Transcript Performance-based Finance in Mozambique

Performance-based Finance (PBF) in
Mozambique
Jhpiego’s collaboration with the Elizabeth
Glaser Pediatric AIDS Foundation - EGPAF
PBF initiative
Edgar Necochea, Director Health Systems Development
Jhpiego - an Affiliate of Johns Hopkins University
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The EGPAF PBF initiative in Mozambique
• Implemented by the Elizabeth Glaser
Pediatric AIDS Foundation with funding
from CDC/PEPFAR (AIDS funds)
• Started in 2009 with cost reimbursement
and PBF component in 2010
• Includes approximately 27 districts and 2
provincial directorates of health
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• Jhpiego has collaborated with EGPAF providing
tools for the assessment of the quality
component of the PBF initiative in Mozambique
in two areas: infection prevention and control
and maternal health
• Jhpiego is improving quality of care in these
areas in the country using its Standards-based
Management and Recognition (SBM-R)
approach
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SBM-R in Mozambique
• Infection Prevention and Control (IPC):
implemented nationally in all hospitals of the
country (45) and 82 health centers, with CDC
support
• Model Maternities: implemented in 34 facilities
planned expansion to 122 by 2014, with USAID
support
• Others: Model wards, pre-service education
• Adopted by the Mozambican MOH, key part of
the MOH national quality strategy
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Mozambican MOH Quality Strategy
1. Promote and guarantee the dissemination and
adoption of evidence-based health practices and
standardize healthcare processes with base on these
practices:
a. Update service delivery norms and guidelines working with the
professional and specialty associations.
b. Continue and expand the implementation of the SBM-R approach
currently used in IPC and Model Wards and Maternities.
c. Promote the use of the WHO check-lists as job aids that reinforce
the adoption of evidence-based practices in areas such as safe
surgery and patient safety.
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The SBM-R approach
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• There is significant amount of
evidence on what works in
healthcare, but…
• Many countries are not implementing
even the basic standards of care in
their facilities
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Rand Corporation study, 2003
• 12 cities in the U.S., 6,712 patients
• 439 performance standards for 30 acute and
chronic conditions and preventive care
• Clinical records review plus phone interviews
• Average: 54.9% recommended care (acute:
53.5%, chronic: 56.1%, preventive: 54.9%)
• Range: between 78.8 (cataracts) and 10.5%
(alcohol dependency)
• Gap between best care based on evidence and
average care
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The critical gap
Between:
 What is known
 What is done
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The reality in many low resource
settings
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Few health workers for service provision
Staff overburdened by workload
Poor working conditions, lack of resources
Low motivation of staff
Weak pre-service education, often staff lack
basic knowledge and skills
• Dysfunctional management systems, including
patient records and information
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What we were looking for
Less emphasis on problem analysis and
more focus on providing a solution that is:
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Practical
User-friendly
Informative
Challenging
Fun
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From evidence to action
Systematic reviews of the evidence
(Scientific basis)
Guidelines
(Synthesis of the evidence)
Standards
(Care maps, check-lists)
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The Standards-Based Management and
Recognition Approach
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Sample performance
standard for EOC
Area: Pregnancy Care
Perf. Standard
1. The facility
conducts a
routine rapid
assessment of
pregnant
women
Verification Criteria
Y, N, NA
Comments
Observe in the reception area or
waiting room if the person who
receives the pregnant woman:
• Asks if she has or has had:
- Vaginal bleeding
- Headache or visual changes
- Breathing difficulty
- Severe abdominal pain
- Fever
• Immediately notifies the health
provider if any of these
conditions are present
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Sample performance
standard for IP
Area: Operating Room
Criteria
1. The cleaning
equipment is
processed before
reuse or storage
Verification Means
Y, N, N/A
Comments
Observe if the mops, buckets,
brushes and cleaning cloths are:
• Decontaminated by soaking for
10 minutes in 0.5% chlorine
solution or other approved
disinfectant.
• Washed in detergent and water.
• Rinsed in clean water.
• Dried completely before reuse
or storage.
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Sample summary form of assessment tool for
MNH - hospital
AREAS
STANDARDS
Care for pregnancy-related complications
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Labor, delivery, immediate postpartum and
newborn care
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Support services (lab., blood bank, pharmacy)
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Infection prevention
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Information, education and community
participation
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Human, physical and material resources
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Management systems
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Total
139
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Assessment tool areas for HIV/AIDS ART
AREAS
STANDARDS
ART treatment readiness assessment (adults)
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ART treatment commencement (adults)
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ART treatment follow-up (adults)
ART treatment readiness assessment (pediatric)
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8
ART treatment commencement (pediatric)
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ART treatment follow-up (pediatric)
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Laboratory
9
Pharmacy
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Medical records and information systems
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IEC and community participation
7
Human and physical resources
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Management systems
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Total
173
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Optimizing
100%
Scientific
(evaluation)
Level of
Certainty
Satisficing
60%
Managerial
0%
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Types and uses of measurement
METHOD
STRENGTHS
LIMITATIONS
Measurements using the
Assessment Tool
Simple, data readily available
Limited to process, level of
certainty relatively low
Tracking of selected result
indicators using routinely collected
data
Data often available, relatively
simple, gives information on results
achieved
Data may not be complete, may
take staff time for data collection
and analysis, may require some
training, results may not be
completely accurate
Tracking of selected result
indicators using specially collected
data
Data is more reliable, gives more
accurate information on results
Usually requires a system and
training for data recording,
collection, and analysis, requires
more staff time and dedication
Tracking of selected result
indicators using randomly selected
case and control sites
Level of certainty of results of
evaluation is high
Requires special and careful
design, a data collection and
analysis system and infrastructure,
trained staff, more costly, requires
more time
ACTION
EVIDENCE
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BASELINE
(JANUARY - JUNE 2010)
PROVINCE
HEALTH FACILITY
STANDARDS ASSESSED
FOLLOW-UP ASSESSMENT
(SEPTEMBER - DECEMBER 2010)
STANDARDS ATTAINED
STANDARDS ASSESSED
STANDARDS ATTAINED
No.
