REPORT OF A HIGH LEVEL INTERNATIONAL

CONFERENCE ON PERFORMANCE BASED FINANCING

6 – 7 MARCH, DAR ES SALAAM, TANZANIA

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ContentsContents.................................................................................................................................................. 2

Credits: .................................................................................................................................................... 4

Acronyms and Abbreviations ................................................................................................................... 5

Executive Summary ................................................................................................................................. 8

The Conference ....................................................................................................................................... 9

Objectives and Expected Outcomes ..................................................................................................... 9

Participation and Moderation ............................................................................................................ 10

Overview of deliberations .................................................................................................................. 10

The Report ............................................................................................................................................ 12

Session 1: .......................................................................................................................................... 12

The Opening .................................................................................................................................. 12

Word from the CSSC Executive Director, Peter Maduki .................................................................. 13

Remarks by the Director of Cordaid, René Grotenhuis ................................................................... 13

Remarks by the Minister of Health and Social Welfare, Hon. Dr. Hadji Mponda (MP) ..................... 14

Opening Speech by H.E. Dr. Mohamed Gharib Bilal, Vice President of the United Republic of Tanzania ........................................................................................................................................ 14

Vote of thanks by H.E. Rt. ArchBishop Jude Thaddeus Ruwa’ichi, OFMCap. .................................... 16

Section 2: .......................................................................................................................................... 18

Summary of Presentations ............................................................................................................. 18

Keynote address on PBF state-of-the-art Evidence of Impacts and risks – Dr. Claude Sekabaraga representing the World Bank ......................................................................................................... 18

PBF Basic Principles and the Multi-country Project – Christian Habineza representing the Multi-country Programme ....................................................................................................................... 20

Health Systems Financing as an input to health system performance by Maximillian Mapunda representing the World Health Organization (WHO) ...................................................................... 22

PBF and Gratuity, prepared by Hon. Sabine Ntakarutimana, Sosthène Hicuburundi, Michel Bossuyt and Emmanuel Ndayegamiye and presented by Sosthène Hicuburundi ......................................... 24

Real Autonomy in Practice - Dr. Kaunda Nachilima, Zambia Experience.......................................... 26

The Role of Civil Society in PBF presented by René Grotenhuis representing Cordaid ..................... 27

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Public Private Partnership in Health: The Tanzanian Experience – Dr. Adeline Kimambo ................ 29

PPP from a Government Perspective: Tanzania – Dr. Mung’ong’o, Asst. Director Ministry of Health and Social Welfare ......................................................................................................................... 30

Key lessons of decentralization - Dr. Claude Sekabaraga, WB ......................................................... 32

Decentralization Policy in Practice: DRC – Dr. Pierre Lokadi, Permanent Secretary MOH ................ 34

Decentralization Policy in Practice: Central African Republic – Jean Michele Mandaba, Minister of Public Health ................................................................................................................................. 36

Studies on the Impact of PBF: Rwanda – Mr. Shema Joseph, MOH Rwanda.................................... 38

Impact of RBF in Somaliland: Practical Lessons by Mrs. Edda Costarelli, EU .................................... 40

Results Based Financing: Afghanistan – Najibullah “Oshang”, RBF Coordinator, Ministry of Public Health ............................................................................................................................................ 44

Intrinsic and Extrinsic Motivation: Shared points on ongoing research – Prof. Kenneth Leonard, University of Maryland .................................................................................................................. 46

European Union Mrs. Edda Costarelli ............................................................................................. 47

Bill and Melinda Gates Foundation - Margreth Cornelius ............................................................... 47

World Bank (Global) - Dr. Claude Sekabaraga ................................................................................. 48

World Bank (Tanzania) – Dr. Emmanuel Malangalila ...................................................................... 49

Donor Harmonization - Tanzania Donor Basket – Kiristine Noejgaard ............................................. 49

Country Experience: Burundi – From Pilot to National Policy – Sosthene Hicuburundi .................... 52

Country Experience: Zambia –State-Church Collaboration - Dr. Dhally Menda ............................... 53

Documentary on DRC’s implementation of a PBF initiative............................................................. 55

Section 3: .......................................................................................................................................... 56

Highlights of Discussions ................................................................................................................ 56

On Health financing ...................................................................................................... 56

On Implementation of PBF/RBF/P4P ............................................................................. 57

Sustainability ................................................................................................................ 57

On Domestic accountability/Political commitment ....................................................... 58

Political commitment as it relates to sustainability ....................................................... 58

PBF Bonuses/pay outs .................................................................................................. 58

Benefits of the Multi-country PBF Network ................................................................... 59

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Data management ........................................................................................................ 59

PBF scale up.................................................................................................................. 60

Decentralization ........................................................................................................... 60

Community involvement............................................................................................... 61

Capacity building .......................................................................................................... 61

Public Private Partnership (PPP) .................................................................................... 61

PBF and Research ......................................................................................................... 61

Section 4: .......................................................................................................................................... 62

Conclusion and Recommendations ................................................................................................ 62

Section 5: .......................................................................................................................................... 63

Closing Ceremony .......................................................................................................................... 63

The Conference Statement – Dr. Fatuma ...................................................................... 63

Remarks by Hon. Minister Jean Michael – Minister of Health, Central African Republic . 63

Ernest Schoffelen, coordinator Multi-country PBF Network on behalf of the Coordinating Committee ................................................................................................................... 64

Closing Remarks by Dr. Fatuma, representing the Ministry of Health and Social Welfare64

Annex 1. List of participants 65

Annex 2. Agenda of the conference 67

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Credits: Sponsor: Cordaid and the European Union

Organizers: Tanzanian Ministry of Health and Social Welfare, Christian Social Services Commission (CSSC) and the PBF Multi-country Network with lead roles by:

Ms. Madina Mukulu Ms. Mecklina Isasi Christian Habines (PBF Multi-country Network Coordinator) Frank Van de Looij (Cordaid) Marjan Kruijzen ( Cordaid) Ernest Schoffelen(Cordaid)

Master of Ceremony during Opening Session: Taji Liundi

Conference Moderator: Peter Maduki, Executive Director, CSSC

Interpreters: Louis Taguaba & Livin Matabaro

Focal Persons for Conference Statement: Father Serge and Madame Marie.

Rapporteurs: Betty Jayne Humplick & Peter Zawadi

Acronyms and Abbreviations ADB - African Development Bank AIDS - Acquired Immuno-Deficiency Syndrome ANC - Ante-Natal Care BAKWATA - Swahili Acronym for the National Muslim Council BP - Blood Pressure CAR - Central African Republic CCT - Christian Council of Tanzania CHAZ - Churches Health Association of Zambia CHI - Community Health Initiative CSOs - Civil Society Organizations CSSC - Christian Social Services Commission DRC - Democratic Republic of Congo ECDCs - Early Childhood Development Centres EU - European Union FBO - Faith Based Organizations FGD - Focus Group Discussion GDP - Gross Domestic Product

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HCWs - Health Care Workers HFs - Health Facilities HICs - High Income Countries HIV - Human Immune-deficiency Virus HR - Human Resources IMR - Infant Mortality Ratio JAS - Joint Assistance Strategy JHSR - Joint Health Sector Review KCMC - Kilimanjaro Christian Medical Centre LGAs - Local Government Authorities LICs - Low Income Countries MCH - Maternal and Child Care MDGs - Millennium Development Goals MICs - Medium Income Countries MMR - Maternal Mortality Ratio MOF - Ministry of Finance MOH - Ministry of Health MP - Member of Parliament NGOs - Non-governmental Organizations NHIF - National Health Insurance Fund OPD - Out Patient Department PBC - Performance Based Contracting PBF - Performance Based Financing PMORALG - Prime Minister’s Office- Regional Administration and Local Government

PNC - Post Natal Care

PPP - Public Private Partnership

RBF - Results Based Financing P4P - Pay for Performance

SSA - Sub-Saharan Africa

SWAp - Sector Wide Approach

TB - Tuberculosis

TBAs - Traditional Birth Attendants

TEC - Tanzania Episcopal Conference

WB - World Bank

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WHO - World Health Organization

WHR - World Health Report

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Executive Summary Background and Introduction

Performance-based financing (PBF) is an innovative approach involving the provision of incentives that are conditional upon a contracted party’s performance and realization of predetermined measurable targets and/or results. It shifts attention from the financing of inputs to outputs based on the premise that due emphasis on input provision has failed to deliver results that are necessary for countries to achieve their Millennium Development Goals (MDGs), while output-based financing also has the potential to improve accountability in delivery of quality services. In this conference two other terminologies that describe performance/results-based payment are used interchangeably. These are Results Based Financing (RBF) and Payment for Performance (P4P).

Initially, the approach was mainly used by international NGOs and Civil Society Organizations (CSOs); however, output-based financing is increasingly being regarded as a cost-effective strategy for health system strengthening and is being embraced by Governments and donors alike. In Rwanda and Burundi, PBF has become part of the national health policy.

In health systems that are based on PBF, the role of each stakeholder is clearly defined. Community organizations carefully check with patients to confirm that medical services were indeed provided as well as their perception of the quality of the services provided. Government bodies (the regulator) are supported in planning, monitoring and controlling the quality of services and healthcare facilities (the provider) are assisted in drafting operational plans to improve their services.

In PBF everybody wins: there are mutual benefits for the donor/funding agency, patient, and healthcare facility. The achievement of desired outcomes and the strong link with accountability benefit the donor/funder. For health care facilities and their staff, the better they perform the more reward they receive and they have more control over the type of services they can provide. And the patient/client gets better quality services provided in a cleaner and more hygienic environment with friendly and attentive healthcare staff. Another attractive feature of the PBF methodology is that each facility determines the best way to operationalize implementation within the universal PBF principles. PBF is also attractive to donor organizations and funding mechanisms because it is cost-effective and ensures value for money.

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The Conference The Conference being reported here was convened by the Multi-country PBF Network to facilitate experience sharing among member countries by providing a platform for Government, donors and CSOs to meet, exchange experiences with each other and with experts in order to capitalize on the best practices and lessons learned during implementation. It was held in Dar es Salaam on the 6th and 7th of March 2012. It was a high level international conference involving high level delegates from Ministerial level all the way down to program level.

The agenda (Annex A) of the conference was very stimulating and provoked lively and informative discussions on PBF in terms of its design, packaging of services, rewards and remuneration, checks and balances and the impact of policies, e.g. decentralization that govern implementation. It also provided an opportunity to celebrate successes in providing healthcare services to populations most in need and served as a call for action to practitioners and policy makers alike to use the experiences, best practices and lessons learned in the different programs to identify essential interventions that will ramp up efforts to realize greater outcomes and impact.

Objectives and Expected Outcomes The main objective as explained above was to share experiences across the different countries implementing the PBF methodology. At the end of the Conference participants were expected to:

1. Be acquainted with state-of-the-art evidence of the impact of PBF on the utilization of health services, quality, human resources, governance, client satisfaction, and some potential risks;

2. Be aware of policy decisions that are required at each level to implement or expand PBF;

3. Be able to assess the (political, economic, social) implications of decentralization and transfer of autonomy

4. Know and value the role of different stakeholders, notably CSOs 5. Be part of an international network with access to experts in Government,

donor/funding agencies and CSOs.

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Participation and Moderation Participants to the International PBF Conference (Annex B) were strategically drawn from among Government ministries, donor organizations, Civil Society and representatives from seventeen (17) countries. They included the seven members of the Multi-country Network: Burundi, Cameroon, the Central African Republic, the Democratic Republic of Congo, Rwanda, Tanzania and Zambia. Besides these member countries of the Multi-country programme, there were participants from Afghanistan, Congo Brazzaville, Mozambique, Somaliland, Zanzibar, Zimbabwe, United States, France, Germany and the Netherlands. The total of 107 participants included Ministers, Directors and Senior Program Officers, members of the PBF multi-network, donor representatives, scholars and researchers.

The Conference was organized around sets of plenary presentations with lead panelists for the different sessions. A wide variety of topical areas were presented by experts from inside and outside the 7 Network countries. A mix of English and French was used to enable full participation by delegates from both Anglophone and Francophone countries under the expert moderation of the CSSC Director Mr. Peter Maduki.

Overview of deliberations Greater efficiency in the use of limited available resources can help countries to achieve more significant health benefits and have a greater chance of realizing the Millennium Development Goals (MDGs). Performance Based Financing has the potential to increase the efficiency of use of scarce resources and can be applied in high-, middle- and low-income countries (HICs, MICs, and LICs) although more research is needed to prove what works in which specific setting. PBF principles can be applied even in resource-limited settings to improve health outcomes; this being a direct result of a number of other processes and actions including, linking PBF into the decentralization process to get real autonomy and real value all the way down to facility level, strengthened health systems, increased utilization and coverage of healthcare services, improved management, and cost-effectiveness. The PBF methodology also contributes towards improved Health Management Information Systems (HMIS) and can be a feasible strategy to harmonize donor support.

Different countries have used different innovative strategies to complement PBF methodology. In Rwanda, the Head of State is fully involved in the process ensuring accountability of the highest order. In the Central African Republic there is a department of PBF in the Ministry of Health and Cameroon has integrated PBF training in the faculty of medicine and established some schools for nurses were the methodology is being taught. Zambia’s experience with waiting homes demonstrates how innovation and real autonomy of healthcare staff can go a long way in identifying different kinds of incentives to attract more patients to healthcare facilities.

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Significant achievements have been realized with regard to use of services, motivation and accountability of health staff, financial accessibility and the creation of partnerships between the public and private sectors (PPP). In countries where health reforms have been successfully implemented and the Government is fully on board, bigger and greater returns have been realized through PBF. However, the importance of decentralization when introducing PBF elements cannot be overemphasized. PBF is not about providing incentives to healthcare staff to increase their motivation; it is more about re-investing resources in better quality care and achieving more equity, a process that requires continuous adaptation in line with the changing needs of the population. A decentralized system ensures the involvement of all stakeholders and provides room for greater autonomy in decision making. Without genuine decentralization, the PBF methodology cannot yield the desired results.

Countries implementing PBF need to be aware of some of the risks and challenges with regard to sustainability of the successes realized and adopt strategies that will produce positive returns. ALL stakeholders (government, civil society and the communities themselves) must be involved in the process from design stage, through implementation to evaluation and assessment of outcomes. And this can best be realized through decentralization to the lowest level of the healthcare system. The role of civil society and the voice of the population are also crucial elements in PBF because their motivation, participation and involvement in the process are useful in monitoring the distortion of PBF principles and other irregularities during implementation including neglect of certain services that cannot be easily quantified. Because it is important that the choice of packages of services to be provided as part of PBF corresponds with the actual needs of the population, data management systems need to be strategically designed to facilitate effective planning and decision making and the generation of evidence to influence policies that will facilitate effective implementation of PBF. This calls for more consultation and experience sharing and research to identify proven best practices to be shared among PBF network members and beyond. The key motivation in PBF is the assumption that “you can change outcomes.”

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The Report This report contains a detailed account of the different sessions of the 2-day conference highlighting key issues, recommendations and suggestions for the way forward. The report is divided into five main sections. Section 1 contains highlights from the opening session. Section 2 provides a summary of the different presentations and Section 3 summarizes the discussions and deliberations that ensued. In Session 4 conclusions and recommendations on the way forward are discussed and Section 5 focuses on the closing session.

Session 1:

The Opening The official opening session was moderated by a highly-regarded Master of Ceremony Taji Liundi who started by requesting a moment of silence in remembrance of the death of a number of people in Congo Brazzaville following a blast in an armory. News of this incident had just been aired on local and international radio and television stations the morning of the conference.

