each of the files is subject to the following criteria (each file 7 points; max 35 points)

9.8.1

Each patient file meets key standard requirements: (i) full personal data of patient; (ii) date and time of admission; (iii) mobile phone number; (iv) date and time of first examination by MD; (v) history taking; (vi) Past history

2 0

9.8.2 Clinical examination done (frequency and rhythm of heartbeat; body temperature; weight; height; respiration rate frequency; in-depth examination of affected system

2 0

9.8.3 Scope of laboratory and other examination corresponds to clinical diagnosis and is compliant with clinical protocols and results of lab tests. Compliance with MSF 'treatment guidelines'.

2 0

9.8.4 Notes on Dr daily examinations which include clinical examination 1 0

9.9

In-patient Care Surgical ward: systematic random sample of 5 patient files from discharged patients who had large surgical procedures from the admission register from the last quarter. Each of the files is subject to the following criteria (if 0 operations then 0 score) (each file 9 points, max 45 points)

9.9.1

Each patient file meets key standard requirements: (i) full personal data of patient; (ii) date and time of admission; (iii) mobile phone number; (iv) date and time of first examination by midwife/Dr; (v) history taking; (vi) Past history

2 0



9.9.2 Clinical examination done: (blood pressure; frequency and rhythm of heartbeat; body temperature; weight; height; respiration rate frequency; assessment of surgical condition; clinical diagnosis and justification) 2 0

9.9.3 Report on surgical procedure and anesthetic method used 2 0 9.9.4 Notes on Dr daily examinations which include clinical examination 2 0 9.9.5 Registration of post-operative infection, if any 1 0


10 Essential Drugs Management [max 20 points] YES NO

10.1 Staff maintains stock cards for ED showing security stock levels = monthly average consumption times 2 (MAC x 2) 4 0

10.1.1 Supply in register corresponds with physical supply: random sample of three ED

10.2 Health facility purchases drugs, equipment and consumables from the Pharmaceutical Council of Nigeria certified distributor, approved by SMOH/SPHCDA

3 0 10.2.1 Latest Pharmaceutical Council of Nigeria certified distribution center list for the State available

10.2.2 Last procurement list is shown which shows the certified distributor which sold the drugs

10.2.2 All drugs and medical consumables are (i) NAFDAC certified and (ii) Generic

10.3 Main pharmacy store delivers drugs to health facility departments according to requisition

10 0 10.3.1 Supervisor verifies whether quantity requisitioned equals quantity served

10.3.2 Drugs to clients are uniquely dispensed through prescriptions. Prescriptions are stored and accessible

10.3.3 Drugs and medical consumables prescribed, are all in generic form

10.4 Drugs stored correctly

2 0 10.4.1 Clean place, well ventilated with all drugs on cupboards, labeled shelves

10.4.2 Drugs and medical consumables stored on alphabetical order, first in - first out basis

10.5 Absence of out of date drugs or drugs with unreadable labels 1 0



10.5.1 Supervisor verifies randomly three drugs and 2 consumables

10.5.2 Out of date drugs well separated from stock

10.5.3 Destruction protocol for out of date drugs available and applied

Total Points (20) ../20 Remarks (EDM)

11 Tracer Drugs (min. stock = Monthly Av. Consumption times 2- Minimum stock is two months average consumption) [max 30 points]

Available YES = or > MAC

X 2

Available NO <

MAC X 2

11.1 Paracetamol 500 mg tab 0.5 0 11.2 Acetyl salicylic Acid 30 mg tab 0.5 0 11.3 Ibuprofen 200 mg caps 0.5 0 11.4 Promethazine 25 mg tab 0.5 0 11.5 Promethazine HCL 50mg/ml vial 0.5 0 11.6 Oxytocin 10IU/ml vial 0.5 0 11.7 Methergine 0.2 ug tab 1 0 11.8 Mebendazole 100 mg tab 0.5 0 11.9 Ferrous Sulfate 325 mg tab 1 0 11.10 Propranolol 80 mg tab 0.5 0 11.11 Nifedipine 10 mg caps 0.5 0 11.13 Amoxicillin 500 mg caps 0.5 0 11.14 Amoxicillin 125 mg/5ml suspension 0.5 0 11.15 Ampicillin 1 gr vial 1 0 11.16 Ampicillin 250 mg vial 1 0 11.17 Gentamicin 40mg/ml vial 1 0 11.18 Metronidazol 500mg/100ml vial 1 0 11.19 Co-trimoxazol 480 mg tab 0.5 0 11.20 Co-trimoxazol 40mg/200mg - 5ml susp 0.5 0 11.21 Doxycycline 100 mg caps 0.5 0



11.22 Erythromycin 250 mg tab 1 0

11.23 Co-artemeter 20/120 mg tab (types 1; 2 3 and 4 all available) 1 0

11.24 Quinine sulfate 200 mg tab 1 0 11.25 Quinine hydrochloride 300 mg/ml vial 1 0 11.26 Sulfadoxine/pyrimethamine 500 mg tab 0.5 0 11.27 ORS sachet 1 0 11.28 Condom 0.5 0 11.29 IUD 1 0 11.30 Contraceptive pill monthly cycle 1 0 11.31 DMPA 150mg vial 1 0 11.32 Contraceptive implant 1 0 11.33 Venflon 18G

0.5 0 11.33.1 Min stock = 10; MAC applies only when higher than 10

11.34 Venflon 22G 0.5 0


11.35 IV giving set 1 0


11.36 Ringers lactate 1L 1 0


(Section 11: Tracer Drugs) 11.37 Dextrose 5% 1L

1 0 11.37.1 Min stock = 5L; MAC applies only when higher than 5L

11.38 IV colloids 500 ml 1 0

11.38.1 Min stock = 5 bags; MAC applies only when higher than 5 bags

11.39 Syringe 5ml 0.5 0 11.40 Syringe 10ml 0.5 0 11.41 Scalp vein needle 1 0




12 Maternity [max 26 points] YES NO

12.1 Sufficient water with antiseptic soap and liquid antiseptic in delivery room 2 0

12.1.1 A functioning water source or at the least 20L; soap available

12.2 Light in delivery room 24 hours 1 0

12.2.1 Electricity, solar light or rechargeable battery lamp or kerosene lamp filled with kerosene

12.3 Waste from Maternity correctly handled 1 0

12.3.1 Bin with lid and safe needle disposal container

12.4 Delivery room is well-maintained

5 0

12.4.1 Walls with durable materials and painted

12.4.2 Curtain between delivery bed and door

12.4.3 Delivery room smells of disinfectant

12.4.4 Floor level cement, without fissures and ceiling not damaged

12.4.5 Windows with curtains and functional door

12.5 Availability and use of the partograph

2 0 12.5.1 At the least 10 forms available for use

12.5.2 Verify three randomly selected partographs whether filled according to the norms

12.6 Deliveries performed by skilled personnel 2 0

12.6.1 Identification of the skilled provider from names in the register

12.7 Availability of scales for weight/length, an obstetrical stethoscope and an aspirator

2 0 12.7.1

Scale to measure height; scale to measure weight (check functionality), aspirator plunged into a non-irritating antiseptic or functional manual/electric aspirator

