Transcript Slide 1

Managing for result –
But: not funding for results?
Madrid, 7 June 2011
KIT-Dev,
Jurrien Toonen
[email protected]
Why Management for results:
A contracting approach
For example Ghana:
Per capita expenditure on health in 5 years
from $US 14 to $US 27
Managing for results – Madrid 07-06 2011
Deliveries attended by Skilled Provider
Upper
West
46%
Upper East
47%
Northern
27%
Ghana:
59%
Brong Ahafo
66%
Volta
54%
Ashanti
73% Eastern
61%
Western
62%
Managing for results – Madrid 07-06 2011
Central
54%
Greater Accra
84%
ANC-1
over 90%
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
13%
Central
17%
Managing for results – Madrid 07-06 2011
Greater Accra
22%
35%
unmet
FP-needs
among
currently
married
women
Maternal HealthProblems Accessing Health Care
Managing for results – Madrid 07-06 2011
Why Management for results:
A contracting approach
For example Mali:
(Besides lack of performance): constraints in Governance
of the health system at operational level
Deconcentrated MOH
Managing for results – Madrid 07-06 2011
Local Government
ASACO
A process-approach (1)
Managing for results – Madrid 07-06 2011
Performance/ Results
Based Financing?
Managing for results – Madrid 07-06 2011
Results, e.g. in the DRC (Kananga)
Indicators
Baseline
Expected
results
(objectives)
–
Results
ealuation
PERFORMANCE
utilization ext consultations
0,14
0,35
0,44
Assisted deliveries
0,45
0,60
0,81
Cesarean sections
0,18
0,40
0,54
Referral received at Regional level
0,15
0,20
0,6
Meetings Health Cttee realised
0,6
0,8
0,83
% subsidy received
ND
0,5
0,9
Coverage fully immunized <1 children
0,7
0,8
0,87
ANC coverage
0,7
0,8
0,96
FP coverage
0,1
2
0,19
Availability Essential Drugs
0,75
0,9
0,98
Accessibility
Managing for results – Madrid 07-06 2011
Family planning increased (Burundi)
1200
1000
800
MIKALAYI
600
400
200
0
TSHIKULA
BUNKONDE
Période
Managing for results – Madrid 07-06 2011
ar
s08
av
ril
-2
00
8
r-0
8
m
fé
vie
er
-0
8
ja
nv
i
7No
v
7De
c
10
/0
7
09
/0
7
08
/0
7
07
/0
7
06
/0
7
05
/0
7
04
/0
7
03
/0
7
NDESHA
02
/0
7
01
/0
7
Niveau atteint
Evolution de la planification familiale
KATOKA
KATENDE
Rwanda – Quality of care improved
Source: BTC/CTB Kigali, Werner X
Managing for results – Madrid 07-06 2011
PBF program in Kasai DRC
reduced user fees payments:
Managing for results – Madrid 07-06 2011
PBF, RBF, P4P – the basics
A contracting approach linking motivations and sanctions to:
• Improvement of productivity and quality of services;
• Expected results, negotiated with those to produce these;
• Creating the conditions to perform well;
• Information collection to measure performance.
• Focus on service delivery at operational level
Objectives:
• Increase equity, accessibility, and quality of health care
• Efficient organisation of the services
Managing for results – Madrid 07-06 2011
A process-approach (2)
Managing for results – Madrid 07-06 2011
A provider payment mechanism for
defined quantity and quality outputs.
PURCHASER
Health
Results
Financial
Incentives
PROVIDER
• Contracting providers and pay for desired results after
being achieved (woman delivered in facility,..)
• rather then ex ante funding inputs to carry out activities
(IEC, ….)
• Flexibility of the facility how to use the funds: used to further
improve quantity & quality will result in higher payment next quarter
Managing for results – Madrid 07-06 2011
PBF – the Principles
A. Performance of health services
(1) availability; (2) competence (adequately diagnose …); (3)
responsiveness (respect….); (4) productivity of health
workers/facilities, and (5) information payments
B. Governance through contracting
C. Planning for results (not needs-based)
C. Purchaser – Provider – Regulator split for Checks &
Balances
C. Autonomy in management & planning service providers
E. Managed market principles, competition, demand-side
D. Involvement of the community in managing the services
F. A process approach is needed to adapt to the context
Managing for results – Madrid 07-06 2011
RBF
Generic
Institut.
Framework
Managing for results – Madrid 07-06 2011
Discussion: Technical sustainability issues
 Perhaps most remarkable – facilities do what they should do ….
 Perverse effects?!
 Instruments for PBF developed (procedures, business plan, ….)
 Quality: conditions in place or Q/C indicators?
 Human resources: PBF without right-size, right skills-mix?
 PBF if limited autonomy/ management capacity in the facility?
Managing for results – Madrid 07-06 2011
Discussion: Financial sustainability issues
 PBF and investments – through input financing, or PBF?
 PBF Financial dependency on external funding?
 Local fund holder:
- ‘new’ PBF structure, or building on existing?
- Local Fund Holder: scaling-up to national program?
- Contracting partners?!
Managing for results – Madrid 07-06 2011
Conclusion
 Increasing funding, only, will not lead to better results
 Supporting national level, only, will not either: renewed focus
on decentralized operational level;
 A contracting approach has the potential to improve
performance – if:
 Well-designed to allow for checks and balances
 health planning will be results-based, not needs-based
 focus on demand-side
 degree of autonomy at decentralized level
 Input based funding leads to shopping lists and business as
usual – Results Based Funding links funding to results; but:
 Technical and financial challenges
 Improved results – says who, which indicators for
productivity and for quality of care: who decides?
Managing for results – Madrid 07-06 2011
Muchas gracias por su atención!
Managing for results – Madrid 07-06 2011
Providers more responsive to the needs
Managing for results – Madrid 07-06 2011
Contracting/ RBF Instruments needed
1. Performance framework between contracting partners
2. Business plans of the provider: outlining strategies and
interventions to attain results, how resources will be used
3. Contracts between
• Purchaser and provider
• Purchaser and regulator
• Purchaser and verifier(s)
4. Reporting on results (H/MIS)
5. Verification on reported results
• Quantity outputs (services) in the Health Facilities
• Quality services in the Health Facilities
• Patient tracking at household level
6. Patient satisfaction as part of quality control
7. Payment modalities
Managing for results – Madrid 07-06 2011
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)
Managing for results – Madrid 07-06 2011
Technical Committee (central and regional); and/or
external independent consulting firm
Contracting/ RBF Instruments needed
1. Performance framework between contracting partners
2. Results-based plans of the provider: outlining strategies/
interventions to attain results, how resources will be used
3. Contracts between
• Purchaser and provider
• Purchaser and regulator
• Purchaser and verifier(s)
4. Reporting on results (H/MIS)
5. Verification on reported results
• Quantity outputs (services) in the Health Facilities
• Quality services in the Health Facilities
• Patient tracking at household level
6. Patient satisfaction as part of quality control
7. Payment modalities
Managing for results – Madrid 07-06 2011
Quality of care in RBF
Approaches:
 Patient perspective vs. professional perspective

