Performance-based Financing
in Liberia:
Experiences of USAID/RBHS
Richard J. Brennan
Rebuilding Basic Health Services
Rebuilding Basic Health Services Overview
• Largest USAIDfunded health project
in Liberia
– Nov 2008 – Oct 2013
• Overall goal: assist
MOHSW with
implementation of
National Health Plan
• Three pillars
– Service delivery
– Systems strengthening
– BCC
• Service delivery
– Implemented through
performance-based
contracts
Performance-based Financing
in Liberia
Facilities Covered by PBF
• RBHS PBCs
– July 09 – June 11
– 4 NGOs (5 contracts)
– 1 NGO grant; 15
facilities
110
97
USAID/RBHS
MOHSW - CHT
• MOHSW Pool Fund
– November 2009
– March 2010
19
MOHSW NGOs
PBF and RBHS
• Objectives of PBCs
– Service delivery at facility & community levels
– Capacity building of CHTs
• Indicator selection
– Highly consultative
• Determining baselines and targets
– Individualized by NGO
Administrative Indicators
• Reported quarterly; possible penalty
associated
INDICATOR
• # joint and total supervisory visits
• % of timely, accurate and complete HIS
reports submitted to the CHT
• % of staff funded by NGOs paid on time
• # of Community Health Development
Committees meetings held per facility
• Submission of timely and complete
quarterly report to RBHS
BASELINE
TARGET
Performance Indicators
• Reported quarterly: annual performance
bonus (year 1); quarterly bonus (from year 2)
INDICATOR
BASELINE
TARGET
• % of priority facilities reaching one-star level in accreditation survey
• % of facilities with no stock-out tracer drugs
• % of patients receiving no more than 3 drugs
• % of children under 1 year who received DPT3/pentavalent-3
• % of children under 5 years with malaria who are treated with ACTs
• % of pregnant women provided with 2nd dose of IPT for malaria
• % of deliveries that are facility-based with skilled attendant
• Number of people tested for HIV and received their results
•Couple-years of contraceptive protection provided by RBHS-supported
facilities
PBF Management:
Verifying data
• Process
– Quarterly
– Random selection of 3 facilities per NGO
– Cross check reports with ledgers / records
• Challenges
– Definitions, e.g. supportive supervision
– Reporting issues, e.g. ORS, ACT
– Discrepancies between facility reports and
ledger reviews by RBHS
PBF Management:
Verifying Data
• Progress: Quarter 1 to Quarter 6
– Clarification of definitions
– Data verification instituted by NGOs
– Fewer discrepancies
• Results
– Increased capacity in data management –
facility and NGO staff
– Improved data quality
– Improved understanding and use of data
PBF Management:
Feedback & Communication
•
•
•
•
•
Monthly all-partner meetings
Quarterly data reviews – all partners, MOHSW
Quarterly partner feedback
Annual stakeholders’ meeting
Others
– County Coordinator reports
– Ad hoc meetings
– Field visits
Targets met (of 14)
RBHS Partners‘ Performance on PBF Indicators, by
NGO, Oct-Dec 2010
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
5
5
Administrative
(of 5)
Service delivery
(of 9)
3.9
3
3.5
4
9
6.0
3
8
5
5
3
6
Distribution of
Performance Bonuses
• Frequency
– Year 1: Annual bonus
– Year 2: Quarterly
bonus
• Incentive systems
determined by NGO
partner, CHT, and
health staff
• Distributed at all
levels
–
–
–
–
CHT
Facility
Community
NGO staff
Distribution of
Performance Bonuses
AFRICARE
EQUIP
IRCLOFA
IRCNIMBA
MTI
70%
41%
19%
35%
38%
-
19%
69%
50%
-
CHT staff
14%
4%
12%
15%
8%
CHT office
upgrades
-
3%
-
-
11%
NGO staff
16%
24%
-
-
21%
NGO office
upgrades
-
-
-
-
19%
Community
-
6%
-
-
-
Awards &
ceremonies
+
2%
+
+
3%
Facility staff
Facility upgrades
Proportion of pregnant women
Maternal health, RBHS-supported Facilities
Jul 2009-Dec 2010
100%
• IPT2 = 132% increase
90%
80%
70%
60%
50%
40%
30%
IPT2
20%
10%
0%
•Facility deliveries = 189% increase
Facility deliveries
Malaria Treatment, RBHS-supported Facilities,
Jul 2009-Dec 2010
16,000
14,000
Number of children U5
12,000
10,000
8,000
6,000
Malaria
4,000
2,000
0
ACT
EPI, RBHS-supported Facilities, Jul 2009-Dec 2010
120%
% children U1 vaccinated with penta-3
100%
80%
60%
40%
20%
0%
1,000
900
5,000
800
700
4,000
600
3,000
500
400
2,000
1,000
300
FP counseling
CYP
200
100
0
0
CYP rise: health fair, refugee influx,
implants
Couple-years of protection
Number of FP counseling visits
6,000
Support to MOHSW
• Selection and harmonization of national
indicators
• Determination of preliminary baselines and
targets
• Development of PBC payment plan and
tool
Lessons learned
• Need precision in indicator definitions
• Importance of flexibility and leniency in
setting targets and assessing progress
• Value of validation process in building
capacity
• Annual payment of bonus too infrequent
• Need to provide more guidance on
bonuses
Future directions
• Improve data collection with new HMIS
• Involve CHT members and facility staff
more in tracking PBF
• Introduce facility feedback tool
– Graphs of last 12 months’ data updated
monthly
– Posted at each RBHS facility and updated
monthly
Future Directions
• Support to MOHSW on PBF
– Develop PBF database (national and
country level) with MOHSW
– Conduct costing of PBF program
(management costs and future extension)
– Development of the national PBF
procedures manual
– Development of PBF M&E and verification
manual and tools