RBF Approach
Results Based Financing
in
Ghana:
About getting started
Rita Tetteh-Quarshie
Rtetteh-quarshie@snvworld.org
Presentation
•
Background of health situation (MCH) in Ghana
•
Planned pilot and implementation of PBF in Ghana by WB
•
The Wapuli case
•
Way forward
Health spending did increase…
•
Recently, Ghana reached a middle income status
•
In Ghana health financing is close to reach Abuja Target for
health spending (=15% of total government expenditure)
•
The per capita expenditure on health has grown from a level of
$6.7 in 1996 to $13.5 in 2005 and $27 in 2008
•
Around 93% of the government contribution is used to pay for
salaries, limiting funding available for services and infrastructure
•
This is a result of the 2006 salary increase – about triplication
- which was not performance based
But performance is off track…
Health indicators in Ghana appear off track and this affects
particularly poor and rural households; i.e.
• U-5 mortality is 80 deaths per 1,000 live births, with 90
in rural and 75 in urban areas.
• Infant mortality rate is 49 per 1,000 live births in urban
and 56 in rural areas.
• The ’08 Ghana Maternal Health Survey estimates
maternal death (MMR) at 451 per 100.000 live births.
Deliveries attended by Skilled Provider – by Region
Delivery by Skilled Provider by Region
Upper East
Upper
West
46%
47%
Northern
27%
Ghana:
59%
Brong Ahafo
66%
Volta
54%
Ashanti
73% Eastern
61%
Western Central
62%
54%
Greater Accra
84%
Use of Modern FP Methods by Region
Upper
West
21%
Upper East
14%
Northern
6%
Ghana:
17%
Brong Ahafo
22%
Volta
21%
Ashanti
16% Eastern
17%
Western Central
13%
17%
Greater Accra
22%
35%
unmet
need
among
currently
married
women
Maternal Health- Problems Accessing Health Care
Reforming the Health System of Ghana?
•
Overall consensus: “no copy & pasting of the Rwanda model”
 Governance institutions and “rules of the game” do exist
 Governance structure is complex, preferably no new institutions
 Existing funding channels, etc
•
So, adapting to the existing Ghanaian context – but how?
•
Hesitation at Central level to kick-off:
 Agree on the principles – but how to implement them in Ghana?
 Sustainability: macro-economic implications?
 Again top-up of salaries health staff through RBF?
 We have already an ex-post provider payment mechanism, NHIS
 Again another reform?
 Assisted delivery is already free of charge
Opportunities and threats to start-up RBF
• Opportunity: existing, functioning governance structures
 Like NHIA: already a purchaser with a verification function
(quantity and quality of services)
 Most facilities already accredited (Q/C)
 District Assembly is already (by law) in charge of health
• Threat: the same existing governance structures
 Resistance to change the “enterprise culture” and power
relations in institutions as well as in individuals
 Changing the “rules of the game” will not be easily
 Actually no clear-cut functional split of functions existing
 Deconcentrated system – complicating checks & balances
National RBF program (MOH/ WB))
• Preparatory activities: Aide Memoire and Concept Note
ready to be signed (March)
• Pre-pilot (2011) to inform pilot (2012 - 2013) in Eastern
and Northern Regions
• Pre-pilot (500 K): regional program to prepare actors
 Supply-side and demand-side incentives
 Situational analysis, legal and financial-amin issues,
 Bottleneck studies household, facility, Local Govt
 Instrument development
 testing payments in 1 district (ER, E Akim), 1 in NR?
• Pilot (11,5 Mio + 1 Mio for Impact Evaluation):
 All districts in NR and ER: 240 Facilities
Institutional Framework in Ghana – hypothesis WB
MOH/PPME
Overvie Technical
w Comm
Cttee
GHS
NHIA
World Bank
MOFEP (other
HIP
donors)
Regional
Health
Directorate
DHMT
DMHIS
CSO/
NGO
Providers
(DH, HC, CHPS)
CHAG GHS Private
District
Assenblee
Pregnant
Women
POPULATION
Funding
Results
Contracting Relation
Verification results
Regulation
Operational research: How to introduce
RBF in Ghana (SNV/KIT experiences)
•
Step 1: Regional workshops to identify need and common vision
•
Step 2: Situational analysis on baselines
•
Step 3: Workshops to identify and match priorities from medical and nonmedical actors to agree on institutional framework (to be tested)
•
Step 4: Assist health facilities to develop results-based action plans on
identified priorities
•
Step 5: Negotiation on contract (and agree on incentives, which may come
out of existing funds)
•
Step 6: Implementation (3 months cycle), evaluation and learning,
payment of incentives, renegotiation of contract
step 6 : Performance Based Financing
step 5: contracting approach
step 4 : develop results-based action plans at health centres & community level
step 3: Identify matching priorities
step 2 : situational analysis and training non-medical partners to anlyse data
step 1: joint understanding of need to develop alternative institutional performance framework
RBF-institutional framework, hypothesis SNV/KIT
Donor
s
MoHealth
policies, norms &
standards, resource
allocation
MoFinanc
e
Funds
NHIA
Steering Cttee
Regional Coord Council
Fund Holder
DMHIS/ payer
Distr Ass
Contractin
g
Regulation/ DHMT
- quality ass/ accreditation
- respect norms & standards
- training and supervision
Area Council
verification
facility
negotiation
Representatives
Community
patient
s
Perform: productivity &
quality
Provision of care
- curative,
- prevention,
- promotion
CSO, NGO, Universities
verification household
Distribution of Roles & Responsibilities
Function
Oversight at local level
(decision-making to pay)
Institutions
Committee composed by: (i) District Assembly (Chair),
DMHIS, DHMT, CHAG, CSO and CHAG
Purchaser (contracting)
District Assembly: District coordinating director to sign
contracts with health facilities (HC & HP and District
hospital)
Verification Quantity of
services in health facility:
District Health Insurance Scheme (technical personnel for
quality assessment will need to be determined)
Verification Quality of Care
in health facility:
District Health Insurance Scheme and CSO
Verification household level:
CSO

