1. Performance Based Financing at Hospital - Liberia Health Systems Strengthening Project (HSSP) July 8, 2013 Harry Neufville Shun Mabuchi

2. Hospitals have not been paid sufficient attention despite their importance, leading to low quality of care High infection rates and post- surgery complications No systematic use of clinical guidelines Accreditation scores on quality are worse than primary facilities Quality of care at Hospitals 1 Health Financing Trend 19% of total health budget allocated to tertiary care in 2010/11 Most external funds (85% of health expenditure in 2009/10) directed at primary care No major donor support to secondary-level hospitals

3. The hospital PBF aims to improve the quality of care at the hospital level 2 Project Development Objective of the HSSP Improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities* 1. Hospital PBF Incentives for improved quality of care (structural and process) Coaching and verification support to hospitals 2. Competency building through GMRP Rotation of faculties and residents to hospitals In-service training to health workers at the hospitals * PBF for Redemption (Montserrado), Phebe (Bong), Tellewoyan (Lofa), JFD (Nimba), and JJ Dosen (Maryland)

4. Hospitals will receive financial incentives and management and clinical support to improve the quality of care 3 PBF on the improve- ment of: Hospital management practices Availability of essential drugs and equipment Adherence to clinical guidelines and protocols Accountability and Motivation Hands-on coaching by LMDC on quality improvement approaches and PBF management In-service training by faculties and residents on appropriate protocols and process of care Competency Building Quality Improve- ment of hospitals

5. Hospital will also receive incentives for the uptake of under-utilized and under-provided hospital services 4 Incentivized Services at Hospitals through PBF Incenti ves Child Health/IMCI 1Complicated and assisted delivery (including C-section) $17 2 Normal deliveries of at-risk referrals $17 3 Counter referral letters returned to health centers $2.5 4 Newborn referred for emergency neonatal care treatment $5 5 Referred under-fives with fever $2.5 6 Minor surgical intervention $5 7 Major surgery (excluding CS, including major trauma) $18 8Patients transported by ambulance $2.5 In service training for nurses, midwifes and PA 9Number of training sessions held for nurses, midwifes and PA according to in-service curriculum and defined protocols 50 10Number of nurses, midwifes and PAs that received specialized in-service training 10

6. Hospitals can use the performance incentives for improving hospital services 5 Investment: 50% of incentives for facilities, equipment, drugs, operational cost Motivation: 50% of incentives for individual health worker incentives Improved quality of care at hospitals Motivated health workers Better facilities More PBF incentives Virtuous cycle of continuous performance improvement with PBF Use of performance incentives by hospitals based on business plan

7. The quality of care and the utilization will be rigorously verified in multiple ways 6 Quarterly verification by LMDC Bi-annual external verification by medical college (e.g., from West African College) 1 2 Quality assessment using rigorous quality checklist Comparison of invoice and register patient by patient Community verification and customer satisfaction by CBOs 3 Direct visit to registered patient to check the actual utilization of services Simple questionnaire on customer satisfaction

8. The HSSP also seeks for the synergetic linkage of PBF and competency building 7 Hospital PBFCompetency Building Quantity incentive finances in-service training to health workers Quality incentive finances the adherence to clinical protocols Motivate toward more trainings In-service training train nurses, midwives and PAs on proper clinical protocols on hospital services Better competency to improve process of care Synergetic linkage of components

9. HSSP Implementation Arrangement 8 Dept. of Admin MOA/Contract Oversight/Support Service Delivery Verification and TA Post- Graduate Medical Council Dept. of Health Services (PBF Unit) Dept. of Health Services (PBF Unit) Target Hospitals HSSP Coordination Office Patients LMDC Dept. of Planning CBOs CHSWT (Local Regulator) CHSWT (Local Regulator) Health Sector Coordination Committee Project Technical Committee Focal Persons’ Forum

10. The project will start from pre-pilot to test and adjust approaches, then scale up to all hospitals 9 1 2 1 Counties 5 Facilities Redemption Redemption Phebe Tellewoyan, JFD, JJ Dosen Population 0.34 million~1 million June-Dec, 20132014-18 Scale-upPre-pilot