Improving DPS/District
Performance and HSS
via Province/District Sub-Granting
Cathrien Alons
Technical Director, EGPAF/Mozambique
Objectives of Presentation
1. Describe the approach of
decentralized subgrants and HSS
within the context of transition
2. Present experience and examples of
sub-grants in Mozambique
3. Describe EGPAF/Mozambique next
steps to modify sub-grants to
introduce performance payments.
EGPAF Mozambique: Twopronged Transition Strategy
1. Build strong national NGO to
successfully compete for and manage
US funds to support high quality HIV
clinical services.
2. Actively strengthen decentralized
MOH to receive and manage external
funds to provide high quality, costefficient HIV clinical services.
Flow of Funds and Loci of Responsibility in Mozambique
International NGOs (EGPAF)
Donors - Money
USG/PEPFAR
•Money
•Resource stewardship
•Attain and report on donor results
•Mentor
•Procurement, logistics
Bilateral/Budget
GOM -
Systems
MOH
•Human Resources
•Financial
•Information
•Logistics
•Governance
•Assure and improve
Quality ?
• Governance
(Delegations of
authorities, health of
population, quality)
• Financing
(mechanisms,
stewardship of
resources)
• Leadership (Policies)
Ariel Foundation
Provinces –
implement
systems
• Engage personnel
• Supervision
• Logistics
• Coordination
• Local Authority
• Assure quality ?
Districts –
Sites-Providers
• Organization of
services
• Supervision
• HR
• Review of Care
• Service provision
• Assure quality?
Communities Patients
• Demand
• Compliance
• PBF?
4
Mozambique Context:
Highly Centralized
• On-going discussion/delays between governors and
MOH regarding fiscal decentralization.
• Ministry assigns and reassigns health staff to sites.
Broad recognition that HR poorly motivated.
• Ministry approves all professional positions.
Provinces hold employment contracts.
• Partner funds do not reach professional positions.
• Districts and health facilities have no budget
autonomy to buy basic supplies, such as soap.
– All supplies, drugs, consumables depend on central
procurement
– Frequent and significant stock-outs.
Transition Objective 2: Strengthen
decentralized MOH to receive funds to
provide quality HIV clinical services
• EGPAF: from “implementer” to “capacitator” in
2009
• Initiated 54 cost-reimbursement sub-grants ($5.6
million) with provinces and district health
authorities.
• First time districts ever planned budgets,
executed and submitted financial reports.
– 75% of sub-grant spending done by districts
• Very positive feedback from MoH, DPS, DDS
• Strengthened partnership with local government
and ownership of integrated services.
Cost-Reimbursement Sub-Grant
Experience: the First Six Months
• Significant time spent developing sub-grantee financial
capacity (6 months)
• Per diems and travel over-budgeted (50% of budget),
but this spending much slower than supplies and
equipment because very labor intensive.
• Fund management: less than 1% of expenses
disallowed, but management burden heavy, as there
was zero tolerance for non-compliance.
• Spending initially much slower due to GOM and USG
compliance, reporting and other requirements
• Rate of spending has accelerated. Recipients have
deadlines and have started to use funds effectively.
Moving to Performance-Based
Funding - 1
Reasons:
1. Increase absorption of available resources
2. Expand utilization of health services
3. Improve motivation and quality of health services
Goal: Get PEPFAR funds to highest priority: limited, poorly
motivated human resources linked to provision of high
quality and quantity integrated HIV clinical services. =
achieving desired results and outcomes.
Moving to Performance-Based
Funding - 2
• PBF expertise on board.
• Collaborative planning with interested DPSs and
SDSMAS.
• Consultative process to define indicators and
implementation processes
• Include in sub-grants to be amended Dec 2010
• Consistent with the MOH Code of Conduct of NGOs.
• Need to carefully define “results” and payments
• Need to provide simultaneous management, effective
supervision and performance-improvement
training/support.
Renewing Sub-Grants and Adding
Performance Component
• Build on sub-grant experience and strengthened
partnerships, will add direct financing to health facilities
based upon quality and quantity of HIV and primary
care services.
– Will continue input financing for “invariables”, such
as salaries (nonprofessionals), equipment, etc.
• Advantages of “buying outputs”:
– Increasing evidence shows effectiveness of PBF
– Increases focus on performance, including defining,
measuring, improving
– Decreases reporting and compliance burden
– Increases decentralized responsibility of health
facilities to improve performance.
Renewing Sub-Grants and Adding
Performance Component
• Build on sub-grant experience and strengthened
partnerships, will add direct financing to health facilities
based upon quality and quantity of HIV and primary
care services.
– Will continue input financing for “invariables”, such
as salaries (nonprofessionals), equipment, etc.
• Advantages of “buying outputs”:
– Increasing evidence shows effectiveness of PBF
– Increases focus on performance, including defining,
measuring, improving
– Decreases reporting and compliance burden
– Increases decentralized responsibility of health
facilities to improve performance.
Thank You