Performance-Based Financing

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  • Will focus
  • In presenting the conceptual framework we start with the assumption that the goal of the health care provision system is the achievement of sustainable, improved health outcomes (Mouse Click) . These improved outcomes are achieved through the provision of high quality health services which adhere to norms and standards and also meet client needs (Mouse Click) . With the provision of good quality services, the population uses the services (Mouse Click) , adheres to the prescribed preventive and curative services (Mouse Click) and thus achieve the desired improved health outcomes. High quality services are only achieved if we have high performing facilities (Mouse Click) and the active participation of the population (Mouse Click) . To ensure that these exist, the ten determinants of quality must be present – six on the facility side (Mouse Click) , and four on the population side (Mouse Click) . By now looking at the inputs and supports to the system brought by the three core strategies, we can see how the determinants of quality are achieved: Performance based financing (Mouse Click) ensures that we have appropriate information for decision-making, adequate financial and material resources, and strong staff motivation and competence on the facility side, while also providing support to assuring financial and geographical access on the population side. Mutual Health Assurance (Mouse Click) ensures that the is financial and geographical access and that patients have the ability to act on their care and prevention needs. MHA also provide strong input into the definition of what are appropriate care services on the supply side. Quality Assurance activities (Mouse Click) come into play by defining and measuring performance, and establishing performance improvement loops to continuously improve the quality of care by impacting both the provider and population interactions.
  • Close collaboration with USG collaborating agencies on PBF for HIV/AIDS services has been initiated since the start of the project
  • Performance-Based Financing

    1. 1. Scaling-Up Performance-Based Financing RandyWilson/IHSSProjectRWANDA JimSetzer/AbtAssociatesUSA
    2. 2. Content  PBF101 –guidingprinciples  Casestudyof PBFinRwanda  Typesof PBF  Projectinterventions  Results
    3. 3. Input vs Output financing  Paymentsinadvancefor salaries,drugs& supplies, runningcosts  Fundsoftenmanagedat higherlevels  Needtojustifyexpenses afterpayment(accounting& audit)  Tenuouslinkbetween fundingandresults  Fundspaidforservices alreadydelivered  Fundsmanagedatlocal level  Needstrongdatacollection & qualitycontrol system  Directlinkbetweenfunding andresults
    4. 4. PBF model – key principles  Separationbetweenproviders, purchasersandcontrollers  PBFfundingdoesnotcovercostof service–justincentivizesit  Traditional inputfinancingmust continuetocomplementPBF  Dataonserviceoutputsmustbe highlyselective(10to15 indicatorsareplenty) andfrom existingsources  Strongserviceanddataquality control mechanismsneededto eliminateincentivetocheatand ensurethatservicesaredelivered accordingtonorms
    5. 5. PBF and RHIS  PBFIndicatorsshouldbeasubsetof dataalready collectedbytheRHIS  “Indicators”aretypicallynumbersof serviceoutputsor coveragerates.  Rewardpositiveindicators(e.g.don’tincentivise#of severelymalnourishedchildrendiagnosed)  PBFpaymentsprovideanincentivefortimelyRHIS reporting–noreport,nopayment!