He then invited delegates to a session comprising local dances, a skit and a song especially composed around the essence of the conference by a renowned artist, Mrisho Mpotto. The gist of the message in the skit was about patients who had gone to a health facility and as they were waiting to be seen by the Doctor, he leaves them standing in the queue and walks away completely ignoring their call for attention. On his way out he meets the doctor coming for the next shift and delegates his duties to this doctor explaining to her that there is a bunch of patients waiting to be seen. While exchanging pleasantries he receives a call from another doctor who will serve the evening shift and instructs him to continue treating his patients, adding that he would come back the following day. However, the doctor from the evening shift fails to attend to all the patients due to patient overload. The song on the other hand urged Tanzanian Doctors to be more vigilant and to respect their call of duty so that they can save lives. It also advocated for more accountability. Both the skit and the song portrayed what was happening in the country at the time of the conference as a result of a nation-wide strike by Medical Doctors and Specialists.

After that brief performance the MC introduced delegates seated at the high table who had accompanied the Guest of Honour, which included the Minister of Health and Social Welfare, Hon. Dr. Hadji Mponda (MP) and the Director of Preventive Services, Dr. Donald Mmbando; the Director of Cordaid, René Grotenhuis; CSSC President, Rt. Archbishop Jude Thaddeus Ruwa’ichi and the CSSC Executive Director, Peter Maduki. He finished by introducing groups of delegates from Burundi, Cameroon, the Central African Republic, the Democratic Republic of Congo and Congo Brazzaville, Rwanda, Zambia, Zimbabwe and Tanzania and representatives of civil society organizations and the private sector. He then invited the CSSC Director to give a word and take over the moderation.

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Word from the CSSC Executive Director, Peter Maduki The CSSC Director welcomed delegates and briefly introduced the conference which he said drew more than 80 participants including Ministers from countries implementing the PBF methodology. He informed delegates that CSSC is an ecumenical body owned by the Christian Council of Tanzania (CCT) and the Tanzania Episcopal Conference (TEC) to foster the promotion and provision of quality services, particularly health and education, and that after the establishment of PPP, the CSSC works closely with the Government, civil society organizations and the private sector in the provision of health and education services through more than 500 health facilities in the country including a consultant referral hospital, teaching hospitals, health centres and dispensaries and Early Childhood Development Centres (ECDCs).

CSSC organized the PBF conference with the Government’s full participation for which the CSSC Director thanked the Government and expressed his hope that the spirit of cooperation would continue to grow. He also thanked the EU for co-financing the conference and the Multicounty PBF network for trusting Tanzania to host it. He ended by expressing his hope that by the end of the conference participants would have a better understanding of the PBF methodology and use the ideas generated at the conference to improve the provision of health services in their respective countries.

Remarks by the Director of Cordaid, René Grotenhuis The Director of Cordaid acknowledged the presence of representatives from different countries at the conference bringing together their experiences and knowledge and sharing challenges in moving PFB forward. What brings them together, he said, their commitment to deliver better services which he said they needed to work on at a daily basis given that more than 130 million people worldwide are falling below the poverty line due to catastrophic health expenditures and that every day 1000’s of women are dying because of lack of access to basic health care, all of which commits delegates to the conference to make the best of health care provided and use the resources as best as they can. The Director of Cordaid reiterated that the PBF conference was meant for sharing, learning and making progress.

Walking delegates back in history he informed them that way back in 1925, more than 85 years ago Cordaid sponsored the first programme for catholic missionary hospitals and that it is now more and more engaged in setting up national health systems to make them stronger, more resilient and more responsive to the needs of the people. PBF is one of the most important and need changing approach. It started in Rwanda in 2002 and over the years has expanded into Burundi, Cameroon, the Central African Republic, and the Democratic Republic of Congo and now it is in Zimbabwe. The Cordaid Director gave a special welcome to the representative from Afghanistan who was there to learn and share his country’s experience at national and international level.

Talking specifically about PBF, he observed that with PBF the role of communities is strengthened, there is more clarity on roles and responsibilities and better accountability. Future efforts will be focused on getting all actors on board, including governments, professionals, CSOs and donors. He hoped the conference would be a signal to other actors that PBF helps, strengthens and capacitates and concluded his remarks by inviting participants to

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share good examples and challenges since the conference is for taking stock of what is happening and how things can be made better.

Remarks by the Minister of Health and Social Welfare, Hon. Dr. Hadji Mponda (MP) The Minister of Health noted that PBF has gained ground as a cost effective strategy for health strengthening and that even though international NGOs, local partners and CSOs were on the forefront in pioneering the strategy and methodology, it is increasingly being embraced by Government officials and donors and countries on the brink of introducing the approach increasing rapidly. He informed delegates that the Ministry of Health and Social Welfare is in the process of rolling out the PBF methodology countrywide and that hosting the conference provided an opportunity to learn more about the health financing strategy. He hoped the discussions during the conference would further enrich participants’ understanding of the best practices in health care financing based on performance.

He further observed that while country health systems continue to respond to the increased burden of diseases, it is important to engage and leverage the private sector appropriately to achieve the set targets because doing so would help to complement Government efforts and maximize output. Through the Primary Health Services Department Programme (MMAM), Tanzania will continue to improve access and expansion of health services in underserved areas since the said programme is addressing human resource (HR) capacity that is necessary for the achievement of quality health and social welfare services at all levels. The country’s efforts in strengthening the Health Information System to collect adequate information and data for planning and decision making which is important for adequately and accurately measuring achievements towards national and global targets including Millennium Development Goals (MDGs).

With those brief remarks he extended a warm welcome to participants noting the impressive turn out and urged them to pay thoughtful attention to the deliberations of the conference. He concluded by welcoming the Guest of Honor to give his inaugural speech.

Opening Speech by H.E. Dr. Mohamed Gharib Bilal, Vice President of the United Republic of Tanzania

Speaking on behalf of the Government of the United Republic of Tanzania the Guest of Honour started his speech by extending a warm welcome to participants from other countries. He then talked about the importance of good health for a country’s development, adding that negative factors that affect a country’s ability to provide quality health services for it people must be overcome through sustained processes of change in the policy and institutional arrangements. This is because current global socioeconomic changes and the high prevalence of poverty and underdevelopment demand a review of the health delivery process and reforms designed to curb the negative effects of these changes need to be designed to bring about equity, efficiency and quality of health and social welfare services to everyone.

He acknowledged PBF is a cost-effective health financing strategy that has gained attention in recent years due to the of attention from inputs to outputs and outcomes, noting that

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remarkable results have been observed in utilization trends for general outpatient consultation services, institutional deliveries, family planning and coverage for antenatal services in different pilot projects. PBF has had a big impact on staff retention due to better remuneration as a result of increased service utilization and can also be implemented in countries with resource constraints to improve the effectiveness and efficiency in their health sector. However the Guest of Honor cautioned participants about the need to be on guard against potential risks that can negatively affect the implementation of PBF, including sustainability of the program and the possibility of health workers inflating records for remunerated activities and/or being forced to deliver services for which they do not have the required competence. He hoped such risks would be addressed during the conference while reviewing strategies. He appealed to participants to apply the recommendations from the conference to ensure smooth achievement of their individual country goals.

Participants were informed that in Tanzania, the PBF concept was introduced in 2006 by the CSSC in collaboration with Cordaid, which has also been involved in PBF projects in six other African countries. In Rwanda were it was introduced first the PBF concept has been successfully integrated in the country’s health policy. The Tanzanian Ministry of Health and Social Welfare started implementing this methodology in the form of incentives to health workers who reached their targets with a view to accelerate the reduction of maternal, newborn and child morbidity and mortality.

The Guest of Honor further informed participants that the Multi-country Network that was established to coordinate activities in the seven countries with support from European Union and Cordaid in collaboration with Tanzania’s Ministry of Health and Social Welfare organized the conference to provide a platform for Government officials, Development Partners, Civil Society Organizations (CSOs) and other stakeholders to discuss policy issues regarding implementation from the presentations on relevant topics from different countries within and outside the network. He believed that would enrich participants’ experiences and provide an opportunity to learn different best practices and come up with implementation strategies.

He reminded participants about the objectives of the conference which were to enable them to understand the PBF concept and its impact on health services; to create awareness on policy decisions required at different levels with a view to improve i implementation and expand capacity in assessing (political, economic and social) implications of the decentralization and transfer of autonomy; and to better understand and value the role of different stakeholders, notably the CSOs.

While admitting that PBF is not a magic bullet to boost health worker performance or a readymade solution to reform fragmented health systems, he expressed his belief that it can be instrumental in achieving better health results and improving the health status of a country’s population compared to what he referred to as “the traditional input financing approach”. He

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shared some highlights on the achievement of health-related MDGs and informed the conference about the growing awareness that outcome related targets which he said cannot be achieved and sustained without adequate and significantly expanded investment in the system that reinforce health services delivery. He further argued that it is crucial to scale up interventions for reducing child and maternal mortality as well as morbidity and mortality due to HIV/AIDS, tuberculosis, malaria and malnutrition, and use appropriate monitoring and evaluation frameworks in order to achieve progress in achieving the health MDGs.

The Guest of Honour observed that fully functioning and equitable health systems remain a priority in efforts to achieve the health MDGs and that there have been some notable achievements in the reduction of childhood morbidity in some countries, adding that high coverage of some of the interventions including immunization, IMCI, vitamin A supplementation and the use of insecticide treated bed nets has been the main stumbling block to greater achievements. The same is not true for Maternal Mortality Ratios (MMR) which is still among the highest in the world and progress towards its reduction (MDG5) has been slow. He noted that the Maputo plan of action for achieving universal access to comprehensive reproductive health that was adopted by the African region, calls for huge investments in this area as well as the strengthened health systems.

Concluding his remarks he acknowledged a decline in the incidence of HIV infection in some countries and urged participants to augment their efforts and determination to overcome the scourge sooner than later. Appealing to them as leaders he encouraged them to strive to have less people becoming infected than those put on treatment. He strongly believed that if everyone plays their part success is inevitable.

Those remarks marked the official opening of the Performance Based Financing International Conference officially opened.

Vote of thanks by H.E. Rt. ArchBishop Jude Thaddeus Ruwa’ichi, OFMCap. A vote of thanks was given by the CSSC President on behalf of CSSC, interested partners and participants to the conference by retired Archbishop Thaddeus Ruwa’ichi who noted that the conference on Performance Based Financing in the Health Sector deserved a high powered dignitary to officiate, adding that even though the conference objectives were ambitious they were motivated by the desire to achieve and translate into tangible results aimed at guaranteeing the citizenry in countries represented at the conference better, accessible, affordable and sustained healthcare services.

He acknowledged that Tanzania was uniquely honored to host the forum and stood to benefit from the experiences that would be shared, especially because the conference was taking place at a critical moment when there were sour labor relations upsetting its health sector, an outcome which is disastrous especially to the marginally poor.

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The Archbishop thanked the Guest of Honor for the insights in his speech on the importance of PBF and the guarantee of quality health care and ensured him that the conference would revisit the hits seriously to shape participants’ understanding of PBF and use them as a stimulus to achieve tangible results.

As the CSSC President, he assured participants that as a faith based organization (FBO), CCSC in partnership with the government will continue to do its utmost to improve the quality of life without any prejudice expressing his hope that the government on its part would continue to guarantee a conducive climate for the obtainment of optimal results in the health sector and other relevant fields that ensure the betterment of its people. This, he said can be achieved through sound policies. He ended his remarks by wishing participants an enriching participation in the presentations, discussion and deliberations.

The opening ceremony ended with a picture taking event with the Guest of Honour that was coordinated by the Master of Ceremony and Conference Coordinating Committee.

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Section 2:

Summary of Presentations This session started with brief introductory remarks by the Conference Moderator, Peter Maduki who explained the process and the expected output of the conference. He informed the conference that a team of six people comprising representatives from Government, CSO and network members to draft a formal conference statement (cf. Annex 6) which would form part of the proceedings of the workshop. The focal points for the Drafting Team were Father Serge and Madame Marie and the statement was developed over the course of 2 days and presented during the closing session.

Below is a detailed account of the deliberations of the different sessions.

Keynote address on PBF state-of-the-art Evidence of Impacts and risks – Dr. Claude Sekabaraga representing the World Bank

This presentation provided an overview of the PBF approach focusing on evidence of impacts and risks. The Presenter gave examples of what has worked well in some of the countries implementing PBF and the risks that need to be taken into consideration, including during the design stage. Below are highlights of the presentation.

Different terminologies -- Results Based Financing (RBF), Performance Based Financing (PBF), Performance Based Contracting (PBC) and Pay for Performance (P4P) -- are used to express the provision of finances based on outputs and outcomes rather than only on the supply inputs to health providers. That is the common vision that guides all these different schemes. PBF/RBF/ PBC/P4P all have the same rationale across different levels of income and provide an easy way to provide better services to the population by re-directing the behavior of health providers towards the interest of the payer.

The PBF methodology shifts from the financing of inputs to outputs and outcomes with the aim of dealing with a low level of efficiency in the utilization of existing resources. The direct linkage between financing and expected results is to influence providers’ behavior towards quantity and quality service delivery. The aim, objectives and rationale of the different schemes are to drive the behavior of providers towards the interests of the payer. With constraints in financing, increasing the value of existing resources is critical.

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Some developed countries of North America and Europe have applied the output/outcome payment concept using different designs and each one with a unique approach. Just to mention a few; USA uses Pay For Performance; Canada provides Health-care bonuses by provinces; UK has adopted a Quality and Outcomes Framework; Australia administers a Practice Incentive Programme for General Practitioners; Spain provides Staff incentives; and Sweden draws Service contracts.

Positive impacts have been recorded in all countries. In the UK hospitals are performing better in fulfilling the standards required in the diagnostics and treatments of some diseases. In Turkey, doctors performed highly when their hospitals and staff received additional financing based of agreed results, more patients were treated and more physicians worked full time registering an increase from 27% to 80%. In Egypt, in some primary health care services, the providers were more responsive to provide quality services when incentivized.

The approach has also been applied in Middle Income Countries (MICs) with equally good results. Turkey conducted pilot studies that were able to enhance the performance of doctors in delivering good quality services from 27% up to 80%. In Low Income Countries (LICs) the approach has been implemented in Afghanistan, Benin, Burundi, Cambodia, Cameroon, Central Africa Republic, Chad, Congo Brazzaville, DRC, Kenya, Nigeria, Rwanda, Sierra Leone, Tanzania, South Soudan, Zambia and Zimbabwe. In Afghanistan, two options were used. One, the government contracted organizations to manage health facilities on its behalf based on key results, and two, the government provided the necessary inputs and managed the facilities on its own. Both options resulted in higher performance when financing was linked to results. Sub-Saharan African countries are among countries that are well advanced in the approach with 3 well functioning national PBF programs in Burundi and Rwanda in East Africa and Sierra Leone in West Africa. The program for Rwanda has been developed in detail as it is among the countries that has done an impact study. A randomized study conducted between 2006 and 2008 noted added value with PBF. It recorded great results in 2007/2008 for all indicators with a clear difference at the level of quality as a result of PBF. In Burundi, the government used PBF exists alongside to finance the provision of free health care to pregnant women and children below five years of age. The demand for the services has increased and indicators have shown great results. as a result of PBF. In Sierra Leone, PBF has already showed some progress in Family planning (FP) & Post Natal Care (PNC) in the first two quarters. Different countries have achieved different levels of successes. In Cameroon, PBF was first implemented in faith based facilities and was expanded to government facilities with significant improvement in health care indicators. There are more than 15 programs ongoing in SSA, which makes it among the first region in the World. All these results confirm that PBF is a powerful financing mechanism for improving the quality of care and quality of services.

