REPUBLIQUE DU BENIN
-----------Fraternité- Justice- Travail
-----------MINISTERE DE LA SANTE
Performance-Based Financing in
Benin: status and perspectives
Workshop « West-Africa» organised by Performance-Based Financing
Community of Practice
Sénégal 18th and 19th March 2011
Alphonse AKPAMOLI, focal point Bénin
Maud JUQUOIS, World Bank
Country specific constraints

Benin context: political stability for nearly 20 years

Health sector context




Inputs globaly adequate (geographical accessibility and
availability of health workers). No major cultural barrier to
access health services: rate of assited delivery very high
(80% in 2006, DHS)
Availability of drugs and equipment remains insufficient and
high prices.
Neonatal and maternal mortalities (MM: 397/1000 in 2006)
decrease slowly
Weak quality of care seems to be the main barrier
2
Human Resources for Health
environment

Revenues of health workers seems low in Benin,
even if it’s possible that bonuses compensate this
situation and that salary structure is adequate.

Bonuses scheme is not linked to performance

Accountability mechanisms of health workers are
very weak (lack of governance): absenteeism,
corruption, drug pilfering, dual job holding and
unresponsiveness to patient needs.
3
Salary at beginning and end of carrier in 4 countries
600000
Medecins generalistes
500000
Infirmiers (IDE)
Sages-femmes
400000
300000
200000
100000
0
debut
fin
BENIN
debut
MALI
fin
debut
fin
NIGER
debut
fin
COTE D'IVOIRE
Source: séminaire RHS de Cotonou (2008)
4
How to improve efficiency,
accountability and governance?
 Solutions
to improve health system
performance:

Give more power to patients/clients

Strengthen health workers motivation

Increase revenues and autonomy of health
facilities
Benin contracting experience: are they
payment for results?

Three experiences:

Performance contracts with 3 health districts
(Banikoara, Aplahoué, sakété):



Experience with Ménontin:



Agreement on PTA and commitment from MoH to pay
some expenditures and train actors on results
Problems to tranfer the funds and actors’ motivation
Public-private partnership,
But not result-based payments.
Ongoing experience in health district of Come
(CTB)
RBF pilot scheme: main features
Supply strengthen with focus on quality
and utilization (equity) of health services
(specifically maternal and child services)
 With a community component for
monitoring
 Capacity building with international
expertise, with an independent control role
 Implement the reform in 8 pilot health
districts (out 34), WB grant.

7
8
Benin RBF pilot scheme (1/5)
•
To continue contracting experience with health
districts:


Contracts between MoH and HF in the 8 pilot health districts
: all public and private not for profit HF, health centres and
hospitals.
Fees for health services (18 indicators) focused on maternal
and child health , and quality adjustment (checklist),
quaterly payments
•
RBF unit to pilot the process inside MoH
•
International Technical Assistance for training and
data control with capacity transfer, and 1 technical
assistant in each RBF health district.
Benin RBF pilot scheme(2/5)
A propice environment for Result-based
management :
•
An increased autonomy for
stakeholders: facilities (CSA, HZ, CHD)
free to buy drugs and small equipments
•
An appropriate flow of funds
•
An intense communication with health
staff and population
Benin RBF pilot scheme (3/5)
Control and verification mechanisms:
Measurement
When ?
Quantitative
indicators (18)
Qualitative
indicators
(check-lists)
Monthly
Quaterly
Control
By who?
Health faciliy team
When ?
By who?
Monthly
Consistency check :
EEZS and “district
controller”
Quaterly
Verification : community
based organizations.
For HC : EEZS and Every 6 months
« district controller » (random sample and
For hospitals : peer unannounced visits)
review and « district
controller »
Verification:
Community based
organizations and
« district controllers »
Benin RBF pilot scheme(4/5)
ACTIVITES
ACTIVITÉS
TRIMESTRIELLES
6. Allocation du
5. Paiement du
ACTIVITE
SEMESTRIELLE
crédit FBR
crédit FBR
4.
7. Dépenses sur
Détermination
le crédit FBR
8. Contrevérification
qualité
du montant du
ACTIVITES
ANNUELLES
ANNUELLES
crédit FBR
9. Audit
3. Mesure et
comptable des
vérification des
dépenses FBR
résultats FBR
1. Négociation
2.
du contrat FBR
Communication
sur les contrats
FBR
12
Benin RBF pilot scheme (5/5)
Motivating rewards
• Significant amount


