Performance based financing in low income
countries
    A panorama of existing
    performance based financing
    schemes...
Objective : provide an overview of PBF
interventions and main trends
 Which countries?
 For how long ?
 How do the sche...
Haiti : “Pay for Performance”
Context :
     Low performance of public health system
     Strong NGO and FBO health faci...
Supply side               Health system
              intervention

             MSH (NGO)              27 NGOs
          ...
Cambodia : Performance incentives
Context :
     Inefficient public health system
     Private practice and under table
...
Supply side                                    Demand side
             intervention                                   int...
Rwanda: PBF
Context :
     Post conflict reconstruction
     Public and faith based facilities
Intervention
       Star...
Administrative
              Supply side                                   Demand side
                                   ...
Key achievements in Rwanda
• Separation of functions. Purchaser – provider –
  regulation – controller split
• Success of ...
Burundi : regional dissemination (1)
Context :
     Post conflict situation. Weaker
      government than in Rwanda
    ...
DRC : Regional dissemination (2)

Context :
  War, weak government, transport
   problems
  Limited health sector resour...
Fonds d’Achat de Service de Santé
Size : 4 provinces. ~14 million people

Specificities :
    Fundholder & contracting ag...
South Kivu
Coverage :
 Idjwi, Katana & Shabunda: 605.000 hab

Specificities :
 Local NGO acts as fundholder and
  contra...
Current trend
• Expansion of schemes similar to Rwanda :
   – Within the region : DRC & Burundi, but also : Central Africa...
Kenya : voucher for maternal health
Intervention
     Started in 2006
     Voucher for maternal health
      & family pl...
Demand side
                                                    intervention
                                             ...
Madagascar
Intervention
     Started in 2008
     “Système tiers payant”
     Emergency obstetric and paediatric
      ...
Supply side
               intervention        Provincial /
                                     District
                ...
How important for providers?
             Transfer to health    % health facility incomes
             facilities $/yr/hab...
Scaling up
         Phase 1 :               Phase 2 :            Phase 3 :
   NGO or project initiative      Multi donor  ...
Who is the fundholder?
 Need an institution to be able to monitor contracts and organize
  control. Flexibility is needed...
Conclusion
 Performance based financing has proved to be
  successful and adaptable in different
  environments
 Not a s...
Thank you for your attention
Nicolas de Borman - A panorama of existing performance based financing schemes
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Nicolas de Borman - A panorama of existing performance based financing schemes

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Nicolas de Borman - A panorama of existing performance based financing schemes