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Despite those impressive impacts, the PBF methodology presents a number of risks including the distortion of staff behavior which needs to be taken into consideration in the design. Most doctors and other health providers enter the field because they love the profession and not for the money. There is a need to take into account the means used to motivate staff. It should be remembered that RBF/PBF/PBC/P4P is not merely payment for improved performance; it is more like purchasing behavior change.

Another risk is that staff can be selective in service delivery and neglect the services that are not remunerated. This can be dealt with by ensuring the indicators are composite and include all the basic services in a cross cutting package. There is a need to take into account the programme strategy to have some indicators that are not selective. For example, the criteria for quality should cover the whole system.

Programme sustainability also presents a risk. The majority of PBF programs are externally financed. When piloting PBF it is important to also test budgeting options to be used during scale up to have programs with leverage of the public resources. Most countries are facing challenges in getting money from the government. Yet another risk is the escalation of costs. While it might be easy to see how many inputs you can purchase, it is very difficult to predict how much you can spend on performance. The verification of result is very crucial and requires a well-developed monitoring system otherwise it can be difficult to finance all the activities. RBF/PBF/PBC/P4P strengthens the health systems in terms of quality of data through the verification mechanism, autonomy of providers with more accountability and human resources for health development by the health facilities themselves. It is critical to take into consideration important design elements to prevent some identified risks. RBF/PBF/PBC/P4P should be seen as a forest and not a tree!

PBF Basic Principles and the Multi-country Project – Christian Habineza representing the Multi-country Programme

In this presentation, participants were introduced to the multi-country PBF project and informed about how the idea came about, the objectives and member countries, how it is funded and how it operates. Following below is an overview of the said presentation.

The PBF multi-country network is part of other existing networks including community practice networks. The definition of PBF used in the network is shared by other experts. It is an approach based on the quality of the services and characterized by a performance contract that specifies the roles of different actors under a regulatory authority. It also aims to deal with the weaknesses of the market place in order to achieve the set objectives. PBF further aims to

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reduce costs through cost recovery and attempts to test the theory through scientific research and studies

The idea to have a network was conceived in 2003 during an experience sharing session in Rwanda to reflect on experiences. Since then the network has been growing steadily. In 2005, experts from DRC, Burundi and Rwanda met and reached a conclusion to continue with PBF. In 2007 and 2008 other countries including Cameroon came on board. This was followed by Tanzania and Zambia in 2009 and in 2010 the PBF multi-country network was born.

The network receives technical support from Cordaid under EU funding with a local partner in each. Country. In Zambia the local partner is the Christian Health Associations of Zambia (CHAZ), In Tanzania it is the CSSC and the Kilimanjaro Christian Medical Centre (KCMC). In Rwanda it is the Health, Development & Performance, in Burundi Coped, in DRC BDOM Boma, in Cameroon CODASC/Diocese of Batouri and in the Central African Republic it is ASSOMESCA. Structurally, the network is governed at two levels; at country level and at international and regional level.

The main objective of the network globally, is to improve performance in the health sector through an active exchange of experience in PBF. Specific objectives include among others, the establishment of a network to learn from research, harmonization of vertical funding and collaboration between the government and the church. PBF also influences (HR) capacity strengthening of other actors to better manage the PBF program, and community participation in the management of the programme. It is a complex project as and each partner in the network tries to respond to the activity that is shared at country level. With PBF, there is a separation of functions with a clear distinction between regulation, service delivery, approaches, payment and consumption, and collaboration between public and private operations.

Other important element in PBF include contracting where there is a clear distinction between the role of the service provider on the ground and the role of the population in assessing user satisfaction with services provided and verification of data submitted by the service provider. PBF also encourages payment through subsidies to allow service providers to respond to the needs on the ground. The PBF methodology is slowly expanding to other sectors as well.

The Multi-country network is a 3-year project with a total envelope of 4M Euro. It does not operate as an isolated intervention; it collaborates with other networks in the world. All information including instruments used in the different countries is shared and can be accessed via google. The network also receives a lot of requests from many countries wishing for information. In order to document the PBF experiences, the network conducts research, HR capacity strengthening, trainings in various countries, updates best practices and conducts advocacy on PBF as a continuous activity.

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The project is soon coming to an end and the midterm review shows that network counties are at different levels of implementation. Some have not started with PBF but the concept is well known in all the 7 countries. The Network has good partnerships with international meetings because there is always a need to improve contacts and exchanges through the website. Research activities met some obstacles as the Network tried to collaborate with academic institutions. However, new partnerships have been formed and hopefully this year the Network will be able to undertake planned research.

In Burundi and Rwanda synergies with projects funded by other sources and multi-country networks have been created. The Zambia model is an interesting development because in the past collaboration between the State and the Church was not very formal but with multi-country interventions it is now concrete. Partners are also able to independently deploy PBF in their respective countries and promote it. The voice of the population has been strengthened and enhanced in the country and so the local community is involved in the verification of data.

The presenter admitted that some results were not entirely due to the multi-country intervention and commended the collaboration of other interventions.

Health Systems Financing as an input to health system performance by Maximillian Mapunda representing the World Health Organization (WHO)

This presentation was about health systems financing and how it relates to health service performance. The presenter explained how different countries allocate money for the health of their people and the pooling mechanisms that exist in the Africa region. He also talked about the WHO African regional strategy and universal health coverage in Africa. Below is a summary of the presentation.

Health Systems financing is a system of mobilizing financial resources in the health sector from different sources (public and private), allocating them to attain technical and allocative efficiency and distributing them to ensure equity and accessibility of health services. The method of payment for health services has a great influence on health service performance.

In the WHO African region, health expenditure levels and government allocation to health is low. There is also a limited pooling mechanism as countries tend to rely on lower pooling mechanisms such as state funded health care systems, social health insurance, community based health insurance and voluntary health insurance. Overall, investment in health systems is low.

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The Payment based financing concept originates from the production theory whereby the market price dictates the volume and participation of the supply. It has been extended to the production of health services. A wide variety of inputs go into the production of health services including drugs, medical supplies and human resources. PBF only addresses incentives or payments that enable labour to produce more, a process that are usually constrained by low salaries, poor working conditions, weak management and supervision and lack of decision making authority. The PBF concept also capitalizes on the fact that recognition of ones performance develops a sense of achievement and motivates a person to try harder.

P4P programmes use different criteria including imposing financial risk onto patients; providing performance incentives to patients that include food, travel support, and money; providing payments to provider based on some measure of performance; providing P4P for both patients and providers; and a performance based element in the transfer of funds from national to local governments.

The main objective of the WHO African Regional health financing strategy is to foster the development of equitable, efficient and sustainable national health financing to achieve the health MDGs and other national health goals. It is in this light that in May 2005 the 58th World Health Assembly (WHA) adopted a resolution that focused on pre-payment of financial contributions for health care. Health financing was also an agenda at the Addis Ababa (2006) WHO Afro Regional Committee meeting where it was realized that in order to reach MDGs, the African region needs more money and needs to use health resources more efficiently. There is a need for greater equity in health service financing and accessibility and expanded coverage of health services particularly those targeting the poor and most vulnerable. The WHO supports this initiative because they address better use of resources.

The health financing strategy is guided by a number of principles that ensure smooth and effective implementation. Among these are country ownership of all health financing processes, equitable access by all, efficiency to ensure that maximum health benefits are derived from scarce resources; transparency in all financial procedures and the expansion of risk sharing mechanisms to increase the proportion of the health. The health financing strategy also requires evidence-based decision-making on a day-to-day basis and aligned partnerships that involve all health-related sectors and various levels of government.

Priority interventions aim at strengthening the three functions of health financing; revenue collection, revenue pooling and risk management, and resource allocation and purchasing. Each party (countries, the WHO, and partners) has a role to play in the process. Countries are expected to nurture national political will and technical leadership while the WHO and partners provide technical and financial support.

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P4P has the potential for facilitating the realization of Universal Health Coverage, an approach that was endorsed by the World Health Report 2011. When the whole population of a country has access to needed health services, that is, prevention, promotion, rehabilitation and treatment – without the risk of financial hardship linked to paying for the use of these services, such country will be said to have achieved universal health coverage. A number of African Heads of State have declared policies of universal coverage in their countries.

Strategies that can facilitate universal health coverage include pre-payment and pooling of resources, promoting the efficient use of available services, promoting solidarity of the whole population and increasing the quality and availability of health services through the use of modern technologies. Among the indicators proposed by the WHO that measure progress towards universal health coverage for these strategies are the mobilization of sufficient funds for health measured by general government expenditure on health as a percentage of total government spending or total health, efficiency of resource utilization and levels of financial risk protection and coverage for vulnerable groups.

PBF and Gratuity, prepared by Hon. Sabine Ntakarutimana, Sosthène Hicuburundi, Michel Bossuyt and Emmanuel Ndayegamiye and presented by Sosthène Hicuburundi

In this presentation, participants heard about Burundi’s six-year experience with PBF, the context in which it is being implemented, its objectives and examples of remuneration systems used. The presenter also shared some of the implementation challenges, gaps and lessons learned. Below is an overview of the presentation.

The BPF initiative in Burundi started in 2006 after studies that did not produce very promising results for a country that was coming out of a crisis. The majority of the country’s 8.5M people did not have access to the health system with high maternal and infant mortality rates, high mortality linked to communicable and non-communicable diseases, weak performance o f the health system characterized by low immunization coverage, very few attended deliveries, insufficient health personnel in terms of number and skills, unmotivated health personnel, weak quality of care and weak organization and management health systems and poor access to health financing. There was also no verification system in place to track performance not to mention problems with data collection. This resulted in payment delays due to huge administrative burden as health facilities needed to write reports of more than 300 pages to be reimbursed.

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To deal with these weaknesses, the Government made a decision to make health a priority and made a substantial increase in its contribution to the national budget from 1.18 to 5.34 USD/per head. PBF was put in place and started with services that are linked to maternal health and the health of children under five. This also formed the basis for the Health Reform from 2009 which entailed decentralization of the system into health districts and the elaboration of a plan for the development of human resources.

The objectives of the PBF scheme were to improve use and the quality of health services offered; improve the mechanisms of verification and reimbursement of the benefits of the package of free health care in favor of the pregnant woman and children of less than 5 years; to motivate and stabilize health personnel and incite them to work in peripheral areas; to reinforce the management, autonomy and the organization of the health system and incorporate the views of the population in the management and resolution of health problems.

The pilot was implemented in an incremental manner starting with the elaboration of national contracts in 2006 to the scaling up of activities to all provinces and combining it with the policy of gratuity in 2010. This was an institutional plan developed to integrate PBF in the gratuity system. The integration of gratuity experienced some problems related to training, lack of a verification system, problems with data collection and motivation. The demand for services at the level of provinces was very high and staff were unmotivated which led to the decline in the quality of services. Payment was delayed and the administrative burden was very high. On average a health facility needed to submit a claim of 300 pages in order to be reimbursed.

The government and partners decided to use PBF as a solution to these problems. The objective was to improve the use and quality of services by increasing the quantity of medicine in health facilities, putting in place a vibrant system to verify women and children below 5 years, creating a conducive working environment and bonus system for staff who have been working in difficult conditions and soliciting the opinion of patients at community level in the verification of the results.

Challenges related to integration of PBF in other health care services included delays in reimbursement of the bills to up 4 to 6 months (and some a were not paid); the absence of a system of verification of the issued bills, demotivated health personnel, and other such challenges. The government decided on the option to finance the package of free health care services through a mechanism based on financing performance to compensate for to these constraints. Results of this initiative included reduced verification process to speed up payment from 2500 to 2 pages. Some partners did not agree to the subsidy system but when combined with PBF the results were great.

Some of the key lessons learned include that PBF can be implemented with other health interventions, subsidy policies can be put in place and that the use of PBF reduces cost when

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the process of verification system is efficient. The Ministry of Finance should also be involved in all sectors and a monitoring system put in place to avoid loss and anticipate problems.

PBF also presents a number of challenges in that it is a very costly system but can bring out good results. The reference system is also costly if not respected for example you can find children six years of age included in the U5 children. The subsidy system has increased the demand for services and there is a need to put in place machinery that can respond to that demand and avail treatment to all levels and find ways to bridge the gap between cost and interventions.

In short, PBF has been able to provide good services to the patients but there is need to do research aimed at further improvement of the system. It is a good approach for staff motivation and behavior change.

Real Autonomy in Practice - Dr. Kaunda Nachilima, Zambia Experience

In this presentation experiences from a pilot project in Mpika Zambia on the benefits of real autonomy at facility level were shared with examples of specific actions that were taken to create demand for services, improve staff motivation, hire staff to address the problem of human resources for health (HRH), enhance innovation and strengthen the community voice. Below are highlights of the presentation.

Four out of 26 facilities (2 hospitals with their affiliated health centers and 2 rural health centers) participated in the PBF pilot project. Initial stages began with capacity building of facility staff and medical officers. The idea of receiving extra money was very exciting to staff and the control over the money gave them a sense of ownership and power which motivated them to develop strategies that would focus on increasing access to services. The Churches Health Association of Zambia (CHAZ) served as fund holder.

The first strategy they developed was demand creation. Health Facilities (HFs) were given targets to meet and they came up with different ways to create demand. They started by attracting women to deliver in HFs by giving them a baby pack containing basic items including pampers. This motivated them to deliver in institutions and increased demand for labor and delivery services. Women were also motivated to bring their children for vaccinations, growth monitoring and promotion with a community health volunteer plotting the weight of children on their growth card. With these two strategies, key indicators started to improve as more women delivered in institutions and more women in the community brought their children for immunization and growth monitoring. The second strategy was to purchase medical equipment and supplies to improve service delivery. Facilities used their PBF funds to procure medical

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equipment such as diagnostic sets, BP machines and laboratory logistics. This helped to improve diagnostic services in the pilot HFs. The third strategy was infrastructure development whereby waiting shelters for pregnant women were put up. This allowed pregnant woman from distant villages to await delivery at the health centre thereby increasing institutional deliveries. The shelter was built using PBF funds. They also fixed a windmill that had been broken down for years and re-connected water supply to the HF and staff houses. This helped to keep the HF environment clean and hygienic and encouraged facility attendance. And to improve staff motivation, the pilot HFs started paying out individual cash bonuses on achievement of performance targets and provided uniforms to all staff including non-medical staff which was useful in identifying staff of different cadres.

In the area of HRH, PBF pilot HFs re-hired retired and vacationing staff to improve coverage and quality of services. HRH is a common problem across many countries as it is hard to keep members of staff in rural facilities so staff that lived locally was re-hired to improve quality of care.

In terms of innovation, staffs were able to save the lives of twins that were born prematurely by constructing an incubator using cotton wool and other materials to keep the babies warm until they grew into full-term babies. And finally, the community voice was strengthened through increased community involvement and training of community members. Hospital advisory committees which have members from among the community took an active role in the PBF. The health facilities also set aside 10% of funds from PBF for community activities and used the funds for various activities including rehabilitation of rural health posts and procurement of bicycles for follow up activities, e.g. dropouts for ANC services. Capacity building for community members was also provided to enhance their collaboration with health workers in the delivery of health services. A sense of ownership was created in the community and each party played their part.