12.8 Availability of a functional vacuum extractor 3 0

12.8.1 Plus a nurse trained in its use, and vacuum extractor effectively used

12.9 Availability of at the least 10 pairs of sterile gloves 1 0 12.10 Availability of at the least 2 sterilized obstetrical boxes

3 0 12.10.1 Content at the least 1 pair of scissors, 2 pliers and one needle holder

12.11 Availability of at the least one episiotomy box

2 0 12.11.1 One sterilized box with needle holder, needles, 1 anatomical plier and 1 surgical plier

12.11.2 Catgut and nylon sutures; antiseptic, local anesthetics, sterile swaps



12.12 Delivery table in good state 1 0

12.12.1 Table in two parts with removable non-torn plasticized mattress and two functional leg supports

(Section 12: Maternity) 12.13 Available equipment for care of the newborn

1 0 12.13.1 Sterile tying string or clip for umbilical cord

12.13.2 1% tetracycline eye ointment non-expired

12.14 Adequate in-patient rooms 1 0 12.14.1 Mattress covered in impermeable plastic

12.14.2 Sheets, blankets and mosquito nets on each occupied bed


13 Antenatal Care [max 7 points] YES NO

13.1 Business plan contains convincing strategies to effectively ensure that at-risk women in the CH/LGA catchment area reaches the hospital 0.5 0

13.1.1 Strategy includes at least once per quarter a capacity building session with HC in-charges on RH/FP

13.2 Weighing scale present, functional and calibrated to zero 0.5 0

13.3 ANC form for HF available and well filled in: last five forms verified

2 0 13.3.1 All: Examinations: weight - BP, uterus height, Parity, Date of last

menstruation 13.3.2 All: Laboratory: albuminuria, glucose

13.3.3 All: Obstetrical examination done: Fetal heart rate, Uterine height, presentation, Fetal movement recorded

13.4 ANC form for HF shows the administration of Ferrous Sulphate/Folic Acid and Mebendazole 1 0

13.5 ANC cards for mother available: at least 10 in stock 0.5 0 13.6 ANC register available and well filled in

1 0 13.6.1

Complete identity, state of vaccinations, date visit, whether high risk pregnancy or not/danger signs



13.6.2 All columns well filled including the identification of problems if any, and actions taken

13.7 ANC conducted by qualified personnel 1 0

13.7.1 Nurse; midwife, verified on ANC cards

13.8 Group IEC/BCC

0.5 0 13.8.1 Group meeting held before FP consultation (check the schedule of health education sessions)

13.8.2 Existence of updated IEC report with (a) topic, (b) number of participants, (c) leader of activity and (d) date and (e) signature


14 HIV/TB [max 8 points] YES NO 14.1 Well-equipped HIV counseling room ensuring privacy:

1 0

14.1.1 Plastered and painted wall of solid material

14.1.2 Smooth cement floor

14.1.3 Ceiling in good condition

14.1.4 Windows with glass and curtains

14.1.5 Doors that close

14.2 Availability of IEC/BCC material related to HIV 1 0 14.2.1 Penis model on the table

14.2.2 A box of condoms on the table which has at the least 50 condoms

14.3 Existence of a VCT/PMTCT counseling register and lab register acc norms 1 0

14.4 Staff trained in counseling 1 0 14.4.1 At the least one staff trained as a councilor

14.4.2 All counseling done by a trained councilor



14.5 Referral system and follow up for HIV clients 1 0

14.5.1 Individual client cards available; planning for CD4 cell counts

14.6 Referral system and follow up for TB patients

2 0 14.6.1 Each AAFB PTB patient has a person attached to him/her who supervises DOTS: proof of in register; mobile phone number of such a supervisor is registered

14.6.2 Each PTB patient has a contact address and/or phone number in both the register and the individual card

14.8 Availability of anti-tuberculosis drugs 1 0 14.8.1 Rifampicin-isoniazid-pyrazinamide : cp120+50+300mg 14.8.2 Streptomycin 1 gr

14.8.3 Etambutol tabs 400 mg


15 Surgery [max 55 points] YES NO 15.1 Blood bank: emergency preparedness 15.1.1 Availability of one transfusion certified staff member 2 15.1.2 Availability of reagents for grouping and X-matching, properly stored 2 15.1.3 Minimum 2 units of fresh blood O rhesus negative type, non-expired available 20

15.1.4 Blood stored according to the norms (between 2 to 4C); refrigerator is functional; has power back up system (functional generator) or kerosene type with stock of kerosene; temperature measured twice daily

5

15.1.5 HIV, RPR and HepB tests available, and blood stored tested 5 15.2 Sterilization according to the norms

3 15.2.1 Functioning steam sterilizer available

15.2.2 Sterilizer in separate room from theater

15.2.3 Use of chemical heat indicators

15.2.4 Register for sterilizations used and completely filled

15.3 Minor surgery done in a separate room from the major surgical procedures 1

15.4 Functioning theater lamp 1



15.5 Functioning theater table 1 15.6 Preparedness

15.6.1 At the least one sterilized major surgery set available, with date of sterilization indicated on the pack 2

15.6.2 At the least one sterilized CS set available, with date of sterilization indicated on the pack 2

15.6.3 At the least 4 L of Ringers Lactate available in the theater 0.5 15.6.4 At the least 2 bags of Colloids available in the theater 0.5 15.6.5 Theater smells of disinfectant, and cleaning schedule is available 1 15.6.6

Nursing/technical Staff trained in anesthesia is presently on duty (at the least ketamine or spinal) 2

15.6.7 Nursing Staff trained in theater procedures presently on duty 2 15.6.8 Qualified Medical Doctor with experience doing CS presently on duty 5


