the role of performance based incentives by dr bill clemmer, ima world health
TRANSCRIPT
Evolving Health Strategies
in South Sudan…..
and the role of
“Performance Based
Incentives”
A Distorted Model…..A Faulty Strategy
County Payam
Population Facility
RRHP
Class
Drug
Cate
gory
2012
Support
Akobo Alale 4,541 Old Akobo PHCU PHCU 139 PRDA
Barmach 27,151 Yidit PHCU PHCU 212 IMC
11 phcu Dilule PHCU PHCU 124 PRDA
3 phcc Akobo Hosp CH 494 IMC
1 ch Buong 10,195 Buong PHCU PHCU 180 IMC
Nukta Thoklial PHCC PHCC 220 NHDF
Thuokwath PHCU PHCU 148 NHDF
Diror PHCU PHCU 200 IMC
Kaikuiny PHCC PHCC 206 NHDF
Tangyang PHCU PHCU 160 IMC
Burmath PHCU* PHCU 150 PRDA
Chiban PHCU PHCU 129 PRDA
Kony ( Meer )PHCU PHCU 150 NHDF
Lange PHCU PHCU 168 PRDA
Walgak 6,613 Walgak PHCC PHCC 312 IMC
Ayod Ayod 17,389 Ayod PHCC PHCC 252 COSV
Korwai 16397 Korwai PHCU PHCU 63 MoH
11 phcu Haat PHCU PHCU 100 MOH
2 phcc Kuachdeng 11,488 Kuachdeng PHCU PHCU 130 SWIDAP
Mogok 11,461 Kandak PHCU PHCU 120 MoH
Mogok PHCU PHCU 171 MoH
Pagil 26,296 Menime PHCC PHCC 140 MoH
Pagil PHCU PHCU 140 SWIDAP
Pajiek 34,489 Canal PHCU (Ayod) PHCU 102 MoH
Gorwai /Kalel PHCU PHCU 106 MoH
Pajiek PHCU PHCU 128 SWIDAP
Wau Jiech PHCU PHCU 123 MoH
Wau PHCU PHCU 129 SWIDAP
Dengjok
18,754
Diror
14,605
Nyandit
27,863
34,678
Bilkey 39,116
A Better Model!
MOH
Directors
DIFID
Donor
Crown Agents
Lead Agent
EE
NB
WB
UN
WA
LK
SMOH
CARE, Merlin, UNIDO, etc.
CHD/NGO
USAID
Donor
JHPIEGO
Lead Agent
CE
WE SMOH
IMC, ADRA, NPA etc.
CHD/NGO
World Bank
Donor
IMA
Lead Agent
JG
UN SMOH
CARE, IMC, SAVE, etc
CHD/NGO
Restructuring Principles
Principle #1_____
• One Donor Per State
• One Fund Manager Per State (IMA, JHPIEGO, CA)
• One Lead “NGO” Agent per County (CARE, IMC, ..)
Dangaji PHCU PHCU RI
Liang PHCU PHCU RI
Bunj RI PHCC PHCC RI
Bouny CH CH RI
Gesm Allah PHCU PHCU RI
Shetha PHCU PHCU RI
Thouyege PHCU PHCU RI
Jamum 7,345 Jamam PHCC PHCU RI
Nila PHCU PHCU RI
Bugaya PHCU PHCU RI
Poumki PHCU PHCU RI
Tonkayo PHCU PHCU RI
Doro PHCC PHCC RI
Jekow 17,929 Jekow PHCU PHCU SAVE
Wunkir PHCU PHCU SAVE
Jotome PHCU PHCU SAVE
Kigile 3,003 Kigle PHCU PHCU SAVE
Maiwut 11,878 Maiwut PHCC PHCC SAVE
Nyetok Nyatok PHCU PHCU SAVE
Pagak 19,000 Pagak PHCC PHCC SAVE
Turu PHCU PHCU SAVE
Uleng PHCU PHCU SAVE
Malek PHCU PHCU SAVE
Maiwut
Jotome 17,202
Turu Payam 17,818
Maban
Boung 12,275
Khor El Amer 6,833
Principle #2 Common Strategy Common Intervention Common Indicators * Prescribed by the MOH * NGOs accountable to and report to MOH
3. Harmonization of Salaries
Principle #3 Harmonize Salaries (between NGO and Government Workers)
IMA and SMOH
devised a revised
salary range helping
to mitigate the large
difference between
former NGO and
MOH supported
facilities; salary
ranges approved by
the SMOH and
implemented in both
States
Unique HSS Elements of
IMA Program in South Sudan
Performance Based Contracting
How did it work?
Incentives were given as Block Grants to Health Facilities and paid out monthly on a
sliding scale based on performance.
(i.e .# vaccines, # deliveries, # patients seen, stock outs, waste management, etc)
How much did it cost?
Maximum amounts attained and paid in
local currency were approximately
• $1200/mo for County Hospitals
• $900/mo for County Health Departments
• $500/mo for Health Centers
Did it work?
During the first six-month period (Jan.-June 2013) approximately $380,000 in
incentives was paid out as cash grants
How did it work?
For those indicators that were linked to payments (i.e. Child Consultations and , ANC1) there was a positive correlation between performance and incentives A strong association was found between ANC1 for
(P-value of < .005).
How did it work?
For those indicators where there was on correlation between money and performance (null hypothesis)
i.e. DPT 3
Correlation between curative care and incentives
With P-values of .7374 for DPT3 the null hypothesis
is confirmed, (i.e.,that there appears to be no or little
association between incentive payments and DPT3
coverage).
Monthly incentives
tied to performance
are provided to
• County Health
Departments (DHOs)
• PHCUs
• PHCCs
• County Hospitals
Indicator Target Requirement Performance Total %
per
indicator
Amount
in SSP
7.1.1.
HMIS:
HMIS report sent to
the SMOH with copy
to IMA/NGO partner
by the 21st of each
month
If no DHIS report is
submitted
No incentive is
paid
25% SSP750 Report submitted but
late
50% is paid
Report submitted and
on time
100% paid
7.1.2 IDSR IDSR sent to MOH
weekly
If no IDSR report is
submitted
No incentive
paid
25% SSP750
If reports received
from 50% or less of
facilities that quarter
50% paid
If reports received
from more than 50% of
facilities that quarter
100 paid
7.1.3.QSC
Supervision
of health
facilities:
Every Facility
receives a QSC
supervision once a
quarter and report is
filled out and
submitted
If no QSC report is
submitted
No incentive is
paid
25% SSP 750
If reports received
from 50% or less of
facilities that quarter
50% is paid
If reports received
from more than 50% of
facilities that quarter
100% paid
7.1.4.
Mo
nthly CHD
and VHC
Meetings
CHD holds monthly
meeting with CHD
members to evaluate
HMIS, IDSR and
QSC data and VHC
committee minutes
are available
If no minutes are
available
No incentive is
paid
25% SSP 750
If minutes from CHD
or VHC available
50% is paid
If minute from both
CHD and VHC
committee available
100% paid
Total
Payment
CHD
100%
SSP 3000
Contracts (not MOUs) were established
between IMA (the fund manager) and
district health officers and facilities
Provides the Districts with a written contract and
payment for services rendered
Is it sustainable?
The ultimate goal is to acknowledge the skills and hard
work of health care workers
and district health departments
…..and pay them accordingly
…..and frankly speaking, if UHC is ever going to be successful, then performance and payment need to be linked… …as in every other enterprise and engagement in our society.
Versus
Asante
Sana!