Experiences from the pilot confirmed that PBF can increase quality of service, improve coverage and facilitate more accurate data collection and management. It also leads to client satisfaction, good governance (checks and balances) and equitable access to quality health care.

The Role of Civil Society in PBF presented by René Grotenhuis representing Cordaid

This presentation emphasized the important role that civil society plays in PBF and in collaborating with the government to create synergies. The presenter also dwelt on Cordaid’s role. Below is an overview of the presentation.

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While recognizing the overall perspective on the role of civil society in PBF there is a need to realize that PBF is not a magic bullet to solve all the problems in health care. Over the last decades a lot of countries made adjustments in their health financing to deal with pervasive effects and adjust it to create new incentives and challenge actors to become more innovative.

The Civil society is a core owner and real stakeholder of services and programs as it encompasses communities. Health is not about patients alone; it has a lot of implications on the communities including social and financial burdens. As such, the role of civil society reflects the role of communities. Civil society is an important stakeholder in health care provision and can play a crucial role in identifying priorities. While working with civil society it is important to be aware of the diversity of CSOs and the diverse interests of the different organized groups them. In PBF, civil society evolves from a recipient to a co-owner of the process and outcome. The community is affected by health problems and therefore it needs to be involved in the verification of quality that requires an effective feedback system. The participation of CSO has implications on service delivery.

The relationship between CSOs and the government is about synergies. Many times though the relationship is approached from a perspective of competition, over roles, resources and control rather than synergies and complementarity. PBF helps to make the system more balanced and looks at the supply side of services. It offers an opportunity for re-balancing the systems and creating more checks and balances. Often times governments are looked upon as being responsible for developing the framework that will guarantee sustainability, affordability and quality. CSOs can play a very significant role of making the system work.

Cordaid’s role in PBF started with a learning experience in Rwanda in 2002. It is now engaged in a number of countries including Afghanistan and negotiations are underway with the World Bank (WB) to initiate it in Haiti. PBF offers capacity building for communities and governments to strengthen synergy through health systems strengthening. The main role and opportunity is to offer networking and knowledge sharing and learning from each other about the challenges and how they have been dealt with. Cordaid is also trying to find new and innovative approaches to develop a health care investment fund to strengthen the PBF system. However, there is a need to remain critical because PBF is not the final answer. Challenges need to be constantly addressed in order to move forward and remain innovative. Cordaid also finances new and innovative approaches including investing in health.

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Public Private Partnership in Health: The Tanzanian Experience – Dr. Adeline Kimambo

This presentation focused on Tanzania’s experience in public private partnership (PPP) in health and provides insights on the policy environment and strategies that govern its implementation. It also highlights the importance of partnership in health, achievements realized and some of the challenges and key messages in PPP. Below is a summary.

The Tanzanian Ministry of Health and Social Welfare’s mission is to have a healthy society with improved social wellbeing that will contribute effectively to personal and national development. The current National Health Policy was reviewed in 2007 in consultation with all stakeholders. It aims at providing direction towards improvement and sustainability of the health status of all Tanzanians with a focus on those most at risk, and to encourage the health system to be more responsive to the needs of the people.

The key objective of the national health policy is to promote and sustain Public Private Partnership in the delivery of services. Others include the adoption of diversified complementary health care financing options, building of coalitions and multi-sectoral collaboration and involvement and representation of stakeholders and the community in health service delivery. Partnership in health is about pooling resources (technical, organisational, geographical, human or financial) and it can be informal or formal. In PPP, effective partnership can only be realized when partners talk to each other (communicate), understand one another (cooperate), combine resources and strengthen individual roles (coordinate) and work together to make a difference (collaborate) as they deal with the complexity of the challenges facing the health sector. Public private partnerships are important in dealing with the complexity of the health and social problems faced by the population. Collaboration among organizations from difference sectors and at different levels is inevitable for solving such complex social problems. There is also a growing awareness that an inter-sectoral approach to health services delivery is more efficient and cost-effective than separate uncoordinated efforts.

Tanzania is among countries in the region that has gathered significant experience in PPP which started way before independence though there was no formal arrangement. After independence, private sector operations were abolished resulting in a decline in the quality of services. The government later re-introduced PPP with a formal partnership agreement. The CSSC participated in the initial discussions and dialogue regarding the establishment of a proper PPP which is now in place. Strategy 6 of the Health Sector Strategic Plan III is on PPP in the achievement of MDGs. To ensure that PPP issues run smoothly and in a coordinated manner there is a special desk at the Ministry dealing with PPP, a technical working group under SWAp, a PPP policy and a strategic plan. What is left is to operationalize it.

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The Government is committed to embrace the concept of PPP and is providing all the support required to make it work. The main challenges that face the PPP process are limited in-depth understanding of the concept which has sometimes led to duplication of effort; mistrust among the different actors which results in withholding of information and lack of team work;, and lack of a strong coordination mechanism to make PPP run smoothly. There is need for rigorous advocacy particularly at lower levels where there is still a lot of competition.

PPP from a Government Perspective: Tanzania – Dr. Mung’ong’o, Asst. Director Ministry of Health and Social Welfare

This presentation focused on the PPP concept from a government perspective using Tanzania’s experience with Faith Based Organizations (FBOs) and Local Government Authorities (LGAs) as a reference point. See details of the presentation below.

There are two types of partners in the private sector category: for-profit (usually private individuals/entities) and not-for-profit (usually organizations).

Until the late 1980s the Tanzanian Government was able to provide quality health care to its citizens, free of charge. However, due to a number of reasons, it had to solicit support from the private sector. Among these reasons are, the government’s inability to fully fund equitable health services; increased population growth that was not matched with the number of HFs; increased costs for providing health care services; increased freedom of choice for type and quality of services; and global trends. At that time, a big number (42%) of HFs, especially in the rural areas were owned by FBOs, so naturally they were the first partners to come on board. In the later years a few for-profit private hospitals were established and joined government efforts in this endeavor. To date, Tanzania has continued to strengthen PPP by improving the working environment within the partnership.

The manner in which the government collaborates with private providers varies but has mainly been in the form of staff and bed grants whereby private HFs are given a certain amount of money (drawn from the basket fund) to pay for staff salaries; government staff being seconded to work in FBO facilities and training institutions owned by FBOs and tax exemptions for various basic equipment and supplies.

Partnership with FBO facilities is also in form of serving as district designated hospitals. To date there are 37 of these, which is a 90% increase from earlier years and the process is done through the designated council hospital management. Two FBO consultant hospitals serve as zonal hospitals and the status of 10 FBO hospitals has been raised to referral regional level hospitals and will be assisted with salaries, specialists, medicine and supplies and equipment.

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On another level, the government has partnered with LGAs to implement a Primary Health Care (PHC) development program. This has been affected through the construction of a dispensary in each village and a health centre in each ward in the country.

Efforts are being made to strengthen PPP including giving the private sector due consideration in the National Health Policy (NHP). The HSSP III ensure full participation of the private sector in all relevant forums such as SWAp, the Joint Health Sector Review (JHSR), various task forces and in the implementation of the Health Sector Reform (HSR) at different levels and in the review of policies and guidelines. In reciprocation, through CSSC and the National Muslim Council of Tanzania (BAKWATA) the government is invited to their forums. The Association of Private Health Facilities in Tanzania represents the private-for-profit entities in national forums.

Achievements in implementing PPP include improved relationships, improved support to the private sector with accreditation to the National Health Insurance Fund (NHIF), improved sharing of resources – the government disburses an equivalent of $1M every month, improved compliance in implementing the NHP and guidelines. Reduced mistrust and increased team spirit have also increased over the years. The private sector used to be at logger heads with the government but now they work together well and even do joint supervision of HFs and service provision. Each party understands the other’s role better. At council level, LGAs second their health workers to work in private facilities who are given service agreements to provide health services in areas where there are no government facilities.

Opportunities for greater PPP exist with increased government recognition of the role of the private sector, continued preference by the people to utilize private facilities and raised awareness of private providers on the need to be represented in policy formulation.

There are also a few challenges that affect this relationship such as the Government’s inability to provide equitable financial support and the shortage of health care workers. Also some private HFs employs untrained health workers and assign them tasks beyond their capacities. This has an impact on the health outcomes. In addition, the private sector is still not organized to have a consolidated bargaining power and the legislation for regulating private health services still needs to be reviewed and fine tuned.

Future plans in this endeavor including plans by the Government to facilitate a better understanding of the concept of PPP among different stakeholders through the technical working group on PPP. The government in collaboration with the private sector is working to update baseline data of health service providers, in terms of who and where so as to have a database which can be tapped into as the need arises. The government is working hard to facilitate the participation of the private sector at council level through guidelines that ensure councils involve the private sector in planning, implementation and evaluation. Efforts in this direction aim at ensuring fund provision to the private sector as per guidelines. The Basket Fund

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includes an allocation for private facilities especially FBOs. At local level the government is supporting LGAs to facilitate team work and advocating for the issuance of service agreements because sometimes FBOs resist such attempts for fear of nationalization. This is done through more and rigorous involvement in different processes.

Key lessons of decentralization - Dr. Claude Sekabaraga, WB

The gist of this presentation is centered on the Presenter’s own personal opinion drawn from experiences of decentralization in the African continent. It highlights the objectives and types of decentralization, how different countries have implemented it and the key results derived from it among other things. See details below.

Decentralization aims at serving the population of a country better, but it is not the only way to do it. There are two main types of decentralization: vertical decentralization which can be in form of deconcentration, devolution, a combination of deconcentration and devolution and/or federalism; and horizontal decentralization which focuses on autonomy. Decentralization is about the relationship between the Central government and federal/ local government or health district, the providers and the citizens. It is about power and say (voice) in the way public goods are managed. Decentralization can involve the transfer of resources to other entities at lower levels or transfer of resources or the power to make decisions regarding the use of those resources from the central government (Ministry of Health) to an autonomous entity at the same level. WHO favors the former as it has an empowering effect on the citizen.

Decentralization is about public goods and services, also referred to as the common risk. The choice of the form of decentralization a country opts for is based on the question “how will the common risk be managed? In the Federal government of Nigeria, the common risk that touched all Nigerian citizens was an epidemic but it was handled differently by different states because of the choice of form of decentralization. In some states immunization coverage was below 10% of universal coverage which presents a lot of risks as the epidemic knows no boundaries. Kenya has a new constitution whereby the health sector is managed by provinces. It is not clear who will manage an epidemic should it occur, will it be the government or the provinces? Another challenge in decentralization is the coordination of interventions. In a country that has bilateral, multi-lateral and global programs supporting different interventions and channeling their resources to different levels it can get very complicated. For example, bilateral and multilateral organizations work together with the country through national programmes but with resources channeled to the local/federal governments and health districts. Global programs channel resources to the Central government (Ministry of Health). And at another level you have international non-governmental organizations (INGOs) channeling their support

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directly to local/federal governments and health districts. This is a big challenge as it impacts on the delivery and accountability of services.

In decentralization there a re six critical issues to be considered:

1. The management of public goods;

2. Political interests and evidence based planning and budgeting;

3. Management of earmarked and block grant transfers;

4. Coordination of partners;

5. Choice between bureaucracy and service delivery;

6. Management of the deconcentration (Health Districts) and devolution services (Local/federal governments).

In the management of public goods health is commonly curative care provided through HFs. However, the common risk is often not taken into consideration as health and education are defined as services to be managed within the local level boundaries. This creates problems because epidemics do not have boundaries.

Political interests and evidence based planning and budgeting is a cross cutting issue. However, personal interests and priorities usually take precedence and resources are allocated based on these interests. This creates a lot of problems when the money allocated for crucial needs is used for other activities, e.g. for election purposes and/or visible interventions (usually construction related) based on the personal interest of the people in power. In such cases, resources transferred to the local governments even if earmarked for specific interventions are driven towards construction projects that are sometimes unrelated to the health needs of the population. It creates conflict between national priorities focused on public goods.

With regard to the management of earmarked and block grants at local level, there is a need to put in place a national target and the population should have a say on the distribution and use of these grants. Strategies to solve any discrepancies need to be developed because the disbursement of earmarked grants represents essential financing of the local/federal government administration, yet, the intended beneficiaries have difficulties accessing it for the set priorities. In many African countries, this is a major constraint in service delivery at local level.

Coordination between partners is a bit confusing at the level of collaboration and the problem is in the chain of command. In many decentralized systems it is difficult to know whether a health intervention will be handled by the central or local government, there are duplication of requests and many times, personal relations determine what ends up being done.

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The choice between bureaucracy and service delivery also presents a challenge and this really affects PBF because in order to serve the citizen better the procedures have to be changed and this often causes resistance. The control of power is usually over service delivery and the main argument used is lack of capacity especially in handling financing.

Management of the health districts at the level of WHO (deconcentration) and local/federal governments (devolution) which is a political definition also causes problems. At the level of WHO boundaries are not considered, the focus is on access to services. At this level the challenge is in how to deal with administrative borders, political interferences and other technical problems. The allocation of government resources by the political entity to the technical entity which is not fully geographically aligned creates problems, especially when the government spends money to a technical entity which happens to be smaller than the political entity. In Rwanda between 2005-2008 it was difficult to take a doctor who studied in the urban area to work in rural areas. This has been a big fight and some people use political power to remain in town. However, some changes have been happening after it was decided that money be sent directly to the hospitals. The number of doctors in rural HFs increased because the hospitals got money and they looked for good doctors. And the competition came in because HFs didn’t hesitate to look for doctors from neighboring countries of Uganda and Burundi when they couldn’t find Rwandan Doctors willing to work in rural facilities. They also put conditions on their employment in that when a doctor wants to leave he is supposed to give a notice of 3 months so that the HF can find a replacement.

In conclusion, the most effective and efficient form of decentralization is to the level that the population receives health services – the hospital, health centre level and resources should be transferred to that level. Resources that are sent to the health district and local/federal government do not reach the service provision level where it is needed most. The autonomy of health facilities on the use of resources works better as a health decentralization strategy and provides a framework for community participation and more accountability and pooling of resources. This is the preferred choice!

Decentralization Policy in Practice: DRC – Dr. Pierre Lokadi, Permanent Secretary MOH

This presentation walked participants through the evolution of RBF in the DRC and included an account of some of the strengths, weaknesses and challenges in the decentralization process and the planned next steps. An overview of the presentation is presented below.

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The Government budget for health is 4.5% and does not take into account revenue for health training. Contracting for RBF started in 2000 with support from the WB, EU, African Development Bank (ADB), the German technical agency (GTZ) and Cordaid. Between 2000-2006 a series of major reforms took place at the Ministry of health from funding into management and tendering. Guidelines were developed for the sector by tapping into experiences from Cordaid supported RBF pilot projects in South Kivu and Katanga. In 2009 the government formalized support to the management structure and organized a high level meeting on the efficiency of Aid which brought about the Kinshasa Agenda. It also institutionalized accounts to monitor where the money is going and for what purpose it is being used. In 2010 the government embarked on the elaboration of sectorial support which brought about the 2011-2015 Health Strategic Development Plan and an HR development plan. In the same year, RBF experiences were reviewed and a Memorandum of Understanding developed for a national scale up of the RBF approach. Health services now have autonomous management with minimal interference from the Central government.

Among the major achievements realized from all these are a formalized structure at the level of administration, drafted guidelines on the implementation of RBF, training of members sent to Kigali and Bujumbura, exchange of information in areas where the approach was implemented and tehe drafting of harmonized training modules based on results of the pilot. Also, a development plan for 2011-2013 has been developed and a mapping exercise of all actors in health is being planned. Recently, 10 trainers of trainers were trained to support the RBF initiative in Kinshasa. They did a briefing on RBF at the central level to ensure that everyone is on the same page.

