1. PBF CONFERENCE 14 TH -17 TH FEBRUARY 2011 BUJUMBURA, BURUNDI DESIGNING OF Sierra Leone simple performance based financing Scheme (PBF) Presented by Michael m. Amara (MoHS – Principal health economist)

2. Outline of the presentation 1.Sierra Leone Simple PBF Scheme Rationale for PBF in Sierra Leone Objectives of Simple PBF Scheme Outline of Simple PBF Scheme Simple PBF Interventions Simple PBF Prices 2011 2.Implementation Arrangements Institutional Structure Key Roles and Responsibilities. Reporting and verification procedures 3.Implementation Process Achievements What Next? 4.Conclusion

4. Rationale for PBF in Sierra Leone  High mortality and morbidity especially among young children and mothers  Financial barriers preventing mothers and children from accessing health care are being tackled through the Free Health Care policy  We also need to improve the availability of good- quality health services for them to access  PBF can help us achieve this!

5. Objectives of Simple PBF Scheme General objective:  To change the behaviour of health providers at facility level for them to deliver more quality services and to increase their productivity in the health sector. Specific objectives:  To increase service utilization at primary health care facility.  To improve quality of service delivery at primary health care facility

6. Outline of Simple PBF Scheme  Start in April 2011, funding available till October 2013  PHUs receive PBF funds every quarter based on delivery of six key Reproductive and Child Health interventions  PBF funds are divided between incentives for staff and investment or operational costs for the facility  DHMT and Local Council supervise and verify service delivery and use of the PBF funds  Ministry of Health and Sanitation has oversight over entire scheme

7. Simple PBF Interventions The Simple PBF Scheme is based on six key RCH interventions: Family planning (BPEHS 7.2) Antenatal care of pregnant women (BPEHS 7.1.1.) Safe childbirth deliveries (BPEHS 7.1.2) Postnatal care of mothers and babies(BPEHS 7.1.4) Routine immunisations for children under one (BPEHS 7.6) Outpatient consultations for children under five (BPEHS 7.7)

8. Simple PBF Interventions (cont) Why were these six interventions chosen? Part of the Basic Package of Essential Health Services Complements Free Health Care policy: all six interventions are aimed at the FHC target groups The most effective interventions for reducing child mortality  help Sierra Leone achieve MGD 4 The most effective interventions for reducing maternal mortality  help Sierra Leone achieve MGD 5

9. SIMPLE PBF PRICES for 2011 PBF IndicatorPBF Price (US$) N1 = Number of new acceptors of modern family planning methods. 2.4 N2 = Number of pregnant women completing series of four antenatal consultations. 1.4 N3 = Number of pregnant women in labour attended by a health professional, at the facility. 2.4 N4 = Number of women completing series of three postnatal consultations 1.4 N5 = Number of children aged less than 12 months completing national EPI immunization course. 1.4 N6 = Number of outpatient visits of children under five 0.1

10. Institutional Structure and Agreements REGULATOR FUND HOLDER N AT IO N AL LE VE L SERVICE PROVIDER INDEPENDENT VALIDATOR CO M M U NI TY LE VE L DI ST RI CT LE VE L Independent Validation Agency Contract Tripartite PBF Agreement District Health Management Team PBF Supervision/ Verification Agreement Peripheral Health Unit or Clinic MoFED: Local Govt. Finance Department Health Management Committee Independent Validation Agency Local Council Ministry of Health and Sanitation

11.  The Ministry of Health and Sanitation is the national regulator of Simple PBF Scheme:  Design of the scheme in collaboration with stakeholders: setting the rules, indicators, prices.  Monitoring and evaluation of implementation  The Ministry of Finance and Economic Development (LGFD) is the national fundholder for the Simple PBF Scheme  Disburses PBF funds to local councils on receipt of verified PBF reports  The Local Council (LC) is the local fundholder and purchaser of health services for the Simple PBF Scheme  Contracts PHUs to provide health services, jointly with the DHMT  Disburses PBF funds to PHUs  Supervision of PHUs jointly with DHMT (focus on financial management and data verification) Key Roles and Responsibilities

