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

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 M&E and verification

manual and tools