The biggest strength in the approach is the sectorial approach and both the ministry and partners have agreed to adopt the strategy. The main documents have been adopted by the technical committee; however, no document can be used until the technical coordinating committee has adopted it.

There are still a few challenges that need to be dealt with, for example, the high number of staff that have not been paid. A contracting system has been introduced with a bonus of 2/3rd which is regarded as more important than the salary. Financial access is still weak when it comes to health.

Studies have shown that the majority of health expenditure cost is handled by the family because health Insurance policies are affected by HIV/AIDS, malaria and TB. Decentralization has been applied in primary and secondary level health care, however without laws that support decentralization that give the necessary power to the health centres it is very difficult to move forward. The Ministry of Health has adopted the key principles of Transparency, Results-based management and Training in PBF, however, there is a weak distribution of staff with more staff in urban areas and a low budget to ensure adequate HR capacities.

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The following next steps have been planned for 2012-2013:

Consolidation of existing projects with the necessary reforms and coaching

Sensitization at all levels and training of the actors at provincial level to have the same

understanding

Structural support which doesn’t require much resources

Development of a functional information system to enable the project to be proactive in solving problems

Advocacy for a progressive increase in the government budget for health; it is difficult to make the approach sustainable if budget does not increase.

The Ministry has to defend the development plan so that the government can set aside money for its implementation. The adoption process needs to be accelerated but this is pending a law on universal coverage that is still in Parliament.

Decentralization Policy in Practice: Central African Republic – Jean Michele Mandaba, Minister of Public Health

This presentation is about experiences of the Central African Republic in implementing PBF in a decentralized system of a country recovering from a crisis. It provides the background within which the program is being implemented, how the process evolved, major achievements and plans for the way forward. Below is a summary of the said presentation.

The Central African Republic is at the heart of Africa. It is landlocked with a population of approximately 4M divided in 7 health regions. Even though health is a priority the health condition of the population is fragile. HIV infection is estimated at 4.9% (2010 data); MMR is around 850/1000, IMR is around 103/1000 births. The financing of the health sector is not enough in relation to the needs of the country. When compared with other countries there are a lot of partners but in central Africa the partnership is more on the humanitarian side. With such a platform it is difficult to achieve the MDGs. There is a need for rigorous advocacy at central level for human and material resources for the health sector.

PBF started in 2007 and in 2008 the government had developed partnership with development partners to support its implementation. A pilot project was conducted in Nana Members near

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Cameroon focusing on 2 pillars: Education and Health. In 2009 the MOH in collaboration with partners conducted major trainings in PBF. A total of 20 doctors were trained in PBF at the central level. In 2010 with advocacy and support of Cordaid, the EU supported PBF projects in 3 districts. Also, continued training of health care providers. In 2011 the MOH conducted a 2nd training as it estimated staff with PBF knowledge were not enough and PBF was launched at national level with partners from Cameroon. In 2012 a PBF cell was created at the MOH.

The main actors in this Endeavour include the MOH which is in charge of regulation, health regions and health districts; Cordaid which does procurement and verification and is represented in all regions and the population and CSOs who raise their voice when things don’t go as they should. As for achievements, interventions in public health are being implemented in 3 health regions that cover a population of 1.5 people which is equivalent to around 30% of the population. In the Education sector, due to chaos in academic inspections, 28,000 students were affected by lack of money. PBF enabled the country to build bridges and construct roads. The country was affected by the crisis and needed to rehabilitate the infrastructure. PBF has reinforced the health system by improving outcomes of key indicators and put in place a system for motivation and stabilization. There is a HR crisis in the country as doctors don’t want to go to the rural areas; however, the system of motivation that was introduced to encourage them to go to the village has started showing some results. Now capacity building is done through PPP as well as the population.

Improvements have also been realized in quality of care indicators. With PBF, data is available every month and it shows increased training of doctors. The strategy is to reduce health tariffs and improve quality of services.

Decentralization of PBF can best be done gradually by distributing the country into smaller operational units. CAR is a huge country divided in 7 health districts. If you ask a Chief doctor to go round all these districts it is difficult. The country needs to be divided into smaller pilot regions that can be better managed and coordinated. PBF provides an opportunity to meet the expectations of the population and jointly deal with challenges on the ground. However there is need to impose regulations to ensure the PBF principles are not compromised.

As part of the way forward, plans are underway to decentralize the health system with proper flowcharts and budget line. Public finance for PBF will be institutionalized with standardized documents including application decrees and contracts and the line of command and hierarchy ironed out. The decentralization of the health system will be done according to health districts and an HR Development Plan elaborated to include career plans. Lastly, all actors in the health sector will be coordinated through a framework of consultation and partnership for health and development. In addition, the dialogue between the MOH and Ministry of Finance (MOF) will be put in an Act. An expert is working on this and some laws will be presented to the Ministry and partners soon.

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It is important to note that PBF cannot solve all problems. There is need for a mindset change at individual health staff level and community level. At the central level they are used to gratuity and are not ready to pay. Sustainability of financing and the fragility of the health system following a crisis are the biggest challenging factors. There are no other development partners except Cordaid.

Studies on the Impact of PBF: Rwanda – Mr. Shema Joseph, MOH Rwanda

Rwanda is bordered by Uganda to the North, Tanzania to the East, the DRC to the West, and Burundi to the South. It a landlocked country that is located 1,200 kilometers from the Indian Ocean, and 2,000 kilometers from the Atlantic Ocean. Rwanda is the most densely populated country with 420 people/km. By 2020 the population is estimated to reach 16M based on an annual population growth rate of approximately 2.6%. Nearly all Rwandans speak the same language ‘Kinyarwanda’ (spoken by over 99% of the population), which is the country’s first official language, followed by French and English.

The health pyramid starts with the MOH at the top level and referral hospitals. There are four geographically-based provinces (North, East, South and West) and the City of Kigali is further subdivided into 30 districts with 40 district hospitals and 30 community-based health facilities; 416 sectors with 420 health centres; 2,148 cells with health community posts and 15,000 villages (Imidugudu) with 4 community health workers in each. The district is the basic political-administrative unit of the country. Before the territorial reform in January 2006, the country was divided into 11 provinces and the City of Kigali, with provinces being further subdivided into districts, sectors and cells. Since then, the country’s administrative structure and associated terminology have changed.

PBF is one of the pillars of health financing and strengthening strategy for the health system in Rwanda. The approach was introduced in order to strengthen the motivation of care providers and results (output) in place of the traditional financing (input-based) which had not yielded any results, and increase the quantity and quality of care for preventive and curative health provided to the public in compliance with set standards. It started in 2002 as a pilot by 2 NGOs in former Butare and Cyangugu provinces. In 2005 it was scaled up and integrated into the HSSP I and implemented in all HFs in the country. Scaling up started during the second phase of decentralization in 2006. The strategy is implemented with 2 main sources of finanance: the government and PBF with contracts between donors and the MOH, the MOH and district HFs, the district HFs and HCWs and between HCWs and the community. PBF is a partnership in a decentralized system.

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Major progress has been made in terms of increased quantity and improved quality of health services provided, increased worker motivation through a performance-based incentive system, and a contracting mechanism between the government and other actors providing the financing and the services all the way down to HF level.

Rwanda’s community PBF is the second stage that focuses on addressing remaining barriers for achieving improved maternal and child health (MCH) outcomes, while the national community PBF model is focused on community health worker cooperatives who get incentives for timely submission of quality data; they report on 26 MCH indicators, and targeted improvements in 3 other indicators, namely; early antenatal care, institutional delivery and treatment of malnourished children. The demand-side incentives model is in form of in-kind incentive payment to women on 4 indicators, that is, early antenatal care, institutional delivery, timely postnatal care, and initiation of long-term modern contraceptive use.

Two evaluations have been conducted. The first evaluation focused on 3 main questions that sought to establish 1) whether PBF increased the quality of contracted health services; 2) whether it improved the quality of contracted health services delivered; and 3) whether it improved child health status.

The second evaluation sought to establish the impact through the following questions:

What effect the intervention has had on specific inputs/outcomes?

How outcomes would change given a change in the intervention?

Whether the treatment group/individual was better off as a result of the intervention?

Whether the intervention was cost-effective?

Results of these evaluations showed that there is a balance at baseline between both treatment and control zones. Expenditures were also the same so incentives were isolated. There was impact on utilization of services and delivery at health facilities; prenatal quality and reduction in child morbidity. In general, the effects from PBF were bigger than most other interventions and the main outcomes include improved health status, a decline in mortality and morbidity, a well functioning Health Management Information System (HMIS) and equitable access to essential medical products and services including vaccines and technologies in health. Other outcomes reported are improved infrastructure, planning, M&E, health financing, quality assurance and cost-effectiveness of the intervention.

Factors that facilitated the above successes include gender budgeting whereby the national budget has a budget line for gender promotion programs; community based health financing which removes financial barriers to quality health care especially for women and children;

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community health programs with 80% health problems solved at the community level through prevention, sensitization and care with the participation of the community.

Decentralization in Rwanda has helped to promote good governance and democracy through wider and more effective participation of the population in decision making. PBF has increased the quantity and the quality of preventive and curative health care provided to the population in terms of standards.

The contribution of innovation in implementation is another contributing factor to the success of PBF in Rwanda. These include: performance contact s with districts (Imihigo) tied to the achievement of goals which each district assigns for the key indicators for development including health. These contracts are signed with the President himself! Another innovation is the audit of maternal and child health deaths to inform on strategies and identify correct measures necessary to prevent future deaths, and the documentation of maternal and child health cycles via a rapid SMS alert system that allows such data to be sent electronically. It cuts down on waiting time and allows for immediate intervention.

Components of the next HSSP, HSSPII include a more vibrant focus on planning and M&E, health financing and HRH including basic and in-service training. There will also be more emphasis on infrastructure, equipment and transport, commodities supply and logistics (including pharmaceuticals), quality assurance, research and governance.

The main challenges that need to be dealt with include sustainability of PBF with government budget. Despite a large contribution from the government, the number of HFs keeps increasing and there is always a need for more money. Geographic accessibility is another major challenge because of the hilly terrain. This affects access to HFs especially for women in labor or those who need emergency obstetric care. There is also a need to continuously revise indicators and increased the PBF award according to the difficulties in achieving the given targets as well as promote equity in PBF awarding.

Impact of RBF in Somaliland: Practical Lessons by Mrs. Edda Costarelli, EU

This presentation was a summary of reported findings on a research study conducted in Somaliland that sought to establish whether PBF does indeed result in improvements of service delivery as well as ownership and sustainability. The findings are presented in more detail below.

EU Somalia has been working with 2 states in Somaliland since 1991 – Somaliland the independent state. The country was not doing very well in terms of development. There were

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very low health facility deliveries (9%) and low ANC attendance (26%) limited to one visit per entire pregnancy. MMR in 2008 was 1200 and IMR in 2010 was 108. The Government budget for health was very low but it has been increasing and is projected to grow to $100M per year. There is high donor dependency. The ratio of donor and government expenditure is 30:1.

The RBF pilot was launched in 2009 as a 5-year $3M project focusing on reproductive health services in 6 facilities – 5 clinics and 1 hospital. A combination of flat rate salary top ups, P4P bonus payments, absolute thresholds, fees to TBAs that refer women to HF facilities for delivery ($5per mother referred), and non-monetary gifts to mothers who delivered in HFs to incentivize them were paid out. The program had absolute targets calculated on the basis of catchment area.

The research sought to establish the general effects of RBF on reported improvements in service delivery, ownership and sustainability. The research method used was a controlled before-and-after design with comparison against 2 control groups of 4 clinics. One group of government-run clinics, and the other of NGO-supported (flat-rate incentives). Both control groups matched in terms of catchment area, urban location and staffing. The study was conducted over a 36-month period; one 12 month period with external support but not PBF and two 12-month periods with external support and PBF. The primary outcome measured was institutional delivery rates and the secondary outcomes included ANC, PNC, OPD visits and FP commodities distributed. The main data sources used were HMIS data on service delivery collected with hindsight in 5 clinics with an RBF scheme; qualitative feedback from focus group discussions (FGDs) with health staff; and semi-structured interviews with various stakeholders.

The study had a number of limitations included the fact that it was a case-control study that relied on data on catchment areas; incentives provided to NGO supported HFs were similar but not identical to the ones provided to government-run HFs; and the impact of the supply-side and the demand-side incentives could not be disentangled. In addition, the study was a small urban focused sample and there were no statitistical tests carried out.

Despite the limitations, the results showed a spike in performance with progressive improvement in selected measures both over time and against control groups. PBF seems to have contributed to improvements in performance above and beyond other resource effects with a strong upwards trend of over performance for HF deliveries. ANC also showed a strong trend with a spillover effect. In PBF interventions there is a tendency for health staff to do what is requested of them at the expense of delivering other services, but in Somaliland there was a positive spillover effect. Results for Out Patient Department (OPD) and PNC were not very impressive.

However, further analysis of the results suggest that the targets were set too low, for example, targets for HF deliveries were set at 50 but went up to 67 which show an over performance

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although the cash incentive given to TBAs contributed to the increase the number of deliveries. There was also a problem in design in that individual incentives were paid out to each nurse. A better way would be to pay the HF and let them distribute the incentive. And even though it is not a quality dimension, there was an increase in self-referrals for deliveries and over-referral to hospital even for uncomplicated cases. Performance was very narrowly defined with no direct evidence of PBF effects on health outcomes.

With regard to ownership and sustainability, there was more focus on sustainability because in Somaliland ownership is an issue. Health staff does not like the PBF system; they are happy to just get a normal flat salary. There was an exaggerated focus on financial bonuses with the MoH acting as a broker for its own staff. PBF is also strongly donor-driven as it is linked to the achievement of MDGs. Decentralization was by default rather than by design and so aspects of reform have not been worked out. As for sustainability, there is no managerial capacity for a handover at the moment; the role of the state has not been defined. The strategy has been approved but roles are not clearly defined, and there is a need to continually re-examine aspects of efficiency and opportunity costs. However, high productivity rates make it worthwhile investing in this model because of the high returns.

Impact of P4P in Tanzania (based on results of a pilot project in Coast region) – Dr. Rose, MOH

In this presentation participants learnt about Tanzania’s experience with a 2-year P4P pilot implemented in Coast region to test the approach and inform national scale up to meet the MOHSW’s goal of accelerating the reduction of maternal, neonatal and child morbidity and mortality. More details of the presentation follow below.

TheP4P pilot described above is funded by the Government of the Kingdom of Norway with technical assistance from Broadband Associates USA and jointly implemented by the Tanzanian MOHSW, the Clinton Health Access Initiative (CHAI) and the Ifakara Health Institute (IHI). The MOHSW continues to pay for inputs, like equipments, training, salaries, medicines and supplies. The pilot site was Coast region which has a population of approximately 1M people.

The objectives of the pilot were to:

1. To improve the efficiency and effectiveness of health service delivery using a results-oriented approach

2. To increase the generation and use of health information for decision making for improved health outcomes

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3. To motivate health care workers to provide quality services

4. To effectively manage, monitor and evaluate the P4P Pilot in the Pwani region

Eligible facilities are those that provide RCH services, report on baseline data and performance cycle data. In Coast region, 209 (84%) of the 249 HFs provide RCH services. Out of these, 7 are hospitals, 17 are Health Centres and 185 are Dispensaries.

