Performance-based Finance (PBF) in Mozambique

1. Jhpiego’s collaboration with the Elizabeth Glaser Pediatric AIDS Foundation - EGPAF PBF initiative Performance-based Finance (PBF) in Mozambique Edgar Necochea, Director Health Systems Development Jhpiego - an Affiliate of Johns Hopkins University

2. 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

3. 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

4. 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

5. 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.

6. The SBM-R approach

7. 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

8. 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

9. The critical gap Between: • What is known • What is done

10. The reality in many low resource settings • 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

11. What we were looking for Less emphasis on problem analysis and more focus on providing a solution that is: • Practical • User-friendly • Informative • Challenging • Fun

12. From evidence to action Systematic reviews of the evidence (Scientific basis) Guidelines (Synthesis of the evidence) Standards (Care maps, check-lists)

13. The Standards-Based Management and Recognition Approach

14. Sample performance standard for EOC Area: Pregnancy Care Y, N, NA Verification Criteria Comments Perf. Standard • The facility conducts a routine rapid assessment of pregnant women • 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

15. Sample performance standard for IP Area: Operating Room Verification Means Comments Y, N, N/A Criteria 1. The cleaning equipment is processed before reuse or storage • 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.

16. Sample summary form of assessment tool for MNH - hospital

17. Assessment tool areas for HIV/AIDS ART

18. Scientific (evaluation) Optimizing 100% Level of Certainty Satisficing 60% Managerial 0%

19. Types and uses of measurement ACTION EVIDENCE

20. Some results for the Model Maternities

21. Some results for the Model Maternities

22. Some results for the Model Maternities

23. Some results for the Model Maternities

24. Motivation • Empowerment • Challenge • Growth • Achievement • Healthy competition • Fun

25. Recognition as an incentive • Feedback • Social recognition • Material recognition

26. The EGPAF PBF initiative

27. 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

28. 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

29. 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)

30. PBF model 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)

31. Equity and quality indicators • 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.)

32. 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)

33. Community verification • Independent verification of quantity service data reported by the health facility • Independent assessment of client satisfaction

34. 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)

35. 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.