1. Performance-based Financing in Liberia: Experiences of USAID/RBHS Richard J. Brennan Rebuilding Basic Health Services

2. Rebuilding Basic Health Services - Overview Largest USAID- funded health project in Liberia –Nov 2008 – Oct 2013 Overall goal: assist MOHSW with implementation of National Health Plan Three pillars –Service delivery –Systems strengthening –BCC Service delivery –Implemented through performance-based contracts

3. Performance-based Financing in Liberia RBHS PBCs – July 09 – June 11 –4 NGOs (5 contracts) –1 NGO grant; 15 facilities MOHSW Pool Fund –November 2009 –March 2010

4. PBF and RBHS Objectives of PBCs –Service delivery at facility & community levels –Capacity building of CHTs Indicator selection –Highly consultative Determining baselines and targets –Individualized by NGO

5. Administrative Indicators Reported quarterly; possible penalty associated INDICATOR BASELINETARGET # joint and total supervisory visits % of timely, accurate and complete HIS reports submitted to the CHT % of staff funded by NGOs paid on time # of Community Health Development Committees meetings held per facility Submission of timely and complete quarterly report to RBHS

6. Performance Indicators Reported quarterly: annual performance bonus (year 1); quarterly bonus (from year 2) INDICATOR BASELINETARGET % of priority facilities reaching one-star level in accreditation survey % of facilities with no stock-out tracer drugs % of patients receiving no more than 3 drugs % of children under 1 year who received DPT3/pentavalent-3 % of children under 5 years with malaria who are treated with ACTs % of pregnant women provided with 2nd dose of IPT for malaria % of deliveries that are facility-based with skilled attendant Number of people tested for HIV and received their results Couple-years of contraceptive protection provided by RBHS-supported facilities

7. PBF Management: Verifying data Process –Quarterly –Random selection of 3 facilities per NGO –Cross check reports with ledgers / records Challenges –Definitions, e.g. supportive supervision –Reporting issues, e.g. ORS, ACT –Discrepancies between facility reports and ledger reviews by RBHS

8. PBF Management: Verifying Data Progress: Quarter 1 to Quarter 6 –Clarification of definitions –Data verification instituted by NGOs –Fewer discrepancies Results –Increased capacity in data management – facility and NGO staff –Improved data quality –Improved understanding and use of data

9. PBF Management: Feedback & Communication Monthly all-partner meetings Quarterly data reviews – all partners, MOHSW Quarterly partner feedback Annual stakeholders meeting Others –County Coordinator reports –Ad hoc meetings –Field visits

11. Distribution of Performance Bonuses Frequency –Year 1: Annual bonus –Year 2: Quarterly bonus Incentive systems determined by NGO partner, CHT, and health staff Distributed at all levels –CHT –Facility –Community –NGO staff

12. AFRICAREEQUIP IRC- LOFA IRC- NIMBA MTI Facility staff 70%41%19%35%38% Facility upgrades -19%69%50%- CHT staff 14%4%12%15%8% CHT office upgrades -3%--11% NGO staff 16%24%--21% NGO office upgrades ----19% Community -6%--- Awards & ceremonies + 2% ++ 3% Distribution of Performance Bonuses

17. Support to MOHSW Selection and harmonization of national indicators Determination of preliminary baselines and targets Development of PBC payment plan and tool

18. Lessons learned Need precision in indicator definitions Importance of flexibility and leniency in setting targets and assessing progress Value of validation process in building capacity Annual payment of bonus too infrequent Need to provide more guidance on bonuses

19. Future directions Improve data collection with new HMIS Involve CHT members and facility staff more in tracking PBF Introduce facility feedback tool –Graphs of last 12 months data updated monthly –Posted at each RBHS facility and updated monthly

20. Future Directions Support to MOHSW on PBF – Develop PBF database (national and country level) with MOHSW – Conduct costing of PBF program (management costs and future extension) – Development of the national PBF procedures manual – Development of PBF M&E and verification manual and tools