Giving community a voice in PBF approaches Jennie van de Weerd

1. Giving community a voice in PBF approaches Jennie van de Weerd Department of Health and Well-Being, Cordaid, The Netherlands What is performance Based Financing ? Performance Based Financing is a systems’ approach that aims at structural reforms throughout the health system. The objective of PBF is to link performance to financing, thus ensuring that funds are efficiently and effectively used for improved quality and coverage of health care services. PBF consists of a number of key principles or ‘building blocks’: • Why is PBF goodfor the population and localcommunities • Better access to health care because PBF payments to facilities will lower the service fees • Better coverage of health services since health care providers are motivated to attract more patients and will devote attention to outreach, working with community health workers etc. • Higher quality of care because health care providers are motivated by PBF to improve the quality of services • Better recording of health services providers, so performance of health facility can be measured (completeness of HMIS reports increases). • Health center committees are involved in preparing and approving the business plan by deciding on key priorities for the health facility • Community organizations are contracted to undertake quality and quantity verification and are able to report results to independent body (purchaser) • Independent community organizations are contracted to perform spot checks and survey patient satisfaction, thus allowing patients to voice their appreciation of health services • Community organizations are represented in national and local steering committees Cordaid and PBF • Lessons learned on community accountability • Health committees are not meaningfully involved in the development of the businessplans. Either committees only exist on paper or they are not taken seriously by health workers. • Health committees are not seen by community as their representatives. • Revision of businessplans is not taking place on a quarterly basis. • HMIS information on performance of health facility is not fed back to the facility and/or the health committee. • Client satisfaction surveys only address those people who have frequented the health facility. To get a better understanding of actual appreciation, including other community members might give a better impression. • Only in some countries, community satisfaction scores influence the quality bonus payable to the health facility. In 2010, it was observed that 22 African countries were planning for, or started some form of RBF pilots programs. Two countries (Rwanda and Burundi) adopted RBF as their national policy and scaled it up successfully, while some others such as the Central African Republic and Cameroon may soon follow. Cordaid is supporting PBF interventions in Rwanda, Burundi, Tanzania, Zambia, Democratic Republic of Congo (DRC), Cameroon, Central African Republic (CAR), Zimbabwe and Congo Brazzaville (RC). Possibilities to pilot the approach are currently being explored in South Sudan en Haiti. Figure 1. Countries where PBF interventions have started are green. PBF interventions will be started up in South Sudan (red) and Haiti (not on map) . PBF results A typical PBF contract holds a maximum of about 15 indicators that attract payment. Indicators to be included should cover the full primary health package but selection and height of incentive are influenced by the priority the government attaches to the specific indicator. Family planning visits, ANC visits and safe delivery are almost always part of tyhe indicator package. A quarterly check on quality of service delivery and community satisfaction, enables the facility to attract an extra bonus. • Next steps • Strengthening of health committees: re-elections, training and community score card development. Pilots in Cameroon, Burundi and DRC (South Kivu) • Increasing representativeness of health committees by addressing gender balance and more focus on reaching poor and vulnerable. • Strengthening the link between community and the health facility: community PBF pilots are taking place in Rwanda (government), Burundi, Afghanistan • Ensure that community satisfaction scores influence the quality bonus payable to the health facility in all interventions (negotiation with facilities and governments). Pilot inclusion of non-patients in satisfaction surveys. Figure 2.Results from Rwanda show that deliveries in health facilities increased with 23,1% in Cyangugu province, while maternal mortality and the cost of deliveries reduced considerably between 2003 and 2010. Figure 3.Results from South Kivu (DRC) between 2005 and 2009, show an increase of safe deliveries from 70 to 97% and an incrase from 0,17 to 0,70 per capita per year in OPD visits. Acknowledgments The information on this poster is based on several publications about Cordaid PBF interventions. Thanks to my colleagues in headquarters, Burundi and South Kivu (DRC) who provided information on the community focused interventions currently being piloted in their regions. Photo credit: Chris van Houts. More information? E-mail: rbf@cordaid.nl Presentedat the mini-conference ‘Community-drivenAccountability’ 20 September 2012, the Hague