real world implementation challenges: scaling-up performance-based financing in rwanda 2006-2008...
TRANSCRIPT
Real World Implementation Challenges: Scaling-up
Performance-Based Financing in Rwanda 2006-2008
CERDI Conference, 17-18 Dec, 2009
Session 3: ‘from pilot to national policy’
György Fritsche, HDNHE, the WB
Rwanda Health CenterRBF/Performance-Based Financing (PBF)
1. Supply Side Intervention
2. Demand-side phenomena
3. Targeting Health Facilities that are made more autonomous
4. Regular, significant incentives reach front line health workers
5. District Support Functions incentivized (monitoring volume and quality: internal controls)
6. District PBF Steering Committee incentivized
7. Central MOH PBF-support department incentivized
Content
Context Process and Actors Implementation Results Challenges to Scaling Up The Perfect Implementation Model
Context
Barrier to Access Services leading to low utilization 0.3/c/yr: Very poor population: one third of the population lives on less
than $0.25 per day and 57% of the population lives on less than $0.45 per day
Poor Health Indicators (2005): MMR 750/100,000; U-5 Mortality Rate 152/1,000 and U-1 Mortality Rate 82/1,000
Inefficient Utilization of Existing Services: a study in Gicumbi (2005) documented less than 2 services/nurse per hour leading to an uptake of 0.8 services/capita/yr (curative and preventive combined)
Actors and Parallel Events
3 PBF Pilots (Cordaid and HNI 2001-2005 and BTC 2005)
Strong GOR leadership: Inclusion of PBF in National Health Strategic Plan 2005-2009
WB – HIPC USAID – interest in PBF for HIV services Lowering the barriers to access: CBHI – scaling up
started January 2006 Mobilizing decentralized government: Imihigo
Process
The WB “roll-out study”
Implementation
1. Strengthening existing Coordination Mechanism (TWG)
2. Information Technology solution to data collection and payment flows
3. Creating new Coordination Mechanism to bridge the gap between policy and implementation: the Extended Team Approach
4. Trainings
5. Continuous Technical Assistance to decentralized authorities
1. Strengthening Existing Coordination Mechanism (TWG)
Regular and frequent meetings Agenda setting Effective documentation and dissemination of
proceedings
2. IT solutions to Data Collection and Payment Flows
Web site www.pbfrwanda.org.rw Web application for data entry and data
retrieval (invoices) Server located with an internet service
provider in country A ‘real time database’ is created from the
district level onward: Payment Orders can be generated easily
PBFBDDMySQL(ISP)
Internet
Access ApplicationInternet Application
Local Copy of MySQL PBF
database
Optional
Excel Pivot Tables and Graphs
INSERT GRAPHIC TO ADD MAP
MAP IS 6.17” TALL
www.pbfrwanda.org.rw
Access to data through the website
Data entry menu
Data entry is easy
Quarterly district invoices
3. Creating New Coordination Mechanisms: the ET
The Extended Team Approach is Bridging the Gap between Policy and Implementation: 11 international agencies 3 MOH departments Meeting once per month last Thursday of each month
½ day, careful agenda setting and effective information dissemination. Minutes available on website
Retreats for capacity building (Excel Pivot Tables and Graphs)
Training of Trainers in PBF
4. Trainings
Using ET mechanism to Train a Cadre of National Trainers in PBF
First start 2006 (after first wave of trainings) Re-launched second half of 2007 Jan-March 2008: 946 health workers trained
through 50 trainings April 2008: seven Phase-II districts: 356 health
workers trained through 13 trainings
5. Continuous TA to the Decentralized Authorities
Quarterly District PBF Steering Committee Meetings Extended Team members: District PBF Focal points
present in the District PBF Steering Committees Assisting in control activities Assisting in the quarterly quality counter-verification
exercises Assisting in the restitution of community client
survey results
Results: Institutional Deliveries
Community Client Survey 3Q08:
The BIG news: RBF/PBF as a powerful method to increase also the quality of services
The BIG news: RBF/PBF as a powerful method to increase also the quality of services
Challenges to Scaling Up
1. Solution to Data Collection and Validation Web application
2. Coordination challenges TWG and ET mechanisms
3. Technical Assistance to the Central MOH and the Decentralized Authorities TWG ET mechanism District PBF Steering Committees
4. Credible Performance Results Use decentralized authorities (Min Local Admin; MOH) with strong TA
support initially for internal control (ex ante) Use NGOs as part of quorum in Decentralized District Level PBF
Steering Committee, and for transparency (ex ante) Use performance frameworks at all levels (Health Facility; Steering
Committee; District Hospital; Central MOH) Mix of third-party and transparent external verification mechanisms
(ex post)
Hogwood and Gunn’s “Perfect Implementation Model”Perfect Implementation Model’, in Hogwood, B., Gunn, I., (1984) ‘Policy analysis for the real world’, Oxford University Press
1. The circumstances external to the implementing agency do not impose crippling constraints;
2. That adequate time and sufficient resources are made available to the program;
3. That the required combination of resources is actually available;
4. That the policy to be implemented is based on a valid theory of cause and effect;
5. That the relationship between cause and effect is direct and that there are few if any intervening links;
…Ten Preconditions for a Successful Top Down Implementation
6. That dependency relationship is minimal;
7. That there is understanding of, and agreement on objectives;
8. That tasks are fully specified in correct sequence;
9. That there is perfect communication and co-ordination, and
10. Those in authority can demand and obtain perfect compliance.
In Rwandan PBF, the MOH was confronted with:No Negative Positive
1 Crippling circumstances *
2 Time not adequate Resources abundant
3 * Required combination of resources were available
4 * Policy to be implemented based on valid cause and effect
5 Many intervening links between cause and effect
Relationship between cause and effect is direct
6 Strong dependency relationship
*
7 No full agreement on objectives
Understanding of objectives
In Rwandan PBF, the MOH was confronted with:
No Negative Positive
8 * Tasks were fully specified in correct sequence
9 * Perfect Communication and Coordination
10 * Those in authority can demand and obtain perfect compliance