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…

• 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.

Health indicators in Ghana appear off track and this affects

particularly poor and rural households; i.e.

Northern27%

Volta54%

Ashanti73%

Brong Ahafo66%

Western62%

Eastern61%

Upper West46%

Central54%

Upper East47%

Greater Accra84%

Deliveries attended by Skilled Provider – by Region

Delivery by Skilled Provider by Region

Ghana: 59%

Use of Modern FP Methods by Region

Northern6%

Volta21%

Ashanti16%

Brong Ahafo22%

Western13%

Eastern17%

Upper West21%

Central17%

Upper East14%

Greater Accra22%

Ghana:17%

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

Funding Contracting RelationResults Verification results

Regulation

NHIA

MOH/PPMEOvervie

w CommTechnical

Cttee

HIP

GHS World BankMOFEP (other

donors)

Regional Health

Directorate

Providers(DH, HC, CHPS)

GHSCHAG Private

DHMT DMHIS

DistrictAssenblee

POPULATION

Pregnant Women

CSO/ NGO

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 non-

medical 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

Area Council verification

facilitynegotiation

Community

Representativespatient

s

Provision of care- curative,

- prevention, - promotion

MoHealthpolicies, norms &

standards, resource allocation

Regulation/ DHMT- quality ass/ accreditation- respect norms & standards- training and supervision

MoFinance

Donors

Fund HolderDMHIS/ payer

FundsNHIA

Steering CtteeRegional Coord Council

Perform: productivity & quality

CSO, NGO, Universities verification household

Distr AssContractin

g

Distribution of Roles & Responsibilities

Function Institutions

Oversight at local level

(decision-making to pay)

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:

Patient tracing

Consumer satisfaction

CSO

Counter verification (quantity and quality)

Technical Committee (central and regional); and/or external independent consulting firm

Regions where PBF is being piloted by SNV

Northern

Volta

Ashanti

Brong Ahafo

Western

Eastern

Upper West

Central

Upper East

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 14January 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

Perverse effects – providers have a financial incentive to deliver excess on targeted services

Quality scoring on total package of activitiesKeep 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 sustainableCarrot and stick Future policy making: make part of actual salary performance based.

Integration of vertical programs Local priority settingQuantity indicators selective, quality indicators comprehensive

Community involvement Decisive in local priority setting to make providers responsive to local needs and demand, in agreeing on paymentsNeed to prepare the non-medical actors,

Resilience of the systemFlexibility

If outputs truly answer to local needs and wants of the populationSo, not a model, but approach

Technical sustainability….Social sustainability…

are health workers prepared for more demandAssisting 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)