Federal Ministry of Health
[Name] State Ministry of Health
National Primary Health Care Development Agency
[Name] State Primary Health Care Development Agencies
Nigeria State Health Investment Project (NSHIP)
Performance-Based Financing User Manual
Draft 13 April 2012
[Address FMOH/NPHCDA]
NSHIP Performance-Based Financing User Manual
TABLE OF CONTENTS
TABLE OF FIGURES .................................................................................................................... 4
TABLE OF TABLES ..................................................................................................................... 4
ACRONYMS .................................................................................................................................. 6
FOREWORD .................................................................................................................................. 8
BACKGROUND ............................................................................................................................ 9
NSHIP- PBF APPROACH ........................................................................................................... 10
DEFINITIONS .............................................................................................................................. 12
INDICATORS AND VALUES .................................................................................................... 17
The Health Service Packages: MPA and CPA .......................................................................... 17
Fee setting for the services: Determining the Subsidies ........................................................... 18
Service Protocol Reference Guide ............................................................................................ 20
The Quality Checklists for Health Facilities ............................................................................. 20
The Performance Framework for the Local Government PHC Department ............................ 22
Subsidized Care for the Indigents ............................................................................................. 23
CONTRACTS ............................................................................................................................... 25
Contract 1: Multilateral Contract for the LGA RBF Steering Committee ................................ 26
Contract 2: Purchase Contract between the SPHCDA and the Health Provider ..................... 27
Contract 3: Motivation Contract between the Health Center Management and the Individual
Health Worker ........................................................................................................................... 27
Contract 4: Contract between the SPHCDA and the LGA PHC Department .......................... 29
Contract 5: Sub-Contract between the Health Provider and a Secondary Health Provider .... 29
PERFORMANCE MANAGEMENT AT THE HEALTH FACILITY ........................................ 30
Business Plan ............................................................................................................................ 30
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Indice Tool................................................................................................................................. 30
Framework for Individual Performance Evaluation................................................................. 31
MONITORING AND EVALUATION ........................................................................................ 32
DATABASE ................................................................................................................................. 33
PAYMENT CYCLE ..................................................................................................................... 36
Rules of Use of the PBF Income................................................................................................ 37
Invoices...................................................................................................................................... 37
CAPACITY BUILDING .............................................................................................................. 37
COORDINATION ........................................................................................................................ 38
ANNEXES .................................................................................................................................... 39
Annex 1: Multilateral Contract for the LGA RBF Steering Committee .................................... 39
Annex 2: Purchase Contract between the SPHCDA and the Health Provider ......................... 49
Annex 3: Motivation Contract between the Health Center Management and the Individual
Health Worker ........................................................................................................................... 60
Annex 4: Contract between the SPHCDA and the LGA PHC Department .............................. 64
Annex 5: Sub-Contract between the Health Provider and a Secondary Health Provider ........ 69
Annex 6: MPA and CPA ............................................................................................................ 71
Annex 7: Service Protocol Reference Guides ........................................................................... 73
Minimum Package of Activities ............................................................................................ 73
Complementary Package of Activities .................................................................................. 78
Annex 8: Quarterly Quality Supervisory Checklist for Health Centers .................................... 83
Annex 9: Quarterly Quality Supervisory Checklist for General Hospitals ............................. 102
Annex 10: Monthly Health Facility Invoice ............................................................................ 123
HEALTH CENTER ............................................................................................................. 123
GENERAL HOSPITAL ...................................................................................................... 125
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Annex 11: Quarterly Consolidated LGA Invoice .................................................................... 127
Annex 12: Performance Framework for the LGA PHC department ....................................... 129
Annex 13: Business Plan for Health Centers .......................................................................... 133
Annex 14: Indice Tool for Health Centers .............................................................................. 145
Annex 15: Individual Performance Evaluation Template ....................................................... 149
Annex 16: Column Headers for PBF Registers ...................................................................... 154
Annex 17: Terms of Reference for the Health Center Health Committee/General Hospital
Governing Board ..................................................................................................................... 155
Health Center: ...................................................................................................................... 155
General Hospital: ................................................................................................................. 157
Annex 18: Terms of Reference for the Indigent Committee .................................................... 159
Annex 19: Indicative Indice Values for Health Center Staff ................................................... 162
TABLE OF FIGURES
Figure 1: The Nigeria PBF Administrative Approach .................................................................. 12
Figure 2: Purchaser-Provider Split in the NSHIP-PBF Approach ................................................ 16
Figure 3: Image of the IT Solution for the PBF Admin System ................................................... 34
TABLE OF TABLES
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Table 1: An example of the application of a rural hardship weighting ........................................ 19
Table 2: Weighting for the 15 Health Center Services in the Quality Checklist .......................... 21
Table 3: Weighting for the 15 General Hospital Services in the Quality Checklist ..................... 22
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ACRONYMS
AIDS
CPA
DFF
DLI
DOTS
DPM
DRF
EDL
EDM
FMOH
HCWM
HMIS
HIV
HRITF
MDG
M&E
MySQL
NAFDAC
NSHIP
MPA
NPHCDA
IC
LGA
PBF
PFMU
PIM
PBF-TSU
PCN
PHC
PHP
PTB
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Acquired Immunodeficiency Syndrome
Complementary Package of Activities
Decentralized Facility Financing
Disbursement Linked Indicator
Directly Observed Therapy for Tuberculosis
Director of Personnel Management
Drug Revolving Fund
Essential Drug List
Essential Drug Management
Federal Ministry of Health
Health Care Waste Management
Health Management Information System
Human Immunodeficiency Virus
Health Results Innovation Trust Fund
Millennium Development Goal
Monitoring and Evaluation
My Structured Query Language
National Agency for Food and Drug Administration and Control
Nigeria State Health Investment Project
Minimum Package of Activities
National Primary Health Care Development Agency
Indigent Committee
Local Government Authority
Performance-Based Financing
Project Finance Management Unit
Project Implementation Manual
PBF Technical Support Unit, unit of the SPHCDA
Pharmaceutical Council of Nigeria
Primary Health Care
Hypertext pre-processor
Pulmonary Tuberculosis
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RBF
SMOH
SPHCDA
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Results-Based Financing
State Ministry of Health
State Primary Health Care Development Agency
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FOREWORD
[Foreword by the Federal Minister of Health/Director NPHCDA]
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BACKGROUND
Performance-Based Financing (PBF) for health services has been introduced in many developing
countries over the past decade: Cambodia, Haiti, Afghanistan, Democratic Republic of Congo,
Rwanda, Burundi, Cameroun, Central African Republic and Indonesia. The approaches in
various contexts differ; but they all aim at increasing the efficiency, effectiveness, quality and
equity of health services offered to the population.
The PBF approach generates interest from Ministries of Health who are looking for ways to
reach the Millennium Development Goals 4, 5 and 6. Reducing child mortality, improving
maternal health and combating HIV/AIDS, malaria and other diseases are high on the agenda.
PBF approaches have been especially successful in improving access to curative services,1 and
increasing the uptake of preventive services such as vaccination in children and pregnant
mothers, voluntary counseling and testing for HIV, institutional deliveries and the use of modern
family planning methods. Whilst increasing the volume of services, PBF also increased
considerably the quality of these services.2
Although PBF approaches differ, they tend to have certain elements in common, they:
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increase managerial autonomy and decision making rights on resources;
use non-governmental agencies for a purchaser role or management support;
introduce a purchaser-provider split;
Enhance monitoring and evaluation.
PBF usually starts with pilot projects after which scaling up to the national level is attempted.
Such has been the case in Rwanda, where successful PBF pilot projects which were started in
2002, convinced the Ministry of Health of their effectiveness, after which PBF was scaled up to
national level during 2006. By the end of 2005, about 40% of the service delivery network was
1
Especially in areas where there were dysfunctional health services, see for instance: SOETERS, R.,
PEERENBOOM, P.-B., MUSHAGALUSA, P. & KIMANUKA, C. (2011) Performance Based Health Financing
Experiment Improves Care in a Failed State. Health Affairs, 30, 1518-1527, or where there are dysfunctional free
health care systems see for instance: MEESSEN, B., SOUCAT, A. & SEKABARAGA, C. (2011) Performancebased financing: just a donor fad or a catalyst towards comprehensive health care reform? Bulletin of the World
Health Organization, 89, 153-156.
2
BASINGA, P., GERTLER, P., BINAGWAHO, A., SOUCAT, A., STURDY, J. & VERMEERSCH, C. (2011)
Effect on maternal and child health services in Rwanda of payment to primary health-care providers for
performance: an impact evaluation. The Lancet, 377, 1421-28.
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covered by PBF pilot programs. Burundi was a similar case: pilot projects were started in 2006,
expanded to cover 40% of the country, and where scaled up nationwide in April 2010.
Conceptually, the Nigeria State PBF approach is a ‘contracting in’ approach. Government, with
technical and financial support from development partners, contracts-in technical assistance to
purchase health services from its own, and faith based health institutions. An internal market is
created in which government purchases services from its own, and private non-for profit and
private for profit health providers.
In this innovative PBF approach, the State Primary Health Care Development Agency
(SPHCDA) is the purchaser of services. The SPHCDA contracts-in a technical agency to carry
out the purchasing function. The State Ministry of Health (SMOH) is the regulator. The Local
Government Primary Health Care Department is contracted to execute the quality supervisory
function. The government through the SMOF/PFMU is the fund holder. This PBF approach
allows multiple fund holders to purchase performance: they can be billed their share and pay
facilities for performance directly.
NSHIP- PBF APPROACH
The Nigerian State Health Investment Project (NSHIP) is a $171M five-year program which will
be implemented in Ondo, Nasarawa and Adamawa States. Of the total amount $20M is a grant
from the Health Results Innovation Trust Fund (HRITF), in addition to a $1M grant for an
impact evaluation. The NSHIP has a 100% Results-Based Financing (RBF) focus.
The various RBF components of this program aim at changing the incentive environment and the
accountability and governance mechanisms at State level, at the Local Government Authority
(LGA) level, and at the health facility level.
A large part of the program concerns the introduction of Performance-Based Financing (PBF) in
the three States. This PBF manual details the institutional arrangements for the PBF system. The
operational details for the larger NSHIP can be accessed through the NSHIP Project
Implementation Manual (PIM). This PBF manual is an integral part of the PIM: it figures as its
annex number 7.
A PBF pre-pilot will be introduced in one select LGA in each State. This will be done before
scaling up in half of the LGAs in each State. The purpose is to build local capacity with PBF and
to adapt PBF to local realities.
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Rather than being a ‘contracting-out’ model (an approach in which non-state actors are
contracted to provide certain services), this hybrid approach is a ‘contracting-in’ approach in
which contracted-in non-state actors and co-opted civil society strengthen Government services.
This PBF approach effectively creates an internal market though which the SPHCDA purchases
health services from public, private and faith based organization-managed health facilities.
Performance-contracts are written throughout the system. Performance frameworks exist for the
Health Facilities, for the community client surveyors, for the Local Government Authority
(LGA) Health Team, and for the SPHCDA PBF-technical support unit.
Figure 1 shows the administrative arrangements for PBF.
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Decentralized transparent governance for PBF is done at the local government level
through a formal steering committee.
There is a purchaser-provider split: the contracting and verification/counter-verification is
done through a specific purchasing unit from the SPHCDA.
Technical assistance, coordinated through a state level extended team mechanism is
systematically provided.
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Figure 1: The Nigeria PBF Administrative Approach
DEFINITIONS
Definition of PBF: Activities and services are purchased through Performance-Based Financing.
The transaction is based on a purchase contract. Both service quantity and service qualities are
rewarded. Services purchased are of a limited number (which typically are 15-24), whilst the
quality consist of hundreds of data elements. The quality measure, through a quantified quality
checklist, or ‘balanced score card’ leads to a single composite quality value.
A working definition of Performance-Based Financing (PBF) was elaborated in 2010 by the
community of practitioners and knowledge institutions in the forefront of PBF development 3:
3
As discussed on the PBF googlegroups forum, a discussion forum of the African PBF Community of Practice, final
consensus working definition as of 17 August 2010.
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“Performance-Based Financing is a health systems approach with an
orientation on results defined as quantity and quality of service outputs.
This approach entails making health facilities autonomous agencies
that work for the benefit of health related goals and their staff. It is also
characterized by multiple performance frameworks for the regulatory
functions, the performance purchasing agency and community
empowerment. Performance-Based Financing applies market forces but
seeks to correct market failures to attain health gains. PBF at the same
time aims at cost-containment and a sustainable mix of revenues from
cost-recovery, government and international contributions. PBF is a
flexible approach that continuously seeks to improve through empirical
research and rigorous impact evaluations which lead to best practices
(see footnote).4”
Definition of Results-Based Financing: Results-Based Financing (RBF) is a term which
encompasses the entire family of incentive approaches, both on the supply-side, and on the
demand-side. PBF is a sub-set of RBF, and is classified as a specific RBF strategy.5
Definition of the Provider: the provider is an institution contracted to supply services. Providers
are health centers and general hospitals, both public and private. Main PBF contract holders are
allowed to sub-contract certain services. Sub-contracted Health providers can be public, private
non-for-profit or private-for-profit. Sub-contracting is a strategy that is negotiated with the
purchaser, through the business plan.
Definition of the Regulator: the regulator is the State Ministry of Health. The SMOH has
multiple levels of regulatory functions related to PBF.
First, the SMOH participates in the design and continuous development of the quantified quality
checklists:
4
PBF draws from micro-economic, systems analysis, public choice and new institutional economics theories. The
effectiveness can be enhanced by demand-side interventions such as equity funds; conditional cash transfer
programs, vouchers schemes and obligatory community based health insurance programs. Definition discussed and
accepted on the African PBF community of practice discussion group, August 2010.
5
Musgrove, P. (2010). Financial and Other Rewards For Good Performance or Results: A Guided Tour of Concepts
and Terms and a Short Glossary. Washington DC.
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
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These quality checklists reflect the priority norms of the SMOH (such as for instance
adherence to the national waste disposal guidelines);
These priority norms are made operational through quality checklists;
The regulatory role is made operational through performance contracting of the LGA
PHC department by the SPHCDA;
The quarterly quality supervisory checklist - applied by the local government health
teams to the PBF health centers - is based on National Health Service deliver norms.
These checklists contribute to a quality bonus of a maximum of 25% on top of the
quarterly quantity bonus earned by the health centers.
Second, the SMOH is closely involved in the peer-evaluations of the general hospitals;

General Hospitals are also subject to a quarterly quality checklist, using a transparent
peer-review mechanism. Here also, a 25% quality bonus is at stake.
Third, the SMOH is part of a tri-partite quorum for the LGA RBF Steering Committee meetings:

Without SMOH presence such steering committee meetings are unable to validate
performance pay for the contracted health facilities.
Fourth, the SMOH participates in the extended team mechanism. This is an implementation
oriented coordination mechanism. More policy and strategy oriented coordination mechanisms
are the State RBF steering committee and the RBF Technical Working Group.

The SMOH, in close collaboration with the SPHCA/PBF-TSU and mobilized partners
drafts policy and strategy related to PBF.
Fifth, the SMOH’s technical collaboration with the State office of the National Agency for Food
and Drug Administration and Control (NAFDAC), the State office of the Pharmaceutical
Council of Nigeria (PCN) and the SPHCDA on drugs and medical consumables:

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

The State NAFDAC and the State PCN will work closely with the SMOH and the
SPHCDA to certify three to four distributors in the State for selling generic drugs to PBF
contracted facilities;
PBF facilities are contractually obliged - guided by availability and best quality/price - to
procure their inputs from one of these certified distributors and to stock generic drugs
only;
compliance is checked through quarterly quality reviews;
Providers paid through public funds will need good guidance on market prices and
relative quality of drugs.
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Definition of the Purchaser: the Purchaser is the SPHCDA. The SPHCDA deploys Verifiers,
about 1 to 2 per local government authority. The SPHCDA roles are:
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performance contracting of health facilities, both public and faith-based organization
managed;
negotiating targets and strategies through the business plans;
contract management and strategic purchasing;
carrying out monthly or bi-monthly verification on the services produced;
once per quarter, the SPHCDA - through select members from grass root organizationscarries out community client surveys to:
a. find out whether the clients have actually received the service (to avoid the
‘phantom patient phenomenon’);
b. to get feedback from clients on their satisfaction and on their perception of the
quality of care;
c. Other information such as for instance how much money the clients paid is also
asked;
Assessing whether the local government health department deliverables have been met.
This makes the SPHCDA a controller for an internal SMOH function (the correct
execution of the regulatory function on behalf of the SMOH);
in consultation with other stakeholders get agreement on the content of the service
packages;
due diligence on validation procedures of the LGA RBF Steering Committees;
printing the quarterly invoice from the web-application and sending to the PFMU and
eventual other fund holders for payment;
Coordination and capacity building for PBF are SPHCDA core functions.
Definition of the Separation of Functions: separation of functions is a core concept of PBF. In
the Nigerian PBF approach it is:



primarily a separation of the purchaser from the provider;
secondly, a separation between the regulator and the purchaser;
Thirdly, there is a separation between the controller and the provider.
An important concept is the purchaser-provider split. The purpose of this split is to avoid or
reduce situations of conflict of interest or collusion. The SPHCDA is a para-statal, with its chief
executive reporting to the Health Commissioner.
A special purchasing unit will be created within the SPHCDA to reinforce this separation of
functions. This Performance-Based Financing Technical Support Unit (PBF-TSU) will be
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staffed by a contracted-in technical assistance agency. The Verifiers will be on the PBF-TSU
pay-roll, including some key technical support staff. Direct line management of this unit including several technical and support functions- will be through SPHCDA staff. The entire unit
will be under a performance framework. This approach has been applied successfully in the
Rwanda and Burundi PBF technical support units.
When products/outputs/performance needs to be assessed, and are linked contractually to money,
having an independent verifier, and credible checks and balances becomes important. See image
below:
Figure 2: Purchaser-Provider Split in the NSHIP-PBF Approach
Definition of the Purchaser-Provider Split: the purchaser-provider split is a concept which
indicates that the purchaser (the SPHCDA) is not providing the services itself. Implicit in this
definition is that the provider is not verifying itself but that the provider is verified by the
purchaser, or by an agent hired by the purchaser.
Description of the role of the Contracts: five contracts are used in the Nigerian PBF approach.
These contracts are described in the section ‘contracts’ and are annexed in full to this manual.
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Contracts are meant to clarify expected performance and to establish the new rules of PBF. It is
vital that all working in the PBF system understand these contracts to a sufficient extent. Clarity
in expected roles, and expected performance and transparency of control procedures and clear
communication of results to all will contribute to lowering the risks, and implementation costs of
PBF.
A strong initial effort in rolling out PBF through well-designed training modules, and continued
strong support to local government RBF steering committees, although costly and timeconsuming, will bear fruit in the mid to long term.
Definition of the Business Plans: business plans in the Nigerian PBF approach are an integral
part of the purchase contract between the SPHCDA and the health facility. Business plans are
unlike action plans: action plans have a tendency to present overinflated targets which are never
met. Business plans on the contrary are carefully negotiated between the SPHCDA and the
health facility and are tied to the purchase contract. The health facilities have to indicate how
they propose to get from A to B, and what interventions, and physical resources will be used to
reach those targets.
INDICATORS AND VALUES
Performance-Based Financing uses a mix of quantity and quality indicators to define the level of
performance of a health institution. Performance frameworks are also applied to the health
administration but in general are more of the process indicator type.
For PBF facilities the quantity performance is measured monthly or bi-monthly and the quality
performance is measured once per quarter. Each defined service has a unit fee/subsidy and the
quality carries a bonus up to 25% of the earnings.
We will discuss in turn:
1.
2.
3.
4.
5.
The health service packages;
Fee setting for the services;
The quality checklists for the health facilities;
The performance framework for the LGA health department;
Subsidized care for the indigents.
The Health Service Packages: MPA and CPA
The PBF health service packages are carefully designed to respond to health problems facing the
Nigerian population. They are based on 12 years of incremental experience gained on purchasing
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indicators/services through PBF. The services chosen have the highest potential to contribute to
meeting the health related Millennium Development Goals. There are two types of health service
packages:
1. Minimum Package of Activities (MPA): for the health center and community level,
2. Complementary Package of Activities (CPA): for the first level referral hospital.
The MPA and CPA are listed in annex 6. Each defined service carries a variable unit fee/subsidy.
Fee setting for the services: Determining the Subsidies
The fees were modeled using a financial risk forecasting method commonly used in PBF
projects.6 Baseline data were drawn from the 2008 Demographic and Health Survey. As the three
States have radically different baselines for the same services, the financial risk forecasting came
up with a different set of average fees for each of the three States.
It is important to note the difference between a PBF fee, and a traditional fee-for-service provider
payment mechanism. In PBF systems it is assumed that the costs for the services are already met
(human resources; building; equipment and various recurrent expenses for vertical programs).
However, these services do ‘not move’; there is low output and a general lack of coverage for
important public health services. Therefore in PBF we talk about ‘subsidies’.
The PBF ‘fee’ for a ‘new outpatient consultation’ is not meant to pay for the cost of delivering
this consultation. It is a subsidy for this service. Depending on local context, total subsidies for
curative care can be around 20-30% of available PBF budget, the rest are subsidies for
preventive services. The level of these PBF subsidies can change, depending on certain equity
adjustments, local priorities and available budget. These variables are discussed below.
The combined subsidies for all services are modeled at $2 per capita per year for the MPA and
$1 per capita per year for the CPA. Within a State, policy makers can decide to allocate a certain
equity weighting for local governments. Such weighting can be based on for instance:
1. distance in travel time to the State capital;
2. health worker population density;
3. Relative poverty measure. Such measures can thus lead to the allocation of a slightly
higher per capita PBF output budget to certain local governments which are scoring
lower on these measures.
6
SOETERS, R. (2011) PBF in Action: Theory and Instruments, course guide Performance-Based Financing. The
Hague.
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Within a given local government area, the purchaser can allocate an ‘equity weighting’ for
relative destituteness of a facility (‘rural hardship’). Contracted facilities can be categorized in
five categories 1 – 5; with a maximum difference in subsidy levels for individual services of
20%. See figure 3 below: the unit fees are illustrative only. The Cat3 column represents the
average fee for that LGA.
Table 1: An example of the application of a rural hardship weighting
An equity calculator has been developed to assist in this calculation. However, the actual
fee/subsidy setting will be done through the web-enabled application (the ‘cloud computing’ see
the section on the database).
The local government health department will have to assist in categorizing its health facilities in
these five categories. The health facility closest to the LGA administrative center would typically
be a ‘Category 1’ health facility, whilst the health facility with the longest travel time to the
administrative center, the furthest from the main road and some other metrics, would typically
fall in a ‘Category 5’ category. The idea is that if one health facility is categorized as a ‘Category
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5’ (+10% fee), that the health planners will have to find another facility to categorize as a
‘Category 1’ (-10%). Namely: the average fee for the LGA is the Cat3 column.
Higher subsidies for services in the most remote and destitute health facility are a way of
providing that facility with the means to attract and retain qualified staff, and to compensate it
for the higher costs of delivering quality health services in general.
Fees/subsidies can be negotiated quarterly, if need be, depending on level of
achievement/performance, and locally and communally perceived needs and targets; this requires
a process of negotiation between the health facility and the purchaser.
Service Protocol Reference Guide
Service protocol reference guides define further the PBF services and list the primary and
secondary data collection tools. They are meant to be used by the health facility, the local
government health authority and the purchaser.
PBF uses defined primary registers for each service, and also has defined secondary registers.
Primary registers are the ones in which the Verifiers will be ‘counting the services’. Secondary
registers are meant for deeper verifications in case of discrepancies, or when there is a ‘counterverification’ exercise.
Signing a purchase contract obliges the health facility contractually to use these defined primary
and secondary data collection tools, according to their set formats. The formats for the column
headers are listed in annex 16. If the primary and secondary data collection tools are not filled in
completely and legibly, then in that case the service concerned will not be remunerated.
Each PBF service line has, apart from identifying information and medical data, a column for the
mobile phone number. If this column is not filled in- just like any other identifying information the service provider will not get paid for that service. Clients will provide their personal mobile
phone number and in case they do not have such, a number of a neighbor, a family member who
lives close, or the village chief.
In the rare instance in which clients cannot provide a mobile phone number, they will have to
sign next to the mobile phone column header.
The service protocol reference guides can be found in annex 7.
The Quality Checklists for Health Facilities
The quality checklists for health facilities consist of a checklist for the health center, and a
different one for the General hospital. These checklists have been developed from existing
checklists in successful PBF projects, and adapted to the Nigerian context. The purpose of these
checklists is to guide the health facility in delivering services according to prevailing norms. The
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focus of these checklists is predominantly on structural quality, although clinical processes
(rational drug prescribing patterns and adherence to defined treatment protocols) is also
measured and rewarded.
These checklists attempt to be as objectively verifiable as possible. Different people measuring
the same thing ought to lead to the same scores. The health center quality checklist will be
applied by the local government health authority; once per quarter to each contracted facility.
The local government health authority will be under a performance contract to carry out this
important function timely and correctly. The local government authority PHC department
performance framework can be found in annex 12.
There will be a third-party counter-verification mechanism set up for this quality checklist:
through a defined protocol, the scores provided by the local government authority will be
counter-verified. The health center quality checklist can be found in annex 8.
The General hospital will also be subjected to a quality checklist, once per quarter. A peerevaluation mechanism will be set up, whereby key technical and administrative staff from other
hospitals, with representatives from the SMOH, SPHCDA and civil society, will peer-evaluate
each other’s performance. Also, a transparent counter-verification mechanism will be set-up. The
General hospital quality checklist can be found in annex 9.
Quality has various dimensions, and the PBF checklists can only measure some dimensions.
Lessons from other PBF projects point at the importance of regular – typically once per year review of the quality checklists. New norms and guidelines can thus be incorporated as they
come available. Feedback from the end users can inform the design. The quality bar can be put
progressively higher.
Table 2: Weighting for the 15 Health Center Services in the Quality Checklist
No
1
2
3
4
5
6
7
8
9
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MPA Service
General Management
Business Plan
Finance
Indigent Committee
Hygiene
OPD
Family Planning
Laboratory
Inpatient Wards
Points
11
9
10
7
25
34
22
10
10
Weight_%
4.4%
3.6%
4.0%
2.8%
10.0%
13.7%
8.8%
4.0%
4.0%
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10
11
12
13
14
15
Essential Drugs
Management
Tracer Drugs
Maternity
EPI
ANC
HIV/TB
20
30
21
18
12
10
249
8.0%
12.0%
8.4%
7.2%
4.8%
4.0%
100.0%
Table 3: Weighting for the 15 General Hospital Services in the Quality Checklist
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CPA Service
General Management
Business Plan
Finance
Indigent Committee
Hygiene & Med Waste
Disp
OPD
Family Planning
Laboratory
Inpatient Wards
Essential Drugs
Management
Tracer Drugs
Maternity
ANC
HIV/TB
Surgery
Points Weight_%
21
6.3%
13
3.9%
15
4.5%
7
2.1%
28
27
21
10
46
8.4%
8.1%
6.3%
3.0%
13.8%
20
42
21
12
10
40
333
6.0%
12.6%
6.3%
3.6%
3.0%
12.0%
100.0%
The Performance Framework for the Local Government PHC Department
The local Government Health Authority has important functions related to the LGA PBF system.
These functions are: (a) regular supervision of its health facilities; (b) application of the quality
supervisory checklists once per quarter to each of the PBF health centers; (c) a capacity building
role; (d) managing the HMIS; and (e) being the secretariat for the local government RBF steering
committee.
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The local government PHC department is under a performance contract with the SPHCDA for its
PBF supportive role. The SPHCDA Verifier will apply the performance framework, and present
the results in the local government RBF steering committee. The performance framework can be
found in annex 12.
Subsidized Care for the Indigents
The poorest of the poor face real problems accessing care. Free health care or selective free
health care is not an option for Nigeria as available public funding is insufficient to pay for good
quality and accessible basic health services.
However, selective free health care could theoretically be subsidized through the PBF providerpayment mechanism, such as has been done for the Burundian SFHC/PBF mechanism.7
Additional funding would have to be made available by the State to reimburse providers for such
selective free health care.
For improving access to health care by the poorest of the poor PBF will introduce a specific
category called ‘new consultation for an indigent patient’. The poorest of the poor - the
indigents- will be able to access curative and preventive services, without paying at the point of
service.
We will first discuss the Drug Revolving Fund concept, and then the quality checklist. After this
we will explain subsidized care for the indigents through PBF.
A Drug Revolving Fund (DRF) will be introduced together with the PBF intervention.
Rates for the drugs and medical consumables of the DRF are determined by the type of the drug,
the source of the drug and the markup. The new rules for these Drugs are:






They should be generic type;
Figure on the Essential Drug List (EDL);
They should be procured from the 3-4 certified distributors at the State level;
Prescriptions should be used for all drugs and medical consumables, and prescriptions
should be kept in the pharmacy;
Modern pharmacy stock control measures will have to be implemented (‘first in first
out’; use of individual stock control cards, etc);
Retail rates will have to be negotiated between the health facility management, the
Health Facility RBF committee (its oversight committee);
7
Meessen, B., A. Soucat, et al. (2011). "Performance-based financing: just a donor fad or a catalyst towards
comprehensive health care reform?" Bulletin of the World Health Organization 89: 153-156.
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
These negotiated rates will have to figure on the public bulletin board for clients to see.
As a condition of the purchase contract all drugs and medical consumables sold from the health
facility ought to be through this formal DRF. Informal DRFs or prescribing from private
pharmacies will not be permitted. If the PBF facility breaks this rule it stands to get cautioned,
receive a penalty or lose its purchase contract.
The PBF intervention will be working closely with grassroots organizations to conduct client
satisfaction surveys. Mobile phone technology will be used intensively, including testing a
citizen’s reporting through sms functions. The average costs of a prescription will therefore be
known. Quality issues such as stock outs of drugs, or being sent to private pharmacies to buy
drugs, will also be obvious.
The quality checklists will be monitoring, and rewarding rational drug prescribing practices.
The above measures are expected to bring down considerably the average variable cost of a
curative consultation. However, these costs might still be too high for the indigents: the poorest
of the poor.
We will introduce a system of subsidized care for the indigents. This system will be piloted on
a small scale so that we can see if it works. We will introduce a single case-based remuneration
category, called ‘new outpatient consultation for the indigent patient’ (MPA) and ‘new outpatient
consultation by a Doctor of an indigent patient’ (CPA). Basic rules are (see also annex 18):




Up to 20% of the total number of new outpatient visits can be claimed under this
category the following month;
There should be created an ‘indigent committee’, with members drawn from the Facility
RBF committee and involving other community representatives appointed by the RBF
committee (see annex 18 for its terms of reference);
This indigent committee is responsible for verifying the accuracy of the application of the
indigent category, especially related to perceived poverty;
The health facility is encouraged to devise innovative methods to ensure accurate
targeting. Such methods will be evaluated through focus group discussions.
The PBF purchase contracts will make the care for the indigents an integral part of the MPA and
CPA and therefore, just as for each of the individual services, adherence to the rules (such as the
correct application of guidelines and procedures, and correct reporting), are a condition for
continuing the purchase contracts.
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Purchase contracts are written with one select health facility in each LGA, whereas there are
more such health facilities in each LGA, and therefore, there is an element of contestability in
each contract. The PBF contracts are not a right, but are conditional on continued good
performance. The various strategies related to each of the services, including the care for the
indigents, are negotiated in the business plans of each contracted facility.
The financial risk forecasting model is set up to make an informed choice, within a given budget,
a given baseline and hundreds of target assumptions, of the actual fee/subsidy paid for each
category. These fees/subsidies can be renegotiated depending on target achievements or when
certain services are overproduced whereas others are under produced (moral hazard).
PBF uses the principle of cross subsidies; it is assumed that the case-based payment reimburses
providers for the average variable cost of a curative treatment. In case the cost for an individual
surpasses the actual reimbursement it is assumed that the health facility will cross-subsidize the
actual variable costs through its other PBF earnings.
In fact, curative care is the gateway for preventive services: one curative care case, such as an
indigent, can lead to additional earnings for mother and child care services and other incentivized
services. It should be quickly understood by health facility managers that attracting more patients
(through offering good quality curative care and available drugs), leads to an opportunity to earn
more through offering additional preventive services.
Health facility managers in PBF projects frequently decrease the level of user charges in order to
attract clients after which additional income can be gained through preventive care subsidies.
CONTRACTS
Five contracts govern the Nigerian PBF approach. These contracts form the new rules and
regulations of the PBF system. Its linked technical documents (quality checklists; performance
frameworks and technical manuals) are part of these new rules and regulations. These contracts
are:
1. A Multilateral Contract for the LGA RBF Steering Committee
2. A Purchase Contract between the SPHCDA and the Provider (health facility)
3. A Motivation Contract between the Health Center Management and the Individual
Health Worker
4. A Contract between the SPHCDA and the Local Government Health Department
5. A sub-Contract between the primary contract holder and a secondary health provider
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The contracts are described shortly below, and are annexed to this guide for more elaborate
reference.
Contract 1: Multilateral Contract for the LGA RBF Steering Committee
A core institutional aspect of the Nigerian PBF approach is the LGA RBF steering committee. It
contains a formalized set of rules, in the form of a multilateral agreement between the members
of the LGA RBF Steering Committee, and the LGA Chairman.
The following organizations and position holders are members of this steering committee:
1.
2.
3.
4.
5.
6.
7.
8.
The LGA Supervisory Councilor for Health
The Primary Health Care (PHC) Coordinator
The representative of the State Ministry of Health
The Chief Medical Officer of the LGA General Hospital
The representative of Health Facilities
The representative of the SPHCDA
The representative of Non-Governmental Organizations active in the LGA
The Director for Local Government Administration (DLG) where available or Director of
Personnel Management (DPM) or his/her representative
9. The Pharmacy Officer
The quorum is formed by (a) the LGA PHC Coordinator (or his/her deputy); (b) the
representative of the SMOH and (c) the representative of the SPHCDA. If any one of these three
position holders is not present then in that case the RBF steering committee meeting cannot be
held, or when held, is not authorized to make any decisions.
Minutes of the steering committee meeting, together with a signed copy of the consolidated LGA
PBF invoice for MPA and CPA, will need to be submitted to the SPHCDA prior to the 10th of
the fifth month.8 Without these deliverables the SPHCDA and the PFMU cannot process the
performance payments.
The steering committee meets at least once per quarter and underscores the decentralized nature
of PBF management. It is at the LGA level where the local actors know their health system best.
It is here where performance data are submitted for scrutiny and validation and for subsequent
action.
8
Months 1-3 are the performance months; by the end of month four latest the LGA RBF Steering Committee has to
convene. The deliverables (minutes of this meeting; consolidated MPA and CPA performance data) have to arrive in
original hard copy, carrying the appropriate signatures, at the SPHCDA prior to the 10th day of the fifth month.
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The local government RBF steering committee contract is in annex 1.
Contract 2: Purchase Contract between the SPHCDA and the Health Provider
The SPHCDA – who is the PBF purchaser - writes purchase contracts with select health facilities
for the delivery of the MPA and the CPA. These purchase contracts are conditional on reaching
an agreement on the business plan for each facility. See annex 13 for the business plan.
The purchase contracts are written for the duration of 12 months. They are conditional on
continued satisfying performance which is defined as: (a) good performance and (b) continued
good performance and (c) agreement on the strategies as laid out in the business plan.
Purchase contracts can be written with public facilities, with private non-for-profit facilities, with
religious facilities and with private for profit facilities on a basis of non-discrimination. In
principle, one main health facility per ward is contracted. For urban areas, other ratios might
apply.
Sub-contracting of other facilities by the main contract holder is allowed pending agreement on
this strategy in the business plan.
The fees/subsidies agreed in the purchase contract are valid for each 3 month period. They can
be renegotiated by the SPHCDA in case: (a) the production is higher than expected; (b) the
production is lower than expected; and (c) certain services are overproduced whilst others are
under produced.
In case the SPHCDA does not issue a new amendment prior to the last working day of the
quarter, the past quarter’s fees/subsidies are automatically continued for a second 3- month
period.
Purchase contracts are not a right or an entitlement. The purchase contract can be found in annex
2.
Contract 3: Motivation Contract between the Health Center Management and the
Individual Health Worker
The health facility management writes a motivation contract with each health worker in its
facility. These motivation contracts indicate the rights and obligations of each health worker. It
indicates the number of points the health worker is entitled to, when the health worker has
carried out his/her job description and when his/her performance is 100% according to the
individual performance evaluation (see annex 15).
The management decides each quarter, based on the financial position of the health facility and
the budget for the following quarter, which part of the budget will be allocated to ‘performance
bonuses’.
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The budget for the following quarter is structured around procurement of drugs and medical
consumables, maintenance of facilities/equipment and facility/equipment upgrade, payment of
contracted medical staff, payment of sub-contracts, and performance bonuses.
Performance bonuses cannot be more than 50% of PBF earnings of the facility. However, a
lesser percentage can be allocated to performance bonuses if the facility decides to invest in its
facilities first (to earn a higher performance score on the quality for instance, or to invest in
equipment or infrastructure in order to provide more services).
The performance bonus budget is then divided by the total number of points. The total number of
points are the sum total of all points in all motivation contracts. Each health worker is thus
entitled to its number of points * point value for that quarter (these point values can differ,
depending on the health facility performance and the investment decisions taken by the
management) * individual performance assessment %. The performance bonuses are paid once
per month.9
Motivation contracts are primarily meant to assist in the provision of good quality MPA and
CPA services. In case of a mismatch between staff, for instance an overabundance of nonmedical staff, and a shortage of medical staff, the health facility management is free to judge
how much points it should allocate to non-medical staff as compared to medical staff. If for
instance a health facility has 20 sweepers but only five medical staff, then it seems appropriate
that the management considers how many sweepers and other non-medical staff it actually needs
to ensure good hygiene and waste disposal and good patient registration.
An internal health facility committee oversees the allocation of the performance budgets and
ensures that the results of the performance evaluations are applied.
Health workers, who are no longer working at the health facility, are not entitled to performance
payments.
See annex 3 for the motivation contract.
Contract 4: Contract between the SPHCDA and the LGA PHC Department
The SPHCDA writes a performance contract with the local government health department. This
contract is meant to support the PHC department in its vital functions related to the LGA PBF
system.
9
Although the health facility is paid once per quarter, the management is expected to plan for monthly bonus
payments to staff.
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The contract is an output-based contract with a performance framework linked to it. The
SPHCDA Verifier will apply the framework once per quarter and present the findings in the
quarterly LGA RBF Steering Committee meeting.
In the LGAs which are classified as DFF, an adapted contract and framework will be introduced.
The contract can be found in annex 4, and the performance framework can be found in annex 12.
Contract 5: Sub-Contract between the Health Provider and a Secondary Health Provider
The main PBF contract holder can sub-contract other facilities present in its ward, to provide
some MPA services. Such a sub-contracting strategy should be indicated in the business plan and
negotiated with and approved by the SPHCDA. It is assumed that such business plans are also
vetted by the Facility RBF Committee and the local government health department.
Sub-contracted facilities can be public, private non-for-profit, religious and private-for-profit
facilities.
The main contract holder is required to assure (a) adequate supervision; (b) quality norms related
to the sub-contracted services; and (c) to ensure that the primary and secondary data collection
tools are used for these sub-contracted services.
Typical services that can be sub-contracted include (a) curative services; (b) immunization
services; (c) family planning services; (d) growth monitoring services; (e) Insecticide treated bed
nets; and (f) new family using a latrine.
The primary data collection tools ought to be present in the main PBF facility during the
verification by the SPHCDA. The SPHCDA will also conduct community client satisfaction
surveys under the sub-contractors.
The primary contract holder will claim all services from the SPHCDA, merging his own
production with the sub-contracted facility’s production. The primary contract holder is entitled
to a management fee of up to 25% of the sub-contracted PBF earnings.
Other arrangements can include for instance remunerating traditional birth attendants to
accompany women to deliver in the main PBF facility, or community health workers to ensure
DOTS for TB patients. Such arrangements do not need a sub-contract and are typically
managed through a tacit agreement between the PBF facility and the individual community
health workers.
See annex 5 for the sub-contract template.
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PERFORMANCE MANAGEMENT AT THE HEALTH FACILITY
Performance Management is at the core of PBF systems.
There are various levels to performance management. There is: (i) higher level performance
management (strategic purchasing by the SPHCDA); (ii) performance management through
supportive action by the local government health authority, and (iii) guidance through the LGA
RBF Steering Committee.
However, here, we explain shortly the three tools used in the facility level performance
management. These tools are meant as an aid for the health facility management to focus their
problem solving skills on the required quantity and quality performance. The first tool is the
business plan; the second the Indice tool, and the third the framework for individual performance
evaluation.
Business Plan
The business plan is used by the health facility management to explain the various targets and
strategies it has devised to improve coverage of good quality services to its population. Close
collaboration with the Facility’s RBF Committee (drawn from key members of the Ward
Development Committee) is required in its design. A valid business plan is necessary for the
purchase contract to take effect. It is also an integral part of the purchase contract: if the health
facility does not do what it has set out to do, it faces a re-negotiation of its purchase contract. It
might when poor performance continues lose its purchase contract.
The business plan template can be found in annex 13.
Indice Tool
The indice tool is available in two forms; one is an excel spreadsheet for use in the General
hospital, where there is IT equipment available. The other is a paper-based tool meant for use in
health centers.
The purpose of the indice tool is to manage health facility income in a holistic fashion. Cash
income for the health facility is from:





The Drug Revolving Fund (DRF);
Eventual other charges (as determined by the health facility RBF committee);
Income from PBF;
Income from sub-contracting;
Cash subsidies from the Government.
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The health facility will need to manage this income from various sources to pay for its expenses:








Purchase of NAFDAC certified generic drugs and medical consumables from select
certified distributors;
Purchase of equipment;
Rehabilitation of facilities;
Pay contracted health staff;
Pay sub-contractors;
Pay community health workers (on a case by case basis when involved in PBF
strategies);
Pay performance bonuses to staff;
Ensure a reasonable cash buffer.
The paper based indice tool can be found in annex 14.
Framework for Individual Performance Evaluation
Health facility managers will use an individual performance evaluation framework, to distribute
the performance bonus budget whilst managing individual effort. An example of such a
performance evaluation framework is provided in annex 15. Health facilities are invited to
expand this framework according to their local insights.
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MONITORING AND EVALUATION
Monitoring and Evaluation (M&E) permeate PBF approaches. PBF has a ‘super M&E’, in which
data are monitored throughout the system and validated at various levels. Most importantly data
are validated at the source (systematic Data Quality Audit) but also at other levels. In addition
data are used intensively at all levels: at the health center level; LGA level; State level, and at the
Federal level. In all, six levels of control/monitoring can be distinguished in the Nigerian PBF
approach.
Each of these six levels contributes to the reliability of the data and the subsequent performance
payments. PBF systems are extremely thorough in the sense that each Naira paid for a service
can be followed to the patient who received that service.
The first level of control is the purchase contract & its linked business plan. This purchase
contract lays down the rules and regulations that govern PBF and include clauses that deal with
fraud. This contract is written between the health center management & its RBF committee and
the SPHCDA. This first level of control ensures that data submitted in the monthly invoice (see
annex 10) are true. These performance data have been compiled by the one responsible for the
service department and have been signed off by the head of the health facility and also by the
president of the Facility RBF committee. Health facilities already count their performance data
many times prior to claiming them. Quality checklists are extensively utilized by the health
facility management to measure progress on the various quality dimensions and to make clear
what they expect from their staff.
The second level of control consists of the monthly or bimonthly (depending on local
circumstances) quantity control by the SPHCDA. The SPHCDA has a purchasing unit (the PBFTSU), which employs its own Verifiers and has as task to verify health facility productivity.
Verifiers count every single entry in the designated primary registers and sign off on the monthly
invoice. Also, data elements that are the same for PBF and for the national HMIS system are
triangulated during this process, thereby enhancing the reliability of key HMIS data at the
source.
The third level of control consists of community client satisfaction surveys. These community
client satisfaction surveys are organized by the SPHCDA who selects grassroots organizations
and selects and trains suitable surveyors among its members. These surveys are meant to answer
three questions: (a) is the client known in the community; (b) has the client actually received the
service, and (c) what was the opinion of the client on the service received. The community client
satisfaction surveys will also judge the reliability of the post-identification methods for the ‘new
outpatient consultation for an indigent patient’ category.
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The program will also experiment with mHealth (mobile phone technology through the sms
function), to get qualitative feedback by community groups, which will be published on the RBF
website.
The fourth level of control consists of the local government health department carrying out the
quarterly quality supervision using the designated checklist (see annex 8). Once per quarter, 15
service areas are checked in each health center. For the General hospital, a different quality
checklist is used (see annex 9), and applied through a different mechanism. The summary data
for each service are entered in the database. A maximum quality bonus of 25% of the quarterly
earnings can be earned.
The fifth level of control consists of the quarterly LGA RBF Steering Committee meetings. In
these meetings, the monthly invoices are compared with the quarterly consolidated LGA PBF
invoice (see annex 11), printed from the web-enabled database. The reason for comparing these
two sets of invoices is to intercept data entry errors whilst at the same time having local
stakeholders have a close look at the results. Furthermore, the quality score of the health centers
is discussed and also the progress on the business plans. Results from the community client
surveys are discussed and plans are drawn up to provide feedback to the authorities, health
centers, and the communities. Minutes of these proceedings are sent to the SPHCDA, together
with the approved quarterly consolidated LGA PBF invoice.
The sixth level of control consists of the SPHCDA doing ‘due diligence’ on procedures; the
received minutes of the LGA RBF Steering Committee proceedings and the signed and approved
consolidated LGA PBF invoices (for both MPA and CPA). Data are triangulated with data from
the database. If all is found well a payment order is printed from the web-enabled database
signed by the head of the PBF-TSU and his/her supervisor and sent to the PFMU (and eventual
other fund holders). The PFMU will execute the payments to the contracted health facilities and
the LGA PHC departments.
Approved and executed payment orders will be published on the PBF website of the NPHCDA.
DATABASE
A web-enabled application forms the backbone of the Nigerian PBF administrative system. This
time-tested solution has led to the successful scaling up of PBF nationwide in Rwanda and
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Burundi with near 100% data completeness, a high degree of timeliness, a very high level of data
reliability and widely available data which are used at all levels of the health system.10
A website will form the portal to the database. This website will also figure news, events,
documents, information related to actors such as their contacts and websites and so on. The
software used for this IT solution, WordPress, MySQL and PHP, are all open source. The
database will offer preconfigured reports, such as the important consolidated quarterly LGA PBF
invoices, but also interactive graphs and tables.
A health facility table of all contracted Nigerian health facilities will be used, in which figures
information such as their bank accounts. The health facilities will use unique identifiers which
will enable them to be linked to other databases such as the HMIS.11 The health facility table will
also be updatable through the web application, for select administrators. The database can also be
accessed through exporting data in Excel, and analyzing trends using the Excel Pivot or Graph
option. Drawback from this approach is the limited internet connectivity in LGAs.
However, SPHCDA staff which will be responsible for data entry will have fast internet access
in its main and also zonal offices. LGA health staffs can use either internet cafes, or mobile 3G
or 4G networks where available to access the web-enabled database. LGA staff will be provided
guest accounts which will enable viewing all data without ability to change the underlying
performance data.
Figure 3: Image of the IT Solution for the PBF Admin System
[Provide Image]
10
Similar systems have been designed for Zambia, and are in preparation for Chad, and DRC.
11
A DHMIS web-enabled platform is planned for Nigeria. Performance data can thus be linked ‘in the cloud’.
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The database will have administrator, author, and editor and guest accounts. The SPHCDA will
have various ‘author’ accounts for its Verifiers attached to each LGA (1-2 per LGA). These
authors can only enter and modify data for their own LGA; however they can look at data from
the entire State (including comparative graphs) and also from other States.
There will be select ‘editor’ accounts for technical assistants from developing partners providing
TA to the national PBF system and for certain core SPHCDA/PBF-TSU staff. These editor
accounts allow for a larger range of editorial functions.
A few select users will have ‘administrator’ accounts which confer the highest level of user
account in which users can be added or modified, including their passwords. The administrators
also have access to a log in which mutations in the database are recorded.
Finally, ‘guest’ accounts allow for access to the database to view and eventually download data
and to print reports without the ability to make changes.
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PAYMENT CYCLE
The payment cycle will be once per quarter. The following steps can be distinguished:
(1) monthly health facility invoices are controlled and signed off by the verifier and brought to
the SPHCDA where the data will be entered in the web-enabled application;12
(2) The last such monthly invoices will arrive at the SPHCDA during month four prior to the end
of week three (month one to three representing the quarter). The quarterly quality checklists
are finalized for the health centers and the information will reach the SPHCDA latest by the
end of the third week of month four;
(3) Data entry through the web-application and printing of the provisory quarterly consolidated
LGA PBF invoice (one for the MPA; one for the CPA for each LGA);
(4) The quarterly LGA RBF Steering Committee meeting is held in which the quarterly
consolidated LGA PBF invoice is approved (or amended if necessary). During this process
the original monthly invoices are compared with the quarterly consolidated LGA PBF
invoice which has been printed from the database. After approval, the approved invoice
together with the LGA RBF Steering Committee meeting minutes are sent as original
hardcopies to the SPHCDA for which the LGA will receive a written proof. All required
documents ought to reach the SPHCDA/PBF-TSU latest the 10th of the fifth month (months
one to three being the quarter under consideration);
(5) The SPHCDA has seven days to do its due diligence after which it produces a payment order
(the payment order is generated through the web-application). The payment order is signed
by the head of the PBF-TSU, by the SPHCDA supervisor of the PBF-TSU and sent to the
PFMU;
(6) The PFMU will process the payments within 14 days (i.e. before the end of the fifth month)
and transfer the performance payments to the health facility bank accounts;
(7) The payment orders will be published on the NPHCDA- PBF website.
12
Or for that matter entered through any functioning internet connection, which could be an internet café, or the
personal 3G/4G mobile internet connection of the Verifier.
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Rules of Use of the PBF Income
PBF earnings are supposed to be used in a holistic manner taking into consideration all cashincome of the PBF facility from all combined sources. As a rule of thumb: a maximum of 50%
can be allocated to staff performance bonuses from the PBF earnings.
Invoices
See annex 10 for a sample of the monthly Health Facility Invoice, and annex 11 for a sample of
the quarterly consolidated LGA PBF invoice.
CAPACITY BUILDING
Capacity building and system strengthening are vital to a successful PBF program. Health
Facilities need to be equipped with basic equipment and rehabilitated to a reasonable extent to
level the playing field for service provision and to offer quality health services equitably.
This will partially be achieved by introducing the business plan concept linked to retroactive
financing. This will enable health facilities to upgrade themselves.
A PBF training program will be devised. The institutional framework of the Nigerian PBF
approach will be explained ending with the contract signing ceremonies. All actors at Federal,
State, LGA, and health facility level will need to be trained. This is a major effort which will
need excellent coordination between the FMOH, NPHCDA, SMOH, SPHCDA and development
partners and operational and financial support from all to make this a reality.
The level of effort required is much larger than any one single agency could undertake
(administration; operations support and so on), therefore, such trainings will need to be
decentralized to the different agencies that have operational capacity to do so. The PBFTSU/SPHCDA will form the core of this coordination effort through its extended team
mechanism.
The following State level training strategy is proposed:
1. Employ a qualified international level master trainer;
2. Select a team of trainers from various agencies (SMOH, SPHCDA and development
partners), a team of about 20- 30 per State would be necessary (cost born by partners for
their staff);
3. Train the trainers in modern andragogic methods and approaches;
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4. Create the training modules for the various target groups, with the trainers, create a
manual for trainers;
5. Train (the first training can be a try-out, then the trainings can be simultaneous and in
parallel);
6. Follow up.
Creating a technical team, which collaborates horizontally to achieve the same mission (the
implementation of the Nigerian PBF approach), tied to the SPHCDA/PBF-TSU (whose members
are also part of this larger technical team) is deemed necessary. This is the so-called ‘extended
team approach’.
A window of opportunity opens by assembling a team of dedicated State level PBF trainers from
various agencies. This extended team can also become part of the State technical resource pool
which can and should be mobilized to offer technical support to the LGA RBF Steering
Committees (where required) and the health facilities, to make PBF a reality (see below under
‘coordination’).
COORDINATION
Coordination is of utmost importance for the successful introduction of the Nigerian PBF
approach. Organizing technical assistants from all concerned State agencies and development
partners engaged in the State PBF roll-out is most essential to a successful implementation. Such
a team can be organized through the PBF-TSU/SPHCD, and will contribute to a successful topdown policy implementation.
The State RBF steering committee and Technical Working Group are the governing organs of
PBF at the State level and double as an important forum for coordination and policy guidance
related to PBF.
The web-enabled application and the website will contribute to making information accessible
for all.
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ANNEXES
Annex 1: Multilateral Contract for the LGA RBF Steering Committee
(…) State Ministry of Health
(…) State Primary Health Care Development Agency
AGREEMENT ON THE FUNCTIONS OF THE LOCAL GOVERNMENT RESULTS
BASED FINANCING STEERING COMMITTEE
THIS AGREEMENT is dated [……………] 201X
BETWEEN:
[Name], the LGA Chairman, representing [Name] LGA
Dr. /Mrs. /Mr. ________________________________________________
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And
The Members of the _________________ Local Government Authority Results-Based
Financing (RBF) Steering Committee
10. The LGA Supervisory Councilor for Health
11. The Primary Health Care (PHC) Coordinator
12. The representative of the State Ministry of Health
13. The Chief Medical Officer of the LGA General Hospital
14. The representative of Health Facilities
15. The representative of the SPHCDA
16. The representative of Non-Governmental Organizations active in the LGA
17. The Director for Local Government Administration (DLG) where available or Director of
Personnel Management (DPM) or his/her representative
18. The Pharmacy Officer
IT IS AGREED as follows:
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1. Purpose of the Agreement
1.1
1.2
The present Agreement aims at establishing the institutional framework and rules that
govern the implementation of the Performance Based Financing (PBF) program at Local
Government Level.
The Performance Based Financing strategy emanates from National Public Health policy.
The Performance Based Financing User Manual (as published by FMOH/NPHCDA)
serves as the principal reference document for all mechanisms agreed to herein and shall
be referred to for further details and interpretation.
2. State Level Management of PBF : a Joint Responsibility of Key Stakeholders
2.1
2.2
The Statewide regulation of PBF shall be under the authorities of the State Ministry of
Health (SMOH) and the State Primary Health Care Development Agency, in close
collaboration with development partners and international agencies.
The SMOH will set up a State RBF Steering Committee that will review the
implementation of PBF at state level, and provide general policy direction. The general
objectives of the PBF program will be informed through collaboration with concerned
Federal and International Institutions. The SPHCDA will provide the secretariat for this
State level RBF Steering Committee.
3. State Level Management of PBF: The State Primary Health Care Development Agency
(SPHCDA)
3.1
The day-to-day management of the PBF program shall be carried out by the SPHCDA.
The SPHCDA shall be responsible for the following:
(a) Facilitate the integration of other Statewide or LGA-wide health programs with PBF;
(b) Purchase the minimum package of activities (MPA), and complementary package of
activities (CPA) through direct purchase contracts with select public, faith-based
institution, or non-for profit Health Facilities (one principal contracted health facility per
ward; based on the principle of non-discrimination and best performance);
(c) In collaboration with the local government health department, negotiate the business plan
contents with the PBF facilities;
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(d) In collaboration with the local government health department, classify all contracted
facilities in ‘Categories 1 to 5’ depending on the perceived rural hardship grading of these
facilities (the health center closest to the LGA administrative centre will typically be
categorized as a ‘Category 1’);
(e) Do strategic purchasing of the MPA and CPA services. Define the subsidies for MPA and
CPA services based on (i) results obtained; (ii) observed moral hazard and (iii) within the
boundaries of a given PBF output budget;
(f) Contract the local government health department for the quarterly quality supervision of
the health centers;
(g) Verify the monthly quantity production of the MPA and CPA services;
(h) Verify the quarterly performance grid of the local government health authority;
(i) Enter the MPA, CPA and quality checklist data in the PBF web-enabled database and
produce the consolidated quarterly LGA PBF invoice for discussion in the LGA RBF
Steering Committee;
(j) Organize community client satisfaction surveys through local grassroots organizations
using a defined protocol;
(k) Perform due diligence on all quarterly LGA RBF Steering Committee deliverables
(minutes of meetings; approved consolidated performance invoices), and facilitate the
payment for performance without ado by the with the SMOH Project Finance
Management Unit (PFMU);
(l) Execute any contractual sanctions imposed by the PBF purchase contracts in case of non
compliance or irregularities on the health facilities.
3.2
The SPHCDA may delegate some of these responsibilities through a written agreement
with a local government entity such as the Primary Health Care unit or to an external
third party organization active at local government level.
4. Local government level management of PBF: The LGA RBF Steering Committee
4.1
4.2
The present agreement establishes a Local Government Results- Based Financing
Steering Committee with the signatories as its members.
The LGA RBF Steering Committee shall ensure coordination of the PBF program and
ensure that the applicable monitoring, control and sanction mechanisms are implemented
within the geographical of jurisdiction of the LGA. The LGA RBF Steering Committee
shall also be entrusted with devising local strategies to improve access and quality of care
at the LGA health facilities.
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5. Members of the PBF LGA Steering Committee
5.1
5.2
5.3
The Steering Committee is chaired by the LGA Supervisory Councilor for Health of the
LGA, or his or her designated deputy.
Other members of the steering committee are the following: (a) the Primary Health Care
(PHC) Coordinator; (c) the Representative of the State Ministry of Health ; (d) the Chief
Medical Officer of the General Hospital, or his deputy; (e) one elected representative of
the contracted health facilities; (f) The representative of the SPHCDA; (g) The
representative of Non-Governmental Organizations active in the LGA (h) The Human
Resources Management Officer; (i) The Pharmacy Officer
The Steering Committee chairman may propose additional members by written request to
the SPHCDA. Any additional members should be chosen for their active involvement in
public health in the LGA and its communities. Non response or non-objection from the
SPHCDA to a proposal from the Steering Committee chairman to add to the above listed
members, within a month of the receipt of the request, shall be considered as a tacit
approval.
6. Functioning of the LGA RBF Steering Committee
6.1
6.2
6.3
6.4
The Steering Committee shall meet at least once every quarter upon invitation to its
members by the Committee chairperson. The Steering Committee shall validly meet and
take resolutions if the minimum tripartite quorum of LGA leadership and representative
from SMOH and representative of the SPHCDA are present. If any or all of these three
parties are absent, the steering committee meeting will be invalid and any decisions or
approvals taken in this meeting, notably: the approval of the monthly and quarterly
performance figures will be invalid. The PHC coordinator shall act as the committee’s
secretary.
The chairman shall invite participants with at least 14 days notice, and will ensure that
the next quarter’s meeting will be planned during a current meeting.
The quarterly RBF Steering Committee meetings shall be held in the last week of the
fourth month.
The minutes of the RBF Steering Committee meeting, signed by the chairman, and the
consolidated quarterly LGA invoice, shall be sent in hardcopy to the SPHCDA. These
deliverables ought to be received by the SPHCDA before the 10th of the fifth month.
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6.5
6.6
The minutes of the meeting should conform to the norms related to Agenda content and
reporting format (see PBF user manual).
The Committee meetings shall have on their agenda at least the following areas of
discussion:
(a) PBF strategy: To present and discuss the data and information related to the PBF health
facilities including activity level, quality of care level and other relevant information; to
review the different strategies in place for the improvement of results and follow-up on
previous decisions of the committee.
(b) PBF dialogue: To give opportunity to every member of the committee and representatives
of the health facilities to express any challenges or difficulties in implementing the
program or their own strategies; to address disputes that are referred to it by members or
stakeholders.
(c) PBF invoice validation: To review, discuss and eventually approve the final consolidated
quarterly invoices of PBF health facilities prior to transmission to the SPHCDA. This
validation process needs to ratify every single original monthly PBF invoice, and all the
quality scores, with the consolidated quarterly LGA PBF invoice. The latter invoice is
drawn from the PBF web-enabled application: verifying whether the data match (the
‘physical evidence’ with the data in the database) is an important validation function.
(d) PBF management support/evaluation: To review and discuss the performance of the LGA
PHC department: the LGA PHC department is under a performance contract to carry out
certain functions related to the well-functioning of the PBF system, in a timely and
correct manner. The SPHCDA Verifier has scored the performance using the
performance evaluation tool. The results are discussed in the plenary.
(e) Care for the indigents: curative care for the indigents is introduced as a pilot mechanism.
The steering committee is required to follow up on the functioning and appropriateness of
the developing targeting mechanisms– whether they target the poorest of the poor and the
near poor -, and to ensure the Indigent committees are functioning appropriately.
7. Monitoring of the LGA RBF Steering Committee
7.1
7.2
The SPHCDA shall monitor the Steering Committee and is authorized to access the
committee’s minutes and any other relevant documents related to committee’s activities.
Receiving the steering committee minutes, created according to strict guidelines,
conjointly with the quarterly consolidated LGA PBF invoice, is a pre-condition for the
SPHCDA and the PFMU to process the performance payments.
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7.3
The SMOH, upon advise from the SPHCDA, may review the modalities of the
Committee’s operations and/or dissolve it appears that irregularities may have
compromised the PBF system in the LGA.
8. Role of the Heath Facilities’ representative
The LGA’s PBF health facilities are represented by one of the Health Facilities heads. He/She
has been elected by the in-charges of the other facilities, during a plenary meeting. She/he shall
have responsible with bringing to the committee’s attention the concerns of the different
facilities’ managers. She/he shall also responsible to inform accurately to the other heads of
facilities about the decisions of the Committee. His/her tenure is 12 months, with the possibility
of one times re-election.
9. Role of Chief Medical Officer of the General Hospital
The Chief Medical Officer of the General Hospital will be part of the RBF Steering Committee.
The first level referral hospital has important functions related to (i) the referral system; and (ii)
training and capacity building.
10. Role of the LGA PHC Department
The LGA PHC Department, hereby represented by its coordinator, shall be responsible of the
following:
(a) General supervision of health facilities within the LGA to ensure that the PBF program is
being implemented according to agreed strategies and policies;
(b) Apply the quality checklist to each PBF health facility, once per quarter and submit these
checklists to the SPHCDA Verifier linked to the LGA, prior to the 20th of the third
month;
(c) Organize the quarterly LGA RBF Steering Committee meetings prior to the end of the
fourth month. Invite members at the least 15 days prior to the steering committee
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meeting. The LGA PHC department will function as the secretariat of this steering
committee. Agenda setting will need to be agreed between the SPHCDA designed LGA
Verifier and the local government health director or his designated PBF coordinator;
(d) Manage financial and human resources diligently towards the achievement of the
recommendations and strategies set by the LGA Steering Committee, the SPHCDA and
the SMOH.
(e) All other functions normally attributed to the department as part of its day-to-day mission
in the LGA.
11. Role of the NGO representative
The NGO representative represents civil society. The NGO representative is chosen among civil
society organizations active in the health or social protection sectors in the local government
area.
12. Dispute resolution
12.1
12.2
12.3
12.4
In the case of dispute relating to the interpretation of the present contract, both parties
agree to refer to the current Performance Based Financing User Manual.
In case of unclarity of certain PBF system elements, the Steering Committee might
request higher level SPHCDA technical support for clarifying certain matters.
In the case of dispute relating to the implementation of the present contract, both parties
agree to refer to the matter to the arbitration of the State RBF Steering Committee which
acts as the regulator of the PBF system in the State. The arbitration decision in the matter
shall be final and binding towards all parties.
The SPHCDA is under no obligation to write a purchase contract for MPA or CPA with
any health institute. Its primary drivers for contracting are (a) good performance and (b)
continued good performance. Past performance budgets or performance fees/subsidies are
no guarantee for future fees/subsidies.
13. Duration of the Contract
The present contract is signed on (_________) for a period of 12 months until (__________). It
shall be renewed tacitly for an additional 12 subject to the terms stipulated in section 1 of the
present contract.
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SIGNED BY
[Name] LGA, hereby represented by the Chairman of [Name] LGA
Dr. /Mrs. /Mr
__________________________
Signature
__________________________
And
The Members of the _________________Local Government Authority Performance Based
Financing (PBF) Steering Committee
1. The LGA Health Director
______________________
2. The Primary Health Care (PHC) Coordinator
______________________
3. The Representative of the State Ministry of Health
______________________
4. The Chief Medical Officer of the LGA General Hospital
______________________
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5. The representative of Health Facilities
______________________
6. The representative of the SPHCDA
______________________
7. The representative of Non-Governmental Organizations active in the LGA
______________________
8. The Director for Local Government Administration (DLG) where available or Director of
Personnel Management (DPM) or his/her representative
______________________
9. The Pharmacy Officer
______________________
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Annex 2: Purchase Contract between the SPHCDA and the Health Provider
(…) State Primary Health Care Development Agency
PERFORMANCE BASED FINANCING (PBF) CONTRACT
FOR THE PURCHASE OF HEALTH SERVICES
No ______________
THIS CONTRACT is dated [……..]
BETWEEN:
The State Primary Health Care Agency (“SPHCDA”) represented by its Executive Chairman
Dr. /Mrs. /Mr.…………………………………………:
And
[Name]
Health Centre, herein referred to as the “facility” or “HF”
Represented by: Mrs. / Mr. [Names]
Mrs. / Mr.: [Names]
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Health Centre
Chair [Name] Facility RBF Committee
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IT IS AGREED as follows:
1. Principles of Performance Based Financing
1.1
1.2
1.3
1.4
The present contract is a performance contract between the SPHCDA and the Health
Facility in the context of the State Performance Based Financing (PBF) program.
The goal of PBF is to increase the provision of quality Basic Health Services to the
population by increasing health facilities’ decisional rights on the management of their
own operations.
The Performance Based Financing strategy emanates from National Strategic Health
Development Plan and NEEDS and Vision 20/20/20. The SPHCDA reserves the right to
amend the applicable policies that serve as the basis of its support to the health centres
prior to the expiry of the present contract.
The Performance Based Financing User Manual (as published by FMOH/NPHCDA)
serves as the principle reference document for all mechanisms agreed to herein and shall
be referred to for further details and interpretation.
2. Duration of the Contract
2.1
2.2
2.3
This purchase contract is valid from [Date ………….] for period of [12] months until
[Date………………].
This contract may be revoked by the SPHCDA unilaterally at anytime, in case of fraud,
or continued underperformance. The annexes and Business Plan (as stipulated in Section
13 herein) form an integral part of the present contract.
The SPHCDA reserves the right to re-negotiate the service fees each 3 month period,
however, the SPHCDA can also decide to keep the fees at their current levels. If such
amendment is not produced on the last working day of the end of the quarter, the current
fee set will be used for the following quarter. After re-negotiation, an amendment with a
new set of negotiated fees will be produced, including a new business plan.
3. Purpose of the Contract
This contract defines the rights and obligations of both parties within the context of the PBF
system: The Health Facility, as the provider of health services and the SPHCDA, the purchaser
of Health Services.
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4. Performance Payments
4.1
4.2
4.3
4.4
4.5
4.6
The SPHCDA shall make Performance payments to the HF according to a fee –for –
service / case based provider payment mechanism, which is also conditioned on the
quality of care. The services that are purchased and corresponding unit fees are listed
in Annex 1.
The payments received by the Health Facility under these terms may be used as
incentives in the form of salary bonuses to its staff members and as reinvestments in
activities, equipments, commodities or infrastructure that contribute directly to the
attainment of improved performance targets and enhanced quality of care to the
population.
The maximum that the HF may budget for worker’s bonuses is 50% of its profits.
Violation of this basic rule may lead to the termination of the present contract by the
SPHCDA.
Any bonus payments by the facility to its workers shall be spread over a period of three
months, in the sense that each entitlement is received monthly by the workers.
In consideration of the fact that non-medical staff are in general over-supply, and
essential medical staff in undersupply, it is agreed that it is up to the HF management,
and its Facility RBF committee, to decide on how many of the non-medical staff it needs
to incentivize to keep basic hygiene, the waste disposal according to applicable norms,
and cleanliness of the premises.
The HF may decide to forfeit bonuses for a limited period and to invest in its
infrastructure or equipment. The HF may choose to invest part of its earnings in
expanding its health workforce through local labor contracts, and invest also in fringe
benefits to attract and retain qualified health staff.
5. Organs of the Health Center
5.1
5.2
The Health Facility shall be jointly represented by the Head of the Facility and the
Chairman of the Facility RBF Committee.
The Health Center in-charge shall put in place an Internal Management Committee to
review individual staff performance and distribution of the funds generated through PBF
and the present contract. This Internal Management Committee shall use (a) the indice
tool for integrated financial management and performance bonus payments; (b) a
motivation contract written with each employee in which its ‘part’ (proportion) of each
quarterly bonus budget is indicated; and (c) minutes to document its proceedings. See the
latest PBF manual for further details.
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6. Mission of the Health Facility
6.1
6.2