  1. 1. Performance based financing in low income countries A panorama of existing performance based financing schemes Nicolas de Borman AEDES AEDES www.aedes.be Rue Joseph II, 1000 Brussels + 32 219 03 06
  2. 2. Objective : provide an overview of PBF interventions and main trends  Which countries?  For how long ?  How do the schemes function? (contracting agent, fundholder)  How large ?  Main trends
  3. 3. Haiti : “Pay for Performance” Context :  Low performance of public health system  Strong NGO and FBO health facilities Intervention  Started in 1999  Performance based payments Size :  Entire country. No particular geographic coverage  500.000 target population in 1999  2,8 million today. ~30% of total population
  4. 4. Supply side Health system intervention MSH (NGO) 27 NGOs Private Service Providers Contracting entity Fundholder ~ 100 health facilities : Technical assistance Hospitals Health centers USAID Funding dispensaries Contract : Payment :   Fixed tranche : 95% of budget Yearly contract   Variable tranche : 0 – 10 % of Only NGO and FBO budget, based on achievement  Agreement on output targets of output target and process (BHP) indicators  Agreement on yearly subsidy  Maximum 105 % of budget needed to achieve target allocated
  5. 5. Cambodia : Performance incentives Context :  Inefficient public health system  Private practice and under table payments Intervention  Started in 1999.  Performance incentives.  Basic health services (health center & hospital)  Different phases and systems  Part of a larger health system reform (equity funds) Coverage:  20 / 77 Health District
  6. 6. Supply side Demand side intervention intervention Operational District Health Equity Funds International NGO Hospital NGO managed Fundholder Donor funded Contracting agency Technical assistance Health Funding : Centers and Multi donor dispensaries Payment : Contract :  Mix of process and output  Contract of health center and indicators hospital  Output, different systems :  Key element : staff behaviour  Flat rate subsidy per service  Limited involvement of provided regulation  Target + ceiling
  7. 7. Rwanda: PBF Context :  Post conflict reconstruction  Public and faith based facilities Intervention  Started in 2001  Performance based financing  Preventive and curative (incl. HIV)  Health Center & Ref. hospital Coverage:  Entire country (~9 million people)  ~450 health facilities
  8. 8. Administrative Supply side Demand side District intervention intervention Contracting entity Ministry of finance Health Hospital Fundholder insurance Funding : Governement of Health Rwanda & Centers and donor (HIV) dispensaries Contract : Payment:   District (decentralized entity of Payment made by MOF and MOPH) contracts service providers. donors   Contract with Steering Committee Flat rate subsidy per service provided. Example: 1$/fully  Public and FBO contracted. But immunized children. private can be subcontracted by  facilities No ceiling  Bonus for quality
  9. 9. Key achievements in Rwanda • Separation of functions. Purchaser – provider – regulation – controller split • Success of integrating public, non-for profit and private facilities • Not only about staff incentives, but PBF is a systemic health financing tool • First scheme to be fully institutionalized
  10. 10. Burundi : regional dissemination (1) Context :  Post conflict situation. Weaker government than in Rwanda  Free health services (woman & U5) Intervention  Since 2006  Similar setting as in Rwanda Coverage:  ~2.000.000 people.  ~25% of the population Difference with Rwanda :  Provincial Funds (vs. national)  Provincial fundholder and contracting agency is NGO/Project  Cordaid (yellow)  Swiss cooperation (Red)  HNI (blue)
  11. 11. DRC : Regional dissemination (2) Context :  War, weak government, transport problems  Limited health sector resources available Interventions  Started in 2006 & 2007  Fonds d’Achat de Service (blue and yellow). Third payer.  Agence d’Achat Sud Kivu (red)
  12. 12. Fonds d’Achat de Service de Santé Size : 4 provinces. ~14 million people Specificities :  Fundholder & contracting agency : Etablissement d’Utilité Publique. Joint donor and government agency. One per province.  Funding from EC Payment :  First phase : in drugs (yellow area)  Second phase : in cash (blue area)
  13. 13. South Kivu Coverage :  Idjwi, Katana & Shabunda: 605.000 hab Specificities :  Local NGO acts as fundholder and contracting agency  Multisector PBF in Shabunda (health, education and road)
  14. 14. Current trend • Expansion of schemes similar to Rwanda : – Within the region : DRC & Burundi, but also : Central African Republic, Sudan, Zambia, Tanzania,… – Elsewhere : Afghanistan, Indonesia, Cambodia,… • But also other output based financing schemes : – Voucher systems : Kenya, Uganda, Bengladesh, India, cambodia,… – targeted interventions : HIV, TB, maternal health. 2 examples. Kenya and Madagascar
  15. 15. Kenya : voucher for maternal health Intervention  Started in 2006  Voucher for maternal health & family planning Coverage:  3 districts + 2 slums in Nairobi  1,7 million people in rural districts Contracted service providers  54 Public, FBO, NGO & private
  16. 16. Demand side intervention Autonomous gov. agency (NACPD) Fundholder Provincial / Contracting body District ng regulator di KFW funding n Fu g in nd Hospital Fu Voucher distributor Poor Woman Health FP or Safe Centers and dispensaries Delivery Voucher Contract & control: Payment:   Agency contracts Voucher Cash, on reception of the distributors voucher  Marketing & management of scheme  Public, FBO and private  Specific role for national insurance : accreditation and quality control
  17. 17. Madagascar Intervention  Started in 2008  “Système tiers payant”  Emergency obstetric and paediatric care Coverage:  2 regions  4 public hospitals
  18. 18. Supply side intervention Provincial / District regulator 2 national NGOs Fundholder Contracting agency Hospital World Bank funding Health Centers and dispensaries Contract  National NGO contracts Hospitals  Public hospitals only  Free healthcare for patients Payment:  Lump sum cost based subsidy per intervention
  19. 19. How important for providers? Transfer to health % health facility incomes facilities $/yr/hab coming from PBF Cambodia 0,25 - 0,5 5 - 25% Rwanda ~1,8 15 - 35% Burundi 0,7 - 2 30 - 35% DRC 0,3 - 1,8 30 - 70% Kenya ~1,7 > 50% Madagascar 0,25 ~25%
  20. 20. Scaling up Phase 1 : Phase 2 : Phase 3 : NGO or project initiative Multi donor Institutionalized Single donor On plan (SWAP) Gov & donor On plan, on budget  Initial phase : Initiative. key role played by NGOs and projects  Second phase : Strengthening. Need to broaden the financial basis. Gradual improvement of system. Key role played by development partners and bi-laterals.  Third phase : Institutionalization. Key role played by the government. Ownership and support from other stakeholders.
  21. 21. Who is the fundholder?  Need an institution to be able to monitor contracts and organize control. Flexibility is needed.  Rationale of having independent contracting entities : private (NGOs, health insurance,…) or public (decentralized government entities, independent gov. agencies). Not a single answer. But :  Reluctance of MOPH to see large share of budget going to INGOs  Reluctance of MOF to see large share of budget going to external independent agencies (even governmental).
  22. 22. Conclusion  Performance based financing has proved to be successful and adaptable in different environments  Not a single model, but flexible and evolutive approach  PBF, a trend that is growing rapidly.  Key challenge : scale up and institutionalization
  23. 23. Thank you for your attention

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