Nr Service Max P % 1 General Management 24

2 Business Plan 8 3 Finance 42 4 Indigent Committee 4

5 Hygiene & Med Waste Disposal 42

6 OPD 103 7 Family Planning 31 8 Laboratory 12 9 Inpatient Wards 155 10 Essential Drugs Management 20 11 Tracer Drugs 30 12 Maternity 26 13 ANC 7



14 HIV/TB 8 15 Surgery 55

Total 567

Name Team leader Evaluation: Signature:

Name Director GH: Signature:

Date: Final Score:



Annex 10: Monthly Health Facility Invoice

Health Center Monthly Provisory Invoice for MPA Services

LGA: Month: Health Center: Year:

Service

Quantity Produced

Unit Fee [In

contract]

Sub-Total Naira

1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital 5 Completely Vaccinated Child 6 Growth monitoring visit Child 7 2 - 5 Tetanus Vaccination of Pregnant Woman 8 Postnatal consultation 9 First ANC consultation before four months pregnancy 10 ANC standard visit (2-4) 11 Second dose of SP provided to a pregnant woman 12 Institutional Delivery 13 FP: total of new users of modern FP methods 14 FP: implants and IUDs 15 VCT/PMTCT/PIT test 16 PMTCT: HIV+ mothers and children born to are treated

according to protocol

17 STD treated 18 New AFB+ PTB patient 19 PTB patient completed treatment and cured 20 Housevisit according to protocol


The current invoice for the month of …………… of ………………………..Health Center is totaled at [………………………………………………] Naira Date…………. Names of the members of the HC Management Committee The HC in

charge:



1…………………………………………. 2…………………………………………. 3…………………………………………. 4…………………………………………. 5………………………………………….

The verifier:



General Hospital Monthly Provisory Invoice for CPA Services

LGA: Month: Hospital: Year:

Service

Quantity Produced

Unit Fee [In

contract]

Sub-Total Naira

1 New outpatient consultation by a Doctor 2 New outpatient consultation by a Doctor of an indigent patient 3 Counter-referral slip arrived at the Health Center 4 Minor Surgery 5 Major Surgery (ex CS) 6 Normal delivery 7 Assisted Delivery 8 CS 9 Inpatient Day 10 Inpatient Day for an indigent patient 11 Postnatal consultation 12 First ANC consultation before four months pregnancy 13 ANC standard visit (2-4) 14 FP: total of new users of modern FP methods 15 FP: implants and IUDs 16 FP: vasectomy and bilateral tuba ligation 17 VCT/PMTCT/PIT test 18 PMTCT: HIV+ pregnant mothers and children born to are

treated according to protocol

19 STD treated 20 New Client put under ARV treatment 21 New AFB+ PTB patient 22 PTB patient completed treatment and cured


The current invoice for the month of …………… of ………………………..Hospital is totaled at [………………………………………………] Naira Date…………. Names of the members of the Hospital RBF Committee The MO in charge:



1…………………………………………. 2…………………………………………. 3…………………………………………. 4…………………………………………. 5………………………………………….

The Verifier:

Annex 11: Quarterly Consolidated LGA Invoice [LOGO]

SPHCDA - SMOH Consolidated Quarterly LGA PBF Invoice

Second Quarter [ YEAR] - [Date]

No Health Facility April May June Subtotal_Q2 Quality%_Q2 Q_Bonus Total_Q2 Bank

account Bank name

1 HC_1 388,377 346,467 332,496 1,067,340 79.1% 211,093 1,278,433 Ac Number Bank Branch


3 HC_2 209,891 287,376 249,289 746,556 74.8% 139,643 886,199 Ac Number Bank Branch




7 HC_7 334,246 317,832 301,358 953,436 67.7% 161,321 1,114,757 Ac Number Bank Branch




11 GH_1 1,278,285 10,506,450 1,293,235 13,077,970 83.9% 2,744,412 15,822,382 Ac Number Bank Branch

Total 4,196,885 13,503,614 4,147,192 21,847,691 76.1% 4,399,855 26,247,546



Present the following quarterly consolidated PBF invoice for [Name] LGA, [Name] State, for the month of July [Year], for the sum total of twenty six million, two hundred forty seven thousand and five hundred forty six Naira (26,247,546); Invoice established in one original copy, of which a copy is kept at [Name] LGA PHC department, and the other at the [Name] SPHCDA

Signed: ..................................., the....../......................../ Year

Prepared by the Chairman of the LGA RBF Steering Ctee:

Signed by the SPHCDA rep:

Last name, first name:

Last name, first name: Signature:

Signature:



Annex 12: Performance Framework for the LGA PHC department

No Indicator/Performance Measure

Primary/Secondary Data Sources

Composite Criteria/Validation Criteria Weight

1 50% of Health Centers have been supervised at least once per quarter

Supervision Report Travel Request Form approved and signed Travel form co-signed by the Head of visited facilities

• Supervision Report Exists and is readily available at LGA/PHC dept.

• At least 50% of all Health Centers have been supervised during the past quarter, and these should not include those Health Centers which have been supervised in the quarter preceding the evaluated quarter

• These supervisory visits are the formative visits and are not the same as the Quantity or Quality Audit visits. The reports should indicate the dates of visits and, at the least, summarize the findings/interventions of each visit.

If any criteria not met: 0 points

15

2 At least two Monthly Meetings with RBF Health Centers in the local Government PHC Department during the past quarter

Meeting Minutes

Participants List

Each of the two meeting reports need to have the following criteria:

• Date and time indicated • Agenda avalable • Signed Participants list avalable • Discussion on the contents of the past month’s

HC monthly reports using the Printed Monthly

10






HC reports (from the HMIS database • Follow up of recommendations and tasks from

previous meeting • Action points listed with tasks attributed

If any criteria are lacking: 0 points: 5 points per valid meeting according to the criteria.

3 At least one half hour training on one specific topic, during the monthly HC staff meetings

In the meeting minutes, a description of the topic as follows:

• Objective of the training • Short Description of the session, referring to

the available national protocol

If above criteria are not met: 0 points

5

4 Monthly HC HMIS report entered in the HMIS database and Report Printed

Printed HC HMIS Monthly Cumulative Report

Data available in the HMIS DB

Monthly HC HMIS reports (original)

• Printed Monthly HC HMIS Report Available and Filed in a Specific File

• Original Monthly HC HMIS Reports Available and Filed in the Specific HC Files at LGA PHC department

• All HC HMIS Reports for all HCs in the LGA available

If one or more criteria not met: 0 points

5






5 Activity Calendar for the Month is Available

The Activity Calendar • Monthly Activity Plan is available clearly describing planned activities with start and finish dates.

