Results Based Financing Initiative for Maternal and Neonatal Health Malawi

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1 Results Based Financing Initiative for Maternal and Neonatal Health Malawi Interagency Working Group on Results-Based Financing Meeting in Frankfurt/ Germany 7 th May 2013 Dr Brigitte Jordan-Harder MD MPH

2 What is the RBF4MNH Initiative? Governments of Norway and Germany provide US$ 10 million ( ) Ministry of Health (RHU) / Options & BBA 4 districts, 18 facilities (MoH BEmONC and CEmONC) Supply side performance agreements Demand side cash transfers for pregnant women

3 RBF4MNH Outcome and Outputs Increase in number of institutional deliveries of good quality in targeted health facilities 1. Increased quality of maternal and neonatal health services in targeted facilities 2. Pregnant women receive cash for transport to and staying at the facility 3. Increased staff motivation 4. Increased community members awareness (women and men) of the importance of institutional deliveries Contributing to reduced maternal and neonatal morbidity and mortality

4 Through Performance incentives to motivate safe deliveries Improved quality of reproductive health services Increase of the number of quality deliveries at health facilities And Cash transfer to eligible women For transport to and staying at the facility

5 Why focus on quality? Maternal Mortality Ratio: from 770 (2000) to 675(2010) = minus 13% Institutional Delivery Rate: from 38% (2004) to 70% (2010) = plus 84% While the Institutional Delivery Rate almost doubled, maternal mortality remained high

6 Problems for provision of quality services Insufficient infrastructure Lacking/ non-functioning equipment Lack of/interruption of continuous provision of essential medicines and consumables Insufficient number and capacity of staff Lack of staff motivation and commitment Missing problem solving attitude of staff Insufficient support and supervision by the DHMT

7 Obstacles faced by women for facility deliveries and timely access Distances and terrain Lack of resources and ability to pay for transport and stay at the facility after delivery Lack of decision making power of women Traditional beliefs and poor awareness Stigma (low age, unmarried)

8

9 The RBF4MNH components M & E Operational Research Infrastructure & equipment RBF Supply side RBF Demand side Independent evaluation Baseline assessment

10 1) Empowering facilities to deliver quality care Service providers and District managers as recipients of incentives: 1. Basic Emergency Obstetric Newborn Care (BEmONC) 2. Comprehensive Emergency Obstetric Newborn Care (CEmONC) 3. District Health Management Team (DHMT)

11 Selection of participating facilities CEmONC/BEmONC clusters Possibility of referral Coverage Minimum quality of care available 24 hours delivery care Results of baseline assessment

12 Measuring Quality of Maternal and Neonatal Healthcare Delivery Structure Process Output Outcome Supervision Safe equipment Staff Medical Equipment Staff training Equipment maintenance Increase in client satisfaction Labour rooms Essential Drugs Data Money Knowledge Referral processes Written procedures and Guidelines Service performance Patient feedback mechanisms Management meetings Budget processes Improvements Based on Patient feedback Increased staff Motivation And problem solving Attitude Accurate reporting and Recording of data And use Increased numbers of institutional deliveries of good quality 12

13 Supply Side Core Indicators and Targets-BeMONC 1 Core Indicators and Targets Weight / Percent Total number of facility based deliveries and number of referrals to CEmONC due to complications at the time of delivery increases by 5 percent from baseline every 6 months. 55% 2 100% maternal and newborn deaths properly audited according to national guidelines. 15% % of pregnant women who arrive at the facility for delivery with unknown HIV status who are tested and treated for PMTCT provided HIV test kits and ART are available. Accurately and completely filled HMIS reports submitted on time to the district health office. Up to date and complete stock cards of essential MNH medicines and commodities on the date of verification Accurate and complete RBF4MNH Initiative specific reports submitted to district health offices on time. 10% 5% 5% 10% Total 100%

14 Quality Deflators for BEmONC Quality Measures 1 Completely and properly filled partographs for all deliveries 2 Use of a uterotonic in third stage labor in all deliveries 3 Use of magnesium sulphate for control or pre-eclampsia and eclampsia when indicated 4 25% of women who deliver per month answer a patient satisfaction survey. At least one suggestion is selected by facility and implemented each quarter 5 Within 48hours after delivery administer Vitamin A to all newborns. 6 Broken maternity equipment reported to DHMT 7 Infection prevention and delivery quality checklist is implemented monthly and one documented action is taken to improve safety and quality each month

15 Supply Side Core Indicators and Targets for CEmONC Indicators and Targets CEmONC Completely and appropriately filled partographs according to national standards for all women who deliver in the facility All pregnant women who arrive at the facility for delivery with unknown HIV status are tested and treated for PMTCT, if they are HIV positive. Use of an uterotonic in third stage labor for all women who deliver in the facility Use of magnesium sulphate for control of pre-eclampsia and enclampsia for all women who show signs of pre-eclampsia or enclampsia who deliver in the facility Weighting 25% 20% 20% 20% Vitamin A administered to all newborns within 48 hours 15% Total 100%

16 Supply Side Deflator Indicators for CEmONC 1 Indicators Facility uses an infection prevention and delivery quality checklist once per month and documents at least one action taken each month to improve safety and quality delivery. 2 All maternal and newborn deaths must be properly audited according to national guidelines. 3 Each month, 25 percent of, or a maximum of 50 women, who have delivered, fill in a patient satisfaction survey administered by a person selected by the facility and at least one issue for improvement that is raised is selected, discussed and a solution proposed and documented. 4 On the day of the verification visit all broken maternity equipment is reported in writing to the DHO Stock Cards of essential MNH drugs and commodities (see Annex 14 for list) are up-to-date and complete on the date of verification Completely filled HMIS reports are submitted on time, no more than 5days after the end of each month. Accurate and complete RBF4MNH Initiative specific data reports submitted not later than 5 days after the end of each month.

