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Performance-based Financing in Liberia: Experiences of USAID/RBHS. Richard J. Brennan Rebuilding Basic Health Services. Rebuilding Basic Health Services - Overview. Largest USAID-funded health project in Liberia Nov 2008 – Oct 2013 - PowerPoint PPT Presentation
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Performance-based Financing in Liberia:
Experiences of USAID/RBHS
Richard J. Brennan
Rebuilding Basic Health Services
Rebuilding Basic Health Services - Overview
• Largest USAID-funded health project in Liberia– Nov 2008 – Oct 2013
• Overall goal: assist MOHSW with implementation of National Health Plan
• Three pillars– Service delivery– Systems strengthening– BCC
• Service delivery– Implemented through
performance-based contracts
Performance-based Financing in Liberia
• RBHS PBCs – July 09 – June 11– 4 NGOs (5 contracts) – 1 NGO grant; 15
facilities
• MOHSW Pool Fund – November 2009 – March 2010
USAID/RBHS
MOHSW - CHT
MOHSW -NGOs
110
19
97
Facilities Covered by PBF
PBF and RBHS
• Objectives of PBCs– Service delivery at facility & community levels– Capacity building of CHTs
• Indicator selection – Highly consultative
• Determining baselines and targets– Individualized by NGO
Administrative Indicators
• Reported quarterly; possible penalty associated
INDICATOR BASELINE TARGET
• # joint and total supervisory visits
• % of timely, accurate and complete HIS reports submitted to the CHT
• % of staff funded by NGOs paid on time
• # of Community Health Development Committees meetings held per facility
• Submission of timely and complete quarterly report to RBHS
Performance Indicators• Reported quarterly: annual performance
bonus (year 1); quarterly bonus (from year 2)INDICATOR BASELINE TARGET
• % of priority facilities reaching one-star level in accreditation survey
• % of facilities with no stock-out tracer drugs
• % of patients receiving no more than 3 drugs
• % of children under 1 year who received DPT3/pentavalent-3
• % of children under 5 years with malaria who are treated with ACTs
• % of pregnant women provided with 2nd dose of IPT for malaria
• % of deliveries that are facility-based with skilled attendant
• Number of people tested for HIV and received their results
•Couple-years of contraceptive protection provided by RBHS-supported facilities
PBF Management:Verifying data
• Process– Quarterly– Random selection of 3 facilities per NGO– Cross check reports with ledgers / records
• Challenges– Definitions, e.g. supportive supervision– Reporting issues, e.g. ORS, ACT– Discrepancies between facility reports and
ledger reviews by RBHS
PBF Management:Verifying Data
• Progress: Quarter 1 to Quarter 6 – Clarification of definitions– Data verification instituted by NGOs– Fewer discrepancies
• Results – Increased capacity in data management –
facility and NGO staff– Improved data quality– Improved understanding and use of data
PBF Management: Feedback & Communication
• Monthly all-partner meetings
• Quarterly data reviews – all partners, MOHSW
• Quarterly partner feedback
• Annual stakeholders’ meeting
• Others– County Coordinator reports– Ad hoc meetings– Field visits
Distribution of Performance Bonuses
• Frequency– Year 1: Annual bonus– Year 2: Quarterly
bonus
• Incentive systems determined by NGO partner, CHT, and health staff
• Distributed at all levels– CHT– Facility– Community– NGO staff
AFRICARE EQUIPIRC-
LOFAIRC-
NIMBAMTI
Facility staff 70% 41% 19% 35% 38%
Facility upgrades - 19% 69% 50% -
CHT staff 14% 4% 12% 15% 8%
CHT office upgrades - 3% - - 11%
NGO staff 16% 24% - - 21%
NGO office upgrades - - - - 19%
Community - 6% - - -
Awards & ceremonies + 2% + + 3%
Distribution of Performance Bonuses
Support to MOHSW
• Selection and harmonization of national indicators
• Determination of preliminary baselines and targets
• Development of PBC payment plan and tool
Lessons learned• Need precision in indicator definitions
• Importance of flexibility and leniency in setting targets and assessing progress
• Value of validation process in building capacity
• Annual payment of bonus too infrequent
• Need to provide more guidance on bonuses
Future directions• Improve data collection with new HMIS
• Involve CHT members and facility staff more in tracking PBF
• Introduce facility feedback tool– Graphs of last 12 months’ data updated
monthly– Posted at each RBHS facility and updated
monthly