Ex ante control: accreditation (being in the conditions to provide quality care)

In RBF, more on: Ex post control (quality of care after being delivered)
Interventions to measure quality of care
Assessment against a standard list if criteria (under construction):
•
assessment of the medical records in the facility, collection of routine medical
technical indicators.
•
Have standard operation procedures been respected;
•
patient interviews: Focus Group Discussions/ In depth Interviews/ exit
interviews in the health facility
•
Simultaneously with verification at household level: population based to assess
patient’s satisfaction;
Managing for results – Madrid 07-06 2011
Ex post
Ex ante
Structure
Process
Dimensions of Quality
ofOutput
Care
Leadership
Leadership
principles,
vision on
Leadership
governance
principles,
and
vision on
management
governance
and
of
quality of
management
care
of quality of
care
Employees (HR)
Primary:
- Right skills mix
- Right size
- staffing
- availability of skilled
personnel
- patient centeredness
- Patient safety
- Accountability
arrangements for
individual staff
Means
Secondary:
- Infrastructure
- Instruments
availability
- Funding use
- Maintenance
- Medicines in stock
- Efficient use of
funding
Strategy & policy
Managing:
- HR policies
- Accountability
arrangement
- Standard
operational
procedures
- Timely reporting
- Planning
- Control
- Quality management
- Evaluate
- Act
Appreciation by
patients, e.g.
-
Timeliness
Illegal charges
Continuity of care
availability of
diagnostic and
testing facilities
Appreciation by
patients
-
Appropriateness of
treatment
Health seeking
behavior
Appreciation by
providers
Appreciation by
providers
- Availability of
diagnostic and
testing facilities
- availability of drugs
- care provided
scientifically sound
-
Organizational areas
Feedback loop (evaluation and learning)
Managing for results – Madrid 07-06 2011
Outcome
-
utilization
(coverage)
effectiveness
(wound
infection,…)
Results areas
Assisted deliveries in DRC/ Kananga
Evolution de Accouchements assistés
Niveau atteint
600
MIKALAYI
500
TSHIKULA
400
BUNKONDE
300
NDESHA
200
KATOKA
100
KATENDE
01
/0
7
02
/0
7
03
/0
7
04
/0
7
05
/0
7
06
/0
7
07
/0
7
08
/0
7
09
/0
7
10
/0
7
7N
ov
7D
ec
ja
nv
ie
r-0
8
fé
vie
r-0
8
m
ar
sav 08
ril
-2
00
8
0
Période
350
300
250
200
MIKALAYI
TSHIKULA
BUNKONDE
150
100
50
0
NDESHA
KATOKA
/0
7
7N
o
7- v
D
ja
nv ec
ie
fé r-08
vi
er
m -08
a
av rs-0
ril 8
-2
00
8
/0
7
10
/0
7
09
/0
7
08
/0
7
07
/0
7
06
/0
7
05
/0
7
04
03
02
01
/0
7
KATENDE
/0
7
Niveau atteint
Evolution des références abouties avec documents
Période
Managing for results – Madrid 07-06 2011
Rwanda – Quality of care improved
Source: BTC/CTB Kigali, Werner X
Managing for results – Madrid 07-06 2011