Patient tracing

Consumer satisfaction
Counter verification (quantity
and quality)
Technical Committee (central and regional); and/or
external independent consulting firm
Regions where PBF is being piloted by SNV
Upper East
Upper
West
Northern
Brong Ahafo
Volta
Ashanti
Eastern
Western Central
Greater Accra
Intervention methodology
•
Lessons learning from experiences elsewhere
•
Define the building blocks for CA/ PBF in other contexts;
•
Site-visits to develop and adapt the working hypothesis with
future local contracting partners at the operational level;
•
defining the institutional framework for the CA/PBF;
•
development of instruments – contextualizing those
developed for elsewhere (Rwanda, Mali, ….)
•
Supporting Local Capacity Builders
(NGOs) to support local
actors to take up their future contracting roles;
•
Negotiation between contracting actors
•
Developing results-based action plans
The case of Wapuli sub-district
• Understanding performance and quality management, current theory
and global practice
•
PBF Introductory workshop at Saboba District: DA,CSOs, NHIS,DHMT,
Providers
•
Health baseline data was presented to stakeholders, put into result chain
•
Issues prioritized for the sub-district health team to work on were:
-Skill delivery
-ANC4+ attendance
-Family planning.
-Malnutrition
•
Issues were confirmed at a community durbar at a health sub-district.
Some results (process)
• Training SNV health advisors and LCB
• Institutional framework for RBF developed:
 Who will purchase, verify, etc?
• Measures taken by the clinic to increase outputs:

Formation of steering committee by the community to help in educating
other community
 A system for compensating TBAs for bringing referring pregnant women to
the clinic for delivery (instant and annual)
 The clinic now opens everyday for ANC and FP activities and the staff work
beyond their working hours.
 Though slow but the traditional leaders are taken measures to release
pregnant women to the clinics.
Results
Months
ANC Registration
ANC Attendance
Delivery
2008
2009
2010
2008
2009
2010
2008
2009
2010
September
59
83
87
269
194
279
15
13
13
October
86
62
56
253
118
222
9
13
20
November
75
66
86
260
207
246
14
7
14
December
33
89
90
181
203
284
5
7
14
January
11
77
239
15
Next steps….
• Further training of NGOs to support actors
• Preparing non-medical actors: holding providers to
account on results
• Preparing medical actors: being creative and
innovative to achieve results (enterprise culture)
• Tools development (like verification: mHealth?)
The approach leaves ‘room’ to address some known
challenges during the process
Potential challenge
How these are mitigated, if RBF is applied as an
approach
Quality scoring on total package of activities
Perverse effects – providers have a financial
incentive to deliver excess on targeted services Keep contracting cycles short (so excesses can be identified soon)
Equity/ inclusivenss – how to ensure access for
the most vulnerable
Women, PWD etc, should be included.
Sustainability (financial)
Understanding the national context. In Ghana using RBFincentives to
top-up already high salaries would not be sustainable
Carrot and stick
Future policy making: make part of actual salary performance based.
Integration of vertical programs
Local priority setting
Quantity indicators selective, quality indicators
comprehensive
Community involvement
Decisive in local priority setting to make providers responsive to local
needs and demand, in agreeing on payments
Need to prepare the non-medical actors,
Resilience of the system
Flexibility
If outputs truly answer to local needs and wants of the population
So, not a model, but approach
Technical sustainability….
Social sustainability…
are health workers prepared for more demand
Assisting clinics in developing ‘results-based action plans)
Questions to the audience….
• How to finance scaling-up to national level ?!?
• Assessing cost-benefit of increased transaction-costs?
• Pay for results: to top-up of salaries – or to invest in
conditions quality of care and « indirect costs »?
• Ho to avoid the “vertical” and “centralistic” approach
of RBF (focusing on MDG4,5)