The Health Facility must ensure that funds generated through PBF are managed in the
general interest of the health centre and, in general, contribute to the improvement of
public health in the community.
In doing so, the health facility (HF) hereby commits to undertake the following:
Develop strategies designed to achieve the overall goals of Performance Based Financing
at HF and community level;
Avoid any activities in contradiction with national health policies and/or accepted
medical ethics;
Inform the Primary Health Care (PHC) Department at the Local Government Authority
of any change in HF personnel, technical skills and equipment at the facility that which
could hamper its capability to render the Services remunerated by the present PBF
contract;
Ensure the permanent availability of all data recording registers and all management tools
at the HF, and ensure that such documents are accessible to the SPHCDA, LGA PHC
department and research companies during the execution of the present contract;
Report in writing any case of fraud or attempted fraud committed by HF staff members to
the SPHCDA and the PHC Department;
Ensure complete transparency and access to information relating to the use of funds
generated through PBF and all others sources;
Distribute part of the revenues generated through PBF and the present contract its staff in
the form of “bonuses” and in accordance with set guidelines. The indice tool will assist
to direct resources to core essential medical staff;
Allocate part of the revenues generated through PBF and the present contract to
operational expenditure (other than personnel remuneration and trainings).
7. Procurement and Prescription of Drugs and Medical Consumables
7.1
7.2
The Heath Facility shall procure all drugs and medical consumables with PBF - Certified
Distributors. The State Agency of the Pharmaceutical Council of Nigeria (PCN), in
collaboration with the SMOH will issue a list of 3 to 4 PBF - Certified Distributors in the
State. The HF shall, at all times, be expected to conform to the list of Certified
Distributors as updated from time to time by the State PCN. In choosing the distributors,
availability of drugs, best price and quality should be the guiding principles.
The facility shall only procure essential drugs (as listed in the approved essential drug
list) and medical consumables in generic form. Procurement of non-essential (not listed
in the essential drugs list) of non-generic drugs (expensive brands drugs whilst cheaper
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7.3
7.4
7.5
7.6
7.7
generic drugs are available) is not allowed. Non-compliance with this obligation may
lead to the termination of the present contract by the SPHCDA.
Procurement of drugs and or medical consumables from non- PCN/PBF - Certified
Distributors will be considered a violation of the purchase contract and may lead to
immediate termination of the present contract by the SPHCDA.
The facility shall keep records of drugs and consumables procurement accessible at the
pharmacy, and in-depth audits will need to show a match of stock-in and stock-out.
The facility shall ensure that all drugs and medical consumables prescribed in the HF are
prescribed through a prescription, which shall be maintained and accessible at all times
for control at the pharmacy. Prescriptions should indicate (a) the name and age of the
patient; (b) the date; (c) clearly legible listed generic drugs with quantities; (d) name and
signature of the prescriber. Prescription of drugs should strictly follow protocols (types of
generics and recommended quantities) as mentioned in the treatment guidelines.
Irrational use of drugs leads to a high cost to the population. Systematic non-adherence to
these treatment guidelines could therefore lead to loss of this purchase contract.
Drugs and medical consumables available at the health facility should be clearly listed
and accessible at the public notice board and at the pharmacy and should: (a) list the unit
price; (b) list the number of items for a typical course, and (c) the unit price (the ‘retail
price’) should not exceed the whole sale price + a reasonable markup as negotiated with
the community and ratified by the Facility RBF Committee.
The existence of informal drug schemes managed by the facility or by its staff is strictly
forbidden under this contract and it may lead to immediate termination of the contract by
the SPHCDA.
8. Quantity audits and provisional PBF invoices
The SPHCDA verification teams shall conduct monthly or bi-monthly Quantity audits by
reviewing all entries made in the designated registers. They will compare their review with the
provisory monthly invoice as prepared by the HF management (see annex 2). Such monthly
quantity control shall be conducted not later than the 15th day of each month, or in some
instances bi-monthly depending on local conditions.
9. Data Collection Registers
9.1
For the purpose of the present contract, each PBF Data Collection Register and its
contents/entries register constitute a financial records document and will be treated as
such. Non-adherence to strict registration norms herein, non-completeness or non-
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9.2
9.3
9.4
legibility of the data in the columns, will lead to non-remuneration of the concerned
services.
The Facility shall adhere to the norms for Primary and Secondary Register Column
Headers as described in the applicable Performance Based Financing Manual. In the
event pre-printed PBF registers are not available, the health facility shall design handwritten registers using the available office stationery according to the above mentioned
norms. .
All numbering, in all registers, from the first day of the PBF contracting, shall start with a
‘1’, and continue for the remainder of the calendar year. The following calendar year, the
numbering should start with a new ‘1’, etc. The end of the month should be clearly
indicated through a line. The numbering should continue into the following month, until
the end the calendar year.
Routine Health Management Information System (HMIS) data shall align with data
from the PBF registers.
10. Quality audits
10.1
10.2
In order to ensure that the services performed by the HF meet satisfactory quality
standards, specific Quality Indicators (as described in the latest PBF manual) will be
assessed every quarter by the LGA PHC department.
The results of these Quality Audits will be factored in the calculation of the overall
performance of the HF and the final PBF invoice as follows:
a. 25% of the total claimed earnings over the preceding months shall be added as
“quality bonus” if the quality score for that quarter is 100%.
b. If the HF’s quality score is 49% or less, the quality bonus is automatically ‘0’ for
the evaluated quarter.
c. A quality score between 50% and 99% will be prorated as follows: Quality
Bonus = % Quality Score * (total earnings for all contracted services over the
past three months).
10.3
The quality audits shall be counter-verified regularly by an independent third party to be
determined by the SPHCDA. If fraud is detected with the quality score, the present
purchase contract may be terminated immediately by the SPHCDA.
11. Validation of the Quarterly Consolidated PBF invoices
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11.1
11.2
The LGA PBF Steering Committee shall, on a quarterly basis, validate the Health
Facility’s monthly PBF invoices and the quality score obtained.
The LGA PBF Steering Committee shall determine the amount earned by the Health
Facility on the basis of the scores obtained in both the quality and quantity controls
conducted respectively by the LGA PHC Department and the SPHCDA verification
teams as described in Section 9 herein.
12. Terms of payment
The amount of each Quarterly Validated final PBF invoice shall be paid into the Health Facility
bank account not later than 60 days after the quarter in which they were earned. For that purpose,
the Health Facility shall operate autonomously its own bank account in which the funds will be
transferred. Guidance on the management of the bank account is available in the PBF manual.
13. Utilization of funds received through PBF, and through all other sources
13.1
13.2
The utilization of funds earned through PBF, and through all other sources, and the
present contract shall be at the discretion of the Health Center Management Committee
within the limits fixed in Section 4 of this contract.
Against this background the health center, shall ensure that all documents are well
secured. All payments made to staff and other beneficiaries should be clearly signed or
thumb printed. Fraud in financial management will be dealt with according to applicable
State Laws. Fraud in financial management may lead to immediate termination of the
present contract by the SPHCDA.
14. External Counter-verification and Misreporting
14.1
14.2
A third party organization shall be contracted by the SPHCDA to conduct random
counter-verifications at community level (the so-called community client satisfaction
surveys) on a periodic basis in order to confirm the Facilities results. In that event, the
Health Facility hereby agrees to grant full access to the relevant records as may be
required.
In case of any irregularities discovered in the course of such counter-verification
(including, but not limited to, inaccurate reporting and “ghost” patients), the Health
Facility shall repay the SPHCDA all PBF funds earned through the present contract. In
addition, the Health Facility may be barred from participating in the PBF program.
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15. Business Plan
Within three months upon the signature of the present contract, the HF shall submit a Business
Plan for the following twelve months of activities (see format in the PBF manual). The Business
plan will outline the strategies considered in order to increase the quantity and the quality of its
services. The Business Plan shall then be reviewed and approved by the SPHCDA and form an
integral part of the present contract. The absence of Business Plan or the non-compliance with its
strategies may lead to the termination of the present contract by the SPHDCA.
16. Care for the Indigents
16.1
16.2
16.3
16.4
16.5
16.6
The Health Facility may allocate a maximum number of 20% of the curative
consultations of the previous month under the reimbursement-category ‘new outpatient
consultation for an indigent patient’ for the current month. When allocated to this
category the patient shall not pay any fee. Patients allocated under the ‘new outpatient
consultation for an indigent patient’ cannot be allocated under ‘new outpatient
consultation’ (see annex 1).
The monthly sum of the number of ‘new outpatient consultations’ and the number of
‘new outpatient consultations for an indigent patient’ shall form the monthly new
outpatient consultations provided by the Health Facility. However, a ‘new outpatient
consultation for an indigent patient’ client or ‘new outpatient consultation’ client can
consume other PBF services. In this case, the additional service shall also be counted
under the additional PBF service.
The reimbursement for a ‘new outpatient consultation for an indigent patient’ category is
based on the cost of an average curative care consultation in the Nigerian context
according to modern treatment guidelines. The reimbursement is also based on the
principle of cross-subsidization: this means that in case the treatment for the indigent
client surpasses the actual treatment costs incurred by the HF, that the HF ‘cross
subsidizes’ this treatment from other sources of income.
The ‘new outpatient consultation for an indigent patient’ category is meant for indigents,
the poorest of the poor. This category shall be recorded using a separate register, and any
other such tools that the facility management, its Facility RBF committee, or its indigent
committee have put in place.
The appropriate use of the ‘new outpatient consultation for an indigent patient’ category
will be verified through the routine verification and through the community client
satisfaction surveys.
A specially designated Indigent Committee shall meet regularly to review the
appropriateness of the post-identification mechanisms. This indigent committee is drawn
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from three members of the Facility RBF Committee and select members of the
community not related to any of the health facility staff. This indigent committee reviews
each month the appropriateness of the allocations (ref PBF user manual).
17. Sub-contracting for defined services in the minimum service package
17.1
17.2
17.3
The Facility may sub-contract with select providers for defined services in the MPA will
be allowed. The sub-contracts – including the proposed services - will need to be
proposed in the business plan, vetted by the LGA PHC department and approved by the
SPHCDA. Sub-contracting can be with public, private non for profit and private for profit
providers.
All sub-contracted services shall be verified by the SPHDA verification teams, and
counter-verified by an independent agency through community client satisfaction surveys
in the same manner as non sub-contracted services. The Health Facility, as principle
contract holder, shall use the approved sub-contracting template (see PBF manual), shall
be responsible for the filing and accessibility of all signed sub-contracts, and ensure
secondary registers are in conformity with applicable norms in the same manner as the
primary registers.
The Facility, as principal contract holder, is responsible for the appropriate quality
standards of care in the sub-contracted facility which is under its direct supervision. It
may use up to 25% of the earnings of its sub-contracted facility for its own administration
costs provided that it is agreed upon in the sub-contract document between both facilities.
Done at …………………………….. On …………./…………/201x
For The State Primary Health Care Agency
Mrs. / Mr.
______________________________
Signed
______________________________
And
Chairman of the Ward Health Committee
Head of the Health Facility
Mrs. /Mr./Dr _____________________
Mrs/Mr/Dr_____________________
Signed
Signed ______________________
______________________
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Annex 1: list of Minimum Package of Health Services for the PBF purchase contract.
Note: fees are valid for the first three months only and subject to possible re-adjustment by the
SPHCDA. Previous fee/subsidy levels are not a guarantee for future fee levels.
No
MPA Service
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
New outpatient consultation
New outpatient consultation for an indigent patient
Minor Surgery
Referred patient arrived at the Cottage Hospital
Completely Vaccinated Child
Growth monitoring visit Child
2 - 5 Tetanus Vaccination of Pregnant Woman
Postnatal consultation
First ANC consultation before four months pregnancy
ANC standard visit (2-4)
Second dose of SP provided to a pregnant woman
Institutional Delivery
FP: total of new users of modern FP methods
FP: implants and IUDs
VCT/PMTCT/PIT test
PMTCT: HIV+ mothers and children born to are treated according to
protocol
STD treated
New AFB+ PTB patient
PTB patient completed treatment and cured
ITN Distributed
New family using a latrine during the past month
17
18
19
20
21
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Annex 2: Provisory Monthly PBF Invoice
Provisory Monthly Invoice for MPA Services
LGA:
Health Center:
Month:
Year:
Quantity
Produced
Service
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Unit Fee
[In
contract]
SubTotal
Naira
New outpatient consultation
New outpatient consultation for an indigent patient
Minor Surgery
Referred patient arrived at the Cottage Hospital
Completely Vaccinated Child
Growth monitoring visit Child
2 - 5 Tetanus Vaccination of Pregnant Woman
Postnatal consultation
First ANC consultation before four months pregnancy
ANC standard visit (2-4)
Second dose of SP provided to a pregnant woman
Institutional Delivery
FP: total of new users of modern FP methods
FP: implants and IUDs
VCT/PMTCT/PIT test
PMTCT: HIV+ mothers and children born to are treated
according to protocol
STD treated
New AFB+ PTB patient
PTB patient completed treatment and cured
ITN Distributed
New family using a latrine during the past month
Grand Total for the month
The current invoice for the month of ……………
[………………………………………………] Naira
of ………………………..Health Center is totaled at
Date………….
Health Center RBF Committee Members:
1………………………………………….
2………………………………………….
3………………………………………….
4………………………………………….
5…………………………………………
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The Verifier:
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Annex 3: Motivation Contract between the Health Center Management and the Individual
Health Worker
Health Facility Worker Motivation Contract
This Contract is dated [………………] 2011
Between:
(Official name)
Health Centre, herein referred as the “facility” or “HF”
Represented by: Ms/Mrs. / Mr. [names…………….]
Head of [………….………..] Health
Centre, and
Mrs. / Mr.: [names………………….] Chair person of the [name of
ward………….] Facility RBF Committee
And
Dr/Ms/Mrs/Mr [names of HF worker], [Job title] herein referred as the “worker”
IT IS AGREED as follows:
18. Principles of Performance Based Financing
1.1
1.2
The present contract is entered between the worker and the facility within the context of
the Performance Based Financing (PBF) program and the Performance Based Financing
Contract for the Purchase of Health Services signed between the facility and the State
Primary Health Development Agency (SPHCDA).
The payment of workers motivation bonuses emanates from National Public Health
policies and as such the Government reserves the right to unilaterally amend applicable
policies prior to the expiry of the present contract.
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1.3
The motivation contract institutes a mode of additional remuneration to the worker, by
way of individual bonuses according to his or her personal work performance with
respect to his or her Job Profile.
19. Validity of the contract: Motivation contract and employment contract
2.1
2.2
The Job Profile of the worker (in annex 1) including the details of his/her tasks at the
Facility form integral part of the present contract.
The motivation contract does not supersede or replace the existing worker’s employment
contract. In the event the worker’s employment contract is terminated, the present
motivation contract shall automatically be terminated without notice.
20. Validity of the contract : Motivation Contract and PBF contract
The existence of this contract is strictly subordinated to the existence and the duration of the PBF
Purchase Contract between the facility and the State Primary Health Development Agency
(SPHCDA). In the event the PBF Purchase Contract is terminated for any reasons, the present
motivation contract shall automatically be terminated without notice.
21. Covenants of the parties
4.1
The Facility worker
21.1
The worker shall use reasonable effort in promoting access of the population to
better quality Health Care, working in collaboration with other facility workers.
21.2
The worker commits his/herself to safeguarding the transparency and veracity of
information regarding the Facility’s operations.
21.3
The worker agrees to be held accountable for fraud or negligence committed by
him/her during the execution of his/her duties.
4.2
The Health Facility
a) The Facility management commits itself to evaluate monthly, in an objective and
transparent way, the performance of the worker in light of his Job Profile and tasks which were
assigned to him.
b) The Facility management commits itself to pay to the worker a performance bonus on a
monthly basis, if the general financial position and the performance income permit, and
according to the terms of the present contract. Performance bonuses are the result of a mix of
productivity and quality of the health facility. If this productivity is low, there will be less money
available for performance bonuses. The health facility management and the RBF Health
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Committee might propose, to invest in upgrading the physical infrastructure and the equipment
first, to gain more performance payments in the future. Such a strategy will be communicated to
the staff. Therefore, the performance bonuses might be forfeited by management, to invest in the
health services offered to the population, but which might, in the middle term, lead to higher
performance rewards by the health facility and its workers.
c) The Facility management commits itself to put all reasonable effort in providing the
worker with the resources necessary for the successful completion of the tasks assigned to
her/him and within the limits of the resources available to the facility.
22. Amount and Calculation of Salary Bonuses
5.1
5.2
5.3
5.4
The payment of individual bonuses shall be approved by the RBF Committee upon
proposal from the Facility Internal Management Committee (IMC) using the result of
Monthly Individual Evaluation and the index corresponding to his/her professional
category as determined by the IMC.
Important: the management of the health facility, in conjunction with the RBF
Committee, may decide to forfeit part or all of the bonus payments for a given quarter, in
order to invest in increasing the quantity and quality of care. Individual performance
bonuses might, therefore, fluctuate considerably each quarter.
The amount payable to the worker shall be calculated as follows: The Indice value
corresponding to his/her professional position, which is hereby fixed at
_____________________ points.
The individual performance award is calculated by multiplying the individual indice
value with the monthly point value with the individual performance evaluation. The
proportion of the Facility’s profits allocated to the payment of facility worker’s bonuses
is determined quarterly by the Facility’s RBF Committee. See the PBF manual and the
indice tool for further guidance.
23. Payment of PBF workers bonuses
The PBF bonuses shall be paid to the workers retrospectively on a monthly basis.
24. Individual performance evaluation
The Internal Management Committee of the HF shall, on a monthly basis, evaluate the worker’s
performance in accordance with the tasks assigned to him. The IMC shall keep individual
performance score cards that will record the worker’s performance. These individual score cards
shall be kept accessible for transparency and audit purposes.
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25. Temporary suspension of the motivation bonuses
In the event of fraud, record falsification, or any other serious irregularity, the RBF Committee
may decide to suspend salary bonuses of all HF Workers for a maximum period of three (3)
months.
26. Resolution of disputes
In the event of any disputes relating to execution of the present contract, either party may resort
to the arbitration of the Facility RBF Committee. All parties hereby agree that such arbitration
shall be final and binding towards all parties.
27. Duration and amendment of the contract
The present contract is valid from [Date ………………] for a period of [12] month until
[Date………….] and it shall be tacitly renewed for as long as the worker’s employment contract
remains in force.
Done at …………………………….. On …………./…………/201x
The Worker
Ms/Mrs. / Mr. ______________________________
Signed
______________________________
And
Chairman of the RBF Committee
Head of the Health Facility
Ms/Mrs. /Mr. _____________________
Ms/Mrs./Mr. __________________
Signed
Signed _______________________
_____________________
Annex 1: Job Profile
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Annex 4: Contract between the SPHCDA and the LGA PHC Department
(…) State Primary Health Care Development Agency
PERFORMANCE BASED FINANCING (PBF) CONTRACT
FOR THE QUALITY SUPERVISION OF HEALTH SERVICES
No _________________
THIS CONTRACT is dated [……..] 2011
BETWEEN:
The State Primary Health Care Agency (“SPHCDA”) represented by its Executive Director
Dr. /Mrs. /Mr.…………………………………………:
And
The [Name]
Local Government Authority Primary Health Care Department
Represented by: Mrs. / Mr.: [Name]
Mrs. / Mr.: [Name]
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Chairperson of […………] Local Government
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IT IS AGREED as follows:
1. Principles of Performance Based Financing
1.1
The present contract is a performance contract between the SPHCDA and the Local
Government Authority Primary Health Care Department (PHCD) in the context of the
State’s Performance Based Financing (PBF) program.
The goal of PBF is to increase the provision of quality Basic Health Services to the
population by increasing financial incentives for health workers and by increasing health
facilities’ decisional rights on the management of their own operations.
The Performance Based Financing strategy emanates from National Public Health and
Poverty Reduction policies. The SPHCDA reserves the right to amend the applicable
policies that serve as the basis of its support to the PHCD prior to the expiry of the
present contract.
1.2
1.3
2. Purpose of the Contract
2.1
The purpose of this contract is to establish a performance contract for the LGA PHCD to
undertake Supervision of the Quality of Care at the LGA’s PBF contracted Health
Facilities based on the applicable Performance Framework (see attached in annex 1).
Part of the payments received under these terms may be used by the PHCD department to
pay for incremental expenses directly related to the Supervision and Control Activities,
including, but not limited to, per-diem for supervision team members, office equipments
and consumables, maintenance and repair of vehicles and communication costs.
Part of the payments received under this performance contract may be used to pay
performance bonuses to staff involved in the supervisory activities.
2.2
2.3
3. Mission of the PHCD within the PBF System
3.1
The Primary Health Care Department (PHCD) shall ensure that Health Facilities in the
LGA provide adequate quality health care services in the general interest of improvement
of public health in the community.
In doing so, the PHCDA hereby commits to undertake the following:
3.2


Conduct timely quarterly quality supervisions of the Health Facilities contracted through
PBF contracts with the SPHCDA (as stipulated in Section 4 herein);
Investigate at facility level any activities in contradiction with national health policies
and/or accepted medical ethics and solve these, and bring these to the attention of the
LGA RBF Steering Committee if necessary;
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


