Eléments essentielles et complémentaires du design du modèle: PBF Centre de Santé Séminaire...
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Eléments essentielles et complémentaires du
design du modèle: PBF Centre de Santé
Séminaire Régional sur le Financement Base Sur La Performance dans le
Secteur de la Santé
Bujumbura, Burundi, 3 au 6 Fév. 2010
György Fritsche/HDNHE-BM
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Messages clés PBF(cartoon de le New Yorker, Janv. 2010)
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PBF type ‘paiement a l’acte’ par l'intermédiaire du secteur de la santé publique dans les pays à faible revenu
Plus de 8 années d’expérience accumulée sur les meilleures pratiques des dessins des modèles PBF en Afrique subsaharienne (Rwanda, Burundi, RDC, RCA et Cameroun);
Paiement a l’acte (pour les services preventives) avec un impact de la Qualité c’est le ‘state-of-the-art’
‘Public’ meaning all health facilities, either ‘government-managed or managed by a non-governmental agency. In quite a few PBF schemes private for profit facilities are sub-contracted by primary recipients for certain services, for instance curative care, or family planning services
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Fee-For-Service Results-Based Financing (FFS-RBF)/Performance-Based Financing (PBF) through the public health sector in low-income countries
Essential Design Elements: these elements are considered crucial for a national PBF system, managed by the government, through internal contracting arrangements
Complementary Design Elements: these elements are considered complementary to a national PBF system. They are judged as having potential to augment the impact of PBF on health services delivered.
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Conceptual Framework: Essential Design Elements at three levels
1. Health Center level
2. District Level
3. Central Level
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Health Center Level; Essential (i) Performance Framework Targeting Health Facilities
(as opposed to individual health workers); Significant financial incentives reaching frontline
health workers (transparent rules/process); Health Center Bank account Regular bonus payments for health workers,
preferably monthly, but at least once per quarter Autonomy (management and
administrative/financial autonomy) to manage resources and to make decisions)
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Health Center Level; Essential (ii)
Health Management Committee (includes community representatives and health center with overall management oversight, 4-5 persons). Purpose: transparent use of performance funds and other decision-making
Purchase contract/agreement (between the Health Management Committee and a higher level authority, e.g. decentralized government). Purpose: this defines the rules of the game/responsibilities of the PBF system
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Health Center Level; Essential (iii)
Services that are purchased need to be ‘PBF-SMART’
Conduct Routine Data Quality Audit Purpose: to ensure the consistency and accuracy of reporting of services delivered –monthly
Conduct Routine Household Visits Purpose: to validate that services were actually delivered and get feedback on services delivered (community client surveys)
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Health Center Level; Essential (iv)
Conduct Routine Quality Checks Comprehensive Quantitative Checklist. Purpose: objectively verify conditions to provide quality care and or quality of actual care provided, with strong impact on performance payments
Regular Audit of the quality measure
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HC Level; Complementary (i)
Try to diversify sources of revenue for the health center (don’t only depend on PBF). E.g. for introducing risk pooling mechanisms such as CBHI, one needs a price signal;
Decentralized Funding for Government Staff paid into health facility bank accounts;
Once per quarter facility performance payment can be converted in monthly bonus installments
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HC Level; Complementary (ii)
Transparent rules can be emphasized through so-called ‘motivation contracts/agreement’; (contracts/agreements between health facilities and the individual health workers);
‘Business plan approach’; Using grassroots organizations in carrying out these
community client surveys
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District level: Essential (i) Significant financial incentives through performance
framework for District Health Management Teams and District Hospitals. Purpose: performance frameworks targeting the support tasks of these institutions
Separation of Functions: (i) creation of a quasi-market through internal contracts (sufficient separation between purchaser, provider and controller); (ii) transparent district level PBF governance mechanism and (iii) as much as possible separate ‘quantity audit’ from ‘quality supervisory function’ (separate teams). Purpose: to lessen conflict of interest situation
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District level: Essential (ii) Intense dedicated TA during introduction and subsequently
making operational and refining PBF system; District level PBF steering committee. Formalized through a
contract/agreement with higher level authorities. Partaking District Director of Health (chair typically), Hospital Director, representatives from Public and Faith-based Organization Health Centers, district aids commission, PBF NGOs etc. Purpose: overall governance of PBF in all its aspects of performance improvements at the district level, including approval of performance invoices (i.e. governing board for PBF at the district level).
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District level: Essential (iii) Civil Society/NGOs: (i) participation in data verification and
(ii) participation in district level PBF steering committee (NGO is part of a quorum)
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District level: Complementary (i) Decentralized management of PBF budgets; Performance framework for decentralized governance of PBF
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Central level: Essential (i) PBF included in national policy and strategy
documents; Dedicated Project Implementation Unit/MOH
department; Dedicated additional TA for program; coordination of
technical assistance; communication; MIS; training and IT support
Leveraging TA with in-country available resources; Strong national technical coordination platform
dedicated to PBF (degrees of freedom; secretariat)
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Central level: Essential (ii) Strong technical coordination platform dedicated to
providing TA on PBF to districts (‘bridging the gap between policy and implementation’);
Ministry of Finance line-item for ‘PBF payments’; MOF: ensure PBF budget is available/protected to
pay performance; Sufficient budget for PBF: estimated ‘output-only
budget’ at about $3/capita/year (70% HC and 30% DH);
Sustainability for PBF funding: donor coordination;
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Central level: Essential (iii) Decision on ‘kick starting’ the payment cycle (4-5 months lag
of first payment as it is output-based); Administrative system able to capture and feedback data
efficiently and effectively (web-based solution advisable); Drugs and medical supplies: ensure access to sufficient supply
at a reasonable quality and price through any mechanism or combination of mechanisms;
Rigorous evaluations (formal third party and formative multi-donor mission type);
Performance payments directly from central to health facility bank accounts;
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Quarterly district invoices
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Central level: Complementary (i) Demand side interventions: conditional cash or in-kind
transfer programs; Significant financial incentives through performance
frameworks for central MOH departments; Issues of Equity and rural hardship compensation frameworks
(analysis of financial inflows per capita per province/district/health facility, and build compensatory mechanisms through PBF payments; but this is hard);
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