17 DHMT Performance Indicators Indicators Weighting Sum of all institutional deliveries across the district meets or exceeds number in previous performance period At least one month supply of essential MNH drugs and commodities available at all facilities in the district On the day of verification a list of essential equipment (agreed with MOH) is in operating condition in RBF facilities 60% 15% 15% 4 Complete HMIS reports are transmitted to Central MOH in time 10%

18 Deflator Indicators for DHMTs The total incentive payment for DHMTs is deflated by the performance score of the RBF facilities in each district, which is calculated as: Sum of all performance payments achieved by facilities in the District (MWK) Maximum performance payments available (MWK) A further 25% (4.2% per month) can be deducted from the DHMTs incentive payment for every month that an identified RBF facility in the district does not participate in the Initiative

19 Allocation of Payment BEmONCs: entire Facility team (70%); investment in service improvement/living conditions (30%). CEmONCs: 40% to invest in entire hospital; 60% to maternity ( 70% for maternity staff, 30% to investment in the maternity ). DHMTs 60% for the entire DHMT team 40% for investments and operational costs

20 Verification 6-monthly verification of - reports submitted by the facilities and DHMTs by visiting - all involved facilities and District offices and countercheck with respective records - randomly selected number of women who delivered at the participating facility

21 Strengthening District Health Systems Incentives paid by the RBF Initiative strengthen district health systems: District governance and management through incentivising their performance and aligning DHMT targets with facility targets promoting supportive supervision Logistics through incentivising district teams for improved drug supply to HFs and better equipment maintenance Health Information System at all levels through incentivising improved data collection, reporting and use at HF and district level

22 Strengthening District Health Systems cont' Incentives paid by the RBF Initiative strengthen district health systems: Promoting an enabling environment for health service providers motivation, productivity and responsiveness to clients and working as a team Improved referral system (contribution of cash transfer)

23 2) Supporting pregnant women to reach HF in time through Provision of cash for Transport Delivery related costs Coming early enough before delivery Staying long enough after delivery

24 Which women are eligible? Women 15 to 49 years old Pregnant women who register at ante natal care services Women who deliver at participating health facilities Women who stay recommended 24/48 hours after delivery

25 Targeting Process Registration at Health Facility Health Surveillance Assistants verify Health Facility Data Compilation District Health Office Approval and Record Keeping Submission of List to District Health Office

26 Financial Management Each participating health facility will be required to manage the funds provided Each participating health facility will have an operating bank account Signatories will be decided by each health facility The District Council will assign some accounts clerk to work closely with health facilities RBF Initiative will be managing the funds at central level

27 Financial Flow RBF Initiative based on delivery estimates per month transfers funds into the bank account of the health facility Health Facility RBF Initiative Officers are informed of the transactions Health Facility RBF Initiative Officers prepare vouchers and cheques Cheques cashed, copies of the transaction sent to District RBF Initiative Coordinator

28 Financial Flow Chart Health Facility prepares reconciliation and financial requests ready for submission RBF Initiative transfers funds into Heath Facility Funds withdrawn by the Health Facility ready for payment Health Facility RBF Initiative Officers informed Health Facility RBF Initiative Officers prepare cheques

29 Cash Transfers Cost compensation for transport, food and buying delivery related items like plastic sheets, chitenje Distance Band (KM) Transport (MK) Delivery Related (MK) Postnatal Upkeep (MK) ,800 1,500 ( 750 every 24 hours) > ,800 1,500 ( 750 every 24 hours) > ,800 1,500 ( 750 every 24 hours) > ,800 1,500 ( 750 every 24 hours) >20 1,500 1,800 1,500 ( 750 every 24 hours)

30 Monitor, Review, Revise, Document Rewarded indicators Processes of demand and supply side component Environmental factors influencing project progress and changes Factors influencing maternal mortality Possible unintended consequences

31 Operational research and evaluation Operational Research: Workload assessment Barriers for assessing services and patient streams External evaluation by University of Heidelberg Germany, College of Medicine Malawi, Harvard University USA, Bergen University Norway Impact of RBF on quality Information available for the initiative Reaching the poor Client satisfaction Community awareness

32 Lessons learnt so far Availability of critical inputs have to be assured and up front improvements financed Complexity of the approach requires substantial time and resources for design and preparation - shortening time for implementation No one fits all design- must be flexible to adjust to local circumstances Improved quality is essential but finding verifiable indicators for rewarding quality a difficult task It takes time for health workers to understand and adopt the RBF concepts requiring intensive supervision & support

33 Lessons learnt so far cont Building district level support into the design is crucial to enable continuous support Embedding the approach in government systems can bring early gains and enhances ownership Involvement of all levels of government in all steps of the design is time consuming but initiates already a change of mind set and action for change

34 Timeline RBF4MNH Preparation Phase 10/ /2013 Performance Agreements signed 1/04/2013 Facility Rehabilitation and supply-side component Cash transfer begins 07/2013 Second incentive payments to facilities 04/2014 First incentive payments to facilities 10/2013

35 Rehabilitation of Nkwhazi BEmONC

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