• Activity Calendar for the Current Month is visible without difficulty on a wall of the LGA Health Office

If one or both criteria not met: 0 points

5

6 Participation in the Quarterly LGA RBF Steering Committee Meetings

LGA RBF Steering Committee Meeting Minutes

Participants List

• LGA RBF Steering Committee meeting held prior to the end of the fourth month.

• Provision of secretariat to the LGA RBF Steering Committee, according to the set formats for such proceedings

• Eventual changes to the minutes of the previous meetings have been fully incorporated.

• Presentation and discussion of the LGA RBF Steering Committee’s last meeting minutes. These had been sent out by email to all parties’ calendar days prior to the meeting.

• Discussion and eventual validation of 3 monthly PBF consolidated invoices (one per month per contracted HC) in the LGA RBF Steering Committee meeting.

• Meeting was held subject to the legal quorum defined in the LGA RBF Steering Committee agreement.

20






If one or both criteria are not met: 0 points

7 Quarterly Quality Performance Evaluation of all PBF HCs done

HC Quality Performance Checklists completed

Travel Request Forms Signed and approved

• All HC Quality performances for the past quarter evaluated before the end of the fourth month and evaluation completed prior to the LGA PBF St Ctee meeting, using the designated Quality Checklists

• Correct use of the HC Quality Performance Evaluation Form (all items filled) including the recommendation sections

• All HC performance evaluation forms correctly filed in a specific folder.

If one or more of the above criteria are not met: 0 points

40

(Maximum 100 Points ) Grand Total


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Annex 13: Business Plan for Health Centers

PBF-Business Plan for Health Centers

Version 28 October, 2011

Analysis of results Month 1 – Month 3 [Year] & plan for Months 4 – 6 [Year]

1. GENERAL INFORMATION

LGA……… Health center……………… Population [Year]: ………

Are there sub-contracted private clinics or health posts? Yes / no

If yes, which? ………………… Qualified staff: ….. Non qualified staff: ….

HEALTH CENTRE STATISTICS

[Years]

Months

OPD Visits

New cases

Hospital bed days

Assisted deliveries in

health facility

Nr of women using FP (new

+ re-attendants)

oral (3 months) & Injectables

Nr ANC visits

(new)

Nr ANC visits

(standard visits)

2. EXTERNAL CONSULTATIONS

What is the monthly target for OPD consultations in your Ward: ...……………


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(Total population in the Ward catchment area /12)

What are the problems concerning OPD consultancies attending your health center?

Analyze the possible factors such as purchasing power of the population to pay fees, fee payment per act or fixed fees, competition with other health facilities, lack of medicines, are there remote villages, is there a lack of qualified personnel, problems with staff motivation. Are there any other problems?

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

What are the strategies proposed to solve the above problems?

Consider increasing qualified staff, outreach strategies, propose new sub contracts with health posts and/or private clinics, decrease fees, the flat-fee pricing or pricing per activity, discuss with untrained practitioners how they will stop practicing, involve the local health authorities.

…………………………………………………………………………..……..……………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

3. REFERRAL OF PATIENTS What is the target for the referral of the seriously ill patients in your Ward catchment area?

(= population / 12 x 5 %) ...…

What problems do you encounter for referral of seriously ill patients? Is feedback received from referral centre? How is transport organized? Are patients willing to be referred?

……………………………………………………………………………….……….……………

……………………………………………………………………………………………………..

………………………………………………………………………………………………………

What strategies do you propose to solve the above problems?


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………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

4. DISTRIBUTION of VITAMIN A (children between 6 and 59 months) PRE-SCHOOL- CONSULTATIONS (children between 12 and 59 months)

Calculate the number of children between the ages of 6-59 months that should receive each month a vitamin A capsule in your Ward health area? ...…. = population x 18 % / 12 x 2 caps

What strategies have you developed to achieve the target? Visits to schools, visits to villages, etc... ………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Calculate the number of children each month that should finish six standard visits for preschool consultations in the age of 12 and 59 months? ...…. = population x 16 % / 4 / 12

What strategies have you developed to achieve the target?

……………………………………………………………..………..………………………………

………………………………………………………………………………………………………

5. VACCINATION

The target group of children aged less than 1 year is 4.3 % of the population of the catchment area. The number of pregnancies in the catchment area is estimated at 4.8 %.

Vaccine Nr of children immunized during the previous 3 months

Target % achieved

% To achieve during next trimester

BCG

DTP3

Measles


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Fully immunized children

Fully immunized pregnant women (TT2+)

Which problems do you encounter in your Ward catchment area?

…………………………………………………………………………….………………………..

…………………………………………………………………………….………………………..


………………………………………………………………………………………………………

……………………………………………………………………………………….……………..

Which resources will you receive for immunizations from other organizations (UNICEF, other ?)

………………………………………………………………………………………………………

………………………………………………………………………………………………………

6. DISTRIBUTION of BED NETS

Calculate the monthly target for bed net distribution to be 100% in your catchment area? …..

= The area of health population / 5 years / 12 months / 1.5 people. One bed net has a life span of 5 years and is used by 1.5 persons on average (child with mother – couple)

What was the bed net coverage rate in the previous quarter?

= Number of nets distributed during the last quarter / (catchment area population / 4 quarters / 5 years / 1.5 people) =......... %

What are the problems related to the distribution of bed nets in your health area?

……………………………………………………..……….………………………………………

……………………………………………………………..……….………………………………



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………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Where do you plan to buy the bed nets? ………………………………………………………………………………………………………

………………………………………………………………………………………………………

7. TUBERCULOSIS What are the monthly targets for tuberculosis detection (population / 100,000 x 150 / 12) and the TB treatment (population / 100,000 x 150 / 12) in your catchment area? ………………………………………………………………………………………………………

What are the problems you encounter with the TB detection and treatment? ………………………………………………………………………….…………………………

…………………………………………………………………………….………………………

What are the strategies you propose to achieve the targets?

……………………………………………………………………….……………………………

…………………………………………………………………….………………………………

…………………………………………………………………….………………………………

8. New Family Using a Latrine

What is the monthly target for new families using latrines in your catchment area?

…………………………………. Population / 4.6 people per household / 12 months / 3 years

What are the problems to achieve the target?

……………………………………………………………………………………….……………..