    6. 6. PBF Control is NOT ‘business as usual’ in data gathering District quality assessment team checkingdata qualityina healthcenter
    7. 7. Assuring Data Quality – Multiple levels of control  ‘ ’Data quantity audits conductedeverymonthoneach indicatorfromeverysite(registervsreport)  Monthly report data are reviewed by district PBF steering committees (comparingtopreviousperiods,identifying outliers,requiringcorrections)  Community client or “phantom patient” surveys every6 monthatasampleof sites–lookforphantompatientsand seeksfeedbackfrompatientsonqualityof care  National PBF cell reviews database each quarter forthe entirecountry–correctionsaremadebeforepayment
    8. 8. Assuring service quality  Quarterly Quality assessments areconductedateach facilitytoassess13componentsof servicequality  Administration,Hygiene,RespectforClinical protocolsfor keyservices,Communityoutreach,etc.  Controllers areDistrictHospital supervisorsanddata managersforhealthcenters,bypeerdistricthospitalsfor Hospital level PBF  Theseassessment score isusedtooffsetPBFpayments
    9. 9. Rwanda PBF Background  WhyPBF?  Lowqualityof healthcare& services  Diminishingcoverage: generallylowutilizationof healthservices  Limitedincentivesforproviderstodeliverpreventiveservicesand HIV/AIDScareandtreatment  Financial barrierstoaccesshealthservices/demandsideproblems  Pilotinitiatives:  In2002, twoNGOsintroducedPBFpilotsschemesinCyanguguandButare provinces  Basedoninitial successMOHincludePBFin2005HealthPolicy  In2005, theBelgianTechnical Cooperation(BTC) beganthirdPBFpilot
    10. 10. Timeline of Performance-based financing in Rwanda
    11. 11. Overview of the three Rwandan Pilot PBF models Model No of Clinics under contract No of Hospitals under contract DHT's under contract Project Budget per capita per year $ PBF Budget reaching clinics per capita per yr $ Average Health Worker Income $/month “Cyangugu” model 26 (+14 HP and 19 private dispensaries) 4 4 $2 (2005) $0.41(i) (2004) $117 (2004) “Butare” model 36 3 4 $0.3 (2005) $0.13 (i) (2004) $110 (2004) “BTC” model 75 4 6 $1.57 (2005) $0.08 (ii) (2005) Base salary + $18 (2005) PBF pilots covered 137 Health Centres (about 40% of total) and 11 District Hospitals (about 30%) by end 2005
    12. 12. Key Rwanda health strategies  In2005,MOHintroducedthreecomplementary strategiestoimprovehealthservices:  CommunityBasedHealthInsurance  Performance-basedFinancing  ContinuousQualityAssurance
    13. 13. Quality Assurance Performance based financing Community-Based Health Insurance High Performing Facilities Appropriateservices and contentof care defined Goodorganization andmanagementof care Appropriate informationfor decision-making Functional referral system AdequateFinancial andmaterial resources StrongStaff Motivationand Competence Active Participation of the Population High quality healthcare Incompliancewith normsandmeets expectations Abilitytoactoncare andpreventionneeds Financial and Geographical Access Freedomtochoose careoptions Well informedand competentclients ,Sustainable Improved Health Outcomes Consistent Use of Health Services Consistent Adherence to Care
    14. 14. Rwandan National PBF Models  PBFmodel forhealth centers  PBFmodel fordistrict hospitals  CommunityPBF  Central level PBFfor MoHdepartment/units
    15. 15. Key PBF Project Achievements  Theprojectreachednationwidecoverageinall 30districtsinApril 2007  Supportfornational implementationof PBF:  Coordinateddesignof newnational PBFmodels(HC, DH, communityandcentral MOHdepartments).  Setupinstitutional structures–Extendedteam, PBFcoordinatingcell  Definedperformanceindicatorsandtheirvalues  Refinedtoolsforqualityassessment  Developeddatabasetoissuecontracts,monitorprogress, andissuepayment orderstohealthfacilities  ContractedwithsitesforHIV services  BuiltcapacitytomanagePBFactivitiesatall levels  ProvidedTA toUSGpartnerstoimplementPBFintheirfacilities
    16. 16. Performance Indicators Defined HealthCenterlevel:  :Outputs 14PHCindicators+ 10HIV indicators; unitfees$0.18- $8.90, measuredmonthly  :Quality 111 compositeindicators(1,058dataelements) across14 services/departments, measuredquarterlybyDHstaff–usingpaper checklist DistrictHospital level:  :Outputs 9HIV indicators; unitfees$0.18-$8.90,measuredmonthly  :Quality Balancedscorecardapproach: (2009) 59composite indicators,over350dataelements–measuredquarterlyusingInfoPath form
