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Enhancing Health Services through Performance-Based Financing in Liberia

This overview discusses the experiences of USAID/RBHS in implementing Performance-Based Financing (PBF) in Liberia from Nov 2008 to Oct 2013. The project's main goal was to assist the Ministry of Health and Social Welfare with the implementation of the National Health Plan, focusing on service delivery, systems strengthening, and behavior change communication. PBF was implemented through performance-based contracts with NGOs, aimed at improving service delivery at facility and community levels, capacity building of Community Health Teams, and enhancing data management. Challenges, results, lessons learned, and future directions are also discussed.

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Enhancing Health Services through Performance-Based Financing in Liberia

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  1. Performance-based Financing in Liberia: Experiences of USAID/RBHS Richard J. Brennan Rebuilding Basic Health Services

  2. Rebuilding Basic Health Services - Overview • Largest USAID-funded health project in Liberia • Nov 2008 – Oct 2013 • Overall goal: assist MOHSW with implementation of National Health Plan • Three pillars • Service delivery • Systems strengthening • BCC • Service delivery • Implemented through performance-based contracts

  3. Performance-based Financing in Liberia • RBHS PBCs • July 09 – June 11 • 4 NGOs (5 contracts) • 1 NGO grant; 15 facilities • MOHSW Pool Fund • November 2009 • March 2010

  4. PBF and RBHS • Objectives of PBCs • Service delivery at facility & community levels • Capacity building of CHTs • Indicator selection • Highly consultative • Determining baselines and targets • Individualized by NGO

  5. Administrative Indicators • Reported quarterly; possible penalty associated

  6. Performance Indicators • Reported quarterly: annual performance bonus (year 1); quarterly bonus (from year 2)

  7. PBF Management:Verifying data • Process • Quarterly • Random selection of 3 facilities per NGO • Cross check reports with ledgers / records • Challenges • Definitions, e.g. supportive supervision • Reporting issues, e.g. ORS, ACT • Discrepancies between facility reports and ledger reviews by RBHS

  8. PBF Management:Verifying Data • Progress: Quarter 1 to Quarter 6 • Clarification of definitions • Data verification instituted by NGOs • Fewer discrepancies • Results • Increased capacity in data management – facility and NGO staff • Improved data quality • Improved understanding and use of data

  9. PBF Management: Feedback & Communication • Monthly all-partner meetings • Quarterly data reviews – all partners, MOHSW • Quarterly partner feedback • Annual stakeholders’ meeting • Others • County Coordinator reports • Ad hoc meetings • Field visits

  10. Distribution of Performance Bonuses • Frequency • Year 1: Annual bonus • Year 2: Quarterly bonus • Incentive systems determined by NGO partner, CHT, and health staff • Distributed at all levels • CHT • Facility • Community • NGO staff

  11. Distribution of Performance Bonuses

  12. Support to MOHSW • Selection and harmonization of national indicators • Determination of preliminary baselines and targets • Development of PBC payment plan and tool

  13. Lessons learned • Need precision in indicator definitions • Importance of flexibility and leniency in setting targets and assessing progress • Value of validation process in building capacity • Annual payment of bonus too infrequent • Need to provide more guidance on bonuses

  14. Future directions • Improve data collection with new HMIS • Involve CHT members and facility staff more in tracking PBF • Introduce facility feedback tool • Graphs of last 12 months’ data updated monthly • Posted at each RBHS facility and updated monthly

  15. Future Directions • Support to MOHSW on PBF • Develop PBF database (national and country level) with MOHSW • Conduct costing of PBF program (management costs and future extension) • Development of the national PBF procedures manual • Development of PBF M&E and verification manual and tools

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