Supervise the Health Facilities regularly (as stipulated in Section 4 herein), investigate
and document for the LGA RBF Steering Committee any change in HF personnel,
technical skills and equipment at the facility that which could hamper its capability to
render the Services remunerated by the present PBF contract;
Investigate and Report in writing any case of fraud or attempted fraud committed by HF
staff members to the SPHCDA and the LGA RBF steering committee;
Ensure complete transparency and access to information relating to the use of funds
received from the SPHCDA in relation to the present contract.
4. Quality audits of the PBF contracted Health Facilities
4.1
4.2
4.3
4.4
For the purpose of this contract, the term ‘PBF facilities’ shall refer to all health facilities
that are contracted and remunerated by the SPHCDA through PBF purchase contracts;
The PHCD verification teams shall conduct Quarterly Control audits by applying the
applicable PBF Quality supervisory checklist (see template in annex 2). This checklist is
updated regularly, typically annually, and the PHCD should use the latest version as
developed and approved by the NPHCDA/SPHCDA;
Such Quarterly Quality supervision shall be conducted at all PBF facilities no later than
the 15th of the fourth month following the quarter and must contain all quality scores for
review and validation by the LGA RBF Steering Committee;
The original of all quality supervisory checklists shall be sent to the SPHCDA, and arrive
there no later than the 20th of the fourth month (the month following the quarter).
5. Business Plans
5.1
5.2
5.3
The PHCD shall review on a quarterly basis the level of implementation of the Business
plans developed by the HFs and part of their PBF purchase contracts. The Business Plans
evaluation shall form part of the PBF Quality Verification checklist as described in annex
2;
The PHCD may, as a result of the review, suggest changes to the business plans in close
collaboration with the Facility RBF Committees and Heads of facilities. The PHCDA has
an important technical supportive and advisory and capacity strengthening role in this
aspect;
In relation to 5.2, it is ultimately the SPHCDA which will have to agree on the proposed
business plan contents, and which consists of a negotiation between the health facility
management and the SPHCDA directly.
6. Performance Remuneration of the PHCD
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6.1
6.2
The budget ceiling for this contract is Naira … (N…). The level of remuneration shall be
directly proportional to the score obtained by the PHCD in accordance with the
performance framework tool (as detailed in Annex 1 of the present contract);
For instance, if the PHCD obtains 75% score in a given quarter, the PHCD shall receive
75 % of the total available performance budget for that quarter.
7. Evaluation of the PHCD Performance
7.1
7.2
7.3
The SPHCDA Verifier shall evaluate the PHCD’s performance every quarter, not later
than the 15th day of the month immediately following each concerned quarter and using
the Performance Assessment Framework;
The SPHCDA Verifier shall sign 1 original of the quarterly performance assessment, the
original will go to the SPHCDA HQ for filing and entry in the web-enabled application; a
copy will remain at the PHCD and will be presented during the following RBF steering
committee meeting;
In case of systematic underperformance, such as not carrying out the quality supervision
in a timely and complete manner, or in the case of fraud with the quality assessments, the
SPHCDA retains the right to unilaterally stop this contract, and to provide this contract to
another party.
8. Terms of payment
8.1
8.2
8.3
The SPHCDA shall directly pay the PHCD by way of bank transfer in the designated
PHCD bank account in quarterly installments;
Payments will be executed along with the performance payments for health facilities, and
will follow the same system of validation, due diligence and approvals (validation in the
LGA RBF Steering Committee; submission of minutes of the meeting and invoices to the
SPHCDA; due diligence of the SPHCDA on the deliverables; payment for performance
by the PFMU);
It is hereby agreed, as a critical pre-condition to the present contract, that the PHCD shall
have direct access and control of the designated bank account.
9. Dispute resolution
9.1
In the case of dispute relating to the interpretation of the present contract, both parties
agree to refer to the most current applicable Performance Based Financing User Manual,
and attempt to resolve the issue in the LGA RBF Steering Committee meeting;
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9.2
9.3
10.
In the case of dispute relating to the implementation of the present contract, both parties
agree to refer to the matter to the arbitration of the State RBF steering committee which
acts as the regulator of the PBF system in the State. The arbitration decision in the matter
shall be final and binding towards all parties.
However, in case of systematic underperformance, as documented in section 7.3, the
SPHCDA retains the right to stop the current contract unilaterally and to contract with
another party.
Duration of the Contract
The present contract is signed on [date] for a period of 12 months. It shall be renewed tacitly for
an additional 12 months subject to the terms stipulated in section 1 of the present contract.
Done at …………………………….. On ……/………/2010
For The State Primary Health Care Agency
Mrs. / Mr.
______________________________
Signed
______________________________
And
Chairperson of the Local Government Authority
LGA PHCD Coordinator
Mrs. /Mr.
_____________________
Mrs. /Mr._____________________
Signed
______________________
Signed ______________________
Annex 1: LGA – PHC Department performance framework
Annex 2: Quality Supervisory Checklist for Health Centers
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Annex 5: Sub-Contract between the Health Provider and a Secondary Health Provider
PERFORMANCE BASED FINANCING (PBF) SUBCONTRACT
Subcontract No.
Between
__________________________________ Health Center (Principal Facility) in [State];
[Ward]
And
__________________________________Health Center/Health Post (Subcontractor)
1.
Purpose of the contract
The present contract is a performance contract between the Principal Facility and the
Subcontractor for the remuneration of health services provided by the subcontractor on a case
based payment basis.
2.
Services delivered
The Health Services provided by the subcontractor and their remuneration are as follows:
No
1
2
3
4
5
Service
New Outpatient Consultation
Fully Vaccinated Child
FP new or existing user of modern FP methods
Growth monitoring visit child
ITN distributed
Fee
The Fee has been adjusted to reflect the administrative overheads that the principal PBF
contractor is allowed to levy on each service of the sub-contractee. This administrative overhead
is meant to pay for the efforts of the main PBF contractor to (a) manage the sub contracting
process; (b) ensure quality services delivered by the sub-contractor; (c) coaching on the use of
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registers; (d) coaching in the use of advanced strategies employed to boost productivity. The
administrative overheads can be up to a maximum of 25% of the Fee value claimed by the main
PBF contractor, from the SPHCDA. It can be a lesser percentage, but not a higher percentage.
3.
Principal contract
The existence of this contract is subordinated to the existence and the duration a Principal PBF
Purchase Contract between the Principal Facility and the State Primary Health Development
Agency (SPHCDA). In the event the Principal Contract is terminated for any reasons, the present
subcontract may automatically be terminated without notice.
4.
Interpretation and reference
Both parties agree to refer to the most current applicable Performance Based Financing User
Manual and the Principal PBF Contract between the Principal Facility and the State Primary
Health Development Agency (SPHCDA) for any matter relating to the interpretation and
execution of obligations inferred by the present contract.
5.
Duration, validity and termination
The present contract is valid for a period of [……] months from [Date ………….] to [Date
……………] subject to satisfaction of both parties. Either party may terminate the contract at
any time. It shall be renewed automatically for additional 12 months periods in the absence of
written notice to the contrary emanating from one of the party prior to the end date.
6.
Dispute resolution
Both parties agree to refer any dispute relating to the present contract to the Facility RBF
Committee. In case of unresolved conflict, the issue will be referred to the LGA RBF steering
committee, whose decision will be final.
SIGNED on ________________
By
Head of ______________Health Center
And
Head of _______Health Center/Post
________________________________
______________________________
Contractor
Sub-contractor
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Annex 6: MPA and CPA
1. Minimum Package of Activities (MPA)
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
MPA Service
New outpatient consultation
New outpatient consultation for an indigent patient
Minor Surgery
Referred patient arrived at the Cottage Hospital
Completely Vaccinated Child
Growth monitoring visit Child
2 - 5 Tetanus Vaccination of Pregnant Woman
Postnatal consultation
First ANC consultation before four months pregnancy
ANC standard visit (2-4)
Second dose of SP provided to a pregnant woman
Institutional Delivery
FP: total of new users of modern FP methods
FP: implants and IUDs
VCT/PMTCT/PIT test
PMTCT: HIV+ mothers and children born to are treated according to protocol
STD treated
New AFB+ PTB patient
PTB patient completed treatment and cured
ITN Distributed
New family using a latrine during the past month
2. Complementary Package of Activities (CPA)
No
1
2
3
4
5
6
7
8
9
10
CPA Service
New outpatient consultation by a Doctor
New outpatient consultation by a Doctor of an indigent patient
Counter-referral slip arrived at the Health Center
Minor Surgery
Major Surgery (ex CS)
Normal delivery
Assisted Delivery
CS
Inpatient Day
Inpatient Day for an indigent patient
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11
12
13
14
15
16
17
18
19
20
21
22
Postnatal consultation
First ANC consultation before four months pregnancy
ANC standard visit (2-4)
FP: total of new users of modern FP methods
FP: implants and IUDs
FP: vasectomy and bilateral tuba ligation
VCT/PMTCT/PIT test
PMTCT: HIV+ pregnant mothers and children born to are treated according to
protocol
STD treated
New Client put under ARV treatment
New AFB+ PTB patient
PTB patient completed treatment and cured
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Annex 7: Service Protocol Reference Guides
Minimum Package of Activities
No
Name MPA Service
Description
Primary Data Collection
Tools13
1
New outpatient consultation
Any new curative care visit during the
past month
Curative Care Register
2
New outpatient consultation of
an indigent patient
During the past month, indigents who
Indigent outpatient register
have been consulted as an outpatients.
Indigents are locally identified. Maximum
of 20% of all new curative consultations
during the previous month.
3
Minor Surgery
Any new minor surgical intervention
during the past month. Minor Surgery
Minor Surgery Register
Secondary Data Collection
Tools14
Original prescription for
drugs dispensed kept at the
pharmacy which includes
cost of drugs. Drugs register
and stock cards conform.
Proceedings indigent
committee
Community Client
Satisfaction Survey: postidentification questionnaire
application
Original prescription for
drugs and medical
See Annex ‘Primary Data Collection Tool Column Headers’. These registers ought to be well-legible with filled all columns filled in. The PBF column
header formats are mandatory. If information is lacking, automatically this service is not remunerated/validated. The Verifier can use a red pen to cross out
the service and or to make annotations. If the mobile phone number is not recorded, the service risks not being remunerated. In case of absence of mobile phone
number the client can provide any number, i.e. from a family member, the neighbor, or the village chief. But a recorded number is mandatory. In the unlikely
case that the client has no number at all to provide, the patient will need to sign the register’s column header.
13
14
The secondary data collection tools can be partially at the health facility, partially with the client. They can be subject to scrutiny during either the routine data
verification exercises, and or during the community client satisfaction surveys. In case there is no trace of such services rendered in the secondary data collection
tools, then the service might be considered ‘not rendered’ ex-post, and sanctions will be applied as per contract.
NSHIP Performance-Based Financing User Manual
No
Name MPA Service
Description
Primary Data Collection
Tools13
defined as (i) Suture; (ii) incision and
drainage; (iii) minor excisions.
4
Referred patient arrived at the
General Hospital
Counter-referral slip available at the
Health Center. Fully filled in by the MD.
The number of valid counter-referral slips
is counted.
Original of counter-referral
slip available at the Health
Center.
5
Completely Vaccinated Child
Vaccination Register
6
Growth monitoring visit Child
7
2 - 5 Tetanus Vaccination of
Pregnant Woman
Child less than 12 months old which has
received all vaccines according to the
national protocol (BCG; DTP3; Measles)
Any new quarterly growth monitoring
visit of a child less than five years old
during the past month. These growth
monitoring visits ought to be monthly
according to the protocol, however, here,
a quarterly visit is remunerated.
Each second to fifth TT vaccination of a
pregnant woman during the past month
8
Postnatal consultation
9
First ANC consultation before
four months pregnancy
Version document1
A post natal consultation held within 48
hours after giving birth, during the past
month.
A first ANC consultation occurs before 4
month’s pregnancy, during the past
Under-five clinic/Nutrition
Register
Secondary Data Collection
Tools14
consumables dispensed kept
at the pharmacy which
includes cost of
drugs/consumables. Drugs
register and stock cards
conform.
Copy of the counter-referral
slip available at the General
Hospital. Referred patient
registered in the outpatient’s
department register.
Under-five card with
vaccination records, held by
the mother.
Under-five card with growth
curve plotted, held by the
mother
ANC register
Individual Card kept at the
HF
Delivery register
ANC card held by the
mother
Vaccination register
Partogram or inpatient form
ANC register
Individual Card kept at the
ANC card held by the
mother
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No
Name MPA Service
Description
Primary Data Collection
Tools13
month.
Any 2-4th standard visit according to the
focused antenatal care visit schedule and
approach. Second visit between 24-28
weeks; third visit at 32 weeks and the
fourth visit at 36 weeks. During the past
month.
HF
ANC register
Individual Card kept at the
HF
10
ANC standard visit (2-4)
11
Second dose of SP provided to
a pregnant woman
The second dose of SP (IPTp), according
to the protocol, during the past month.
ANC register
Individual Card kept at the
HF
12
Normal delivery
A delivery attended by a trained attendant
at the health facility during the past
month.
Delivery Register
13
FP: total of new and existing
users of modern FP methods
FP register
Individual Card kept at the
HF
14
FP: implants and IUDs
Any new or existing user of injectable
contraceptive or oral contraceptive pills,
during the past month. An injection
represents three month’s protection and a
FP visit for OAC should provide three
month’s worth of pills.
Any new user of implant or IUD, during
the past month.
Version document1
FP register
Individual Card kept at the
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Secondary Data Collection
Tools14
ANC card held by the
mother
Medical prescriptions for
Ferrosulphate, Vermox and
SP kept at the pharmacy.
Drugs register and stock
cards conform.
ANC card held by the
mother; medical
prescription for SP kept at
the pharmacy. Drugs
register and stock card
conform.
Partogram; eventual drugs
and medical consumables
dispensed through the
prescriptions kept at the
pharmacy; drugs register
and stock cards conform.
Eventual drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Eventual drugs and medical
consumables dispensed
NSHIP Performance-Based Financing User Manual
No
Name MPA Service
Description
Primary Data Collection
Tools13
HF
15
VCT/PMTCT test
Any new VCT or PMTCT test carried out
during the past month.
Any new HIV+ mother and newborn
child treated according to the PMTCT
protocol, during the past month.
Any new STD treated according to
syndromic treatment protocol, during the
past month
VCT register
16
17
PMTCT: HIV+ mothers and
children born to are treated
according to protocol
STD treated
18
New AFB+ PTB patient
A new AFB sputum positive Pulmonary
Tuberculosis patient diagnosed, at the
facility, during the past month.
Tuberculosis register
19
PTB patient completed
treatment and cured
A former AFB+ PTB patient completed
DOTS, and cured after treatment proven
by negative sputum examinations, during
the past month.
Tuberculosis register
20
ITN Distributed
ITN distributed, during the past month.
ITN register
21
New family using a latrine
During the past month, the individual
Latrine register
Version document1
ARV register; delivery room
register
Curative Care Register
Page 76
Secondary Data Collection
Tools14
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Laboratory register; stock
records
PMTCT register; laboratory
register; stock records.
Drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Laboratory register. Slides
kept for counterverification/quality
assurance.
Laboratory register. Slides
kept for counterverification/quality
assurance.
Drugs register.
Stock control card conform.
Proof of acquisition,
purchase of ITNs available.
Site visit
NSHIP Performance-Based Financing User Manual
No
Name MPA Service
Description
Primary Data Collection
Tools13
effort of a community health worker who
has delivered a package of behavioral
change communication including on
hygiene to a family. The objectively
verifiable measure of his BCC is the use
of a newly constructed latrine in the
catchment area (Ward), next to the
household of this family, during the past
month. Construction according to the
norms. Maximum one latrine per
household.
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Secondary Data Collection
Tools14
NSHIP Performance-Based Financing User Manual
Complementary Package of Activities
No
Name CPA Service
Description
Primary Data Collection
Tools15
1
New outpatient consultation by Any new curative care OPD visit attended
a doctor
by a Doctor during the evaluated month
Curative Care Register
2
New outpatient consultation by Any new curative care OPD visit by an
a doctor of an indigent patient indigent patient attended by a Doctor
during the evaluated month. Indigents
identified according to local norms.
Maximum of 20% of all new curative
consultations and or admissions during
Indigent register
Secondary Data Collection
Tools16
Original prescription for
drugs dispensed kept at the
pharmacy which includes
cost of drugs. Drugs register
and stock cards conform.
Lab/radiology register
contains proof of requested
exams.
Proceedings Indigent
committee
Community Client
Satisfaction Survey
See Annex ‘Primary Data Collection Tool Column Headers’. These registers ought to be well-legible with filled all columns filled in. The PBF column
header formats are mandatory. If information is lacking, automatically this service is not remunerated/validated. The Verifier can use a red pen to cross out
the service and or to make annotations. If the mobile phone number is not recorded, the service risks not being remunerated. In case of absence of mobile phone
number the client can provide any number, i.e. from a family member, the neighbor, or the village chief. But a recorded number is mandatory. In the unlikely
case that the client has no number at all to provide, the patient will need to sign the register’s column header.
15
16
The secondary data collection tools can be partially at the health facility, partially with the client. They can be subject to scrutiny during either the routine data
verification exercises, and or during the community client satisfaction surveys. In case there is no trace of such services rendered in the secondary data collection
tools, then the service might be considered ‘not rendered’ ex-post, and sanctions will be applied as per contract.
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No
Name CPA Service
Description
the previous month.
A counter-referral note filled by the MD,
sent to the health center, during the
evaluated month. The feedback must at
least mention the diagnosis and treatment
received. The carbon copy of the referral
note is only remunerated when it is
accompanied by a short note with name,
date and signature of the health center incharge.
Primary Data Collection
Tools15
3
Counter-referral slip arrived at
the Health Center
4
Minor Surgery
Any new minor surgical intervention
during the evaluated month. Minor
Surgery defined as (i) Suture; (ii)
Herniotomy; (iii) Subcutaneous cyst
removal; (iv) I&D; (v) amputation of a
finger/toe
Minor Surgery Register
5
Major Surgery (ex CS)
Any new major surgical intervention
during the evaluated month. Major
surgical intervention defined as a
laparatomy for any cause (bar CS), or
amputation of a large limb.
Theater register
Version document1
Carbon copy of the original
referral slip, filled in by the
MD.
Page 79
Secondary Data Collection
Tools16
Original prescription for
drugs and medical
consumables dispensed kept
at the pharmacy which
includes cost of
drugs/consumables. Drugs
register and stock cards
conform. Lab/radiology
register contains proof of
requested exams. Original
referral slip available at the
Health Center
Original prescription for
drugs and medical
consumables dispensed kept
at the pharmacy which
includes cost of
drugs/consumables. Drugs
register and stock cards
conform. Lab/radiology
register contains proof of
requested exams.
Original prescription for
drugs and medical
consumables dispensed kept
at the pharmacy which
includes cost of
NSHIP Performance-Based Financing User Manual
No
Name CPA Service
Description
Primary Data Collection
Tools15
6
Normal delivery
A normal delivery attended by a trained
attendant in this facility, during the
evaluated month.
Delivery register
7
Assisted delivery
An assisted delivery attended by a Doctor
in this facility, during the evaluated
month.
Delivery register
8
CS
A CS carried out at this facility during the
evaluated month.
Delivery register or theater
register
9
Inpatient Day
One day admission of an admission of a
minimum of three days duration and
discharged alive, during the past month.
General admission register for
each department
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Secondary Data Collection
Tools16
drugs/consumables. Drugs
register and stock cards
conform. Lab/radiology
register contains proof of
requested exams.
Partogram and inpatient file;
eventual drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Partogram and inpatient file;
eventual drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Partogram and inpatient file;
eventual drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register
In patient form kept at the
health facility
NSHIP Performance-Based Financing User Manual
No
Name CPA Service
10
Postnatal consultation
11
First ANC consultation before
four months pregnancy
12
ANC standard visit (2-4)
13
FP: total of new users of
modern FP methods
14
FP: implants and IUDs
15
FP: vasectomy and bilateral
tuba ligation
Version document1
Description
Primary Data Collection
Tools15
Secondary Data Collection
Tools16
A post natal consultation held within 48
hours after giving birth, during the past
month.
A first ANC consultation occurs before 4
month’s pregnancy, during the evaluated
month.
Any 2-4th standard visit according to the
focused antenatal care visit schedule and
approach. Second visit between 24-28
weeks; third visit at 32 weeks and the
fourth visit at 36 weeks. During the
evaluated month.
ANC register
ANC card kept at the health
facility
ANC register
ANC card kept at the health
facility.
ANC register
Any new or existing user of injectable
contraceptive or oral contraceptive pills,
during the past month. An injection
represents three month’s protection and a
FP visit for OAC should provide three
month’s worth of pills.
Any new user of implant or IUD, during
the evaluated month.
FP register
A vasectomy and bilateral tuba ligation
carried out at this facility, during the
evaluated month
Theater register
ANC card kept at the health
facility. Medical
prescriptions for
Ferrosulphate, Mebendazole
and Fansidar kept at the
pharmacy. Drugs register
and stock cards conform.
Eventual drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Eventual drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Family Planning Register
FP register
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No
Name CPA Service
16
VCT/PMTCT/PIT test
17
PMTCT: HIV+ pregnant
mothers and children born to
are treated according to
protocol
STD treated
18
19
New Client put under ARV
treatment
20
New AFB+ PTB patient
21
PTB patient completed
treatment and cured
Version document1
Description
Primary Data Collection
Tools15
Any new VCT or PMTCT or PIT test
carried out during the evaluated month.
Any new HIV+ mother and newborn
child treated according to the PMTCT
protocol, during the evaluated month.
VCT/PMTC register
Any new STD treated according to the
syndromic treatment protocol, during the
evaluated month
Curative Care Register
Any new patient (pediatric or adult) HIV
positive who started ARV (Antiretroviral
therapy), including transferred in, during
the evaluated month.
A new AFB sputum positive Pulmonary
Tuberculosis patient diagnosed, at the
facility, during the past month.
ART Register
A former AFB+ PTB patient completed
DOTS, and cured after treatment proven
by negative sputum examinations, during
the past month.
ARV register; delivery room
register
Tuberculosis register
Tuberculosis register
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Secondary Data Collection
Tools16
Laboratory register; stock
records
PMTCT register; laboratory
register; stock records.
Drugs and medical
consumables dispensed
through the prescriptions
kept at the pharmacy; drugs
register and stock cards
conform.
Patient files
Laboratory register: Slides
kept for counterverification/quality
assurance.
Laboratory register: Slides
kept for counterverification/quality
assurance.
Drugs register.
Annex 8: Quarterly Quality Supervisory Checklist for Health Centers
[Name……….] MOH/[Name……….] PHCDA
Quarterly Quality Review of Health Centers
version 31 October 2011
Date:
Name Supervisor:
LGA:
Ward:
HF:
Population:
Medical Staff Total:
Non-Medical Staff Total:
1
1.1
1.1.1
1.2
1.2.1
1.3
1.4
1.4.1
1.5
1.5.1
1.6
1.6.1
1.7
General Management [max 11 points]
YES
NO
1
0
2
0
1
0
3
0
1
0
1
0
1
0
Presence of map of health facility catchment area
Health map of the health area available and on the notice board of HF
showing villages, main roads, natural barriers, special points and distance
HMIS reports - business plan - minutes of meetings and
patient cards well stored
In cupboard and in box files and accessible by duty manager
Staff duty roster available and well displayed up to date for
current month and visible for staff and patients
Technical meetings with staff conducted monthly and
minutes available
Each monthly minutes contain: (i) date of the meeting; (ii) signed list of
participants; (iii) follow-up of decisions taken during the previous meeting;
(iv) there is a list of developed recommendations or decisions taken; (v) each
month the fmonthly financial balance is discussed; (vi) minutes of the
meeting are signed by the chair. Each report according to norms = 1 p
Standard Sheets for referral available
At least 10 sheets
Availability of radio or mobile phone for communication
between health facility and general hospital
Radio or mobile phone functional with batteries and/or call credit and contact
details on the phone
HMIS reports are filled, updated and transmitted to the
LGA on schedule
NSHIP Performance-Based Financing User Manual
1.7.1
1.8
1.8.1
After verification of the SPHCDA of the monthly MPA invoice and signed
receipt of acknowledgement available
HMIS data analysis report for the quarter being assessed
concerning priority problems
Three priority health problems are followed each quarter and data have been
updated up to the month prior to the supervisor's visit
Total Points (11)
1
0
../11
xxxx
YES
NO
2
0
2
0
1
0
1
0
1
0
2
0
../9
xxxx
Remarks
2
2.1
2.1.1
Business Plan [max 9 points]
Quarterly business plan for the current period made and
accessible
Valid and renegotiated
2.2
Business plan prepared with key stakeholders
2.2.1
Facility RBF Committee Members involved
2.2.2
Representative (s) of subcontracted private clinics or health posts involved (if
applicable)
2.3
Business plan contains convincing geographic coverage plan
2.3.1
Strategies for sub-contracts (e.g. villages at more than one hour by foot)
2.3.2
Mobile strategies (EPI, FP; PNC, LITN distribution, latrines)
2.4
Business plan analyses presence of untrained informal
practitioners in catchment area
2.4.1
HF treats this subject in the BP, and suggests a strategy for discouraging
2.5
Business plan analyses presence of trained practitioners
operating without any permission
2.5.1
BP may suggest to include them or to discourage if quality conditions are not
met
2.6
Business plan shows a plan to assure financial accessibility
for the population
2.6.1
Business plan shows negotiated rates between HF, committee and community
2.6.2
Business plan shows planning for care for the indigents
Total Points (9)
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Remarks
3
Finance [max 10 points]
3.1
Financial and accounting documents available and well kept
3.1.1
Monthly report of treasury available and correctly filled
3.1.2
Theoretical balance of cash-book corresponds to liquidity in cash
3.2
Document available to show that quarterly calculation of
incomes, running costs, investments and variable
performance subsidies are done
3.2.1
This document guarantees running costs: = salaries, purchase of drugs and
equipments, subcontracts, petty cash for small expenditures, social marketing,
maintenance and rehabilitation
3.2.2
This document calculates the performance bonus according to the formula:
performance bonuses = income of the quarter - running costs
3.3
Contract salaries and benefits + performance bonuses do not
exceed 50% of total HF income through PBF
3.4
Existence of fixed basic salaries and monthly performance
bonus system is know by staff
3.4.1
Established criteria for the performance bonus calculation through (i) basic
performance index + (ii) seniority + (iii) responsibility + (iv) overtime hours
worked - hours lost + (v) quarterly performance evaluation
Total Points (10)
YES
NO
2
0
3
0
2
0
3
0
../10
xxxx
Remarks
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4
Care for the Indigents [max 7 points]
4.1
Planning for Care for the Indigents expenditures
4.1.1
20% of curative consultations of the previous month: documented quantity in
monthly management meetings
4.2
Indigent committee meets monthly
4.2.1
The Indigent committee meets monthly to review the Care for the Indigent
Category use. Each monthly minutes contain: (i) date of the meeting; (ii)
signed list of participants; (iii) follow-up of decisions taken during the
previous meeting; (iv) there is a list of developed recommendations or
decisions taken; (v) each month the fmonthly financial balance is discussed;
(vi) minutes of the meeting are signed by the chairman. Each report according
to norms = 2 p
Total Points (7)
YES
NO
1
0
6
0
../7
xxxx
YES
NO
1
0
1
0
1
0.5
0.5
0
0
0
Remarks
5
Hygiene and Sterilization [max 25 points]
5.1
Fence health facility available and well-maintained
5.1.1
Fence exists, can be closed at night and there are no holes
5.2
Availability of a garbage bin in the courtyard
5.2.1
Bin with lid accessible to clients which is not full
5.3
Presence of sufficient latrines/toilets which are well-maintained
5.3.1
At least two latrines/toilets
5.3.2
Floor without fissures with single hole and lid
5.3.3
Recently cleaned without visible fecal matter
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5.3.5
Door lockable from the inside, super structure with roofing, without flies and
no smell
Smells of disinfectant
5.4
Presence of sufficient showers which are well-maintained
5.4.1
At least one bathing facility
5.3.4
0.5
0.5
0
0
1
0.5
0.5
0
0
0
5.4.3
Bathing facility with running water, or container with at the least 20 L of
water
Evacuation of the waste water in a sanitation pit
5.5
Waste pit for Heath Care Waste is available and according to the norms
5.5.1
Waste disposal pit minimum 2 meters deep, lined with clay, concrete or brick
or plastic, it is fenced and has a bright flag.
5.5.2
The waste pit is a minimum of 15 meters from the health facility, minimum
of 50 meters from a household, and 100 meters from a water source
5.5.3
Health Care Waste is not visible (covered by at the least 10 cm of soil or
lime)
5.5.4
The health facility maintains a register indicating the date of the creation of
the pit(s), and the location (s)
5.6
Courtyard clean
5.6.1
No waste or medical waste in the courtyard
5.7
Sterilization according to norms using a pressure sterilizer
5.7.1
Sterilizer functional
5.7.2
Sterilization protocol available and utilized
5.9
Hygienic conditions assured during wound dressing and
injections
5.9.1
Yellow and Red Bins for medical waste with lid and foot pedal, lined
5.9.2
Security box for needles well positioned, and used
5.9.3
Needle cutter available and used
5.9.4
Container/bowl with lid containing disinfectant used for putting used
instruments
5.10
Disposal of Health Care Waste according to National Norms
5.4.2
5.10.1
5.10.2
Waste disposal of non-contaminated waste in Black Bin with lid and foot
pedal, lined
Waste disposal of contaminated HCW in Yellow Bins with lid and foot pedal,
lined
5.10.3
Waste disposal of organic HCW in Red Bins with lid and foot pedal, lined
5.10.4
Protective gear for personnel managing HCW available; boots, plastic shorts,
thick plastic/rubber gloves
Total Points (25)
6
0
1
0
3
0
2
0
6
0
../25
xxxx
Remarks
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6
Curative Consultations [max 34 points]
6.1
Good conditions in waiting area
6.1.1
Sufficient benches and or chairs protected against sun and rain and waiting
area is not inside room
6.2
Unit fees of drugs displayed to the public
6.2.1
Easily visible in the waiting area, updated, with (i) unit price per item; (ii)
price for a standard treatment of the drug
6.2.2
Drugs are all generics
6.3
Existence of waiting card system with numbers
6.4
Consultation room in good condition
6.4.1
Walls with durable materials well painted, floor paved with cement without
fissures, undamaged ceiling
6.4.2
Consultation room and waiting space separated assuring confidentiality
6.4.3
Windows with curtains
6.4.4
Functional door with lock
6.5
Consultation room (where emergencies are received) has
24/7 light
6.5.1
Electricity or solar light or functioning high pressure kerosene light present
6.6
Consultations are done by skilled staff
6.6.1
Identification of consulting staff in register
6.7
Consulting staff is well-dressed
6.7.1
Clean blouse and footwear
6.8
Correct numbering of registers
6.8.1
Correct numbering and closed at the end of the month
6.9
Service availability 7/7
6.9.1
Supervisor verifies entries in register for the last three Sundays
6.10
Malaria protocol put on wall and accessible for staff
6.10.1
National protocol for diagnosis and treatment of simple and severe malaria
6.11
Simple malaria correctly treated
6.11.1
Register see last five cases of simple malaria and review treatment acc
protocol
Version document1
YES
NO
1
0
1
0
1
0
3
0
1
0
2
0
1
0
1
0
1
0
1
0
1
0
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NSHIP Performance-Based Financing User Manual
6.13
WHO flow diagram for ARI put on wall and accessible for
staff
ARI protocol applied
6.13.1
See last five cases of ARI and review treatment acc protocol
6.12
1
0
1
0
1
0
1
0
6.15
WHO protocol for Diarrhea put on wall and accessible for
staff
Diarrhea protocol applied
6.15.1
See last five cases of Diarrhea and review treatment acc protocol
6.16
Proportion of consultancies treated with antibiotics <30%
6.16.1
See last 100 cases in register, check diagnosis and calculate the rate (< 30
cases)
4
0
MSF treatment guidelines available in consultancy room
Knowledge of tuberculosis danger signs and criteria for
referral
1
0
1
0
1
0
1
1
0
0
1
0
1
0
2
0
2
0
6.14
6.17
6.18
6.18.1
6.18.2
Select any available qualified medical staff, and ask the question on TB
dangers signs
Answer must contain at least 4 of the following signs: (i) weight loss; (ii) loss
of appetite; (iii) fever; (iv) cough of more than 15 days duration; (v) night
sweating
6.19
Stethoscope and BP machine available and functional
6.19.1
Let nurse check BP and review measure
6.20
Thermometer available and functional
6.21
Otoscope available and functional
6.22
Examination bed available with mattress
6.22.1
Non-torn, plastic cover, specific for the OPD consultations only
6.23
Weighing scale available and functional
6.23.1
Inspect in comparison with known weight of supervisor: after weighing, the
balance should return to zero
6.24
Integrated Management of Childhood Illnesses strategy is
applied
6.24.1
Protocol is available in the consultation room
6.24.2
The last five IMCI cases are traced in the register and comply with the IMCI
strategy
6.25
Determination of nutritional status
6.25.1
6.25.2
Determination of nutritional status of all children under 5 who come for
consultation
Determination of nutritional status of all women with a sick child under 6
months of age
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6.25.3
Screening record of nutritional status available, up to date and properly filled
out
Total Points (34)
../34
xxxx
YES
NO
2
0
2
0
2
0
1
0
3
0
2
0
3
0
3
0
Remarks
7
Family Planning [max 22 points]
7.1
At least one qualified staff trained in Family Planning
7.2
Confidentiality in consultancy room assured
7.2.1
Room with closed doors, curtains at windows or non transparent glass
7.3
Family planning methods available and visible in
demonstration box for potential users
7.3.1
Condoms; OAC; Injectable; Implant; IUD; beads are available in the
demonstration box
7.3.2
Penis model available on the desk; box with condoms available with at the
least 50 condoms
7.4
Staff correctly calculates number of clients expected monthly
for oral and injectable contraceptives
7.4.1
For example for 10.000 population (target is entire ward catchment pop) =
10.000 * 22.5% * 25%/12 * 4 * 90% (assuming 25% unmet need; 22.5%
target population; 90% of oral/inject AC at HC level
7.5
Business plan contains strategy to achieve FP targets
7.5.1
Collaboration with public sector, private sector and social marketing, mobile
strategies, advocacy among local leaders etc
7.5.2
Involvement of HF staff in strategies
7.6
Stock of oral and injectable contraceptives in adequate
7.6.1
for example for 10.0000 pop 72 doses of oral (3 month cycles) and injectable
methods combined
7.7
IUD available and staff trained to use it
7.7.1
at least five IUDs and at the least one staff trained to use it
7.8
Implant method available and staff trained to use it
7.8.1
at least five implants available and staff trained to use it
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7.9
Strategies available for transfer of persons to hospital
seeking permanent FP methods
7.9.1
Referral system worked out - strategy to reduce prices; mobile strategy for
surgery?
7.10
FP individual cards available and filled according to the
format
7.10.1
Check at least five cards for BP, hepatomegaly, varices, weight
Total Points (22)
2
0
2
0
../22
xxxx
YES
NO
1
0
1
0
Remarks
8
Laboratory [max 10 points]
8.1
Laboratory technician or technologist available
8.2
Laboratory is open every day of the week
8.2.1
Supervisor verifies the last 4 Sundays in laboratory register
8.3
List of laboratory examinations visible for the public with
fees
1
0
8.4
Results recorded correctly in laboratory register and match
with results in inpatient sheets or OPD examination cards
1
0
8.4.1
Supervisor verifies last five results
8.5
Availability of parasites demonstrations
8.5.1
On plastic paper, in a color book, or put on wall
8.5.2
Blood smear: Vivax, Ovale, Falciparum and Malariae
1
0
8.5.3
Stools: Ascaris, entamoeabae, ankylostoma and schistosome
8.6
Microscope available and functional
8.6.1
functional objectives; immersion oil available, mirror or electricity
1
0
8.6.2
blades, cover glass, GIEMSA available
8.7
Malaria rapid tests available
8.7.1
At the least 20 tests available in the laboratory; non-expired
1
0
8.8
Centrifuge available and functional
8.9
Waste evacuation correctly carried out
1
1
0
0
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8.9.1
Organic waste in a bin with lid with disinfectant
8.9.2
Security box for sharp objects available and destroyed according to waste
disposal guidelines
8.10
Personnel adequately washes dirty pipettes in containers
with disinfectant
Total Points (10)
1
0
../10
xxxx
YES
NO
1
0
2
0
0.5
0.3
0.3
0
0
0
2
0
1
0
2
0
1
0
../10
xxxx
Remarks
9
In-patient Wards [max 10 points]
9.1
Guard duty roster clearly visible for staff and followed up
9.1.1
Supervisor verifies guard duty's report - names and signatures
9.2
Furniture available and in good state
9.2.1
Each bed has a (i) plastic covered mattress, (ii) mosquito net, (iii) clean
sheets, (iv) night table
9.3
Patient comfort and hygiene
9.3.1
The wards are clean: no debris on the floor; and wards smell of disinfectant
9.3.2
Space between the beds is at the least one meter
9.3.3
Each ward has access to drinking water
9.4
Light available in each ward
9.4.1
Electricity; solar light or rechargeable battery lamp
9.5
Confidentiality
9.5.1
Women in separate ward from men; the inside of the wards are not visible
from the outside
9.6
In patient register available and is well maintained
9.6.1
check identity and hospital bed days
9.7
Recording forms for hospitalizations available and well filled
and well stored
9.7.1
At least 10 blanks; supervisor verifies 5 filled forms
9.7.2
Weight, temperature, and eventual laboratory exams recorded
9.7.3
Treatment monitoring checked
Total Points (10)
Remarks
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10
Essential Drugs Management [max 20 points]
10.1
Staff maintains stock cards for ED showing security stock
levels = monthly average consumption / 2
10.1.1
Supply in register corresponds with physical supply: random sample of three
ED
10.2
Health facility purchases drugs, equipment and consumables
from the Pharmaceutical Council of Nigeria certified
distributor, approved by SMOH/SPHCDA
10.2.1
Latest Pharmaceutical Council of Nigeria certified distribution center list for
the State available
10.2.2
Last procurement list is shown which shows the certified distributor which
sold the drugs
10.2.3
All drugs and medical consumables are (i) NAFDAC certified and (ii)
Generic
10.3
Main pharmacy store delivers drugs to health facility
departments according to requisition
10.3.1
YES
NO
4
0
3
0
10
0
2
0
1
0
../20
xxxx
Supervisor verifies whether quantity requisitioned equals quantity served
10.3.2
Drugs to clients are uniquely dispensed through prescriptions. Prescriptions
are stored and accessible
10.3.3
Drugs and medical consumables prescribed, are all in generic form
10.4
Drugs stored correctly
10.4.1
Clean place, well ventilated with all drugs on cupboards, labeled shelves
10.4.2
Drugs and medical consumables stored on alphabetical order, first in - first
out basis
10.5
Absence of out of date drugs or drugs with unreadable labels
10.5.1
Supervisor verifies randomly three drugs and 2 consumables
10.5.2
Out of date drugs well separated from stock
10.5.3
Destruction protocol for out of date drugs available and applied
Total Points (20)
Remarks
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11
Tracer Drugs (min. stock = Monthly Av. Consumption / 2)
[max 30 points]
Availabl
e YES >
MAC / 2
Availabl
e NO <
MAC / 2
11.1
Paracetamol 500 mg tab
1
0
11.2
Ibuprofen 200 mg caps
1
0
11.3
Promethazine 25 mg tab
1
0
11.4
Oxytocin 10IU/ml vial
1
0
11.5
Mebendazole 100 mg tab
1
0
11.6
Ferrous Sulfate 325 mg tab
1
0
11.7
Penicillin V 250 mg tab
1
0
11.8
Amoxicillin 500 mg tab
1
0
11.9
Amoxicillin 200 mg/5ml suspension
1
0
11.10
Co-trimoxazol 480 mg tab
1
0
11.11
Co-trimoxazol 40mg/200mg - 5ml susp
1
0
11.12
Doxycycline 100 mg caps
1
0
11.13
Erythromycin 250 mg tab
1
0
11.14
Co-artemeter 20/120 mg tab
1
0
11.15
Sulfadoxine/pyrimethamine 500 mg tab
1
0
11.16
ORS sachet
1
0
11.17
Condom
1
0
11.18
Metronidazol 250 mg tab
1
0
11.19
Sterile gloves
1
0
11.20
Venflon 18G
11.20.1
Min stock = 10; MAC applies only when higher than 10
1
0
11.21
Venflon 22G
11.21.1
Min stock = 10; MAC applies only when higher than 10
1
0
11.22
IV giving set
11.22.1
Min stock = 10; MAC applies only when higher than 10
1
0
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11.23
Ringers lactate 1L
11.23.1
Min stock = 5L; MAC applies only when higher than 5L
11.24
Dextrose 5% 1L
11.24.1
Min stock = 5L; MAC applies only when higher than 5L
11.25
IV colloids 500 ml
11.25.1
1
0
1
0
Min stock = 5 bags; MAC applies only when higher than 5 bags
1
0
11.26
Syringe 5ml
1
0
11.27
Syringe 10ml
1
0
11.28
Needle 18G
1
0
11.29
Needle 22G
1
0
11.30
ITN
1
0
../30
xxxx
YES
NO
1
0
1
0
1
0
1
1
1
1
1
1
0
0
0
0
0
0
Total Points (30)
Remarks
12
Maternity [max 21 points]
12.1
Sufficient water with soap in delivery room
12.1.1
A functioning water source or at the least 20L
12.2
Light in delivery room 24 hours
12.2.1
Electricity, solar light or rechargeable battery lamp or kerosene lamp filled
with kerosene
12.3
Waste from Maternity correctly handled
12.3.1
Bin with lid and safe needle disposal container, specific for the maternity
room use only
12.4
