Performance-based Financing in Liberia: Experiences of USAID/RBHS

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Performance-based Financing in Liberia
Experiences of USAID/RBHS

• Richard J. Brennan
• Rebuilding Basic Health Services

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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

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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

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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

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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
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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 priority facilities reaching one-star level in accreditation survey of priority facilities reaching one-star level in accreditation survey
of facilities with no stock-out tracer drugs of facilities with no stock-out tracer drugs of facilities with no stock-out tracer drugs
of patients receiving no more than 3 drugs of patients receiving no more than 3 drugs of patients receiving no more than 3 drugs
of children under 1 year who received DPT3/pentavalent-3 of children under 1 year who received DPT3/pentavalent-3 of children under 1 year who received DPT3/pentavalent-3
of children under 5 years with malaria who are treated with ACTs of children under 5 years with malaria who are treated with ACTs of children under 5 years with malaria who are treated with ACTs
of pregnant women provided with 2nd dose of IPT for malaria of pregnant women provided with 2nd dose of IPT for malaria of pregnant women provided with 2nd dose of IPT for malaria
of deliveries that are facility-based with skilled attendant of deliveries that are facility-based with skilled attendant of deliveries that are facility-based with skilled attendant
Number of people tested for HIV and received their results Number of people tested for HIV and received their results Number of people tested for HIV and received their results
Couple-years of contraceptive protection provided by RBHS-supported facilities Couple-years of contraceptive protection provided by RBHS-supported facilities Couple-years of contraceptive protection provided by RBHS-supported facilities
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PBF ManagementVerifying 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

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PBF ManagementVerifying 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

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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

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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

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Distribution of Performance Bonuses
AFRICARE EQUIP IRC-LOFA IRC-NIMBA MTI
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
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Support to MOHSW

• Selection and harmonization of national
  indicators
• Determination of preliminary baselines and
  targets
• Development of PBC payment plan and tool

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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

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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

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Future Directions

• Support to MOHSW on PBF
• Develop PBF database (national and country level)
  with MOHSW
• Conduct costing of PBF program (management costs
  and future extension)
• Development of the national PBF procedures manual
  
• Development of PBF ME and verification manual
  and tools