………………………………………………………………………………………………………

What strategies do you propose to achieve the targets?

………………………………………………………………………………………………………

………………………………………………………………………………………………………


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……………………………………………………………………………………………….……..

9. FAMILY PLANNING

Calculate the number of couples (women) who should use per month oral and Injectables FP methods in your catchment area if we take 22.5 % as the target …………….

New + existing users = population x 25 % / 12 x 22.5 % x 4

How many cases of birth spacing do you think you can reach per month during the next quarter?

……………………………………..……………..

What problems do you encounter concerning the use of oral & Injectables methods in your area of health?

………………………………………………………………………….…………………………

……………………………………………………………….……………………………………

What are the strategies you propose to achieve the target?

Recruit additional nurses, collaboration with local NGOs, outreach strategies, use private sector through sub-contracts, social marketing strategies, advocate with local politico-administrative authorities, opinion leaders, churches, will explain how to deal with side effects.

………………………………………………….…………………………………………………..

…………………………………………………….………………………………………………..

……………………………………………………….……………………………………………..

Where do you obtain the inputs for family planning? ………………………………………………….…………………………………………….……..

Explain your strategies for applying IUD and implants in your catchment area? ……………………………………………………….…………………………………….………..

……………………………………………………….……………………………………….……..

Explain your strategies for tubal ligations and vasectomy in your catchment area in collaboration with the referral hospitals?

……………………………………………………………..……………………………..…………


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………………………………………………………………………………………….……...……

10. ANTENATAL CARE

Calculate the target for the number of new antenatal care consultancies per month?

= population x 4.8 % / 12 ............

Calculate the target for the number of standard antenatal standard consultancies per month to achieve the target for pregnant women who visits at least 3 times the standard consultations?

= population x 4.8 % / 12 x 3............

What are the problems concerning the targets and the quality of care in antennal care? …………………………………………………………………………………………..………….

………………………………………………………………………………………………………

What strategies do you propose to achieve the above targets?

…………………………………………………………………………………….....……………..

…………………………………………………………………………………..….……….………

………………………………………………………………………………………………….…..

11. DELIVERY CARE AND ABORTIONS

Calculate the rate of coverage of pre-natal assistance in the quarter spent? …. %

= Number of realized births / population x 4.8 % / 12 months

What is the target for your health area? ... Deliveries per month

= Population x 4.8 % / 12 months

What are the problems encountered in your catchment area?

Availability of qualified staff with permanent duty roster? Clean delivery room confidentially assured, equipment (delivery kit, sterile delivery boxes, vacuum extractors, and suture), Sterilization procedures (gloves, plastic apron, and disinfection) conditions of hospitalization (space, ventilation, bed net) existence of Partogram and correct use.

……………………………………………………………………………..………………………

……………………………………………………………………………..………………………


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……………………………………………………………………………..………………………

What strategies do you propose considering the above factors?

Increase qualified staff, buy equipment, change hygiene and sterilization procedures, rehabilitate infrastructure, training staff, open a new maternity, etc …………………………………………………………………………………………..…………

…………………………………………………………………………………….………….……

……………………………………………………………………………………………..………

What are the problems concerning unsafe abortions in your catchment area?

Maternal deaths after illegal abortions, cases of pregnancy after rape, lack of access to safe abortions? …………………………………………………………………………………………..…………

…………………………………………………………………………………….………….……

What strategies do you propose to solve the above problems?

………………………………………………………………………………………………….…

12. HUMAN RESSOURCE MANAGEMENT

What remuneration the health facility pays to staff based from different revenues such as government salaries, cost-recovery and performance subsidies?

[Staff 1] N……….. [Staff 2] N...……. [Staff 3] N... Unskilled workers N.....

……………

Is this reasonable related to the needs of the health staff?

………………………………………………………………………………………………………

………………………………………………………………………………………………………

What additional revenues would be required to increase the staff remuneration? ………..

What is the proportion of staff remuneration related to total revenues? ………………………


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Staff categories Current staff numbers

Staff required next quarter

Staff 1

Staff 2

Staff 3

Administrative staff

Unskilled medical staff

Cleaners, drivers, etc

Gardeners, security

TOTAL

13. OTHER RESOURCES

Describe the situation regarding the availability of essential drugs (including for family planning and bed nets) and how will you improve it during the contract period? ………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Describe the situation concerning the availability of medical equipment and how will you improve it during the contract period?

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Describe the situation regarding the availability of furniture and office supplies and how will you improve it during the contract period?


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………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Describe the situation with regard to infrastructure and how will you improve it during the contract period?

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

14. FINANCIAL PLANNING Estimate your financial needs based on the above proposed strategies:

Revenues Past monthly

revenues Proposed monthly

revenues new Quarter Cost recovery (user charges) Cost recovery (pre-payment schemes) Salaries from government & other sources PBF subsidies from fund holder Contribution from other sources Other Cash xxxxxx Bank balance at the end of the quarter TOTAL

Expenses Past monthly

expenses Proposed monthly

expenses new Quarter Salaries Performance bonuses Drugs and medical consumables Subsidies for sub-contracts Cleaning and office costs Transport costs


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Social marketing Infrastructure rehabilitation Equipment and furniture Other Put into reserve

TOTAL Statement of Quarterly Financial Activities for the past Quarter :

Statement of Quarterly Financial Activities

Quarter/Year:

N_R Revenue Categories Revenues N_E Expense Categories Expenses 1 Cost recovery (user-charges) 9 Salaries 2 Cost recovery (pre-payment) 10 Performance bonuses

3 Salaries from Government & other sources 11 Drugs and medical consumables

4 PBF Subsidies from fund holders 12 Subsidies for sub-contract 5 Contributions from other sources 13 Cleaning and office costs 6 Other 14 Transport costs 7 Cash in hand 15 Social marketing

8 Bank balance at the end of the quarter 16 Infrastructure rehabilitation

Total Revenue 17 Equipment and furniture

18 Other

19 Put into reserve

Total Expenses

Balance (Total Revenue - Total Expenses)

Signed at………………………………. the ……./……./[Year]

Signatures:

…………………… ………………….