Indicator targets were either set as overall results to be achieved or as gradual/step-wise improvements from prior performance for which 100% achievement received full payment and 75-99% achievement received half payment.

Data collection is done using routine HMIS tools and death audits conducted during site visits. Data is routinely verified during supportive supervisory visits by the CHMT; specific verification once per cycle; 6-monthly by the Regional Certification Committee (RCC) and by the National Verification Committee (NVC) for overall validation of results and request payments to be made by NHIF. There are also independent verifications done in form of spot checks.

Payment are made directly into the facility bank account and managed through the National Health Insurance Fund. Approvals for withdrawal of funds from the facility account for facility improvements are done by the Health Facility Governing Committee with oversight provided by the District Medical Officer (DMO). Incentive payment is split between facility Improvements and staff.

Evaluation of the Pilot is done for process monitoring (to track and assess implementation progress including whether implementation is progressing according to the design and to identify areas for improvement, examine acceptability of the scheme and ), impact assessment (to assess the effect of P4P on health care coverage and quality of care), and economic evaluation (to cost implementation).

A number of challenges have been faced during implementation including operational challenges such as irregular supportive supervision by management teams, challenges related to data such as unmatched DHIS and P4P indicators and routine data validation, financial challenges including delays in channeling funds from NHIF to facility accounts and to individual staff. However, the project has however managed to deal with each of those challenges through the development of checklists to facilitate more effective supportive supervision which are also used by the CHMT for incentive payment, the matching of HMIS, DHIS and P4P indicators and synchronization of HMIS and P4P implementation to deal with data-related challenges, and the allocation of more funds to purchase essential equipment and supplies to deal with delays in funds disbursement. Issues of verification processes and costs are dealt with by strengthening DHIS/HMIS to facilitate accurate data collection.

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Some important lessons have been learnt during implementation that will be useful in guding the scale up. For example, it has been established that the current project pilot cost is approximately $1/capita per year at full pay-out and can be brought down to $0.4/capita per year during scale up because some of the management activities can be integrated to the management responsibilities of the CHMT. For the project to collect accurate data it needs to have a sound HMIS in place and in order to have effective supportive supervision by the Council Health Management Team, it is necessary to include data verification in their task list.

Results Based Financing: Afghanistan – Najibullah “Oshang”, RBF Coordinator, Ministry of Public Health

This presentation aimed at sharing experiences in implementing RBF in a post-war country and the challenges of doing that. Below is an overview of the presentation.

Afghanistan is faced with tough geographical conditions and a dispersed population. Around 80% of its 25M population lives in an area affected by a 30-year civil war which damaged most of the systems especially the health system. During the time of the war the Ministry of Public Health lost most of its capacity as such, health services are very poor, inequitably distributed with rural areas highly underserved and very high MMR (1600/100,000 live births) and under-five mortality rates (257 deaths/1,000 live births). Coordination among stakeholders is also very weak.

After 2002, the new government and the MOPH took over stewardship of the health system. The government established a Grant and Contract Management Unit (GCMU) and started contracting out the delivery of health services. To ensure accountability, provinces were divided among donors. A basic package of health services and essential package of hospital services were defined and a HMIS established to oversee data collection.

Huge progress was made from 2004-2008 despite the limited amount of money budgeted for salaries and equipment to cover the whole PHC system.

In October 2010, a 3-year PBF intervention was piloted in 11 out of 34 provinces with financial support from the World Bank. It was implemented on a contractual basis with NGOs with rewards and penalties based on performance. The RBF scheme is integrated into current health system. The general objective is to improve child and maternal health by providing incentives to health workers to increase key maternal and child health outputs; and further improve the quality of health care services in general. It was built on the existing contracting mechanism involving a third party in M&E and purchaser-provider split. Incentives were given to both NGOs

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and health facilities (intervention groups) against a combination of output (quality and quantity) indicators. The control groups did not receive any payments.

Monitoring and verification is done through HMIS to measure volume of service (quantity) and a national monitoring checklist and facility survey to measure quality of services. Verification of the HMIS data is done on a quarterly basis and comprises facility based and community based data verification, and quarterly verification. A heavy penalty is charged for misreporting.

RBF indicators for the basic package health service level include, contraceptive prevalence rate (CPR), antenatal care (ANC), post-natal care (PNC), Skilled Birth Attendant (SBA), Vaccination (DPT3) and Tuberculosis case detection.

RBF indicators for essential package health service level mainly focus on quality of health service and include among others, institutional deliveries occurring within a hospital (HMIS), successful treatment of severely malnourished children (HMIS), equity in institutional delivery (BSC) and infection prevention (BSC).

Frequency of payment for RBF was done every 6 months by the MOH to the Implementer and every 3 months by the Implementer to health care workers. The division of payments among health care workers is done on the basis of a written agreement between implementing agency and healthcare workers and decisions regarding how the funds will be shared amongst facility staff are determined at the facility level, while payments to the health facility are based on a combination of quantity and quality of service for indicators above baseline and verified by a third party.

Impact evaluation will be done by comparing baseline h/h survey and end of project after 3 years.

In order to measure the effect of the RBF intervention, the evaluation design will be two pronged: on the one hand it will look at the effect of RBF on coverage of maternal and child health services; and on the other at the effect of RBF on the quality of health service. It it will be done in both treatment and control health facilities.

The main challenges that need to be dealt with include improving the scheme to adapt PBF in the process of linking with donor agencies – EU, Cordaid, Ministry and implementers - to pilot the intervention and then implement the real PBF and later on scale up. The bright side of this story is that despite the fighting and insecurity that the country is facing, there are some things going well especially for health and education.

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Intrinsic and Extrinsic Motivation: Shared points on ongoing research – Prof. Kenneth Leonard, University of Maryland

In this mini-presentation, the presenter shared some points on an ongoing research he is engaged in by responding to two observations raised during the 1st day of the conference; one, that intrinsically motivated health workers may not react positively to extrinsic incentives and the second, that PBF is not about motivation of health workers, it is about creating a system in which health facilities can afford to improve their services and use PBF funds for motivation if they so choose. Following below are more details on the presentation.

There are several views about health worker motivation. One implied view is that a health worker is “intrinsically motivated” as such they do not need outside stimuli to serve the poor/sick or people in need. Likewise, increases in extrinsic motivation (wages/bonuses/etc) will increase the effort of extrinsically motivated health workers.

Another view that is backed by evidence from Behavioral Economics, Psychology and from the ongoing research referred to her suggests that this view is not complete. The question we need to ask is whether there are “intrinsically motivated” individuals; i.e. the kind that would do what they are supposed to do even if there is no extrinsic motivation. This research shows that such individuals do exist but they are very few (1 in every 5 at the most) and they can be found in all sectors and it is feared that they may not react positively to extrinsic incentives and/or may not like the new system.

Evidently, ALL health workers will respond to intrinsic motivators; and if these motivators are increased, they will also increase effort. The intrinsic motivators are the “wage” of intrinsic motivation which means, intrinsic motivation is NOT a fixed characteristic that makes health workers perform better, and rather, it is a characteristic that makes them respond to intrinsic incentives. There are three major types of intrinsic wages:

Autonomy, that is, the ability to choose how to serve, owning the right to make decisions about the work place and owning the feeling of accomplishment when decisions are successful’

Esteem and Recognition for achievement, which includes earning and owning the respect and appreciation of customers and fellow colleagues;

Norms, that is, feeling a sense of pride in being seen as choosing to conform to publicly recognized norms.

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PBF increases the extrinsic and intrinsic wage and its focus is less about motivation of health workers and more about creating a system to improve health systems and service provision. There is a danger that intrinsically motivated workers might not like the new system.

PBF has 3 distinct features:

Team work, which helps to create a sense of belonging and individual pride in team effort;

Data, which allows individuals and teams to “own” the process and take credit for their accomplishments even if no extra cash payment is forthcoming. Data helps to show that something is being done.

Autonomy, PBF is guided by the assumption that “you can change outcomes.” This is a key lesson because before PBF people could not comprehend this.

It should not be feared that without extrinsic motivators health workers will not do the right thing. There are a few who always do what is required of them, regardless. However, it is important to make sure that PBF increases the opportunities to earn intrinsic rewards by creating both intrinsic and extrinsic motivators.

European Union Mrs. Edda Costarelli

There is some discussion about RBF taking place at the EU headquarters and a number of pilots in different countries. The feedback will be used to develop guidelines on RBF funding. Last year some money was set aide for the MDG initiative with a competitive mechanism for the allocation of funding, part of which will be contracted through RBF modalities.

Bill and Melinda Gates Foundation - Margareth Cornelius

The foundation does not have any policy with regard to PBF. As a private philanthropy, the foundation operates differently. Its mission is to ensure that every person has a right to a health y and productive life and have therefore focused on bringing down the cost of technologies for education – e.g. through libraries. Initially the focus was on technology. Now 12 years later we are in foundation 2.0 windows. In the new step in the evolution of the organization we understand the focus on technology and products is only valuable if it is focused on improved service delivery. The foundation was happy to learn about innovative

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ways to improve services. It will share findings with colleagues and impress upon them on the potential of PBF.

The foundation indirectly supports PBF in the form of contributions to large funding agencies like global alliances for immunization and the Global Fund which use PBF approaches in their relations with recipient countries, but it has not yet directly invested in PBF. There is a possibility that they might. The actual size of resources is quite small despite the big name; but the foundation aims to capitalize on new innovations and initiatives.

World Bank (Global) - Dr. Claude Sekabaraga

Since a number of years back the WB has been supporting countries at the level of investment in the form of International Development Assistance (IDA) for investment programs in the form of credit or donations. For example, WB is managing Norway and UK money.

A new instrument has been approved by the bank via a program for resources pertaining to RBF as well as an output budget program where the WB and the recipient country request for resources to improve indicators at sectoral level. Health can be part of this arrangement. The WB has a team in Washington at global level which focuses on RBF, manages the trust fund and supports programs at operational level. A lot of money is available for countries through this arrangement but recipients need to have a project before requesting and they can get from 80-100%.

Three interventions can be financed under this arrangement:

Impact evaluation where the programmed will be analyzed. Countries can request up to USD15M but need to have 15M from an IDA program.

Program Evaluation for which countries can request up to USD250, 000 to assess PBF but they need to have an IDA program.

Knowledge exchange and learning at the level of capacity building through exchanges. Countries can request up to USD125, 000 for workshops and conferences to exchange experiences on the programmed.

The WB has 2 Technical Assistance (TA) hubs; one in Nairobi and another in Washington DC for implementation follow up. Also supports the development of tools, e.g. Monitoring and Evaluation Tool for PBF. The organization is organizing workshops and conferences and community based interventions with partners including the African Development Bank to work

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together with government and other partners. There are many colleagues working on the ground.

World Bank (Tanzania) – Dr. Emmanuel Malangalila

Recently, the WB in collaboration with the Tanzania government set aside USD100M to improve basic services at district level. The fund was approved in December 2011 and became effective on March 1, 2012. It will be launched next week.

The development objective behind this move is to improve geographical access and utilization of services by factoring in elements of performance and equity. The project is part of basket fund disbursement therefore needs agreement with partners who are pooling resources on how it should operate.

The allocation mechanism for district basket has a lot of variation especially when based mainly on population. The proposal is to start with a few indicators including resource use, HR, facility-based deliveries to be compared across districts and rewards be given to the district as well not only to individuals. Better performing districts will be rewarded and can use the resources in their Council Health Plans (CHPs).

The idea has been presented to development partners but it is not yet decided when to start. The opportunity to factor in performance e and equity issues will be taken up by the technical working group to capitalize on ownership by government and communities.

The PBF project is very timely as the government is currently developing health financing policies and trying to put up a health finance strategy. The WB will be counting on existing experiences and hopes to work together with financial institutions on this Endeavour.

Donor Harmonization - Tanzania Donor Basket – Kirstine Noejgaard

The Tanzania Donor Basket is a joint funding mechanism popularly known as the Health Basket Fund. It was established in 1999 by the Government of Tanzania, represented by the MOHSW, MOF and Prime Minister’s Office Regional Administration and Local Government (PMORALG) and 6 Development Partners in accordance with the principles of the Sector Wide Approach (SWAp). Partners pool un-earmarked resources to support implementation in the health sector of Tanzania Mainland through the Health Sector Strategic Plan III (HSSP III) which is jointly defined by all health sector stakeholders within SWAp. The channeling of resources through

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such a modality confirms commitment towards more effective and efficient use of aid resources in line with the Tanzanian Government as elaborated in the Joint Assistance Strategy (JAS).

Currently there are 10 partners contributing to the Basket who work in an environment of policy dialogue under SWAp. The group operates through technical committee meetings and 12 technical working groups – one for health financing. The Health basket fund is a pooled funding mechanism with a finance committee that meets once a year. Within SWAp there is also a development partners group for health (DPG-Health) that meets monthly.

Projects supported in mainland include Global Fund initiatives and bilateral projects. In the last financial year, the basket set aside $19/capita which is about 10.4% government share of expenditure.

The Donor Basket is managed under a proper legal framework with an MOU signed by all parties that clearly states the roles and responsibilities between development partners and the Government of Tanzania. The MOU for 2008-2015 was based on HSSP II and III, the medium term expenditure framework (MTEF) of the MOHSW and PMO-RALG, comprehensive council health plans (CCHPs) and side agreements for each fiscal year before disbursement. The MoF IS responsible for releasing the resources to the Sector on a semi-annual basis. The Donor Basket overseen by District Executive Officers and approved by the Regional Administrative Secretary (RAS) with support from the Regional Health Management Team (RHMT).

The HBF process entails the disbursement of contributions through the Government system managed as Government resources and accounted for as part of the MoHSW and PMORALG budget. This is followed by priority setting and allocation of HBF integral part of the GoT planning and budgeting cycle. Thereafter, donors take part in key processes including budget allocation, review of district plans, monitoring of results, auditing and overall management, all of which take place twice a year in the Basket Financing Committee. At the end of each FY, annual fiscal accounts for central and district level are undertaken, submitted for scrutiny and followed up to the Audit Sub Committee (involves basket partners, Director of Policy and Programs, the Chief Accounts of Ministries, as well as Controller and Auditor General (CAG). The budget is monitored through the HMIS through a performance profile report, audited by the CAG. The whole process is aligned to the national government system.

More than half of HBF money is channeled directly to all the 132 districts with $1.30 USD/capita. The District basket contributes to the development budget of district health plans, as an addition to the Government Health Block Grant which mainly covers recurrent costs (salaries, allowances). An equitable resource allocation formula has been developed to give more funds to the more deprived districts and Councils Health Management Teams and District Executive Directors are responsible for preparing the Comprehensive Council Health Plans,

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budgets, subsequent implementation using CCHP Guidelines and inputs from facilities and other stakeholders. A small share of the HBF goes to the central level to support the provision of PHC services (primarily purchase essential medicines and commodities, support to Sexual Reproductive and Child Health programs, immunization).

The resource allocation formula used currently distributes the money to LGAs based on four factors:

Population (70 %)

Poverty count (10 %)

Under-five mortality (10%)

District vehicle route/distance between facilities (10%

The formula is planned to be revised in 2012/2013. So far the district basket has played an important role in the devolution of health services delivery to local government level.

Over the years increased allocation from <1$ - 1.30$. This has helped to strengthen health service delivery. The combination of increased funding with financial decentralization has enabled districts to selectively increase resources for key interventions. This has contributed to 38% reduction of U5 mortality in Tanzania between 1999 and 2007/08 (THMIS 2007/8). The HBF has also rehabilitated over 25% of the dilapidated primary health facilities in the districts (1315 Dispensaries and 197 Health Centres).

