Evolving Health Strategies

in South Sudan…..

and the role of

“Performance Based

Incentives”

A Distorted Model…..A Faulty Strategy

County Payam

Population Facility

RRHP

Class

Drug

Cate

gory

2012

Support

Akobo Alale 4,541 Old Akobo PHCU PHCU 139 PRDA

Barmach 27,151 Yidit PHCU PHCU 212 IMC

11 phcu Dilule PHCU PHCU 124 PRDA

3 phcc Akobo Hosp CH 494 IMC

1 ch Buong 10,195 Buong PHCU PHCU 180 IMC

Nukta Thoklial PHCC PHCC 220 NHDF

Thuokwath PHCU PHCU 148 NHDF

Diror PHCU PHCU 200 IMC

Kaikuiny PHCC PHCC 206 NHDF

Tangyang PHCU PHCU 160 IMC

Burmath PHCU* PHCU 150 PRDA

Chiban PHCU PHCU 129 PRDA

Kony ( Meer )PHCU PHCU 150 NHDF

Lange PHCU PHCU 168 PRDA

Walgak 6,613 Walgak PHCC PHCC 312 IMC

Ayod Ayod 17,389 Ayod PHCC PHCC 252 COSV

Korwai 16397 Korwai PHCU PHCU 63 MoH

11 phcu Haat PHCU PHCU 100 MOH

2 phcc Kuachdeng 11,488 Kuachdeng PHCU PHCU 130 SWIDAP

Mogok 11,461 Kandak PHCU PHCU 120 MoH

Mogok PHCU PHCU 171 MoH

Pagil 26,296 Menime PHCC PHCC 140 MoH

Pagil PHCU PHCU 140 SWIDAP

Pajiek 34,489 Canal PHCU (Ayod) PHCU 102 MoH

Gorwai /Kalel PHCU PHCU 106 MoH

Pajiek PHCU PHCU 128 SWIDAP

Wau Jiech PHCU PHCU 123 MoH

Wau PHCU PHCU 129 SWIDAP

Dengjok

18,754

Diror

14,605

Nyandit

27,863

34,678

Bilkey 39,116

A Better Model!

MOH

Directors

DIFID

Donor

Crown Agents

Lead Agent

EE

NB

WB

UN

WA

LK

SMOH

CARE, Merlin, UNIDO, etc.

CHD/NGO

USAID

Donor

JHPIEGO

Lead Agent

CE

WE SMOH

IMC, ADRA, NPA etc.

CHD/NGO

World Bank

Donor

IMA

Lead Agent

JG

UN SMOH

CARE, IMC, SAVE, etc

CHD/NGO

Restructuring Principles

Principle #1_____

• One Donor Per State

• One Fund Manager Per State (IMA, JHPIEGO, CA)

• One Lead “NGO” Agent per County (CARE, IMC, ..)

Dangaji PHCU PHCU RI

Liang PHCU PHCU RI

Bunj RI PHCC PHCC RI

Bouny CH CH RI

Gesm Allah PHCU PHCU RI

Shetha PHCU PHCU RI

Thouyege PHCU PHCU RI

Jamum 7,345 Jamam PHCC PHCU RI

Nila PHCU PHCU RI

Bugaya PHCU PHCU RI

Poumki PHCU PHCU RI

Tonkayo PHCU PHCU RI

Doro PHCC PHCC RI

Jekow 17,929 Jekow PHCU PHCU SAVE

Wunkir PHCU PHCU SAVE

Jotome PHCU PHCU SAVE

Kigile 3,003 Kigle PHCU PHCU SAVE

Maiwut 11,878 Maiwut PHCC PHCC SAVE

Nyetok Nyatok PHCU PHCU SAVE

Pagak 19,000 Pagak PHCC PHCC SAVE

Turu PHCU PHCU SAVE

Uleng PHCU PHCU SAVE

Malek PHCU PHCU SAVE

Maiwut

Jotome 17,202

Turu Payam 17,818

Maban

Boung 12,275

Khor El Amer 6,833

Principle #2 Common Strategy Common Intervention Common Indicators * Prescribed by the MOH * NGOs accountable to and report to MOH

3. Harmonization of Salaries

Principle #3 Harmonize Salaries (between NGO and Government Workers)

IMA and SMOH

devised a revised

salary range helping

to mitigate the large

difference between

former NGO and

MOH supported

facilities; salary

ranges approved by

the SMOH and

implemented in both

States

Unique HSS Elements of

IMA Program in South Sudan

Performance Based Contracting

How did it work?

Incentives were given as Block Grants to Health Facilities and paid out monthly on a

sliding scale based on performance.

(i.e .# vaccines, # deliveries, # patients seen, stock outs, waste management, etc)

How much did it cost?

Maximum amounts attained and paid in

local currency were approximately

• $1200/mo for County Hospitals

• $900/mo for County Health Departments

• $500/mo for Health Centers

Did it work?

During the first six-month period (Jan.-June 2013) approximately $380,000 in

incentives was paid out as cash grants

How did it work?

For those indicators that were linked to payments (i.e. Child Consultations and , ANC1) there was a positive correlation between performance and incentives A strong association was found between ANC1 for

(P-value of < .005).

How did it work?

For those indicators where there was on correlation between money and performance (null hypothesis)

i.e. DPT 3

Correlation between curative care and incentives

With P-values of .7374 for DPT3 the null hypothesis

is confirmed, (i.e.,that there appears to be no or little

association between incentive payments and DPT3

coverage).

Monthly incentives

tied to performance

are provided to

• County Health

Departments (DHOs)

• PHCUs

• PHCCs

• County Hospitals

Indicator Target Requirement Performance Total %

per

indicator

Amount

in SSP

7.1.1.

HMIS:

HMIS report sent to

the SMOH with copy

to IMA/NGO partner

by the 21st of each

month

If no DHIS report is

submitted

No incentive is

paid

25% SSP750 Report submitted but

late

50% is paid

Report submitted and

on time

100% paid

7.1.2 IDSR IDSR sent to MOH

weekly

If no IDSR report is

submitted

No incentive

paid

25% SSP750

If reports received

from 50% or less of

facilities that quarter

50% paid

If reports received

from more than 50% of

facilities that quarter

100 paid

7.1.3.QSC

Supervision

of health

facilities:

Every Facility

receives a QSC

supervision once a

quarter and report is

filled out and

submitted

If no QSC report is

submitted

No incentive is

paid

25% SSP 750

If reports received

from 50% or less of

facilities that quarter

50% is paid

If reports received

from more than 50% of

facilities that quarter

100% paid

7.1.4.

Mo

nthly CHD

and VHC

Meetings

CHD holds monthly

meeting with CHD

members to evaluate

HMIS, IDSR and

QSC data and VHC

committee minutes

are available

If no minutes are

available

No incentive is

paid

25% SSP 750

If minutes from CHD

or VHC available

50% is paid

If minute from both

CHD and VHC

committee available

100% paid

Total

Payment

CHD

100%

SSP 3000

Contracts (not MOUs) were established

between IMA (the fund manager) and

district health officers and facilities

Provides the Districts with a written contract and

payment for services rendered

Is it sustainable?

The ultimate goal is to acknowledge the skills and hard

work of health care workers

and district health departments

…..and pay them accordingly

…..and frankly speaking, if UHC is ever going to be successful, then performance and payment need to be linked… …as in every other enterprise and engagement in our society.

Versus

Asante

Sana!