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Improving DPS/District Performance and HSS via Province/District Sub-Granting

Improving DPS/District Performance and HSS via Province/District Sub-Granting. Cathrien Alons Technical Director, EGPAF/Mozambique. Objectives of Presentation. Describe the approach of decentralized subgrants and HSS within the context of transition

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Improving DPS/District Performance and HSS via Province/District Sub-Granting

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  1. Improving DPS/District Performance and HSS via Province/District Sub-Granting Cathrien Alons Technical Director, EGPAF/Mozambique

  2. Objectives of Presentation • Describe the approach of decentralized subgrants and HSS within the context of transition • Present experience and examples of sub-grants in Mozambique • Describe EGPAF/Mozambique next steps to modify sub-grants to introduce performance payments.

  3. EGPAF Mozambique: Two-pronged Transition Strategy • Build strong national NGO to successfully compete for and manage US funds to support high quality HIV clinical services. • Actively strengthen decentralized MOH to receive and manage external funds to provide high quality, cost-efficient HIV clinical services.

  4. Flow of Funds and Loci of Responsibility in Mozambique

  5. Mozambique Context: Highly Centralized • On-going discussion/delays between governors and MOH regarding fiscal decentralization. • Ministry assigns and reassigns health staff to sites. Broad recognition that HR poorly motivated. • Ministry approves all professional positions. Provinces hold employment contracts. • Partner funds do not reach professional positions. • Districts and health facilities have no budget autonomy to buy basic supplies, such as soap. • All supplies, drugs, consumables depend on central procurement • Frequent and significant stock-outs.

  6. Transition Objective 2: Strengthen decentralized MOH to receive funds to provide quality HIV clinical services • EGPAF: from “implementer” to “capacitator” in 2009 • Initiated 54 cost-reimbursement sub-grants ($5.6 million) with provinces and district health authorities. • First time districts ever planned budgets, executed and submitted financial reports. • 75% of sub-grant spending done by districts • Very positive feedback from MoH, DPS, DDS • Strengthened partnership with local government and ownership of integrated services.

  7. Cost-Reimbursement Sub-Grant Experience: the First Six Months • Significant time spent developing sub-grantee financial capacity (6 months) • Per diems and travel over-budgeted (50% of budget), but this spending much slower than supplies and equipment because very labor intensive. • Fund management: less than 1% of expenses disallowed, but management burden heavy, as there was zero tolerance for non-compliance. • Spending initially much slower due to GOM and USG compliance, reporting and other requirements • Rate of spending has accelerated. Recipients have deadlines and have started to use funds effectively.

  8. Moving to Performance-Based Funding - 1 Reasons: • Increase absorption of available resources • Expand utilization of health services • Improve motivation and quality of health services Goal: Get PEPFAR funds to highest priority: limited, poorly motivated human resources linked to provision of high quality and quantity integrated HIV clinical services. = achieving desired results and outcomes.

  9. Moving to Performance-Based Funding - 2 • PBF expertise on board. • Collaborative planning with interested DPSs and SDSMAS. • Consultative process to define indicators and implementation processes • Include in sub-grants to be amended Dec 2010 • Consistent with the MOH Code of Conduct of NGOs. • Need to carefully define “results” and payments • Need to provide simultaneous management, effective supervision and performance-improvement training/support.

  10. Renewing Sub-Grants and Adding Performance Component • Build on sub-grant experience and strengthened partnerships, will add direct financing to health facilities based upon quality and quantity of HIV and primary care services. • Will continue input financing for “invariables”, such as salaries (nonprofessionals), equipment, etc. • Advantages of “buying outputs”: • Increasing evidence shows effectiveness of PBF • Increases focus on performance, including defining, measuring, improving • Decreases reporting and compliance burden • Increases decentralized responsibility of health facilities to improve performance.

  11. Renewing Sub-Grants and Adding Performance Component • Build on sub-grant experience and strengthened partnerships, will add direct financing to health facilities based upon quality and quantity of HIV and primary care services. • Will continue input financing for “invariables”, such as salaries (nonprofessionals), equipment, etc. • Advantages of “buying outputs”: • Increasing evidence shows effectiveness of PBF • Increases focus on performance, including defining, measuring, improving • Decreases reporting and compliance burden • Increases decentralized responsibility of health facilities to improve performance. Thank You

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