A Joint External Evaluation done in 2007 confirmed that the HBF it is a good tool to ensure health systems strengthening and decentralization of responsibility for health services to LGAs.. There is strong government commitment to contribute to the fund and earmarked funding has been reduced. Currently, a Health Financing Strategy, with PBF elements is being developed.

In 2008/2009 discussions ended with HBF Partners decisions to pilot P4P thru bilateral funds due to several risks factors including among others, the focus on PBF bonuses and allowances, poor design and development of indicators and the fact that compromising on minimum standards is harming service users. Unmet expectations and results by health workers make it even more demotivating. It also does not fill with the Service Agreement between FBOs and the government.

The World Bank has proposed that in future RBF can be introduced through Performance and Equity indicators by 2012/2013 for the District Basket allocation and this has been received positively by Partners. Proposed indicators include performance indicators with outpatient attendances per clinical health worker. This is because data is readily available and collected regularly and it shows how well districts are doing with the resources they have. Equity

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indicator measures the number of clinical health workers per 10,000 populations and is acceptable because data is readily available and collected regularly, there is more readily available than funding data which needs to come from the MOF and it looks at the distribution of key health care delivery inputs.

Country Experience: Burundi – From Pilot to National Policy – Sosthene Hicuburundi

This presentation provides an overview of Burundi’s journey with PBF from pilot to National Policy and includes the approach and lessons learned.

Burundi is now out of a crisis and is in a post-crisis period which coincides with the transitional phase. Since 2005 the government has been trying to develop reforms in the health sector. Before, the country had different partners supporting different interventions. With the introduction of PBF, roles were defined across regulation, supervision, verification and financing. The MOH was responsible for regulation while NGOs handled procurement, financing and verification functions. With another check by a third party organization. The main results and outputs from this shift include more motivated health workers, improved service delivery; greater satisfaction of the population confirmed by a survey and strengthened PPP.

At some point the government wanted to scale up but needed to decide on a model to use. All Partners were involved in the discussion and they agreed to integrate PBF into the gratuity of PPP. Looking to scale up without compromising key principles of PBF and are aiming for transparency and the maintenance of autonomy between the public and private sector. The governance system will be maintained.

The MOH has put in place a virtual basket fund with a common verification system with some flexibility. A Technical cell has been established to serve as a tool of the MoH that brings on board different partners during implementation. A verification provincial committee has been developed to oversee the performance and verification of quantity.

Key aspects of the new system include all public trainings accepted in the for profit with uniformity in indicators. This has helped to harmonize operations. Of the 48 indicators, 19 are for production, 7 for U5 and 66% of the budget by the govt for gratuity and PBF.

The uniformity of indicators has helped to stop double payment to workers. Some hospitals had a lot of bonuses linked to PBF and others not. Under the new system all bonuses are supposed to be paid under PBF. A database has been established and internet is used to produce bills and special reports. Each partner uses their own procedures for disbursement. Before scale

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up, payment network was checked by NGO; after scale up it is checked at different levels and verifications submitted at the level of the province.

Some key lessons have been learned in the process. These include the importance of starting with a pilot, the need to take realities on the ground into consideration and prepare scale up for national consensus. Reforms need to be done before scale up as they can bring out relevant elements, and choice of model should consider financial and implementation aspects. It is very important to avoid copy, cut and paste models from other countries especially at the level of administration and public service. M&E needs to be carried out based on realities and done regularly to adapt to reality. The MOF needs to be involved from the very beginning especially with regard to aspects the involve legal issues such as the law of public procurement.

PBF can be an efficient strategy but it cannot be productive as a vertical program. Health providers think it is a health policy but it is a tool that can enhance health service delivery. Some people think PBF is the only solution; it is crucial to use a system that embraces synergies so that all partners can be involved to maximize results. In Burundi, PBF involves the central government.

Country Experience: Zambia –State-Church Collaboration - Dr. Dhally Menda

This presentation is a success story about State-Church collaboration in health care delivery as experienced by Zambia.

The Zambian health sector is characterized by a mix of partners providing health care with the biggest role assumed by the government. In the private sector, Mission Health Facilities form the largest private health care provider’s services in Zambia and are represented by the Churches Health Association of Zambia (CHAZ) mainly in the rural areas and include mine hospitals.

CHAZ was formed in 1970 as an interdenominational (Catholic and Protestant) umbrella organization. It oversees 146 Church Health Institutions (CHIs) in 10 Provinces and 56 Districts managing 36 Hospitals, 81 RHCs, 29 Community Based Programmes and 9 Training Schools.

CHAZ is a the Technical Wing of the Church in Health responsible for representation & advocacy, resource mobilization (financial, drugs, etc…) and the provision of admin., logistics, technical support and capacity building.

CHAZ’ collaboration with government is done through an MOU that clearly stipulates its role as a member of the Sector Advisory Group and Technical Working Group at the MOH. At MOH level, CHAZ provides health care services in line with the government’s mandate. The aim is to

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complement and synergize services. CHAZ operates mostly in the rural and hard to reach areas and receives support from the government through grants to cover CHI’s running costs, health worker secondment and the provision of essential drugs, reagents and other commodities. At SAG level, CHAZ represents the interests of CSOs in health through various consultative meetings, policy forums and joint annual review meetings. As part of the TWG, CHAZ supports the government at the level of policy and programs. CHAZ has the advantage of the leadership in the churches who meet directly with the President whenever there is a burning issue. The Board Chair interacts with Minister of health and helps to push the agenda for CSO and faith institutions. CHAZ has reached an agreement with the Government that where CHAZ has a presence there should be no government-run facility.

CHAZ is one of the principle recipients of funds under the Global Fund and has received 146M to date to implement TB, Malaria and HIV/AIDS programs. CHAZ funds districts for the work they are doing and reports on them and it operates within existing framework, it buys into the HSSP.

In PBF, CHAZ is involved in the national RBF Project governed under the Health Care Financing (HCF) TWG Policy making body and actively participates in the following functions:

As a member of the National PBF Steering Committee which oversees all output based financing mechanisms and coordinates its implementation. At this level, CHAZ participates in the design of the PBF institutional framework.

Through an Advisory Role in the Health Care Financing TWG for all PBF initiatives

As part of the team designing the PBF Institutional Framework for Zambia, enshrining PBF in both the Sixth National Development Plan (SNDP) and the National Health Strategic Plan (NHSP 2011 – 2015)

A number of challenges are faced in the PBF project which range from inadequate health workers in PBF facilities, inadequate funding in some PBF facilities, insufficient funds to procure needed equipment and delays in regulatory decision making processes, e.g. opening of bank accounts for Government owned HFs. At CHAZ level, there are no control districts to compare results for confounding factors with the intervention districts.

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Documentary on DRC’s implementation of a PBF initiative

A short film on PBF experiences in DRC was shown in between the question and answer session to break the monotony. The narrator explained the rationale and justification for PBF and how it was implemented. Below is a summary of the message disseminated:

PBF was piloted as a strategy for financing health services to improve quality

It is done on a contractual agreement between one actor and another actor

It is implemented using finances raised by the government through development partners

PBF ensures that money is spent appropriately and in the right place

Crated a performance purchasing urgency ; first PBF agreement signed in 2011

Changes brought about by PBF are rigorously documented

A specific budget line for PBF created

Experience sharing done through training institutions for health that are involved in the initiative

Ward activities carried out with great results

Payment is made more or less on time and there is a good system for verification of results

Everything has changed; we now know that performance starts with hygiene, how we greet our patients all the little tings that we used to neglect

A Road map and strategic vision have been provided with the introduction of PBF; facilities have developed an action plan

The focus is on maternity services and results are visible - everyone who comes to the health facility seems to be satisfied

We have conducted our own self-assessment to see how we are progressing, whether we are adhering to quality control - we also get supervisory visits

The first to benefit from this innovative model are the patients

Exchange of ideas is crucial and encouraged

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PBF has brought about change; now health workers are happy to work knowing that they will receive some motivation – we have cleaner facilities, friendlier services with no extra money is asked of patients and better organized staff

What has changed? In the maternity ward a woman had to buy bleach and other things including gloves. Today everything is available. The hospital covers her expenses and they are only billed at the end

PBF was launched after training and was followed by facility meeting

Attendance records are kept and late comers are penalized when distributing bonuses. This has resulted in less absence from work. Before a person goes out on private errands she needs to find a back up

The Pharmacy no longer handles money. There is a Bursar to write receipts and payments are made at the cashier

Patient utilization has increased - the number of deliveries has increased from between 4-9 to 79 in just one month!

Patient s know what they need to pay for and only pay at only one spot– the cashier

The destiny of the hospital is decided upon in consensus with facility personnel

Quality of care has improved

Section 3:

Highlights of Discussions

On Health financing

One of the fundamental issues in health financing is to remove financial barriers so that more people can access services and to use resources more efficiently. There are 3 dimensions of health financing: mobilization allocation and distribution. Africa is operating far below the recommended WHO health expenditure figures. The average allocation is very low at the same time we are under performing in terms of expenditure. The emphasis is on efficient use of available resources, however, we need to mobilize more resources to be able to expand coverage at the same time provide quality care.

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The issue of funding is fundamental when we talk about lack of resources when there are other issues – in Cameroon we have just distributed mosquito nets worth 37 billion but we cannot see the impact on the fight against malaria, maybe the PBF could be integrated?

There is a tendency to relate efficiency with more allocation of funds, yet in DRC we undertook a study and we realized that the in some districts we were able to achieve the same results with less money. The cost was $3/per capita while other countries have invested up to 10/per capita but they don’t have better results.

On Implementation of PBF/RBF/P4P

In PBF, it is not the resources that determine the results. It is more about the strategy used. The first strategy is to reduce the cost of intervention to achieve more results. When Afghanistan started implementing PBF, there was no gratuity but they were able to combine strategies to achieve impressive results in terms of coverage.

P4P and PBF is not for the motivation of staff! This assumption should be completely removed from our mindsets. The objective of P4P/PBF is to increase performance. Inputs are only provided when results can be verified.

PBF is very useful not only for the health sector but for other services as well, e.g. agriculture. But we need to get more arguments why PBF is important.

With regard to reforms aimed at facilitating implementation of PBF, best practices from PPP can be tapped into and approach the issue in a broader and more inclusive context.

In some HFs, P4P does not work because the HR lacks the necessary skills, knowledge and competencies. It is also important that equipment, medicine and infrastructure are strengthened and HMIS improved so that coverage can be monitored. If the P4P package forgets to incorporate all these elements then the HF in question will not be able to deliver what we are trying to do with P4P.

PBF implementation is more efficient with facility-based performance targets otherwise there is a risk of PBF being a tool for a projectile approach, with each player using PBF to bring in their own set of indicators. Another alternative is to implement regionalization of donors wherby one donor/NGO covers an entire region.

Sustainability

The issue of sustainability of the PBF strategy is a crucial issue for the involvement of the government. Member countries need to exchange experiences to see how we can sustain this strategy and enhance the indicators of health.

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Health systems of our countries functioned well in the beginning but today for us to use PBF it means there is a problem. There are many factors that destabilize the health system. Today the funding that is obtained mainly comes from external sources. We need to change our mindset to own these interventions and manage the handover at the end of the project. In CAR from the moment the PBF approach was introduced it was well received and the government’s support is very visible. However, in some countries the issue of sustainability is a bit worrying especially where the support is almost coming to an end.

On Domestic accountability/Political commitment

Rather than calling it domestic accountability perhaps the term ‘local resource mobilization’ is more appropriate. It is important to mobilize a lot of resources and lobby for more resources, but the issue is not lack of commitment by governments rather how to share the minimal resources available. In resource-constrained countries, when the government allocates more money to one sector it means the other sectors suffer. Therefore a government’s inability to allocate more resources to health should not necessarily be interpreted as a lack of commitment.

Political commitment as it relates to sustainability

It has been proved that PBF leads to a more sustainable health care delivery system. But not all countries implementing PBF have shown promise of sustainability. Need to ask what else has to be in place. Is it domestic accountability? Or is it about political commitment? Experiences from Rwanda and Burundi confirm that political will is very important. The mere fact that there is commitment from the government is a great step forward towards sustainability. In PBF it is difficult to get results without political will. A counter argument is that even in the absence of political will external actors like NGOs can help. But at the level of service delivery all actors need to be involved and the system has to be centralized. This requires political will.

PBF Bonuses/pay outs

There is a risk that PBF may potentially lead to over consumption of services; since the more units delivered the more money is paid out. “The objective of being more efficient is closely associated with the risk of being inefficient.”

In PBF remuneration/rewards must be linked to the achievement of specific indicators. Having results framework helps to increase accountability because it is tied to performance and the motivation and implementation systems are guided by results.

The cost of the bonuses or payments made in PBF is escalating and it is difficult to have a limit on them. Tanzania’s experience is different because the bonus has been set on the percentages of the catchment area and this makes it easier to control. Its also not very risky in terms of sustainability.

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The issue of pay outs is tricky especially when payments are done at facility level. After PBF and with the aspect of motivation some HFs are cutting on the number of staff so that they get bigger bonuses,. This is especially the case when bonuses are paid to the facility. We need to develop an indicator that will push staff to work smarter to avoid the issue of de-motivation

Distribution of bonuses/rewards can be challenging if all actors are not involved in determining mode and criteria to be used. Sometimes there is a need to sensitize health facility staff on the benefits of reinvesting into the system so that they get greater rewards in future.

Benefits of the Multi-country PBF Network

There are three levels that the multi-country PBF network can be of benefit to its members and help to avoid reinventing the wheel. The first level is the sharing of tools and materials. In order to boost PBF interventions in different countries, especially countries that are just starting, there is need to learn from colleagues who have longer experience and tap into the lessons learned. Experts from countries that have implemented PBF for a while are open to assist in the implementation of new interventions in neighboring member countries. At the second level, is the issue of HR. We need to work as a network and strengthen mutual collaboration in terms of training of trainers and other kinds of support from veterans in the field. The third level which determines the results is the exchange of experiences. Rwanda and Burundi have a made a lot of progress but now Cameroon and other countries are coming up and trying to scale up the interventions this is due to the exchanges that occurred at the level of the network. Afghanistan is new in the field but there are lessons that other countries can tap into.

Data management

A well functioning HMIS should be a pre-requisite for an efficient PBF programme. Providers need to fill the registers properly so that during triangulation there are no gaps.

The cost of verification of the data is very tricky. In the absence of a good M& E mechanism, data can be incorrectly entered or fabricated to influence the rewards. In such cases verification costs can be extremely high, as high as 10-12% of the total project budget and sometimes even higher than the actual pay out. This needs to be looked into.

Access to timely and accurate data is a big challenge especially if payment is based on results that come from data. Need to find a way around this since PBF systems rely on data to show results. In DRC for example the HMIS is very complex and this might delay bonus payment.

In Zambia all HFs are required to report on a monthly basis. There is already a reporting system in place. The initial phase of PBF was not done very well as there were problems with data accuracy and timeliness. However, the introduction of PBF helped to solve this problem as some facilities appointed a specific person to be in charge of data. Talk about finding a solution

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in the problem. The monitoring system fits with the mainstreamed activities. The quality component is collected by the DHMT and the quantitative is collected by an agency.

