National Community Health Performance-based Financing: design and implementation of supply-side model

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1 National Community Health Performance-based Financing: design and implementation of supply-side model PBF workshop Bujumbura February 16 th, 2011 Ludwig De Naeyer (MSH)

2 Rwanda CPBF Interventions Second generation of PBF to address remaining barriers for achieving improved MCH outcomes and TB outcomes Choice and unit fee based on national priorities and expected quantities mainly for preventive activities CHW cooperatives receive incentives payment for: Timely submission of quality SIScom reports Offer for 5 MCH-indicators and 2 TBindicators

3 Quantity Indicators (selection of SIScom) Unit fee in dollar Applied unit fee in RWF Indicator 1. Nutrition Monitoring: Number of children monitored for nutritional status (6-59 mois) $ 3.24/12 RWF ANC : Number of women accompanied/referred to HC for prenatal care within first 4 months of pregnancy $ 2.24 RWF 10,000 3.Deliveries: Number of women accompanied/referred to HC for assisted deliveries $ 2.73 RWF 13,000 4.FP: Number new Family Planing users referred by CHWs for modern family planning methods $ 2.90 RWF 4,000 5.FP: Number of regular users using long term methods (IUD, Norplant, Surgical/NSV contraception) $ 2.11 RWF 1,000 6.Nb of TB suspects examined referred by CHW $ 45 RWF 26,550 7.Nb of TB patients followed by CHW per month $ 51/6 RWF 5,000

4 Cooperative performance and Reporting (quality aspect)

5 Cooperative Income 2009 (data WB/SPH) 2009 Income Amount in RWF Donor Central Govt Other Income Generating Activities Mutuelle Drugs User Fees Local Govt RWF 394,034 RWF 355,906 RWF 195,650 RWF 103,142 RWF 52,548 RWF 51,852 RWF 24,715 RWF 12,458

6 2010 CHW Cooperative Data 2009 Annual Expenses Investment Other Outreach activities Salary Per diems Building Maintanence Equipment Purchase RWF 37,828 RWF 34,331 RWF 30,925 RWF 28,806 RWF 18,533 RWF 13,310 RWF 214,105 6

7 Cooperative functioning (data WB/SPH) 47% of cooperatives and 38% of CHW charge patient fees CHW COOPERATIVE Preventive Care Consultation RWF 84 RWF 157 Copayment RWF 78 RWF 111 Drugs RWF 139 RWF 197 Curative Consultation RWF 72 RWF 123 Copayment RWF 92 RWF 107 Drugs RWF 171 RWF 185

8 2010 CHW Cooperative Data Main Difficulties in Delivering Community Health Lack of equipment Inadequate salary Lack of training Lack of supplies Lack of coordination with Cell SC Lack of communication with HF Lack of supervision Lack of community support Lack of coordination with HF 31.77% 27.60% 17.80% 17.18% 15.54% 51.56% 73.82% 84.45% 83.50% 8

9

10 Data validation and control Payment per unit reported so possibility of gaming Still mainly paper based Done by HC supervisor monthly External audits planned but not performed yet

11 PBF-Payment for cooperative Quarterly via HC-account After validation of the data by sector steering committee (members are HC-head, the supervisor of the CHWs at the HC, the in charge of social affairs and a member of the civil society) Two parts: Maximum amount for reporting depends on the target population of the cooperative. This is adjusted by the quality score. Productivity (i.e. offer services) = unit fee * Quantity First payment made for October November 2010: average of 3700 $ for indicator and 900 $ for report Cooperatives use earnings for income generating activities and for dividend for CHWs.

12 Cooperatives Reporting: 97% for 2010 to date out of 427 HC and Dispensaries

13 Cooperative performance reports Started during the last quarter 2010 (n=261) Average quality score: 82% Contrat signe entre le Comite de Pilotage du secteur et Coopérative d'asc disponible 4.3 Coopérative d'asc a obtenu l'autorisation du district 4.2 Coopérative d'asc a un stock minimum de 2 mois pour le rapportage mensuel des indicateurs (rapport SIS Com) 4.9 Coopérative d'asc a un livre de caisse avec au moins la preuve de 3 transactions pour le trimestre passe 4.3 Réunion des membres de la Coopérative tenu ce trimestre et compte rendu disponible 4.7 Président de la Coopérative d'asc élu 4.8 Coopérative d'asc a obtenu le statu légal 1.4 L'information complète du compte bancaire de Coopérative d'asc disponible: # du compte, nom de la banque, nom(s) du compte 4.9 Coopérative d'asc a un plan d'affaires (couvrant la période actuelle) 7.1 Promptitude du Rapport 13.9 Exactitude du Rapport 14.4 Complétude du Rapport 13.3

14 Baseline data for Incentivized Indicators Monthly Average per cooperative for October- Indicator November Nutrition Monitoring: Number of children monitored for nutritional status (6-59 mois) ANC : Number of women accompanied/referred to HC for prenatal care within first 4 months of pregnancy 26 3.Deliveries: Number of women accompanied/referred to HC for assisted deliveries 26 4.FP: Number new Family Planing users referred by CHWs for modern family planning methods 39 5.FP: Number of regular users using long term methods (IUD, Norplant, Surgical/NSV contraception) HMIS data 6.Nb of (TRUE) TB suspects examined referred by CHW Nl. HMIS data/ SIS: 4 7.Nb of TB patients followed by CHW (total fee) 4

15 Lessons learnt / challenges PBF incentives ensured rapid increase in SISCom reporting In the presence of a strong monitoring system PBF can be introduced for cooperatives to stimulate and reward activities of CHWs at community level. Quarterly payments are feasible and will hopefully lead to an increase of MCH and TB-activities. The results of this intervention will be assessed by an independent unit through an Impact Evaluation study. Data quality supervision and external audits still need to be introduced to verify data quality

16 2010 CHW Cooperative Data In the past 12 months, how many times was performance assessed? Members (internal): 3.97 Members (external): 1.18 Cooperative (external): 0.52 No 73% Is Member Compensation Linked to Performance Assessment? Yes 27% 16

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