•
around 200 millions FCFA (3.8 MioUSD) by
district by year
Depending on results
Some freedom to use RBF credit, but
without creating individualism


A part of the credit is for staff incentives, the
other part to buy small equipments, drugs, IEC
activities…
Staff bonus is proportional to the worker index
(with a weighting in favor of small salaries)
Impact evaluation of RBF Benin pilot scheme



Research questions: RBF or additional budget
unconditionned with results? Importance of health
facilities’ management autonomy
Thus, two interventions in cross-design:
 4 groups of HF(T1-2-3 et C1) and an additional
control group(C2), without additional budget.
 Identification in the 8 districts, with random
allocation of facilities between the 4 groups
Baseline survey : health facility survey, staff
survey, households survey, with diversified tools.
14
Impact Evaluation Design
ADDITIONAL FUNDING FOR HEALTH FACILITIES ?
YES
MANAGEMENT
AUTONOMY
FOR HEALTH
FACILITIES ?
NO
NO
YES
CONDITIONAL
ON RESULTS
(RBF)
YES
BUT NOT
CONDITIONAL ON
RESULTS
T1
T2
(500 HH
and 50
HF)
(500 HH
and 50
HF)
T3
C1
C2
(500 HH
and 50
HF)
(500 HH
and 50
HF)
(500 HH
and 50
HF)
15
Project Causal chain
Project
Development
Objectives
1. Increase coverage
of quality maternal
and neonatal services
2. Strengthen
institutional capacity
of the Ministry of
Health
Intermediate
Outcomes
Objectives
Health System
Strengthening
Objectives
Project
Components
1.1. Improve quality of
maternal and neonatal
health services for the
whole population
Stronger accountability
of health facilities and
health workers
1. Result-Based
Financing
(IDA and Norwegian
funding)
1.2. Equitable utilization
of maternal care
services
Enhanced financial
accessibility to health
services
2. Reform of the Health
Equity Fund and health
card implementation
Evidence-based,
comprehensive and
decentralized processes
for planning, budgeting
and management
3. Strengthening of
planning, budgeting and
management processes
2.1. Improve allocation
of government budget
across districts and
facilities
2.2. Prepare SWAp
implementation
16
Implementation agenda/Work plan

Impact Evaluation:

Baseline survey:






Dec 2010-Mach 2011
Questionnaires tested
Surveyors trained (began 1st Nov)
Follow-up survey No.1: Oct-Dec 2011
Follow-up survey No.2: Oct-Dec 2012
Cost effectiveness analysis (2011)
RBF Program :


Effectiveness :
Launch:
31 March 2011
April 2011
17
RBF Perspectives in Benin

RBF Norway and World Bank(4 years )





World Bank: 7 millions USD
Technical partnership


Norway: 11 millions USD
World Bank(8ZS), CTB (5 ZS), 4 ZS with GAVI
and 17 ZS with GF, so 34ZS/34ZS covered with
experience sharing (tools et results)
World Bank and UNICEF: traning support, drugs
and equipements
(Agreement letter between partners)
Complement with other partners (GAVI, GF)
Benin State
Questions

Technical sustainability:
How can it be effectively ensured through knowledge
transfer activities (transfer with progressive
reduction of TA)?

Could RBF Financial sustainability be
reached when donors will stop their
support? (RBF cost will be US$1.3/hab; for the government,
it would represent 10.1% health budget)

How to ensure effective monitoring
with a local NGO?
19
Ensemble nos pays, avec la communauté
internationale, le rêve sera une réalité