    17. 17. Performance Payment Mechanism developed Performance Payments = (# serviceoutputs* Unitfees) * %QualityscoreΣ No Indicator Quantity Fee Amount RWF 1VCT: number of clients tested 899 500 449,500 2PMTCT: number of pregnant women tested 101 250 25,250 3PMTCT: Number of couples and partners tested 134 2,500 335,000 809,750 Quarterly quality score X 87% Payment amount 704,483
    18. 18. Performance Payment Amounts Combined PBF payments to Health Centers and Hospitals to date (from USGpartners(Pepfarfunded), BelgianTechnical Cooperation,Global Fund) Service package 2006 2007 2008 2009 YTDGrand Total Primary Health Care Package $186,093 $ 1,160,087 $2,918,035 $1,916,588 $6,180,804 HIV/AIDS package $27,874 $ 867,077 $2,490,787 $1,614,068 $4,999,806 Grand Total $213,967 $2,027,164 $ 5,408,823 $3,530,656 $11,180,610
    19. 19. M&E Mechanism developed: Multiple levels of control  Setupof validationandaccountabilityfunctions (conductedbyDistrictHospital staff fortheirownHC,andas peerevaluationsfortheDHlevel)  Harmonizedquantity verification tools(dataquality)  Developedquality evaluation checklists(servicequality)  Twonational protocolsforcounterverificationof reportedservicesinPBFweretestedandadopted  “ /Phantom patient” client satisfaction surveys conductedby local NGO  Quality counter verification bytheExtendedTeam
    20. 20. PBF Information System developed MonthlyPBF Reports PBF Database Quarterly Quality Assessments PBFContracts Contracts & Amendments Indicator Trend Graph Quarterly Payment Voucher Bank Payment Voucher Thematic Maps INPUTS OUTPUTS
    21. 21. PBF Application Environment PBF Database (MySQL) Internet Access Application Internet Application (PhP) Excel Pivot Tables and Graphs
    22. 22. Contract Management Procedures  PerformanceContracts(withbusiness plan) havebeendevelopedandsigned:  MSHsigned88subcontractswith HFtopurchaseHIV services.  Contractswith9DH(forPCA)  MSHassistMOHtocontract416 HCforPHCand39DH  and30contractswithsteering committees  Creationof adatabaseapplicationto managecontracts, amendmentsand payments
    23. 23. Coordination with Partners  Closecollaborationwithall collaboratingagencies(USG& other) onPBFforHIV/AIDSserviceswasinitiatedthrough extended team forum:  Monthlymeetingsforinformationsharingandexplanationof the technical developmentssurroundingPBF  Regulartrainingsessionstostrengthenpartners’TA capacity:  PBFdatabasedataentryandPivottableanalysis  PBFmodel andprocedures  Trainingof Trainers  Financial riskforecastingandelectroniccontractmanagement  WorkshopstobuildconsensusonPBFmodel
    24. 24. Results 1. IncreaseintheVolumeof Services 3. Increaseof theQualityof Services 5. ProviderEnthusiasmandMotivation
    25. 25. Increase in Volume of Services (after 39 months) PBF Indicator 2006 /January average /month health center (258 health centers on )average 2009March / /average month health center (297 health centers on )average Percentage increase ( / 2)linear log R Institutional Deliveries 21 39.7 89% (log 0.77) New Curative Consultations 985 1835 86.3% (log 0.28) ANC new cases 100.8 76.2 -24% (log 0.05) Family Planning new users 15.5 58.6 278% (linear 0.79) Family Planning users at the end of the month 175.2 1005.6 473.9% (linear 0.98)
    26. 26. Increase in Volume of Services PBF Indicator October 2006 average/ month/ health center (6 health centers) December 2009 Average/month/ health center (6 health centers) Percentage increase (linear R2) VCT clients tested 158 372 135% (0.45) PMTCT children born to HIV+ mothers seen for CTX treatment 7 29 (dec 09) 325% (0.75) Number of HIV+ clients treated with CTX 55 134 143% (0.82)
    27. 27. Results for Institutional Deliveries
    28. 28. Increase in the Quality of Services in Health Centers (1)
    29. 29. Increase in the Quality of Services in Health Centers (2)
    30. 30. RwandaCommunityPBFModel  :Purchasers theSector(HealthCenterlevel) SteeringCommittees  :Controllers theHCstaff underguidancefromtheSectorSteeringcommittees  :Providers theCommunityHealthWorkerCooperatives(representing60,000 CHWs)  22 indicators selected–samereportforCHWMISandPBF  Different models beingtested:  Onelumpsumpaymentforonequarterlydeliverable: theCHWcompiledreport  Variablepaymentbasedonselectedoutputs  Clientincentives–e.g.clothingfornewbornsdeliveredinfacilities  Aligning incentives (HCPBFqualitygridincludesincentivestomonitor CHWoutputs, CHWindicatorscanbevalidatedagainstHCdata)  :Data transmission from15,000villagesusingcell phones(inprogress)

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