Delivery room is well-maintained
12.4.1
Walls with durable materials and painted
12.4.2
Curtain between delivery bed and door
12.4.3
Delivery room smells of disinfectant
12.4.4
Floor level cement, without fissures and ceiling not damaged
12.4.5
Windows with curtains and functional door
12.5
Availability and use of the Partogram
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12.5.1
At the least 10 forms available for use
12.5.2
Verify three randomly selected partograms whether filled according to the
norms
12.6
Deliveries performed by skilled personnel
12.6.1
Identification of the obstetrician from names in the register
12.7
Availability of scales for weight/length, an obstetrical stethoscope and an
aspirator
12.7.1
Tape to measure length
12.7.2
2
0
Scale to measure weight (check functionality)
Aspirator plunged into a non-irritating disinfectant or functional
manual/electric aspirator
1
1
1
0
0
0
12.8
Availability of at the least 10 pairs of sterile gloves
1
0
12.9
Availability of at the least 2 sterilized obstetrical boxes
12.9.1
Content at the least 1 pair of scissors, 2 pliers and one needle holder
2
0
12.10
Availability of at the least one episiotomy box
12.10.1
One sterilized box with needle holder, needles, 1 anatomical plier and 1
surgical plier
1
0
12.10.2
Catgut and nylon sutures; antiseptic, local anesthetics, sterile swaps
12.11
Delivery table in good state
12.11.1
Table in two parts with removable non-torn plasticized mattress and two
functional leg supports
1
0
12.12
Available equipment for care of the newborn
12.12.1
Sterile tying string or clip for umbilical cord
1
0
12.12.2
1% tetracycline eye ointment
12.13
Adequate in-patient rooms
12.13.1
Mattress covered in impermeable plastic
1
0
12.13.2
Sheets, blankets and mosquito nets on each occupied bed
../21
xxxx
YES
NO
1
0
12.7.3
Total Points (21)
Remarks
13
13.1
EPI and Pre-School Consultation [max 18 points]
Personnel calculates correctly target for fully vaccinated
children
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13.1.1
Target = population * 4% / 12
13.1.2
The target population concerns the ward population
13.2
EPI fridge
13.2.1
Presence of a fridge - temp form available, filled twice a day including the
day of the visit
13.2.2
Temperature remains between 2 and 8C in register sheet
13.2.4
Supervisor verifies functionality of thermometer
13.2.5
Temperature between 2 and 8C also according to the thermometer
13.3
Chemical Temperature Indicator
13.3.1
Presence of a chemical temperature indicator which shows temperature acc to
the norms
13.4
Appropriate storage of vaccines
13.4.1
Freezing compartment: Measles
13.4.2
Non-freezing compartment: BCG, DTP + HepB, TT, thinners
13.4.3
Absence of vaccines which are expired
13.4.4
Readable labels on all vaccines
13.5
Appropriate stock of vaccines
13.5.1
BCG, DPT, Polio, Yellow Fever, HBV, Measles, Tetanus
13.5.2
Presence of stock control cards for all vaccines; concordance paper and
physical stock verified
13.6
Cold Chain maintenance
13.6.1
If kerosene fridge: stock of at the least 14L Kerosene; if solar fridge: battery
not damaged
13.7
Cold packs are well frozen
13.7.1
At the least 5
13.8
Syringes available
13.8.1
Auto-blocking at least 30; for dilution - at least 3
13.9
Waste collection availability of safe disposal box
13.10
Stock of U5 growth cards available
13.10.1
At the least 10
13.11
Child immunization register well maintained
13.11.1
System is capable of identifying drop outs and Fully Vaccinated Children
13.12
Conditions in waiting area for immunization services
13.12.1
Sufficient benches and or chairs, protected against sun and rain
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0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
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13.14
Patients receive numbered waiting buttons according to
their arrival
Baby weighing scale available and in working condition
13.14.1
Balance calibrated to zero + pants available, clean and in good condition
13.15
Group IEC/BCC
13.15.1
Group meeting held before vaccinations
13.15.2
Existence of updated IEC report with (a) topic, (b) number of participants, ©
leader of activity, (d) date and (e) signature
13.16
Existence of a system to recover drop-outs
13.16.1
Schedule, record of appointments, classified invidual charts
13.13
Total Points (18)
1
0
1
0
1
0
1
0
../18
xxxx
YES
NO
1
0
1
0
3
0
Remarks
14
Antenatal Care [max 12 points]
14.1
Business plan contains convincing strategies to effectively
conduct ANC for all pregnant women in catchment area
14.1.1
Fixed strategy; and advanced strategy for distant villages: catchment area
covers entire ward
14.2
Weighing scale present, functional and calibrated to zero
14.3
ANC form for HF available and well filled in: last five forms
verified
14.3.1
All: Examinations: weight - BP, Size, Parity, Date of last menstruation
14.3.2
All: Laboratory: albuminuria, glucose
14.3.3
All: Obstetrical examination done: Fetal heart rate, Uterine height,
presentation, Fetal movement recorded
14.4
ANC form for HF shows the administration of Ferrous
Sulphate/Folic Acid and Mebendazole and SP (for the last
five forms above)
2
0
14.5
ANC cards for mother available: at least 10 in stock
1
0
14.6
ANC register available and well filled in
14.6.1
Complete identity, state of vaccinations, date visit, whether high risk
pregnancy or not/danger signs
2
0
14.6.2
All columns well filled including the identification of problems if any, and
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actions taken
14.7
ANC conducted by qualified personnel
14.7.1
Nurse; midwife CHO or CHEW, verified on ANC cards
14.8
Group IEC/BCC
14.8.1
Group meeting held before FP consultation
14.8.2
Existence of updated IEC report with (a) topic, (b) number of participants, (c)
leader of activity and (d) date and (e) signature
Total Points (12)
1
0
1
0
../12
xxxx
YES
NO
1
0
1
0
1
0
1
0
1
0
2
0
1
0
Remarks
15
HIV/TB [max 10 points]
15.1
Well-equipped HIV counseling room ensuring privacy:
15.1.1
Plastered and painted wall of solid material
15.1.2
Smooth cement floor
15.1.3
Ceiling in good condition
15.1.4
Windows with glass and curtains
15.1.5
Doors that close
15.2
Availability of IEC/BCC material related to HIV
15.2.1
Penis model on the table
15.2.2
A box of condoms on the table which has at the least 50 condoms
15.4
Existence of a VCT/PMTCT councelling register and lab
register acc norms
Staff trained in councelling
15.4.1
At the least one staff trained as a councilor
15.4.2
All councelling done by a trained councilor
15.5
Referral system and follow up for HIV clients
15.5.1
Individual client cards available; planning for CD4 cell counts
15.6
Referral system and follow up for TB patients
15.3
15.6.2
Each AFB PTB patient has a person attached to him/her who supervises
DOTS: proof of in register; mobile phone number of such a supervisor is
registered
[Define further composite criteria]
15.7
Laboratory equipment for testing for PTB
15.6.1
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15.7.1
[Define reagents for AFB testing; stock control cards for reagents; slides etc]
15.7.2
[Define measures for quality assurance testing of slides]
15.8
Availability of anti-tuberculosis drugs
15.8.1
Rifampicine-isoniazide-pyrazinamide : cp120+50+300mg
15.8.2
Streptomycin 1 gr
15.8.3
Etambutol tabs 400 mg
Total Points (10)
1
0
../10
xxxx
Remarks
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Service
General Management
Business Plan
Finance
Indigent Committee
Hygiene
OPD
Family Planning
Laboratory
Inpatient Wards
Essential Drugs Management
Tracer Drugs
Maternity
EPI
ANC
HIV/TB
Total
Name Supervisor
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Max
11
9
10
7
25
34
22
10
10
20
30
21
18
12
10
249
P %
Signature
:
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Name Head of Clinic/Staff
Signature
:
Date:
Final
Score:
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Annex 9: Quarterly Quality Supervisory Checklist for General Hospitals
[Name……….] MOH/[Name……….] PHCDA
Quarterly Quality Review of General Hospitals
version 31 October 2011
Date:
Name Peer-Evaluation Team leader:
LGA:
Ward:
CH:
Population:
Medical Staff Total:
Non-Medical Staff Total:
0
0.1
Participation in Peer-Evaluation
YES
NO
YES
NO
All or nothing for two evaluations (penalty 10% of total
current evaluation value)
0.1.1
Mandatory participation of the entire evaluation team (Director; Chief Nurse,
Administrator or deputies) in two quarterly peer evaluations for the current
quarter
0.1.2
Peer review teams should arrive prior to 10 am on the day of the planned
evaluation, bar acts of God
Remarks
1
General Management [max 21 points]
1.1
General Hospital RBF Committee meets once per month. Each complete report
is worth 1.5 points; max 3 reports
1.1.1
Date of the meeting
0.1
1.1.2
Agenda
0.1
1.1.3
Signed list of participants
0.1
1.1.4
Follow-up of the decisions taken during the previous meeting
0.1
1.1.5
Implementation of recommendations or decisions adopted at the previous
meeting
0.1
1.1.6
In each issue section there is a description of the problem
0.1
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1.1.7
In each issue section there is a list of developed recommendations or decisions
taken
0.1
1.1.8
In each issue section there is a deadline to solve the issue
0.1
1.1.9
In each issue section there is a responsible named
0.1
1.1.10
Each month the monthly financial balance is discussed
0.5
1.1.11
Minutes of the meeting are signed by the chairman (minutes should be separate
documents)
0.1
1.2
HMIS reports - business plan - minutes of meetings well
stored
1.2.1
In cupboard and in box files and accessible by the administrator
1.3
Staff duty roster 24/7 available and well displayed up to date
and visible for staff and patients
1.4
Management Team Meetings conducted Monthly and minutes available. Each
complete report is worth 1.5 points; max 3 reports
1.4.1
Date of the meeting
0.1
1.4.2
Agenda
0.1
1.4.3
Signed list of participants
0.1
1.4.4
Follow-up of the decisions taken during the previous meeting
0.1
1.4.5
Implementation of recommendations or decisions adopted at the previous
meeting
0.1
1.4.6
In each issue section there is a description of the problem
0.1
1.4.7
In each issue section there is a list of developed recommendations or decisions
taken
0.1
1.4.8
In each issue section there is a deadline to solve the issue
0.1
1.4.9
In each issue section there is a responsible named
0.1
1.4.10
Each month the monthly financial balance is discussed
0.5
1.4.11
Minutes of the meeting are signed by the chairman (minutes can be in a
register)
0.1
1.6
Availability of radio or mobile phone for communication
between General Hospital and health centers
1.6.1
Radio or mobile phone functional with batteries and/or call credit and contact
details of all RBF/DFF facilities
1.6.2
List of phone number of health facility in-charges available and up to date
1.7
HMIS reports are filled, updated and transmitted to the
SMOH
1.7.1
After verification of the SPHCDA of the monthly CPA invoice
1.7.2
Completely filled according to the prevailing formats
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1.8
HMIS data analysis report for the quarter being assessed
concerning priority problems
1.8.1
Three priority health problems are followed each quarter and data have been
updated up to the month prior to the quality evaluation visit
1.8.2
Through a chart, follow up on monthly (i) average length of stay; (ii) average
bed occupancy rate, (iii) Bed turnover rate and (iv) income/expenses
1.9
Ambulance available and functional
1.9.1
Vehicle log book available and maintained/filled
1.9.2
Vehicle maintenance register available and filled
1.9.3
Ambulance available and functional
Total Points (21)
4
0
4
0
../21
xxxx
YES
NO
2
0
2
0
2
0
1
0
Remarks
2
2.1
2.1.1
Business Plan [max 13 points]
Quarterly business plan for the current period made and
accessible
Valid and renegotiated
2.2
Business plan prepared with key stakeholders
2.2.1
Hospital RBF Committee involved
2.3
Business plan analyses Hygiene and waste management
2.4.1
HF treats this subject in the BP (toilets; showers; medical and non-medical
waste disposal; safe sharps disposal practices; general cleanliness; infection
prevention), and suggests a strategy for improvement
2.5
Business plan analyses Quality of Medical Care
2.5.1
BP may suggest to include them or to discourage if quality conditions are not
met
2.6
Business plan shows a plan to assure financial accessibility for the population
2.6.1
Business plan shows negotiated rates between HF, Indigent Committee and
community
1
0
2.6.2
Business plan shows the mechanism how the GH identifies indigents, and how
it assesses eligibility, and how it deals with decision making on difficult cases
4
0
2.6.3
Business plan shows planning for the resources available for financing care for
the indigents
1
0
../13
xxxx
Total Points (13)
Remarks
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3
Finance [max 15 points]
YES
NO
2
0
3.1
Financial and accounting documents available and well kept
3.1.1
Monthly report of treasury available and correctly filled
3.1.2
Theoretical balance of cash-book corresponds to liquidity in cash
3.2
Document available to show that quarterly calculation of incomes, running
costs, investments and variable performance subsidies are done
3.2.1
This document guarantees that running costs: = salaries, purchase of drugs and
equipments, subcontracts, petty cash for small expenditures, food for patients,
maintenance and rehabilitation and financial buffer
3
0
3.2.2
This document uses the MS Excel 'indice tool' for its information. The 'indice
tool' is shown and the calculations for the coming quarter are explained.
3
0
3.2.3
This document calculates the performance bonus according to the formula:
performance bonuses = income of the quarter - running costs
3
0
3.3
Contract salaries and benefits + performance bonuses do not
exceed 50% of total HF income through PBF
2
0
3.4
Existence of fixed basic salaries and monthly performance
bonus system is know by staff
2
0
3.4.1
Established criteria for the performance bonus calculation through (i) basic
performance index + (ii) seniority + (iii) responsibility + (iv) overtime hours
worked - hours lost + (v) quarterly performance evaluation
../15
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Total Points (15)
Remarks
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4
Indigent Committee [max 7 points]
4.1
Planning for Care for the Indigent expenditures
4.1.1
20% of curative consultations of the previous month: documented quantity in
monthly management meetings
4.2
Indigent committee meets monthly
4.2.1
The Indigent committee meets monthly to review the care for the indigent
category use. Each monthly minutes contain: (i) date of the meeting; (ii) signed
list of participants; (iii) follow-up of decisions taken during the previous
meeting; (iv) there is a list of developed recommendations or decisions taken;
(v) each month the fmonthly financial balance is discussed; (vi) minutes of the
meeting are signed by the chairman. Each report according to norms = 2 p
Total Points (7)
YES
NO
1
0
6
0
../7
xxxx
YES
NO
2
0
1
0
1
0
Remarks
5
Hygiene and Medical Waste Disposal [max 32 points]
5.1
Fence health facility available and well-maintained
5.1.1
Fence exists, can be closed at night and there are no holes
5.2
Availability of a garbage bin in the courtyard
5.2.1
Bin with lid accessible to clients which is not full, one for each ward
5.3
Presence of sufficient latrines/toilets which are well-maintained
5.3.1
One toilet/latrine per 10 beds working flush or water container with sufficient
water
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5.3.2
Floor without fissures with single hole and lid (latrine) or lid with functioning
cover (seating style toilet)
1
0
5.3.3
Recently cleaned toilet/latrine without visible fecal matter
1
0
5.3.4
Door lockable from the inside but not from the outside, super structure with
roofing, without flies (mosquito screening), floor clean
1
0
5.3.5
Functional lighting
1
0
5.3.6
Water container/functioning tap and soap for hand washing available for each
toilet block
1
0
5.3.7
Cleaning schedule next to toilet, and toilet/latrine smells of disinfectant or
deodorant
1
0
5.4
Presence of sufficient showers which are well-maintained
5.4.1
One shower per ten beds
1
0
1
0
1
0
5.4.3
Shower with running water, or container with at the least 20 L of water and
cup for scooping
Door lockable from the inside but not from the outside, super structure with
roofing, without flies (mosquito screening), floor clean
5.4.4
Functional lighting
1
0
5.4.5
Cleaning schedule next to shower and shower smells of disinfectant or
deodorant
1
0
5.5
Waste pit for Health Care Waste is available and according to the norms
5.5.1
Waste disposal pit minimum 2 meters deep, lined with clay, concrete or brick
or plastic, it is fenced and has a bright flag.
5.5.2
The waste pit is a minimum of 15 meters from the health facility, minimum of
50 meters from a household, and 100 meters from a water source
5.5.3
Health Care Waste is not visible (covered by at the least 10 cm of soil or lime)
5.5.4
The health facility maintains a register indicating the date of the creation of the
pit(s), and the location (s)
5.6
Courtyard clean
5.6.1
No waste or medical waste in the courtyard
5.7
Hygienic conditions assured during wound dressing and
injections
5.7.1
Yellow and Red Bins for medical waste with lid and foot pedal, lined
5.7.2
Security box for needles well positioned, and used
5.7.3
Needle cutter available and used
5.7.4
Container/bowl with lid containing disinfectant used for putting used
instruments
5.8
Disposal of Health Care Waste according to National Norms
5.8.1
Waste disposal of non-contaminated waste in Black Bin with lid and foot
pedal, lined
5.4.2
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0
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5.8.2
Waste disposal of contaminated HCW in Yellow Bins with lid and foot pedal,
lined
5.8.3
Waste disposal of organic HCW in Red Bins with lid and foot pedal, lined
5.8.4
Protective gear for personnel managing HCW available; boots, plastic shorts,
thick plastic/rubber gloves and a trolley to transport the HCW
Total Points (32)
../32
xxxx
YES
NO
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
Remarks
6
Curative Consultations [max 27 points]
6.1
Good conditions in waiting area
6.1.1
Sufficient benches and or chairs protected against sun and rain
6.2
Unit fees of drugs displayed to the public
6.2.1
Easily visible, updated, with (i) unit price per item; (ii) price for a standard
treatment of the drug
6.2.2
Drugs are all generics
6.3
Existence of waiting card system with numbers
6.4
Consultancy room in good condition
6.4.1
Walls with durable materials well painted, floor paved with cement without
fissures, undamaged ceiling
6.4.2
Consultancy room and waiting space separated assuring confidentiality
6.4.3
Windows with curtains
6.4.4
Functional door with lock
6.5
Consultancy room (where emergencies are received) has 24/7
light
6.5.1
Electricity or solar light or functioning high pressure kerosene light present
6.6
Consultancies are done by skilled staff
6.6.1
Identification of consulting staff in register
6.7
Consulting staff is well-dressed
6.7.1
Clean blouse with identification tag and shoes (no slippers)
6.8
Correct numbering of registers
6.8.1
Correct numbering and closed at the end of the month
6.9
Service availability 7/7
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6.9.1
Supervisor verifies entries in register for the last three Sundays
6.10
Malaria protocol put on wall and accessible for staff
6.10.1
National protocol for diagnosis and treatment of simple and severe malaria
6.11
Uncomplicated malaria correctly treated
6.11.1
Register see last five cases of simple malaria and review treatment acc
protocol
6.12
Severe malaria correctly treated
6.12.1
Register see last five cases of severe malaria and review treatment acc protocol
6.14
WHO flow diagram for ARI put on wall and accessible for
staff
ARI protocol applied
6.14.1
See last five cases of ARI and review treatment acc protocol
6.13
1
0
1
0
1
0
1
0
1
0
1
0
1
0
6.16
WHO protocol for Diarrhea put on wall and accessible for
staff
Diarrhea protocol applied
6.16.1
See last five cases of Diarrhea and review treatment acc protocol
6.17
Proportion of consultancies treated with antibiotics <30%
6.17.1
See last 100 cases in register, check diagnosis and calculate the rate (< 30
cases)
2
0
6.18
MSF treatment guidelines available in consultancy room
1
0
6.19
Knowledge of tuberculosis danger signs and criteria for
referral
Answer must contain at least 4 of the following signs: (i) weight loss; (ii) loss
of appetite; (iii) fever; (iv) cough of more than 15 days duration; (v) night
sweating
1
0
6.19.1
6.20
Stethoscope and BP machine available and functional
6.20.1
Let nurse check BP and review measure
1
0
6.21
Thermometer available and functional
1
0
6.22
Otoscope available and functional
1
0
6.23
Examination bed for OPD consultations only
6.23.1
Available mattress, non-torn, plastic cover
1
0
6.24
Weighing scale available and functional
6.24.1
Inspect in comparison with known weight of supervisor: after weighing, the
balance should return to zero
1
0
6.25
Integrated Management of Childhood Illnesses strategy is
applied
1
0
6.15
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6.25.1
Protocol is available in the consultation room
6.25.2
The last five IMCI cases are traced in the register and comply with the IMCI
strategy
6.26
Determination of nutritional status
6.26.1
Determination of nutritional status of all children under 5 who come for
consultation
6.26.2
Determination of nutritional status of all women with a sick child under 6
months of age
6.26.3
Screening record of nutritional status available, up to date and properly filled
out
Total Points (27)
1
0
../27
xxxx
YES
NO
2
0
2
0
2
0
1
0
Remarks
7
Family Planning [max 21 points]
7.1
At least one qualified staff trained in Family Planning
7.2
Confidentiality in consultancy room assured
7.2.1
Room with closed doors, curtains at windows or non transparent glass
7.3
Family planning methods available and visible in
demonstration box for potential users
7.3.1
Condoms; OAC; Injectable; Implant; IUD; beads are available in the
demonstration box
7.3.2
Penis model available on the desk; box with condoms available with at the
least 50 condoms
7.4
Staff correctly calculates number of clients expected monthly
for oral and injectable contraceptives
7.4.1
For example for 100.000 population (target is entire LGA catchment pop) =
100.000 * 22.5% * 25%/12 * 4 * 10% (assuming 25% unmet need; 22.5%
fertile women; 10% of oral/inject AC at hospital level)
7.5
Staff correctly calculates number of clients expected monthly
implants and IUDs
1
0
7.5.1
For example for 100.000 population (target is entire LGA catchment pop) =
100.000 * 22.5% * 8%/12 * 4 * 10% (assuming 8% unmet need; 22.5% fertile
women; 10% of implants/IUDs at hospital level)
7.6
Business plan contains strategy to achieve FP targets
3
0
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7.6.1
Collaboration with public sector, private sector and social marketing, mobile
strategies, advocacy among local leaders etc
7.6.2
Involvement of HF staff in strategies
7.7
Stock of oral and injectable contraceptives is adequate
7.7.1
[refine: for example for 100.000 pop 100 doses of oral (3 month cycles) and
injectable methods combined]
7.8
IUD available and staff trained to use it
7.8.1
at least 20 IUDs and at the least one staff trained to use it
7.9
Implant method available and staff trained to use it
7.9.1
at least 20 implants available and staff trained to use it
7.10
FP individual cards available and filled according to the
format
7.10.1
Check at least five cards for BP, hepatomegaly, varices, weight
Total Points (21)
2
0
3
0
3
0
2
0
../21
xxxx
YES
NO
1
0
1
0
Remarks
8
Laboratory [max 10 points]
8.1
Laboratory technician or technologist is available
8.2
Laboratory is open every day of the week
8.2.1
Supervisor verifies the last 2 Sundays in laboratory register
8.3
List of laboratory examinations visible for the public with
fees
1
0
8.4
Results recorded correctly in laboratory register and match
with results in inpatient sheets or OPD examination cards
1
0
8.4.1
Supervisor verifies last five results
8.5
Availability of parasites demonstrations
8.5.1
On plastic paper, in a color book, or put on wall
8.5.2
Blood smear: Vivax, Ovale, Falciparum and Malariae
1
0
8.5.3
Stools: Ascaris, entamoeabae, ankylostoma and schistosome
8.6
Microscope available and functional
8.6.1
functional objectives; immersion oil available, mirror or electricity
1
0
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8.6.2
blades, cover glass, GIEMSA available
8.7
Malaria rapid tests available
8.7.1
At the least 20 tests available in the laboratory; non-expired
8.8
Centrifuge available and functional
8.9
Waste evacuation correctly carried out
8.9.1
Organic waste in a bin with lid
8.9.2
Security box for sharp objects available and destroyed according to waste
disposal guidelines
8.11
Personnel adequately washes dirty pipettes in containers with
antiseptic
Total Points (10)
1
0
1
0
1
0
1
0
../10
xxxx
YES
NO
2
0
8
0
4
0
2
0
1
0
2
0
Remarks
9
In-patient Wards [max 46 points]
9.1
Guard duty roster clearly visible for staff and followed up
9.1.1
Supervisor verifies guard duty's report - names and signatures
9.2
Furniture available and in good state
9.2.1
Each bed has a (i) plastic covered mattress, (ii) mosquito net, (iii) clean sheets,
(iv) night table
9.3
Patient comfort and hygiene
9.3.1
The wards are clean: no debris on the floor; and wards smell of disinfectant
9.3.2
Space between the beds is at the least one meter
9.3.3
Each ward has access to drinking water on the ward
9.4
Light available in each ward
9.4.1
Electricity; solar light or rechargeable battery lamp
9.5
Confidentiality
9.5.1
Women in separate ward from men; the inside of the wards are not visible
from the outside
9.6
In patient register available and is well maintained
9.6.1
check identity and hospital bed days
9.7
In-patient Care Gyn/Obs ward: systematic random sample of 5 patient files
from discharged patients who have delivered from the delivery register from the
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last quarter. Each of the files is subject to the following criteria:
9.7.1
Each patient file meets key standard requirements: (i) full personal data of
patient; (ii) date and time of admission; (iii) mobile phone number; (iv) date
and time of first examination by midwife/Dr; (v) Anamnesis; (vi) Past history
2
0
9.7.2
Clinical examination done (blood pressure; frequency and rhythm of heartbeat;
body temperature; weight; height; respiration rate frequency; assessment of
obstetrical condition
2
0
2
0
1
0
4
0
9.7.3
9.7.4
Justification of clinical diagnosis and elaborate description of obstetrical
proceedings (including post partum hemorrhage; pre-eclampsia; premature
birth etc). Compliance with MSF 'obstetric guidelines'.
Notes on midwife/Dr daily examinations which include clinical examination
9.7.5
Partogram: both sides filled correctly (opening; prolapsus; VE each 4 hours at
the least; frequency and rhythm of heartbeat of mother and child each 30 min
at the least; contractions every 30 min)
9.8
In-patient Care Pediatric ward: systematic random sample of 5 patient files
from discharged patients from the admission register from the last quarter.
Each of the files is subject to the following criteria:
9.8.1
Each patient file meets key standard requirements: (i) full personal data of
patient; (ii) date and time of admission; (iii) mobile phone number; (iv) date
and time of first examination by MD; (v) Anamnesis; (vi) Past history
2
0
9.8.2
Clinical examination done (blood pressure; frequency and rhythm of heartbeat;
body temperature; weight; height; respiration rate frequency; in-depth
examination of affected system
2
0
9.8.3
Scope of laboratory and other examination corresponds to clinical diagnosis
and is compliant with clinical protocols and results of lab tests. Compliance
with MSF 'treatment guidelines'.
2
0
9.8.4
Notes on Drs daily examinations which include clinical examination
1
0
9.9
In-patient Care Surgical ward: systematic random sample of 5 patient files from
discharged patients who had large surgical procedures from the admission
register from the last quarter. Each of the files is subject to the following criteria
(if 0 operations then 0 score):
9.9.1
Each patient file meets key standard requirements: (i) full personal data of
patient; (ii) date and time of admission; (iii) mobile phone number; (iv) date
and time of first examination by midwife/Dr; (v) Anamnesis; (vi) Past history
2
0
9.9.2
Clinical examination done: (blood pressure; frequency and rhythm of
heartbeat; body temperature; weight; height; respiration rate frequency;
assessment of surgical condition; clinical diagnosis and justification)
2
0
9.9.3
Report on surgical procedure and anesthetic method used
9.9.4
Notes on Drs daily examinations which include clinical examination
9.9.5
Registration of post operative infection, if any
2
2
1
0
0
0
../46
xxxx
Total Points (46)
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Remarks
10
10.1
Essential Drugs Management [max 20 points]
Staff maintains stock cards for ED showing security stock
levels = monthly average consumption / 2
10.1.1
Supply in register corresponds with physical supply: random sample of three
ED
10.2
Health facility purchases drugs, equipment and consumables
from the Pharmaceutical Council of Nigeria certified
distributor, approved by SMOH/SPHCDA
10.2.1
Latest Pharmaceutical Council of Nigeria certified distribution center list for
the State available
10.2.2
Last procurement list is shown which shows the certified distributor which
sold the drugs
10.2.2
All drugs and medical consumables are (i) NAFDAC certified and (ii) Generic
10.3
Main pharmacy store delivers drugs to health facility
departments according to requisition
10.3.1
Supervisor verifies whether quantity requisitioned equals quantity served
10.3.2
Drugs to clients are uniquely dispensed through prescriptions. Prescriptions are
stored and accessible
10.3.3
Drugs and medical consumables prescribed, are all in generic form
10.4
Drugs stored correctly
10.4.1
Clean place, well ventilated with all drugs on cupboards, labeled shelves
10.4.2
Drugs and medical consumables stored on alphabetical order, first in - first out
basis
10.5
Absence of out of date drugs or drugs with unreadable labels
10.5.1
Supervisor verifies randomly three drugs and 2 consumables
10.5.2
Out of date drugs well separated from stock
10.5.3
Destruction protocol for out of date drugs available and applied
Total Points (20)
YES
NO
4
0
3
0
10
0
2
0
1
0
../20
xxxx
Remarks
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11
Tracer Drugs (min. stock = Monthly Av. Consumption / 2)
[max 42 points]
Availabl
e YES >
MAC / 2
Availabl
e NO <
MAC / 2
11.1
Paracetamol 500 mg tab
1
0
11.2
Acetyl salicylic Acid 30 mg tab
1
0
11.3
Ibuprofen 200 mg caps
1
0
11.4
Promethazine 25 mg tab
1
0
11.5
Promethazine HCL 50mg/ml vial
1
0
11.6
Oxytocin 10IU/ml vial
1
0
11.7
Methergine 0.2 ug tab
1
0
11.8
Mebendazole 100 mg tab
1
0
11.9
Ferrous Sulfate 325 mg tab
1
0
11.10
Propanolol 80 mg tab
1
0
11.11
Nifedipine 10 mg caps
1
0
11.12
Penicillin V 250 mg tab
1
0
11.13
Amoxicillin 500 mg tab
1
0
11.14
Amoxicillin 200 mg/5ml suspension
1
0
11.15
Ampicillin 1 gr vial
1
0
11.16
Ampicillin 250 mg vial
1
0
11.17
Gentamicin 40mg/ml vial
1
0
11.18
Metronidazol 500mg/100ml vial
1
0
11.19
Co-trimoxazol 480 mg tab
1
0
11.20
Co-trimoxazol 40mg/200mg - 5ml susp
1
0
11.21
Doxycycline 100 mg caps
1
0
11.22
Erythromycin 250 mg tab
1
0
11.23
Co-artemeter 20/120 mg tab
1
0
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11.24
Quinine sulfate 200 mg tab
1
0
11.25
Quinine hydrochloride 300 mg/ml vial
1
0
11.26
Sulfadoxine/pyrimethamine 500 mg tab
1
0
11.27
ORS sachet
1
0
11.28
Condom
1
0
11.29
IUD
1
0
11.30
Contraceptive pill monthly cycle
1
0
11.31
DMPA 150mg vial
1
0
11.32
Contraceptive implant
1
0
11.33
Venflon 18G
11.33.1
Min stock = 10; MAC applies only when higher than 10
1
0
11.34
Venflon 22G
11.34.1
Min stock = 10; MAC applies only when higher than 10
1
0
11.35
IV giving set
11.35.1
Min stock = 10; MAC applies only when higher than 10
1
0
11.36
Ringers lactate 1L
11.36.1
Min stock = 5L; MAC applies only when higher than 5L
1
0
11.37
Dextrose 5% 1L
11.37.1
Min stock = 5L; MAC applies only when higher than 5L
1
0
11.38
IV colloids 500 ml
11.38.1
Min stock = 5 bags; MAC applies only when higher than 5 bags
1
0
11.39
Syringe 5ml
1
0
11.40
Syringe 10ml
1
0
11.41
Needle 18G
1
0
11.42
Needle 22G
1
0
../42
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Total Points (42)
Remarks
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12
Maternity [max 21 points]
12.1
Sufficient water with soap in delivery room
12.1.1
A functioning water source or at the least 20L; soap available
12.2
Light in delivery room 24 hours
12.2.1
Electricity, solar light or rechargeable battery lamp or kerosene lamp filled
with kerosene
12.3
Waste from Maternity correctly handled
12.3.1
Bin with lid and safe needle disposal container
12.4
Delivery room is well-maintained
12.4.1
Walls with durable materials and painted
12.4.2
Curtain between delivery bed and door
12.4.3
Delivery room smells of disinfectant
12.4.4
Floor level cement, without fissures and ceiling not damaged
12.4.5
Windows with curtains and functional door
12.5
Availability and use of the Partogram
12.5.1
At the least 10 forms available for use
12.5.2
Verify three randomly selected partograms whether filled according to the
norms
12.6
Deliveries performed by skilled personnel
12.6.1
Identification of the obstetrician from names in the register
12.7
Availability of scales for weight/length, an obstetrical
stethoscope and an aspirator
12.7.1
Scale to measure height; scale to measure weight (check functionality),
aspirator plunged into a non-irritating antiseptic or functional manual/electric
aspirator
12.8
Availability of a functional vacuum extractor
12.8.1
Plus a nurse trained in its use, and vacuum extractor effectively used
12.9
Availability of at the least 10 pairs of sterile gloves
12.10
Availability of at the least 2 sterilized obstetrical boxes
12.10.1
Content at the least 1 pair of scissors, 2 pliers and one needle holder
12.11
Availability of at the least one episiotomy box
12.11.1
One sterilized box with needle holder, needles, 1 anatomical plier and 1
surgical plier
12.11.2
Catgut and nylon sutures; antiseptic, local anesthetics, sterile swaps
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NO
1
0
1
0
1
0
5
0
1
0
2
0
1
0
3
0
1
0
1
0
1
0
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12.12
Delivery table in good state
12.12.1
Table in two parts with removable non-torn plasticized mattress and two
functional leg supports
12.13
Available equipment for care of the newborn
12.13.1
Sterile tying string or clip for umbilical cord
12.13.2
1% tetracycline eye ointment
12.14
Adequate in-patient rooms
12.14.1
Mattress covered in impermeable plastic
12.14.2
Sheets, blankets and mosquito nets on each occupied bed
Total Points (21)
1
0
1
0
1
0
../21
xxxx
YES
NO
1
0
1
0
3
0
Remarks
13
13.1
Antenatal Care [max 12 points]
Business plan contains convincing strategies to effectively
ensure that at-risk women in the CH/LGA catchment area
reaches the hospital
13.1.1
Strategy includes at least once per quarter a capacity building session with HC
in-charges on RH/FP
13.2
Weighing scale present, functional and calibrated to zero
13.3
ANC form for HF available and well filled in: last five forms
verified
13.3.1
All: Examinations: weight - BP, Size, Parity, Date of last menstruation
13.3.2
All: Laboratory: albuminuria, glucose
13.3.3
All: Obstetrical examination done: Fetal heart rate, Uterine height,
presentation, Fetal movement recorded
13.4
ANC form for HF shows the administration of Ferrous
Sulphate/Folic Acid and Mebendazole
2
0
13.5
ANC cards for mother available: at least 10 in stock
1
0
13.6
ANC register available and well filled in
13.6.1
Complete identity, state of vaccinations, date visit, whether high risk
pregnancy or not/danger signs
2
0
13.6.2
All columns well filled including the identification of problems if any, and
actions taken
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13.7
ANC conducted by qualified personnel
13.7.1
Nurse; midwife CHO or CHEW, verified on ANC cards
13.8
Group IEC/BCC
13.8.1
Group meeting held before FP consultation
13.8.2
Existence of updated IEC report with (a) topic, (b) number of participants, (c)
leader of activity and (d) date and (e) signature
Total Points (12)
1
0
1
0
../12
xxxx
YES
NO
1
0
1
0
1
0
1
0
1
0
2
0
1
0
Remarks
14
HIV/TB [max 10 points]
14.1
Well-equipped HIV counseling room ensuring privacy:
14.1.1
Plastered and painted wall of solid material
14.1.2
Smooth cement floor
14.1.3
Ceiling in good condition
14.1.4
Windows with glass and curtains
14.1.5
Doors that close
14.2
Availability of IEC/BCC material related to HIV
14.2.1
Penis model on the table
14.2.2
A box of condoms on the table which has at the least 50 condoms
14.4
Existence of a VCT/PMTCT councelling register and lab
register acc norms
Staff trained in councelling
14.4.1
At the least one staff trained as a councilor
14.4.2
All councelling done by a trained councilor
14.5
Referral system and follow up for HIV clients
14.5.1
Individual client cards available; planning for CD4 cell counts
14.6
Referral system and follow up for TB patients
14.3
14.6.2
Each AFB PTB patient has a person attached to him/her who supervises
DOTS: proof of in register; mobile phone number of such a supervisor is
registered
[Define further composite criteria]
14.7
Laboratory equipment for testing for PTB
14.6.1
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14.7.1
[Define reagents for AFB testing; stock control cards for reagents; slides etc]
14.7.2
[Define measures for quality assurance testing of slides]
14.8
Availability of anti-tuberculosis drugs
14.8.1
Rifampicine-isoniazide-pyrazinamide : cp120+50+300mg
14.8.2
Streptomycin 1 gr
14.8.3
Etambutol tabs 400 mg
Total Points (10)
1
0
../10
xxxx
YES
NO
Remarks
15
Surgery [max 40 points]
15.1
Blood bank: emergency preparedness
15.1.1
Availability of one transfusion certified staff member
15.1.2
Availability of reagents for grouping and X-matching, properly stored
15.1.3
Minimum 2 units of fresh blood O rhesus negative type, non expired available
15.1.4
Blood stored according to the norms (between 2 to 4C); refrigerator is
functional; has power back up system (functional generator) or kerosene type
with stock of kerosene; temperature measured twice daily
5
15.1.5
HIV, RPR and HepB tests available, and blood stored tested
5
15.2
Sterilization according to the norms
15.2.1
Functioning steam sterilizer available
15.2.2
Sterilizer in separate room from theater
15.2.3
Use of chemical heat indicators
15.2.4
Register for sterilizations used and completely filled
15.3
Minor surgery done in a separate room from the major
surgical procedures
1
15.4
Functioning theater lamp
1
15.5
Functioning theater table
1
15.6
Preparedness
15.6.1
At the least one sterilized major surgery set available, with date of sterilization
indicated on the pack
2
15.6.2
At the least one sterilized CS set available, with date of sterilization indicated
on the pack
2
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2
5
3
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15.6.3
At the least 4 L of Ringers Lactate available in the theater
15.6.4
At the least 2 bags of Colloids available in the theater
15.6.5
Theater smells of disinfectant, and cleaning schedule is available
15.6.6
Nursing/technical Staff trained in anesthesia is presently on duty (at the least
ketamine or spinal)
15.6.7
Nursing Staff trained in theater procedures presently on duty
15.6.8
Qualified Medical Doctor with experience doing CS presently on duty
0.5
0.5
1
2
2
5
Total Points (40)
../40
xxxx
Remarks
No
Service
Max
1
General Management
21
2
Business Plan
13
3
Finance
15
4
Indigent Committee
7
5
Hygiene & Med Waste Disp
32
6
OPD
27
7
Family Planning
21
8
Laboratory
10
9
Inpatient Wards
46
10
Essential Drugs Management
20
11
Tracer Drugs
42
12
Maternity
21
13
ANC
12
14
HIV/TB
10
15
Surgery
40
Total
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P %
337
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Name Team leader Evaluation:
Signature
:
Name Director GH:
Signature
:
Date:
Final
Score:
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Annex 10: Monthly Health Facility Invoice
HEALTH CENTER
Monthly Provisory Invoice for MPA Services
LGA:
Health Center:
Month:
Year:
Service
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Quantity
Produced
Unit Fee
[In
contract]
SubTotal
Naira
New outpatient consultation
New outpatient consultation for an indigent patient
Minor Surgery
Referred patient arrived at the Cottage Hospital
Completely Vaccinated Child
Growth monitoring visit Child
2 - 5 Tetanus Vaccination of Pregnant Woman
Postnatal consultation
First ANC consultation before four months pregnancy
ANC standard visit (2-4)
Second dose of SP provided to a pregnant woman
Institutional Delivery
FP: total of new users of modern FP methods
FP: implants and IUDs
VCT/PMTCT/PIT test
PMTCT: HIV+ mothers and children born to are treated
according to protocol
STD treated
New AFB+ PTB patient
PTB patient completed treatment and cured
ITN Distributed
New family using a latrine during the past month
Grand Total for the month
The current invoice for the month of …………… of ………………………..Health Center is
totaled at [………………………………………………] Naira
Date………….
Names of the members of the HC Management Committee
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The HC in charge:
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NSHIP Performance-Based Financing User Manual
1………………………………………….
2………………………………………….
3………………………………………….
4………………………………………….
5………………………………………….
The Verifier:
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GENERAL HOSPITAL
Monthly Provisory Invoice for CPA Services
LGA:
Hospital:
Month:
Year:
Service
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Quantity
Produced
Unit Fee
[In
contract]
SubTotal
Naira
New outpatient consultation by a Doctor
New outpatient consultation by a Doctor of an indigent patient
Counter-referral slip arrived at the Health Center
Minor Surgery
Major Surgery (ex CS)
Normal delivery
Assisted Delivery
CS
Inpatient Day
Inpatient Day for an indigent patient
Postnatal consultation
First ANC consultation before four months pregnancy
ANC standard visit (2-4)
FP: total of new users of modern FP methods
FP: implants and IUDs
FP: vasectomy and bilateral tuba ligation
VCT/PMTCT/PIT test
PMTCT: HIV+ pregnant mothers and children born to are
treated according to protocol
STD treated
New Client put under ARV treatment
New AFB+ PTB patient
PTB patient completed treatment and cured
Grand Total for the month
The current invoice for the month of …………… of ………………………..Hospital is totaled
at [………………………………………………] Naira
Date………….
Names of the members of the Hospital RBF Committee
1………………………………………….
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2………………………………………….
3………………………………………….
4………………………………………….
5………………………………………….
The Verifier:
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Annex 11: Quarterly Consolidated LGA Invoice
[LOGO]
SPHCDA - SMOH
Consolidated Quarterly LGA PBF Invoice
Second Quarter [ YEAR] - [Date]
No
Health
Facility
April
May
June
1 HC_1
388,377
346,467
332,496
1,067,340
79.1%
211,093
2 HC_2
403,452
343,435
334,022
1,080,909
77.8%
210,291
3 HC_2
209,891
287,376
249,289
746,556
74.8%
139,643
4 HC_4
204,554
225,741
192,657
622,952
68.1%
106,058
5 HC_5
162,569
151,514
140,774
454,857
79.8%
90,687
6 HC_6
364,879
507,704
499,233
1,371,816
78.2%
268,327
7 HC_7
334,246
317,832
301,358
953,436
67.7%
161,321
8 HC_8
278,297
234,197
238,095
750,589
79.1%
148,485
9 HC_9
372,372
396,327
327,466
1,096,165
73.6%
201,612
10 HC_10
199,963
186,571
238,567
625,101
75.5%
117,925
10,506,450 1,293,235
13,503,614 4,147,192
13,077,970
21,847,691
83.9%
76.1%
2,744,412
4,399,855
11 GH_1
1,278,285
Total 4,196,885
Subtotal_Q2 Quality%_Q2
Q_Bonus
Total_Q2
Bank
account
1,278,433 Ac Number
Ac Number
1,291,200
Ac Number
886,199
Ac Number
729,010
Ac Number
545,544
Ac Number
1,640,143
Ac Number
1,114,757
Ac Number
899,074
Ac Number
1,297,777
Ac Number
743,026
Ac Number
15,822,382
26,247,546
Bank name
Bank Branch
Bank Branch
Bank Branch
Bank Branch
Bank Branch
Bank Branch
Bank Branch
Bank Branch
Bank Branch
Bank Branch
Bank Branch
NSHIP Performance-Based Financing User Manual
Present the following quarterly consolidated PBF invoice for [Name] LGA, [Name] State, for the month of July [Year], for the sum total of
twenty six million, two hundred forty seven thousand and five hundred forty six Naira (26,247,546);
Invoice established in one original copy, of which a copy is kept at [Name] LGA PHC department, and the other at the [Name] SPHCDA
Signed: ..................................., the....../......................../ Year
Signed by the SPHCDA
Prepared by the Chairman of the LGA RBF Steering Ctee:
rep:
Last name, first name:
Last name, first name:
Signature:
Signature:
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Annex 12: Performance Framework for the LGA PHC department
No
Indicator/Performance Primary/Secondary Data
Measure
Sources
1
50% of Health Centers
have been supervised at
least once per quarter
Composite Criteria/Validation Criteria
 Supervision Report Exists and is readily
available at LGA/PHC dept.
 At least 50% of all Health Centers have been
supervised during the past quarter, and these
should not include those Health Centers which
have been supervised in the quarter preceding
the evaluated quarter
 These supervisory visits are the formative
visits and are not the same as the Quantity or
Quality Audit visits. The reports should
indicate the dates of visits and, at the least,
summarize the findings/interventions of each
visit.
Supervision Report
Travel Request Form
approved and signed
Travel form co-signed by the
Head of visited facilities
Weight
15
If any criteria not met: 0 points
2
At least two Monthly
Meetings with RBF
Health Centers in the
local Government PHC
Department during the
past quarter
Version document1
Meeting Minutes
Participants List
Each of the two meeting reports need to have the
following criteria:




Date and time indicated
Agenda avalable
Signed Participants list avalable
Discussion on the contents of the past month’s
HC monthly reports using the Printed Monthly
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No
Indicator/Performance Primary/Secondary Data
Measure
Sources
Composite Criteria/Validation Criteria


Weight
HC reports (from the HMIS database
Follow up of recommendations and tasks from
previous meeting
Action points listed with tasks attributed
If any criteria are lacking: 0 points: 5 points per
valid meeting according to the criteria.
3
At least one half hour
training on one specific
topic, during the
monthly HC staff
meetings
In the meeting minutes, a description of the topic as
follows:


Objective of the training
Short Description of the session, referring to
the available national protocol
5
If above criteria are not met: 0 points
4
Monthly HC HMIS
report entered in the
HMIS database and
Report Printed
Version document1
Printed HC HMIS Monthly
Cumulative Report

Printed Monthly HC HMIS Report Available
and Filed in a Specific File
 Original Monthly HC HMIS Reports Available
Data available in the HMIS
and Filed in the Specific HC Files at LGA
PHC department
DB
 All HC HMIS Reports for all HCs in the LGA
Monthly HC HMIS reports
available
(original)
If one or more criteria not met: 0 points
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No
Indicator/Performance Primary/Secondary Data
Measure
Sources
5
Activity Calendar for
the Month is Available
6
Participation in the
Quarterly LGA RBF
Steering Committee
Meetings
The Activity Calendar
LGA RBF Steering
Committee Meeting Minutes
Composite Criteria/Validation Criteria

Monthly Activity Plan is available clearly
describing planned activities with start and
finish dates.
 Activity Calendar for the Current Month is
visible without difficulty on a wall of the LGA
Health Office
If one or both criteria not met: 0 points


Participants List




Version document1
Weight
LGA RBF Steering Committee meeting held
prior to the end of the fourth month.
Provision of secretariat to the LGA RBF
Steering Committee, according to the set
formats for such proceedings
Eventual changes to the minutes of the
previous meetings have been fully
incorporated.
Presentation and discussion of the LGA RBF
Steering Committee’s last meeting minutes.
These had been sent out by email to all parties’
calendar days prior to the meeting.
Discussion and eventual validation of 3
monthly PBF consolidated invoices (one per
month per contracted HC) in the LGA RBF
Steering Committee meeting.
Meeting was held subject to the legal quorum
defined in the LGA RBF Steering Committee
agreement.
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No
Indicator/Performance Primary/Secondary Data
Measure
Sources
Composite Criteria/Validation Criteria
Weight
If one or both criteria are not met: 0 points
7
Quarterly Quality
Performance Evaluation
of all PBF HCs done
HC Quality Performance
Checklists completed
Travel Request Forms Signed
and approved