Health Facility in-Charge Head of SPHCDA Purchasing Unit


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Name: Name:

Copies: Health facility, fund holder and health authority


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Annex 14: Indice Tool for Health Centers

Indice Tool

For Health Centers Contracted by the SPHCDA through Performance Based Financing

Version 13 December 13

1. Revenues and Expenses for the Past Quarter: Statement of Quarterly Financial Activities 2. Revenues and Expenses for the Past month and Proposed Monthly Revenues and

Expenses for the Next Quarter 3. Budget for Performance Bonuses; Point Value and monthly Performance Bonus 4. Indice

1. Revenues and Expenses for the Past Quarter (only enter cash revenues and cash expenses):

Statement of Quarterly Financial Activities

Quarter/Year:

N_R Revenue Categories Revenues N_E Expense Categories Expenses 1 Cost recovery (user-charges) 9 Salaries 2 Cost recovery (pre-payment) 10 Performance bonuses

3 Salaries from Government & other sources 11

Drugs and medical consumables

4 PBF Subsidies from fund holders 12 Subsidies for sub-contracts 5 Contributions from other sources 13 Cleaning and office costs 6 Other 14 Transport costs 7 Cash in hand 15 Social marketing

8 Bank balance at the beginning of the quarter 16 Infrastructure rehabilitation

Total Revenue 17 Equipment and furniture

18 Other

19 Put into reserve

Total Expenses

Balance (Total Revenue - Total Expenses)


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2. Revenues and Expenses for the Past month and Proposed Monthly Revenues and Expenses for the Next Quarter

Revenues Past monthly

revenues Proposed monthly

revenues new Quarter Cost recovery (user charges) Cost recovery (pre-payment schemes) Salaries from government & other sources PBF subsidies from fund holder Contribution from other sources Other Cash in hand xxxxxx Bank balance at the end of the quarter TOTAL

Expenses Past monthly

expenses Proposed monthly

expenses new Quarter Salaries Performance bonuses Drugs and medical consumables Subsidies for sub-contracts Cleaning and office costs Transport costs Social marketing Infrastructure rehabilitation Equipment and furniture Other Put into reserve

TOTAL


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3. Budget for Performance Bonuses; Point Value and monthly Performance Bonus

Budget for Performance Bonuses for next quarter (a) Naira

Number of Points for all staff for the past quarter (b) Points

Point value (pv) coming quarter = (a) / (b) Naira

Maximum point value per month (pm) = (pv) / 3 Naira

Individual monthly performance bonus =

(% individual performance score (p)) * (individual indice value (i)) * (pm)

Naira

4. Indice

• The indice tool used (a) the maximum point value for each staff member, from his or her motivation contract; (b) the individual performance evaluation for each staff member and (c) the point value for the following quarter obtained from section 3;

• Each month of the following quarter, staff is assessed using the individual performance evaluation (annex 15 of the PBF user manual); the score is recorded in a specific register;

• Indice scores are discussed within the facility management team and presented to the Facility RBF committee;

• Each month, before the middle of the following month and after vetting by the Facility RBF committee, staff receives their variable performance bonus;

• Staff who is not in employment at the facility during the month in which the bonus is paid out, is not entitled to a performance bonus payment;

• Unspent bonus is automatically versed into the reserve fund; • The facility management in close collaboration with the Facility RBF committee reserves

the right to invest in the facility infrastructure or equipment instead of paying out the performance bonuses. Such a decision ought to be endorsed by the overall majority of the staff.

No Family name, first name

Indice Monthly_Point_Value %_Perform_Eval Gross_Bonus Taxes Net_Bonus

(i) (pm) (p) (pb) =

(i)*(p)*(pm) (t) (pb) - (t) 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22

Total (b)

Annex 15: Individual Performance Evaluation Template Individual Performance Evaluation for Health Staff

Criteria 25% Score 50% Score 100% Score Max Score

1 Professional Awareness includes the following: (20 points)

Timeliness Arrived frequently late

(at the least four times past month)

Arrived sometimes late

(1 to 3 times per month)

Was always on time 8

Availability Has been frequently absent from his/her service without any clear motive

(at the least four times past month)

Has been a few times absent from his service without clear motive


Was never absent from his/her service without known and valid motive

8

Uniform Did not wear a uniform during working hours

(even once per month)

Neglected uniform (dirty or torn or not ironed)

Uniform always worn and proper (washed ; ironed and not torn)

4

2 Team spirit includes the following: (30 points)

Interpersonal Relationship

Frequently in conflict with colleagues (reported more than once to his/her superior during the past month)

Sometimes in conflict with colleagues (reported once to his/her superior)

Never in conflict with colleagues

8

Collaborative spirit

Frequently refused to assist colleagues when asked

Sometimes refused to assist colleagues

Never refused to assist colleagues

8


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(more than once per month) (even once)

Dedication Frequently left work unfinished without somebody taking over under the argument that official working hours were up

(more than 3 times past month)

Sometimes left work unfinished without somebody taking over using the argument that official working hours were up


Never left work unfinished without somebody taking over

8

Initiative Has never done any additional work Has always awaited a command from higher up to carry out additional work

Has at least once done additional work without supervisor asking him/her to do so

6

3 Technical Competency and flexibility during work: (40 points)

Organization Never has a daily work schedule (assessed during internal work supervision)

Not always has a daily work schedule (at least once during internal supervision)

Always has a daily work schedule

10

Quality of work Never adheres to specific work related norms and standards

(assessed during internal supervision)

Not always adheres to work related norms and standards

(found at least once during

Always adheres to specific work related norms and standards

14


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internal supervision)

Quantity of work

Never finishes his/her daily work based on his/her own daily work schedule

(assessed during internal supervision)

Not always finishes his/her work based on his/her own daily work schedule

(found at least once during internal supervision)

Always finishes his/her work according to his/her daily work schedule

16

4 Willingness and aptitude for personal development : (10 points)

Takes into account advice and recommendations from previous internal and external supervisory visits

Never takes care of such recommendations (concluded during internal and external supervisory visits)

Not always takes care of such recommendations

(if this happens once or more)

Always takes into account recommendations of internal and external supervisory visits

10

TOTAL POINTS 100

5 Participation to Results and the Past Monthly Performance Score

Participation to Results and the past monthly performance score (quantity and quality) through presence during working days during the past three months :

Number of official working days = (N);

100% P =


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NB: We take into account actual working days without taking into account any valid reasons for absence such as vacation, leave, sickness, absence through disciplinary action, formal trainings etc. An exception to this rule are Rest and Recuperation days (allocated by the health facility management), which, when accorded, are considered official working days.

number of days actually worked = (n);

Percentage of days performed = (P) (P) = ( n/N) * 100

Result of the individual monthly performance evaluation = (Total of the Scores for items 1 to 4) * P

Prepared at:

Date………………………………...