No.
%
No.
No.
%
73
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15.1
76
34
44.7
77
19
24.7
65
5
7.7
69
15
22.2
77
29
37.7
77
29
28.7
77
21
27.0
77
35
49.5
61
15
24.6
59
22
37.3
77
32
41.6
66
20
30.3
44
8
18.2
39
6
15.4
77
29
37.7
66
12
18.2
65
34
52.3
42
16
38.1
72
24
33.3
75
45
60.0
60
19
31.7
79
14
17.7
79
10
12.7
65
16
24.6
74
22
29.7
76
27
35.5
73
58
79.5
63
49
77.8
76
42
55.3
79
34
43.0
75
27
36.0
79
51
64.6
62
18
29.0
63
33
52.4
70
21
30.0
59
45
76.3
74
31
41.9
48
26
54.2
62
22
35.5
65
27
41.5
62
24
38.7
62
23
37.1
57
11
19.3
48
9
18.8
56
13
23.2
79
47
59.5
73
18
24.7
66
21
31.8
72
10
13.9
79
53
67.1
Maputo Central Hospital
Maputo City
José Macamo General Hospital
Mavalane General Hospital
Chamanculo General Hospital
Manhiça Health Center
Maputo Province
Matola II Health Center
Boane Health Center
Xai Xai Provincial Hospital
Gaza
Manjacaze Rural Hospital
Chicumbane Rural Hospital
Inhambane Provincial Hospital
Some results
for the Model
Maternities
Inhambane
Chicuque Rural Hospital
Homoine Health Center
Beira Cental Hospital
Sofala
Buzi Rural Hospital
Macurrungo Health Center
Chimoio Provincial Hospital
Manica
1st of May Health Center
Catandica Rural Hospital
Tete Provincial Hospital
Tete
Songo Rural Hospital
Matundo Health Center
Quelimane Provincial Hospital
Zambézia
Mocuba Rural Hospital
Gurué Rural Hospital
Nampula Central Hospital*
Nampula
Monapo Rural Hospital*
Nacala Porto General Hospital*
Lichinga Provincial Hospital
Niassa
Cuamba Rural Hospital
Chihualua Health Center
Pemba Provincial Hospital
Cabo Delgado
Montepuez Rural Hospital
Natite Health Center
* initial evaluation redone, June 2010
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Some results for the Model Maternities
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Some results for the Model Maternities
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Some results for the Model Maternities
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Motivation
• Empowerment
• Challenge
• Growth
• Achievement
• Healthy competition
• Fun
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Recognition as an incentive
• Feedback
• Social recognition
• Material recognition
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The EGPAF PBF initiative
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Components
• Cost-reimbursement (input-based): provider
receives funds based on budget line items,
submits justifications to EGPAF (without
receipts, no payment); approximately 60% of
budget
• Performance-based (output-based): provider is
paid for services delivered (without service, no
payment); approximately 40% of budget
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Functions and entities
• Regulator/Provincial health directorate: monitors
quantity and quality of services, establishes
procedures for usage of PBF funds
• Purchaser/EGPAF: verifies and pays
• Provider/Health facility & District health
department: provides services
• Consumer/civil society: utilizes services, controls
results, and measures client satisfaction
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Quantity indicators
• HIV indicators (50%): PMTCT (4),
Pediatric HIV (5), Care and treatment
program (6)
• Non-HIV indicators (50%): MCH
program/TB/Primary health (6)
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PBF model
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EGPAF –Mozambique PBF model is similar to the
Rwanda model based on price for service
HIV indicators taken from PEPFAR indicators, with
comparatively robust M&E system.
Additional components are the quality tools (IMQ, MM
and PCI) approved by MOH.
Equity bonus (for remote districts)
Patient satisfaction bonus (based on independent patient
satisfaction survey)
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Equity and quality indicators
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Equity factor: 0.20 or 0.25
HIV Quality Index (QI): 0.25
Infection Prevention and Control QI: 0.125
Model Maternity QI: 0.125
Client Satisfaction Index: 0.05
These are percentages of the total amount for quantity
(quality represents 75% of the amount for quantity.)
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Reporting and verification
• Quarterly and semi-annual reports from
beneficiaries
• Verification: Quality tools: quarterly for
HIV(IMQ); Infection Prevention and Control and
Model maternities: semi-annual
• When targets are met for a particular quantity
indicator, it will receive a 4% bonus (of the total
amount for the specific indicator)
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Community verification
• Independent verification of quantity service
data reported by the health facility
• Independent assessment of client
satisfaction
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Equity factor
• For districts that face greater obstacles in
service delivery (lack of investment,
resources, or other constraints)
• Amount to 20 or 25% of the total amount
for quantity x Price(Basis for payment)
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Use of funds
• A minimum of 60% of funds should be
used for health staff incentives
• A maximum of 40% for other activities like
reinvestment in the HF.
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