12.  The District Health Management Team (DHMT) is the local regulator of the Simple PBF Scheme  Leads on implementation and training at district level  Supervision of PHUs jointly with LC (focus on clinical supervision and data verification)  The Peripheral Health Unit (PHU) is the service provider for the Simple PBF Scheme  Provides primary healthcare services to the population, including the six key PBF interventions  Receives and spends PBF funds  Reports regularly to DHMT and Local council on service delivery and use of PBF funds  A contracted agency (NGO or CSO) working in conjunction with local health management committees will provide independent validation of the PBF performance reports Key Roles and Responsibilities (cont)

13. Implementation Process: Achievements  Technical Team formed to design the Simple PBF Scheme and draft the Operational Manual  Consultative meetings held with World Bank staff and  Technical support funded by World Bank  First draft of the operational manual circulated for comments and inputs  Consultative meeting with all stakeholders: MoHS directors and managers, DMOs, district M&E officers, Local Council chairs, health sector development and implementing partners  Revised draft of the operational manual produced and circulated for further comments and inputs  Training Manual for Training of Trainers produced  Training of Trainers (TOT) conducted in Bo, 11 th – 21 st January 2010 (DHMT and LC M&Es, District Health Sisters)

14. Implementation Process: What Next?  Finalise the Operational Manual for approval by MoHS and submission to the World Bank  Districts to organise Cascade training for PHU In-Charges and other key personnel (February/March 2011)  Roll-out of revised data reporting tools  PBF implementation starts on 1 st April 2011

15. PBF Reporting, Supervision and Verification Process MoFED: Local Govt. Finance Department District Health Management Team Ministry of Health and Sanitation Peripheral Health Unit or Clinic PHU submits DHIS forms to DHMT by 5 th of every month Joint Supervision and Verification checklist completed and data entered by quarter end DHMT completes data entry of all forms and submits DHIS data to MoHS by 15 th of every month DHMT submits PBF report to LC by 18 th of month after quarter end, cc MoHS LC certifies PBF Report and submits to MoHS by 30 th of month after quarter end MoHS approves reports from LCs, compiles and forwards to LGFD by 5 th of second month after quarter end DHIS Data ____ PHU DHIS forms Internal Verification Team Supervision and Verification Checklist Local Council PBF Report Certified PBF Report Approved and Compiled PBF Report

16. PBF Payment Disbursement Process District Health Management Team Ministry of Health and Sanitation Peripheral Health Unit or Clinic LGFD receives PBF Report and by 5 th and disburses PBF payments to LCs by 10 th of second month after quarter end PBF Payment for PHUs and Internal Verification Team ____ Internal Verification Team PBF Payment for PHU ____ PBF Payment for IVT ____ LC disburses PBF payments to PHU and IVT accounts by 15 th of second month after quarter end Local Council MoFED: Local Govt. Finance Department LGFD copies disbursement information to MoHS LC copies disburse-ment information to DHMT Report on disburse-ment to LCs Report on disburse-ment to PHUs Approved and Compiled PBF Report

17. PBF Financial Record Keeping and Reporting Process Ministry of Health and Sanitation Peripheral Health Unit or Clinic PHU submits PBF financial report to DHMT by 5 th of month after quarter end LC approves aggregated financial report and submits to LGFD by end of month after quarter end LGFD approves financial reports from LCs, compiles and forwards to MoHS by 10 th of second month after quarter end Local Council PHU PBF Financial Report Compiled PBF Financial Reports Internal Verificatio n Team IVT submits PBF financial report to DHMT by 5 th of month after quarter end Aggregated PBF Financial Report I VT PBF Financial Report Approved PBF Financial Report District Health Management Team Aggregated PBF Financial Report DHMT aggregates PHU financial reports and submits to LC by 15 th of month after quarter end, copying MoHS MoFED: Local Govt. Finance Department Consolidated Interim Financial Report LGFD submits consolidated Interim (un- audited) Financial Report to WB – IDA by 45 days after quarter end

18. Conclusion The PBF system will not replace the existing structure of healthcare services, but will complement them and increase the health workers’ productivity.

19. Thank you