For the internal performance evaluation team, (Names, functions, and signatures)

…………………………………………………………………………………

…………………………………………………………………………………


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Employee (Name and signature)

…………………………………………………………………………………

Annex 16: Column Headers for PBF Registers

[Available as a separate draft document: not yet inserted as it is being finalized]


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Annex 17: Terms of Reference for the Health Center Health Committee/General Hospital Governing Board

Health Center:

Health Center RBF Committee SMOH/SPHCDA Version 111010

The Health Center RBF Committee has a strong link to the Ward Development Committee (WDC). Whereas the WDC has been created to oversee all health facilities at the Ward level, the Health Center RBF Committee, is put in place to function as the governing board of the contracted RBF facility. The General Hospital RBF Committee will function as the governing board for the general hospital.

Membership of the Health Center RBF Committee:

• The Chair (who is the chairperson of the WDC) or his or her designate; • elect members of the WDC; • Officer in charge of the health center (non-voting member); • One technical staff of the health center (non-voting member); • Headmaster of the school.

Functions of the Health Center RBF Committee:

• Discuss the quarterly quantity and quality performance of the Health Center and advice

the Health Center management in areas of possible improvements; • Ensure that the health center management can operate with a reasonable level of

autonomy to reach the objectives agreed upon in the business plan; • Appoint the Indigent committee of the Health Center among its members, and select

community representatives; • The Chair of the Health Center RBF Committee is the co-signatory on the Health Center

Bank account; • The Chair of the Health Center RBF Committee co-signs, conjointly with the in-charge of

the health center, the purchase contract with the SPHCDA;


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• To review and approve the performance appraisal of health facility workers according to applicable workers’ motivation contracts;

• To approve the utilization of income received by the Health Facility (cash from DRF, PBF and other sources), and in particular the proportion to be used as staff bonus payments or as infrastructure/equipment investment according to the Purchase Contract signed between the HF and the SPHCDA;

• Discuss and agree on the content of the business plan and related activities in the health center prior to submission of the business plan for negotiations with the SPHCDA;

• Follow up on the implementation of the business plan; • Liaise with the WDC.

Operational Guidelines:

The Health Center RBF Committee shall:

• Meet once per month at a date agreed in advance by members; • Record minutes of meetings; • Minutes of meetings shall be signed by the Chairman and Secretary after adoption at

subsequent meetings; • The members of the HC RBF Committee are participating on a voluntary and merit basis,

and apart from government agreed per diems, are not entitled to further compensation; • The quorum for a valid Committee meeting is 3 of its members present and must include

the Health Center RBF Committee chair, its treasurer and the health facility in charge.


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General Hospital:

General Hospital RBF Committee

SMOH/SPHCDA

Version 111011

The General Hospital RBF Committee will function as the governing board for the general hospital. Its membership and terms of reference are modified to create a better fit between the new PBF intervention, and the GH-RBF Committee.

Membership of the General Hospital RBF Committee:

• Chairperson: a respectable person from the community, appointed by the LGA Chair • LGA PHC coordinator • Chief medical officer (non-voting member) • General Hospital administrator (secretary and non-voting member) • Representative of the traditional ruler • Representative of a women’s group

Functions of the General Hospital RBF Committee:

• Ensure that the hospital management can operate with a reasonable level of autonomy to reach the objectives agreed upon in the business plan;

• Appoint the Indigent committee of the hospital among its members, and select community representatives;

• The Chair of the GH-RBF Committee signs, conjointly with the in-charge of the hospital, the purchase contract with the SPHCDA;

• To approve the utilization of income received by the hospital (cash from DRF, PBF and other sources), and in particular the proportion to be used as staff bonus payments or as infrastructure/equipment investment according to the Purchase Contract signed between the hospital and the SPHCDA;

• Discuss and agree on the content of the business plan and related activities in the hospital prior to submission of the business plan for negotiations with the SPHCDA;

• Follow up on the implementation of the business plan.

Operational Guidelines:


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The GH-RBF Committee shall:

• Meet once per month at a date agreed in advance by members; • Record minutes of meetings; • Minutes of meetings shall be signed by the Chairman and Secretary after adoption at

subsequent meetings; • The members of the GH-RBF Committee are participating on a voluntary and merit basis,

and apart from government agreed per diems, are not entitled to further compensation; • The quorum for a valid GH-RBF Committee meeting is 3 of its members present and

must include the GH-RBF Committee chair, and the CMO.


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Annex 18: Terms of Reference for the Indigent Committee

Terms of Reference

For the Indigent Committee

SMOH/SPHCDA

Version 10 December 2013

The SMOH/SPHCDA is testing a new approach to assist the poorest of the poor to access good quality medical care in the State PBF program.

This new program will allow health facilities to categorize up to 5% of the curative consultations of the past month, to be categorized under ‘new consultation by an indigent patient’ (at the Health Center) or ‘new consultation by a Doctor of an indigent patient’ (at the General Hospital) categories.

The health facility is allowed to claim a higher reimbursement for this category of care, under the following conditions:

1. The patient is indeed very poor; 2. The total number per month is limited to 5% of the total new consultations of the past

month (excluding the ‘new consultation by an indigent patient’ category of that month); 3. For the General Hospital an additional special rule applies:

a. For admissions, up to a total of 7 days, the GH can claim one such category for each admission day;

b. Beyond 7 days up to a total of 15 days, the GH will be cross-subsidizing the care from other sources of income;

c. Beyond 15 days the GH can claim one such category for each additional day up to five days;

d. Beyond 20 days, the GH will need to contact the designated SPHCDA verifier to discuss this issue.

4. There is a functioning Indigent Committee which oversees regularly the correct identification of the poorest of the poor;

5. The purchase contract with the SPHCDA is valid for the time period (which also depends on the correct use of this category);


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6. The health facility continues to provide excellent quality care for these indigents, just like for any other patient (as measured through the quality checklist and documented in the business plan);

7. If the care for the individual indigent surpasses the negotiated subsidy for this category; that the health facility/RBF Committee agrees to cross-subsidize the care for this individual indigent, from other sources of income.

This new program will be evaluated. Its success or failure to target care to the poorest of the poor will determine whether it will be expanded, or halted.

The Indigent Committee and the Facility RBF Committee will be extremely important in representing the voice of the poorest of the poor, and to make this program a success.