All HC Quality performances for the past
quarter evaluated before the end of the fourth
month and evaluation completed prior to the
LGA PBF St Ctee meeting, using the
designated Quality Checklists
Correct use of the HC Quality Performance
Evaluation Form (all items filled) including
the recommendation sections
All HC performance evaluation forms
correctly filed in a specific folder.
If one or more of the above criteria are not met: 0
points
(Maximum 100 Points ) Grand Total
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Annex 13: Business Plan for Health Centers
PBF-Business Plan for Health Centers
Version 28 October, 2011
Analysis of results Month 1 – Month 3 [Year] & plan for Months 4 – 6 [Year]
1. GENERAL INFORMATION
LGA………
Health center………………
Population [Year]: ………
Are there sub-contracted private clinics or health posts?
If yes, which? …………………
Yes / no
Qualified staff: ….. Non qualified staff: ….
HEALTH CENTRE STATISTICS
[Years]
Months
OPD
Visits
New
cases
Hospital
bed days
Assisted
Nr of women
deliveries in
using FP (new
health facility + re-attendants)
Nr ANC
visits
Nr ANC
visits
(new)
(standard
visits)
oral (3 months)
& Injectables
2. EXTERNAL CONSULTATIONS
What is the monthly target for OPD consultations in your Ward: ...……………
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(Total population in the Ward catchment area /12)
What are the problems concerning OPD consultancies attending your health center?
Analyze the possible factors such as purchasing power of the population to pay fees, fee payment
per act or fixed fees, competition with other health facilities, lack of medicines, are there remote
villages, is there a lack of qualified personnel, problems with staff motivation. Are there any
other problems?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
What are the strategies proposed to solve the above problems?
Consider increasing qualified staff, outreach strategies, propose new sub contracts with health
posts and/or private clinics, decrease fees, the flat-fee pricing or pricing per activity, discuss
with untrained practitioners how they will stop practicing, involve the local health authorities.
…………………………………………………………………………..……..……………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
3.
REFERRAL OF PATIENTS
What is the target for the referral of the seriously ill patients in your Ward catchment area?
(= population / 12 x 5 %) ...…
What problems do you encounter for referral of seriously ill patients? Is feedback received from
referral centre? How is transport organized? Are patients willing to be referred?
……………………………………………………………………………….……….……………
……………………………………………………………………………………………………..
………………………………………………………………………………………………………
What strategies do you propose to solve the above problems?
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………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
4.
DISTRIBUTION of VITAMIN A (children between 6 and 59 months)
PRE-SCHOOL- CONSULTATIONS (children between 12 and 59 months)
Calculate the number of children between the ages of 6-59 months that should receive each
month a vitamin A capsule in your Ward health area? ...…. = population x 18 % / 12 x 2 caps
What strategies have you developed to achieve the target? Visits to schools, visits to villages,
etc...
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Calculate the number of children each month that should finish six standard visits for preschool
consultations in the age of 12 and 59 months? ...…. = population x 16 % / 4 / 12
What strategies have you developed to achieve the target?
……………………………………………………………..………..………………………………
………………………………………………………………………………………………………
5.
VACCINATION
The target group of children aged less than 1 year is 4.3 % of the population of the catchment
area. The number of pregnancies in the catchment area is estimated at 4.8 %.
Vaccine
BCG
DTP3
Measles
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Nr of children immunized
during the previous 3 months
Target
%
achieved
% To
achieve
during next
trimester
NSHIP Performance-Based Financing User Manual
Fully immunized
children
Fully immunized
pregnant women (TT2+)
Which problems do you encounter in your Ward catchment area?
…………………………………………………………………………….………………………..
…………………………………………………………………………….………………………..
What strategies have you developed to achieve the target?
………………………………………………………………………………………………………
……………………………………………………………………………………….……………..
Which resources will you receive for immunizations from other organizations (UNICEF, other ?)
………………………………………………………………………………………………………
………………………………………………………………………………………………………
6.
DISTRIBUTION of BED NETS
Calculate the monthly target for bed net distribution to be 100% in your catchment area? …..
= The area of health population / 5 years / 12 months / 1.5 people. One bed net has a life span of
5 years and is used by 1.5 persons on average (child with mother – couple)
What was the bed net coverage rate in the previous quarter?
= Number of nets distributed during the last quarter / (catchment area population / 4 quarters /
5 years / 1.5 people) =......... %
What are the problems related to the distribution of bed nets in your health area?
……………………………………………………..……….………………………………………
……………………………………………………………..……….………………………………
What strategies have you developed to achieve the target?
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………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Where do you plan to buy the bed nets?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
7.
TUBERCULOSIS
What are the monthly targets for tuberculosis detection (population / 100,000 x 150 / 12) and the
TB treatment (population / 100,000 x 150 / 12) in your catchment area?
………………………………………………………………………………………………………
What are the problems you encounter with the TB detection and treatment?
………………………………………………………………………….…………………………
…………………………………………………………………………….………………………
What are the strategies you propose to achieve the targets?
……………………………………………………………………….……………………………
…………………………………………………………………….………………………………
…………………………………………………………………….………………………………
8.
New Family Using a Latrine
What is the monthly target for new families using latrines in your catchment area?
…………………………………. Population / 4.6 people per household / 12 months / 3 years
What are the problems to achieve the target?
……………………………………………………………………………………….……………..
………………………………………………………………………………………………………
What strategies do you propose to achieve the targets?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
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……………………………………………………………………………………………….……..
9.
FAMILY PLANNING
Calculate the number of couples (women) who should use per month oral and Injectables FP
methods in your catchment area if we take 22.5 % as the target …………….
New + existing users = population x 25 % / 12 x 22.5 % x 4
How many cases of birth spacing do you think you can reach per month during the next quarter?
……………………………………..……………..
What problems do you encounter concerning the use of oral & Injectables methods in your area
of health?
………………………………………………………………………….…………………………
……………………………………………………………….……………………………………
What are the strategies you propose to achieve the target?
Recruit additional nurses, collaboration with local NGOs, outreach strategies, use private sector
through sub-contracts, social marketing strategies, advocate with local politico-administrative
authorities, opinion leaders, churches, will explain how to deal with side effects.
………………………………………………….…………………………………………………..
…………………………………………………….………………………………………………..
……………………………………………………….……………………………………………..
Where do you obtain the inputs for family planning?
………………………………………………….…………………………………………….……..
Explain your strategies for applying IUD and implants in your catchment area?
……………………………………………………….…………………………………….………..
……………………………………………………….……………………………………….……..
Explain your strategies for tubal ligations and vasectomy in your catchment area in collaboration
with the referral hospitals?
……………………………………………………………..……………………………..…………
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………………………………………………………………………………………….……...……
10.
ANTENATAL CARE
Calculate the target for the number of new antenatal care consultancies per month?
= population x 4.8 % / 12
............
Calculate the target for the number of standard antenatal standard consultancies per month to
achieve the target for pregnant women who visits at least 3 times the standard consultations?
= population x 4.8 % / 12 x 3............
What are the problems concerning the targets and the quality of care in antennal care?
…………………………………………………………………………………………..………….
………………………………………………………………………………………………………
What strategies do you propose to achieve the above targets?
…………………………………………………………………………………….....……………..
…………………………………………………………………………………..….……….………
………………………………………………………………………………………………….…..
11.
DELIVERY CARE AND ABORTIONS
Calculate the rate of coverage of pre-natal assistance in the quarter spent? …. %
= Number of realized births / population x 4.8 % / 12 months
What is the target for your health area?
... Deliveries per month
= Population x 4.8 % / 12 months
What are the problems encountered in your catchment area?
Availability of qualified staff with permanent duty roster? Clean delivery room confidentially
assured, equipment (delivery kit, sterile delivery boxes, vacuum extractors, and suture),
Sterilization procedures (gloves, plastic apron, and disinfection) conditions of hospitalization
(space, ventilation, bed net) existence of Partogram and correct use.
……………………………………………………………………………..………………………
……………………………………………………………………………..………………………
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……………………………………………………………………………..………………………
What strategies do you propose considering the above factors?
Increase qualified staff, buy equipment, change hygiene and sterilization procedures,
rehabilitate infrastructure, training staff, open a new maternity, etc
…………………………………………………………………………………………..…………
…………………………………………………………………………………….………….……
……………………………………………………………………………………………..………
What are the problems concerning unsafe abortions in your catchment area?
Maternal deaths after illegal abortions, cases of pregnancy after rape, lack of access to safe
abortions?
…………………………………………………………………………………………..…………
…………………………………………………………………………………….………….……
What strategies do you propose to solve the above problems?
………………………………………………………………………………………………….…
12.
HUMAN RESSOURCE MANAGEMENT
What remuneration the health facility pays to staff based from different revenues such as
government salaries, cost-recovery and performance subsidies?
[Staff 1] N……….. [Staff 2] N...…….
[Staff 3] N...
Unskilled workers N.....
……………
Is this reasonable related to the needs of the health staff?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
What additional revenues would be required to increase the staff remuneration?
………..
What is the proportion of staff remuneration related to total revenues? ………………………
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Staff categories
Current staff
numbers
Staff required next quarter
Staff 1
Staff 2
Staff 3
Administrative staff
Unskilled medical staff
Cleaners, drivers, etc
Gardeners, security
TOTAL
13.
OTHER RESOURCES
Describe the situation regarding the availability of essential drugs (including for family planning
and bed nets) and how will you improve it during the contract period?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Describe the situation concerning the availability of medical equipment and how will you
improve it during the contract period?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Describe the situation regarding the availability of furniture and office supplies and how will you
improve it during the contract period?
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………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Describe the situation with regard to infrastructure and how will you improve it during the
contract period?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
14.
FINANCIAL PLANNING
Estimate your financial needs based on the above proposed strategies:
Revenues
Past monthly
revenues
Cost recovery (user charges)
Cost recovery (pre-payment schemes)
Salaries from government & other sources
PBF subsidies from fund holder
Contribution from other sources
Other
Cash
Bank balance at the end of the quarter
TOTAL
Expenses
Salaries
Performance bonuses
Drugs and medical consumables
Subsidies for sub-contracts
Cleaning and office costs
Transport costs
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Proposed monthly
revenues new Quarter
xxxxxx
Past monthly
expenses
Proposed monthly
expenses new Quarter
NSHIP Performance-Based Financing User Manual
Social marketing
Infrastructure rehabilitation
Equipment and furniture
Other
Put into reserve
TOTAL
Statement of Quarterly Financial Activities for the past Quarter :
Statement of Quarterly Financial Activities
N_R Revenue Categories
Revenues
1
Cost recovery (user-charges)
2
Cost recovery (pre-payment)
Salaries from Government & other
3
sources
4
PBF Subsidies from fund holders
5
Contributions from other sources
6
Other
7
Cash in hand
Bank balance at the end of the
8
quarter
Total Revenue
N_E
9
10
Quarter/Year:
Expense Categories
Salaries
Performance bonuses
11
12
13
14
15
Drugs and medical consumables
Subsidies for sub-contract
Cleaning and office costs
Transport costs
Social marketing
16
17
18
19
Infrastructure rehabilitation
Equipment and furniture
Other
Put into reserve
Total Expenses
Balance (Total Revenue - Total
Expenses)
Signed at………………………………. the ……./……./[Year]
Signatures:
……………………
………………….
Health Facility in-Charge
Head of SPHCDA Purchasing Unit
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Expenses
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Name:
Copies:
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Name:
Health facility, fund holder and health authority
NSHIP Performance-Based Financing User Manual
Annex 14: Indice Tool for Health Centers
Indice Tool
For Health Centers Contracted by the SPHCDA through Performance Based Financing
Version 25 October, 2011
1. Revenues and Expenses for the Past Quarter: Statement of Quarterly Financial Activities
2. Revenues and Expenses for the Past month and Proposed Monthly Revenues and
Expenses for the Next Quarter
3. Budget for Performance Bonuses; Point Value and monthly Performance Bonus
4. Indice
1. Revenues and Expenses for the Past Quarter (only enter cash revenues and cash
expenses):
Statement of Quarterly Financial Activities
N_R Revenue Categories
Revenues
1
Cost recovery (user-charges)
2
Cost recovery (pre-payment)
Salaries from Government & other
3
sources
4
PBF Subsidies from fund holders
5
Contributions from other sources
6
Other
7
Cash in hand
8
Bank balance at the end of the quarter
Total Revenue
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Quarter/Year:
N_E
9
10
11
12
13
14
15
16
17
18
19
Expense Categories
Expenses
Salaries
Performance bonuses
Drugs and medical
consumables
Subsidies for sub-contracts
Cleaning and office costs
Transport costs
Social marketing
Infrastructure rehabilitation
Equipment and furniture
Other
Put into reserve
Total Expenses
Balance (Total Revenue Total Expenses)
NSHIP Performance-Based Financing User Manual
2. Revenues and Expenses for the Past month and Proposed Monthly Revenues and
Expenses for the Next Quarter
Past monthly
revenues
Revenues
Cost recovery (user charges)
Cost recovery (pre-payment schemes)
Salaries from government & other sources
PBF subsidies from fund holder
Contribution from other sources
Other
Cash in hand
Bank balance at the end of the quarter
TOTAL
xxxxxx
Past monthly
expenses
Expenses
Proposed monthly
revenues new Quarter
Proposed monthly
expenses new Quarter
Salaries
Performance bonuses
Drugs and medical consumables
Subsidies for sub-contracts
Cleaning and office costs
Transport costs
Social marketing
Infrastructure rehabilitation
Equipment and furniture
Other
Put into reserve
TOTAL
3. Budget for Performance Bonuses; Point Value and monthly Performance Bonus
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Budget for Performance Bonuses for next quarter (a)
Naira
Number of Points for all staff for the past quarter (b)
Points
Point value (pv) coming quarter = (a) / (b)
Naira
Maximum point value per month (pm) = (pv) / 3
Naira
Individual monthly performance bonus =
Naira
(% individual performance score (p)) * (individual indice
value (i)) * (pm)
4. Indice
 The indice tool used (a) the maximum point value for each staff member, from his or her
motivation contract; (b) the individual performance evaluation for each staff member and
(c) the point value for the following quarter obtained from section 3;
 Each month of the following quarter, staff is assessed using the individual performance
evaluation (annex 15 of the PBF user manual); the score is recorded in a specific register;
 Indice scores are discussed within the facility management team and presented to the
Facility RBF committee;
 Each month, before the middle of the following month and after vetting by the Facility
RBF committee, staff receives their variable performance bonus;
 Staff who is not in employment at the facility during the month in which the bonus is
paid out, is not entitled to a performance bonus payment;
 Unspent bonus is automatically versed into the reserve fund;
 The facility management in close collaboration with the Facility RBF committee reserves
the right to invest in the facility infrastructure or equipment instead of paying out the
performance bonuses. Such a decision ought to be endorsed by the overall majority of the
staff.
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Indice Monthly_Point_Value %_Perform_Eval
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Family name, first name
Total (b)
(i)
(pm)
(p)
Gross_Bonus
(pb) =
(i)*(p)*(pm)
Taxes
Net_Bonus
(t)
(pb) - (t)
Annex 15: Individual Performance Evaluation Template
Individual Performance Evaluation for Health Staff
Criteria
25% Score
50% Score
100% Score
Max
1 Professional Awareness includes the following: (20 points)
Timeliness
Arrived frequently late
Arrived sometimes late
(at the least four times past month)
(1 to 3 times per month)
Was always on time
8
Availability
Has been frequently absent from his/her Has been a few times absent
service without any clear motive
from his service without clear
motive
(at the least four times past month)
(1 to 3 times per month)
Was never absent from his/her
service without known and
valid motive
8
Uniform
Did not wear a uniform during working
hours
Neglected uniform
(dirty or torn or not ironed)
Uniform always worn and
proper (washed ; ironed and
not torn)
4
(even once per month)
2 Team spirit includes the following: (30 points)
Interpersonal
Relationship
Frequently in conflict with colleagues
(reported more than once to his/her
superior during the past month)
Sometimes in conflict with
colleagues
(reported once to his/her
superior)
Never in conflict with
colleagues
8
Collaborative
spirit
Frequently refused to assist colleagues
when asked
Sometimes refused to assist
colleagues
Never refused to assist
colleagues
8
Score
NSHIP Performance-Based Financing User Manual
Dedication
(more than once per month)
(even once)
Frequently left work unfinished without
somebody taking over under the
argument that official working hours
were up
Sometimes left work
unfinished without somebody
taking over using the argument
that official working hours
were up
(more than 3 times past month)
Never left work unfinished
without somebody taking over
8
Has at least once done
additional work without
supervisor asking him/her to
do so
6
Not always has a daily work
schedule (at least once during
internal supervision)
Always has a daily work
schedule
10
Not always adheres to work
related norms and standards
Always adheres to specific
work related norms and
standards
14
(1 to 3 times per month)
Initiative
Has never done any additional work
Has always awaited a
command from higher up to
carry out additional work
3 Technical Competency and flexibility during work: (40 points)
Organization
Never has a daily work schedule
(assessed during internal work
supervision)
Quality of work Never adheres to specific work related
norms and standards
(assessed during internal supervision)
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(found at least once during
NSHIP Performance-Based Financing User Manual
internal supervision)
Quantity of
work
Never finishes his/her daily work based
on his/her own daily work schedule
(assessed during internal supervision)
Not always finishes his/her
work based on his/her own
daily work schedule
Always finishes his/her work
according to his/her daily work
schedule
16
Always takes into account
recommendations of internal
and external supervisory visits
10
TOTAL POINTS
100
(found at least once during
internal supervision)
4 Willingness and aptitude for personal development : (10 points)
Takes into
account advice
and
recommendatio
ns from
previous
internal and
external
supervisory
visits
Never takes care of such
recommendations
(concluded during internal and
external supervisory visits)
Not always takes care of such
recommendations
(if this happens once or more)
5 Participation to Results and the Past Monthly Performance Score
Participation to Results and the past monthly performance score (quantity and quality)
through presence during working days during the past three months :
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Number of official working
days = (N);
100% P =
NSHIP Performance-Based Financing User Manual
NB: We take into account actual working days without taking into account any valid
reasons for absence such as vacation, leave, sickness, absence through disciplinary action,
formal trainings etc. An exception to this rule are Rest and Recuperation days (allocated by
the health facility management), which, when accorded, are considered official working
days.
number of days actually
worked = (n);
Percentage of days performed
= (P)
(P) = ( n/N) * 100
Result of the individual monthly performance evaluation = (Total of the Scores for items 1 to 4) * P
Prepared at:
Date………………………………...
For the internal performance evaluation team, (Names,
functions, and signatures)
……………………………………………………………………
……………
……………………………………………………………………
……………
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Employee (Name and
signature)
……………………………………………………………………
……………
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Annex 16: Column Headers for PBF Registers
[Available as a separate draft document: not yet inserted as it is being finalized]
NSHIP Performance-Based Financing User Manual
Annex 17: Terms of Reference for the Health Center Health Committee/General Hospital
Governing Board
Health Center:
Health Center RBF Committee
SMOH/SPHCDA
Version 111010
The Health Center RBF Committee has a strong link to the Ward Development Committee
(WDC). Whereas the WDC has been created to oversee all health facilities at the Ward level, the
Health Center RBF Committee, is put in place to function as the governing board of the
contracted RBF facility. The General Hospital RBF Committee will function as the governing
board for the general hospital.
Membership of the Health Center RBF Committee:





The Chair (who is the chairperson of the WDC) or his or her designate;
elect members of the WDC;
Officer in charge of the health center (non-voting member);
One technical staff of the health center (non-voting member);
Headmaster of the school.
Functions of the Health Center RBF Committee:





Discuss the quarterly quantity and quality performance of the Health Center and advice
the Health Center management in areas of possible improvements;
Ensure that the health center management can operate with a reasonable level of
autonomy to reach the objectives agreed upon in the business plan;
Appoint the Indigent committee of the Health Center among its members, and select
community representatives;
The Chair of the Health Center RBF Committee is the co-signatory on the Health Center
Bank account;
The Chair of the Health Center RBF Committee co-signs, conjointly with the in-charge of
the health center, the purchase contract with the SPHCDA;
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




To review and approve the performance appraisal of health facility workers according to
applicable workers’ motivation contracts;
To approve the utilization of income received by the Health Facility (cash from DRF,
PBF and other sources), and in particular the proportion to be used as staff bonus
payments or as infrastructure/equipment investment according to the Purchase Contract
signed between the HF and the SPHCDA;
Discuss and agree on the content of the business plan and related activities in the health
center prior to submission of the business plan for negotiations with the SPHCDA;
Follow up on the implementation of the business plan;
Liaise with the WDC.
Operational Guidelines:
The Health Center RBF Committee shall:





Meet once per month at a date agreed in advance by members;
Record minutes of meetings;
Minutes of meetings shall be signed by the Chairman and Secretary after adoption at
subsequent meetings;
The members of the HC RBF Committee are participating on a voluntary and merit basis,
and apart from government agreed per diems, are not entitled to further compensation;
The quorum for a valid Committee meeting is 3 of its members present and must include
the Health Center RBF Committee chair, its treasurer and the health facility in charge.
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General Hospital:
General Hospital RBF Committee
SMOH/SPHCDA
Version 111011
The General Hospital RBF Committee will function as the governing board for the general
hospital. Its membership and terms of reference are modified to create a better fit between the
new PBF intervention, and the GH-RBF Committee.
Membership of the General Hospital RBF Committee:






Chairperson: a respectable person from the community, appointed by the LGA Chair
LGA PHC coordinator
Chief medical officer (non-voting member)
General Hospital administrator (secretary and non-voting member)
Representative of the traditional ruler
Representative of a women’s group
Functions of the General Hospital RBF Committee:






Ensure that the hospital management can operate with a reasonable level of autonomy to
reach the objectives agreed upon in the business plan;
Appoint the Indigent committee of the hospital among its members, and select
community representatives;
The Chair of the GH-RBF Committee signs, conjointly with the in-charge of the hospital,
the purchase contract with the SPHCDA;
To approve the utilization of income received by the hospital (cash from DRF, PBF and
other sources), and in particular the proportion to be used as staff bonus payments or as
infrastructure/equipment investment according to the Purchase Contract signed between
the hospital and the SPHCDA;
Discuss and agree on the content of the business plan and related activities in the hospital
prior to submission of the business plan for negotiations with the SPHCDA;
Follow up on the implementation of the business plan.
Operational Guidelines:
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The GH-RBF Committee shall:





Meet once per month at a date agreed in advance by members;
Record minutes of meetings;
Minutes of meetings shall be signed by the Chairman and Secretary after adoption at
subsequent meetings;
The members of the GH-RBF Committee are participating on a voluntary and merit basis,
and apart from government agreed per diems, are not entitled to further compensation;
The quorum for a valid GH-RBF Committee meeting is 3 of its members present and
must include the GH-RBF Committee chair, and the CMO.
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Annex 18: Terms of Reference for the Indigent Committee
Terms of Reference
For the Indigent Committee
SMOH/SPHCDA
Version 26 October 2011
The SMOH/SPHCDA is testing a new approach to assist the poorest of the poor to access good
quality medical care in the State PBF program.
This new program will allow health facilities to categorize up to 20% of the curative
consultations of the past month, to be categorized under ‘new consultation by an indigent
patient’ (at the Health Center) or ‘new consultation by a Doctor of an indigent patient’ (at the
General Hospital) categories.
The health facility is allowed to claim a higher reimbursement for this category of care, under the
following conditions:
1. The patient is indeed very poor;
2. The total number per month is limited to 20% of the total new consultations of the past
month (excluding the ‘new consultation by an indigent patient’ category of that month);
3. For the General Hospital an additional special rule applies:
a. For admissions, up to a total of 7 days, the GH can claim one such category for
each admission day;
b. Beyond 7 days up to a total of 15 days, the GH will be cross-subsidizing the care
from other sources of income;
c. Beyond 15 days the GH can claim one such category for each additional day up to
five days;
d. Beyond 20 days, the GH will need to contact the designated SPHCDA Verifier to
discuss this issue.
4. There is a functioning Indigent Committee which oversees regularly the correct
identification of the poorest of the poor;
5. The purchase contract with the SPHCDA is valid for the time period (which also depends
on the correct use of this category);
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6. The health facility continues to provide excellent quality care for these indigents, just
like for any other patient (as measured through the quality checklist and documented in
the business plan);
7. If the care for the individual indigent surpasses the negotiated subsidy for this category;
that the health facility/RBF Committee agrees to cross-subsidize the care for this
individual indigent, from other sources of income.
This new program will be evaluated. Its success or failure to target care to the poorest of the poor
will determine whether it will be expanded, or halted.
The Indigent Committee and the Facility RBF Committee will be extremely important in
representing the voice of the poorest of the poor, and to make this program a success.
The Purpose of the Indigent Committee is:



To ensure that the category ‘new consultation by an indigent patient’ (Health Center) or
‘new consultation by a Doctor of an indigent patient’ (General Hospital) is used only by
the poorest of the poor;
To advocate and raise awareness within the local community of this assistance
mechanism for the poorest of the poor;
To solve problems that may arise with this assistance mechanism.
The Indigent Committee rules are:
1. The members of the Indigent Committee (IC) are appointed by the Facility RBF
Committee.
2. The members of the IC are (4):
 A Chair (a respected member of the local community; not related to a health
facility staff member; not a member of the Facility RBF Committee)
 A Secretary (member of the Facility RBF Committee)
 Two members (appointed from the local community; not related to a health
facility staff member; not a member of the Facility RBF Committee)
3. Gender: the IC membership should have at least a 50/50 representation of women, a
higher representation of women is desirable; a higher representation of men is not
permissible (e.g.: 2 women and 2 men are acceptable; 3 or 4 women are desirable; 3 or
more men are not permissible).
Its proceeds are:

The IC should meet at the least once per month and review and vet the application of the
‘indigent payment category’;
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

Minutes should be recorded in a register and signed by the participants and dated;
Their report should figure in the Facility RBF Committee proceedings.
A Special Note on its Functions:



The IC committee is encouraged to find and apply local solutions to improve the postidentification measures;
Such measures taken will be systematically evaluated, and will inform guidelines in the
larger PBF pilot which will be extended across Ondo, Nassarawa and Adamawa states;
The most innovative and effective solution will be awarded an award and a special
recommendation by the State RBF Steering Committee.
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Annex 19: Indicative Indice Values for Health Center Staff
15 Nov 2011
No
1
2
3
4
5
6
7
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Category of Worker
In-charge
Community Health Officer
(CHO)
Nurses/midwives
Community Health Extension
Worker
Technician
Junior Community Health
Extension Worker
Security/cleaners
Indice Value
90-100
80-90
80-90
60-70
60-70
25-30
10