The Purpose of the Indigent Committee is:

• To ensure that the category ‘new consultation by an indigent patient’ (Health Center) or ‘new consultation by a Doctor of an indigent patient’ (General Hospital) is used only by the poorest of the poor;

• To advocate and raise awareness within the local community of this assistance mechanism for the poorest of the poor;

• To solve problems that may arise with this assistance mechanism.

The Indigent Committee rules are:

1. The members of the Indigent Committee (IC) are appointed by the Facility RBF Committee.

2. The members of the IC are (4): • A Chair (a respected member of the local community; not related to a health

facility staff member; not a member of the Facility RBF Committee) • A Secretary (member of the Facility RBF Committee) • Two members (appointed from the local community; not related to a health

facility staff member; not a member of the Facility RBF Committee) 3. Gender: the IC membership should have at least a 50/50 representation of women, a

higher representation of women is desirable; a higher representation of men is not permissible (e.g.: 2 women and 2 men are acceptable; 3 or 4 women are desirable; 3 or more men are not permissible).

Its proceeds are:

• The IC should meet at the least once per month and review and vet the application of the ‘indigent payment category’;


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• Minutes should be recorded in a register and signed by the participants and dated; • Their report should figure in the Facility RBF Committee proceedings.

A Special Note on its Functions:

• The IC committee is encouraged to find and apply local solutions to improve the post-identification measures;

• Such measures taken will be systematically evaluated, and will inform guidelines in the larger PBF pilot which will be extended across Ondo, Nassarawa and Adamawa states;

• The most innovative and effective solution will be awarded an award and a special recommendation by the State RBF Steering Committee.


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Annex 19: Indicative Indice Values for Health Center Staff

14 December 2013

No Category of Worker Indice Value 1 In-charge 90-100 2 Community Health Officer

(CHO) 80-90

3 Nurses/midwives 80-90 4 Community Health Extension

Worker 60-70

5 Technician 60-70 6 Junior Community Health

Extension Worker 50-60

7 Security/cleaners 15


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Annex 20: Terms of Reference for the Health Center and General Hospital Internal Management Committee

TERMS OF REFERENCE

HEALTH FACILITY INTERNAL MANAGEMENT COMMITTEE

HEALTH CENTER and GENERAL HOSPITAL Version 15 December 2013

_____________________________________________________________________________

HEALTH CENTER

I. ROLE OF THE HEALTH FACILITY INTERNAL MANAGEMENT COMMITTEE

The Internal Management Committee (IMC) acts as the management team of the Health Facility. The Health Facility Internal Management Committee reports to Facility RBF Committee.

II. MEMBERS OF THE HEALTH FACILITY- IMC

II.A- HEALTH CENTER

The members of the Health Center- IMC are chosen among the facility’s staff as follows: 1. Officer In-charge (OIC) of HC : Chairman/person (Main Signatory on bank accounts ) 2. Representative of trained staff/Deputy OIC : Vice- Chairman/Person (alternate signatory

on bank accounts) 3. Representative of supportive staff 4. Treasurer of the HF (alternate signatory on bank accounts) 5. Secretary: Any skilled person appointed by the OIC.

II.B- GENERAL HOSPITAL

The members of the General Hospital – IMC are chosen among the facility’s staff as follows:

1. Principal Medical Office (PMO): Chairman/person (Main Signatory on bank accounts )


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2. Secretary of the hospital: Vice- Chairman/Person 3. Chef Nursing Officer I/C 4. HMIS Officer 5. Head of Units (all) including Hospital Accountant (alternate Signatory on bank accounts) 6. Representative of supportive staff

III. FUNCTIONS

The Committee’s function is to discuss the internal issues of the facility’s personnel and management and in particular the following: • Ensure the quality and reliability of data that will be submitted to the LGA – PHC

department and the SPHCDA; • Discuss the monthly quantity and quality performance of the Health Facility and review

the strategies and identify areas of improvements; • Reach the objectives agreed upon in the business plan; • Ensure that the Indigent Committee is functional; • Prepare for the Facility RBF Committee the monthly income and expense statement. The

utilization of income received by the Health Facility (cash from the drug revolving funds and other internal revenues, PBF subsidies and other sources), and in particular the proportion to be used as staff bonus payments or as infrastructure/equipment investment according to the Purchase Contract signed between the Facility and the SPHCDA;

• Collaborate with the Facility RBF Committee to prepare the business plan and related activities in the health center prior to submission of the business plan for negotiations with the SPHCDA;

• Establish final indices for staff; • Sign motivation contract with each staff ; • Calculate the monthly performance incentive for staff according to the guidelines

provided in the PBF user manual; • Evaluate the monthly individual performance of staff; • Collaborate closely with the community through the Facility RBF Committee to IV. OPERATIONAL GUIDELINES:

To meet at least once per month to do and or assess the following:

• Performance of the health facility: in terms of quantity and quality; • Level of implementation of the Business Plan;


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• Finance: monthly treasury report: revenues & expenditures, balance on bank accounts;

• Prepare the projection of the budget for the next month/quarter: revenues & expenditures;

• Drugs management including the availability of qualitative drugs; • Staff management: on-the-job trainings, monthly performance evaluations, bonus

payments, etc. • Record minutes of meetings; • Minutes of meetings shall be signed by the Chairman and Secretary after adoption at

subsequent meetings; • The members of the Facility- IMC Committee are participating on a voluntary basis,

and apart their fixed salary and PBF bonus, are not entitled to further compensation; • Other relevant topics.

V. COMMITTEE PROCEDURES

a) The Committee must convene at least once per month, preferably within the health

facility. b) The Treasurer is the in-charge of Finance c) The Secretary is responsible for preparing the meetings members and keeping records

of the meetings’ proceedings in writing minutes. Records must be kept and available for control at the Health Facility;

d) Quorum for the Health Center - IMC: The quorum for a valid Health Center Internal Management Committee meeting is that at the least 3 members are present including the head of the facility; the finance in-charge and the secretary;

e) Quorum for the General Hospital –IMC: The quorum for a valid Committee meeting is 5 of its members present and must include the hospital PMO, the Secretary, the Accountant, CNO In-charge and its HMIS Officer;

e) The Committee takes its decision by consensus; in case of disagreements a majority vote of the members present at the meeting is done. In case of deadlock, the head of facility casts the deciding vote.

Documents

Nigeria State Health Investment Project (NSHIP ...siteresources.worldbank.org/EXTPBFTOOLKIT/Resources/7364043... · Minimum Package of Activities ... NSHIP Nigeria State Health Investment