The problem of quality of data can be a result of a poor HMIS system but is can be due to deliberate cooking of data in order to get bigger bonuses. For the latter there is a need to introduce a mechanism to punish deliberate irregularities especially given the cost for verification of data. In Zambia when they do data verification they check for quality as well. If they are not satisfied with quality of data the HF does not get the funds they were expecting.

PBF scale up

Scaling up of the programme needs to be accompanied by some modification of the institutional framework so that accountability to perform at optimal level is in-built in the scheme of service.

Decentralization

PBF and Decentralization: While there is a separation of functions at the level of decentralization there could be a lot of overlapping at implementation level. In Nigeria for example, there is a federal government that manages resources but there is no explicit arrangement on how to use these resources to serve the citizens. There might be a need to put in place contractual agreements to identify who does what and this will establish a link with PBF. When there is no clarity on expectations there is a problem. PBF could become a tool for decentralization.

Decentralization is a process that has been going on for many years; some countries have succeeded and others are still struggling with it. PBF just started recently and if we want to establish the link, PBF is a catalyst for decentralization. Just like in chemistry, PBF is an enzyme among others that may facilitate the decentralization process.

With the PBF if there is no decentralization it will not be possible to realize objectives. In DRC the government has put in place health districts and this is in order to ensure that a sick person in the most marginalized area can have service. We have some pilot regions that are broken down to health districts to ensure that the health structures are visible and the citizens of the republic can access this service. There are also laws in place to accompany the implementation of decentralization.

Need to link PBF with decentralization to avoid a shift in attention from one player to another depending on where the money is. Linking PBF into decentralization will help to get real autonomy and real value. It will also help to shift the focus off bonuses.

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Community involvement Programmes need to be innovative in finding ways to involve communities. When PBF started in Zambia they used to give out monetary incentives and things went well. But when they stopped things started dwindling. They had to come up with non-monetary incentives including food when they come for a meeting and some authority, e.g. signing the minutes of meetings that concern the community by community chairperson. This has kept them motivated and we work well together.

Capacity building

Capacity building is a process which should include capacity building for donors to crate some flexibility because many projects die when the project comes to an end. It we do not involve technical partners nothing can work, likewise if domestic partners are not involved nothing will work.

Public Private Partnership (PPP)

In order for PPP to be efficient and not competitive there is need for efficient coordination. The issue of coordination has been a big challenge. Yet, without good coordination mechanism each partner does their own thing. In Zambia, besides the Technical coordinating group they also have a PPP coordinating body that coordinates PPP activities of the different partners – it is comprised of representatives from all partner groups. Coordination helps to provide clarity on responsibilities. One of the progresses made in PBF is in defining the roles and responsibilities of the different stakeholders. It becomes easier and clearer when there is clarity on the different roles and responsibilities. PBF helps to achieve this.

The amazing experience of Tanzania and Zambia regarding collaboration between the Church and the State in health care provision is quite impressive. It does provide a lot of food for thought on the way forward.

PBF and Research

With support from the WB, CAR undertook dialogue with the dean of the faculty of medicine in Doula and Yaounde and they bought the idea immediately. PBF will be scaled up and we can anticipate that the young doctors will not be disconnected from this approach. From 5th year there is a curriculum that has been prepared to incorporate modules based on research that will be done over a few trimesters. At the 4th year they are now at the level of validating the programme. 6 trainers were sent to Rwanda and have already started providing training in hospitals. We have realized that universities are centres of excellence for research and this is a good example of collaboration between the state and institutions of higher learning.

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Section 4:

Conclusion and Recommendations Implementation of PBF methodology in the seven PBF network countries has confirmed the assumption that linking incentives to performance contributes to improved access, quality and equity of service outputs. It has also confirmed that greater autonomy in planning and management by service providers and involvement of the population in managing and evaluating the services fosters a sense of ownership and responsibility to excel. Furthermore, the PBF concept promotes entrepreneurship among service providers and other stakeholders involved in the contracting process as they gain skills in developing business plans, innovations and creative solutions that can be applied to improve service and increase coverage.

However, there are some potential risks and challenges that need to be dealt with as countries gain more experience and gather more lessons and best practices. These include capacity issues both in terms of numbers and skills particularly in activities like monitoring and management of health information systems which may compromise time spent on actual service delivery. There is also a danger of PBF programmes to be donor-driven or donor-dependent in terms of priorities and demands and less responsive to the needs of the targeted population. The issue of sustainability (institutional, financial and technical) is closely linked to this.

During discussions on various aspects of health care financing, a number of pre-requisites for the implementation of PBF programs were identified, including autonomy at service delivery level that provides room for innovative strategies and solutions aimed at increased performance, sufficient capacity to provide a variety of activity packages, and a functioning data collection and management system to facilitate accurate and timely reporting and evidence based planning.

To prevent donor-dependency, it is important to have an in-built exit-strategy at the design stage so that the programme strives for sustainability from the onset. The exit strategy should clearly define who will take over the roles previously assumed by the funding mechanism, whether it will be the government or an independent NGO. Sustainability can also be ensured if PBF programs are integrated in health insurance plans and district/council or municipal health plans. Successes realized in Rwanda confirm the importance of country ownership in PBF initiatives; ALL national and local stakeholders (government, civil society and communities) need to be involved in the set up.

Decentralization to the lowest level of the health system is inevitable as it creates real autonomy for providers and a sense of belonging and responsibility among the population. Finally, since the PBF methodology is still evolving and in order to take into account lessons

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learned and best practices, there is a need for more research to feed into the strategic planning process from the facility level all the way up to national health sector level.

Section 5:

Closing Ceremony

The Conference Statement – Dr. Fatuma

The closing ceremony was marked by the adoption of a joint Conference Statement that was developed in the course of two days by a small group of 4 members. It was ready out by Dr. Fatuma, a representative from the Tanzanian Ministry of Health and Social Welfare and received the endorsement of all participants. The statement took into consideration issues raised in the different sessions and contains key observations and recommendations. A full text of the statement is appended to this report as Annex 6.

Remarks by Hon. Minister Jean Michael – Minister of Health, Central African Republic

Speaking on behalf of his country, the Honorable Minister thanked the Organizing Committee for giving him the honor to speak at the conference and the Government of Tanzania not only for the quality of reception but also for the political will that they have shown towards this conference translated through the speech by the VP that set the scene for the conference by making PBF a point of interest. He thanked the organizers; Cordaid, CSSC, HTP for their efforts in creating the right atmosphere for participants to exchange experiences on PBF. He congratulated the various speakers for the clarity of their messages and the conference Moderator for moderating and managing the conference by keeping the deliberations focused in the right direction. He hoped all participants were able to get relevant information from the different sessions, adding that the conference was a classroom and that participants attended the conference because they wanted to learn and later make good use of the knowledge gained in their respective countries. Similarly, he hoped the partner organizations including NGOs that had taken part in the conference would do what is necessary to support network countries to implement the PBF approach which is innovative and adaptable to the needs of the different countries.

The lessons on PBF that were learned and the exchanges that were made have given each participant something to take home with them for application in their respective heatlh systems. He added that their presence was not about taking part n a high level meeting, rather to know how to put it in good use because health continues to be a sovereign issue.

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Ernest Schoffelen, coordinator Multi-country PBF Network on behalf of the Coordinating Committee

Mr. Ernest Schoffelen walked participants back to the reasons why the conference was organized in the first place, which he said was to share experiences and the potential risks and challenges and discuss ways to deal with the latter. The conference also sought to provide a platform to share observations about the different models of PBF and harmonize the different approaches, which he hoped had been realized. He noted that participants may be going home with more questions than answers but that was not bad since it showed that some critical thinking had been going on.

The conference had also wanted to reinforce the network of people who know each other and he hoped that had been achieved. He thanked all the peopole who made the conference possible particularly the some of the presenters adding that thoughts from different stakeholders involved in making PBF a success including representatives from government, representatives of the donor community, CSOs and from the academic society who provided the evidence of what works and what doesn’t work in which circumstances. He noted that the PBF network needed to work with academic and knowledge institutions.

Ending his remarks he gave special thanks to the Tanzanian MOH, the CSSC, specifically Madina Mukulunand Mecklina Isasi who had been working behind the scenes, Christian Hebeneza from the multi-country Network and most especially the Moderator Mr. Peter Maduki for making the conference a great success.

Closing Remarks by Dr. Fatuma, representing the Ministry of Health and Social Welfare

Dr. Fatuma acknowledged the presence of Honorable Ministers in, what she described as a big and important conference, and apologized for the absence of the MOHSW due to other important issues that needed to be addressed at the ministry. She assured them that their presence in the country was highly valued by the Ministry and the government as a whole.

She also thanked delegates for their participation and expressed her hope that every country had gained something from being at the conference, assuring them that Tanzania had gained more because it was represented by more presenters.

She urged them to concentrate on what was discussed and implement what is possible when they arrive in their countries, adding that it would be good to see progress in PBF implementation to make sure that the PBF Conference had produced something cost-effective. In conclusion she assured conference delegates that the government and MOH in particular was happy to have hosted the conference and invited them back to Tanzania.

With those few remarks the International PBF conference was officially closed.

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A1 Burundi Abbé Emmanuel NDAYEGAMIYE Directeur de COPED2 Burundi Dr. Michel BOSSUYT Chef de mission Cordaid Burundi3 Burundi Dr Sabine NTAKARUTIMANA Ministre de la Santé Publique et de la Lutte

contre le Sida 4 Burundi Monsieur Sosthène HICUBURUNDI Directeur Général des Ressources du MSPLS

5 Cameroon MR. ANGWAFO III FRU FOBUZSHI Minister of Public Health (Secretary General)6 Cameroon MR. MOH TANGONGHO SYLVESTER

Minister of Finance (Director General )7 Cameroon Mr ENANJOUM MBWANGA Coordinator for PAISS8 Cameroon Fr Serge Patrick MONDOMOBE Coordinator of CODASC/Batour9 Cameroon Jean Pierre Tsafack network participant

10 RCA Mr. Jean Michel MANDABA Ministre de la Santé Pub, de la Population, et de lutte contre ler Sida

11 RCA Mr Patrice NGOUPANDÉ Chief of Service for the Economic and Financial Planning to the Ministry of Finance and the budget

12 RCA Sébastien DACKPA Director. Ex. Assomesca 13 RCA Dr Joseph BAGALWA MASHEKA CORDAID BANGUI1516 RDC Adolphe Malanga PBF Coordinator - cordaid17 RDC Dr Pierre LOKADI: Permanent Secretary18 RDC Célestin BUKANGA National PBF coordinator19 RDC Mdm. Annie Lefèvre Chef de mission Cordaid RDC20 RDC Sud Kivu Pacifique MUSHAGALUSA MPH, Economiste de la Santé, HP,

Coordinateur AAP/Sud Kivu

21 Congo Brazzaville Dr Bernice Mesmer NSITOU, MD Coordonnateur délégué, Programme de Développement des Services de Santé, Ministère de Santé

22 Congo Brazzaville Dr Denis Batubenga Responsable AASS Brazzaville23 Congo Brazaville Dr. Andre Salemo Permanent Secretary - MoH congo

24 Rwanda BUGINGO Emmanuel representativ Director Community Development local administration

25 Rwanda SHEMA Joseph Representative PBF unit in MOH26 Rwanda Christian Habineza Director HDP27 Rwanda Gaspard Hakizimana PBF Coordinator28 Rwanda Emmanuel Ngabirenga

29 Zambia Dr. Nchilima Kaunda DMO, Mpika District30 Zambia Clement Chibanga Coordinator PBF CHAZ31 Zambia Dr. Dhally Menda Director of Health Programs

32 The Netherlands René Grotenhuis Director Cordaid33 The Netherlands Ernest van Schoffelen Senior program officer34 The Netherlands Marjan Kruijzen Senior program officer35 The Netherlands Frank.van.de.Looij Senior program officer3637 Kenya Claude R. Sekarabaga Senior health system strenghtening and RBF

specialist

Republic Democratic of Congo

Congo Brazzaville

NO. COUNTRY FULL NAMEPOSITION

Burundi

Zambia

Cameroon

Republic of Central Africa

The Netherlands

Kenya

Annex1. List of Participants

Rwanda

66

3637 Kenya Claude R. Sekarabaga Senior health system strenghtening and RBF

specialist38 Kenya Edda Costarelli Health Expert

Delegation of the European Union to the Republic of KenyaSomalia Operations

39 Kenya Pascal Bijveve RD CHAI40 Kenya Judith Kallemberg Manager, cash on delivery CHAI

41 Zimbabwe Dr Gibson Mahlanga Principal Director of preventive services 42 Mozambique Ntak Idiong Benson Elizabeth Glaser pediatric aids foundation, TA

health policy and PBF43 Afghanistan Dr. Saifuddin Hemat RBF M&E consultant MoPH44 Afghanistan Dr. Najibullah Oshang MD Result Based Financing (RBF) Coordinator,

Health Economics and Financing Directorate (HEFD), Ministry of Public Health(MoPH), Afghanistan

45 France Hugues TEMPLE-BOYER Project DirectorConseil Santé S.A.46 USA Kenneth Leonard Prof. UMD47 USA Margaret Cornelius Program Officer, Health Economics & Finance

Global Health Policy & Advocacy 48 Germany René Queffelec Project Manager & Consultant

Kenya

Other countries

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49 Tanzania Archbishop Thaddeus Jude Ruwaichi CSSC President

50 Tanzania Dr. Frederick C. Kigadye Executive Secretary51 Tanzania Dr.Hadji Mponda Minister - MOHSW52 Tanzania Dr.Regina Kikuli Ag PS53 Tanzania Dr. Donald Mbando Ag CMO54 Tanzania Edwin Mun’gon’go Ass Drector Preventive services MOHSW55 Tanzania Dr. Adeline Kimambo CSSC President56 Tanzania Joackim P Kessy PBF Tutor - KCMC57 Tanzania Frederick Bonnet Hospital Reforms Advisor MOHSW58 Tanzania Sule T. M. Michael Zonal PBF Coordinator59 Tanzania Askofu Dr. Israel-Peter Mwakyolile Chair CSSC/ZPF/SZ60 Tanzania Joshua Levens P4P Manager, CHAI61 Tanzania Kelly M. Crystal Country Director, CHAI62 Tanzania Maximillian Mapunda WHO63 Tanzania Emmanuel Malangalila Senior Health Specialist WB64 Tanzania Lucy K. Simbila Senior Operation Officer NSSF65 Tanzania Mapesa J. M Christian Council of Tanzania66 Tanzania Dr.Rosina Lipyoga P4P Coordinator, Pwani Project67 Tanzania Dr. Fatuma Maganga P4P Pilot Officer68 Tanzania Anna E. Olasfdottir IHT P4P69 Tanzania Nick Bain Advisor Public Financial Management70 Tanzania Mehjabeen Alrakhia Norwegian Embassy71 Tanzania Betty J . Humplick Consultant - Raportuar72 Tanzania Martin Zawadi Asst. Rapporter 73 Tanzania Patrick Kibopele Ag DMO-RDC74 Tanzania Peter Maduki Executive Director-CSSC75 Tanzania Kenedy Mbwette IT Specialist76 Tanzania Rachel Mkundai PR77 Tanzania Tumaini Mdee QCH78 Tanzania Mmamdani Masuma IHI79 Tanzania Chare Stokes PS. Techn Advisor80 Tanzania Peter J Snienga STA-PMORALG81 Tanzania Kirstine Nojgaard DANIDA/EDUC82 Tanzania Catherine Sungura Protocol83 Tanzania Minof Kuper GDC-GIZ84 Tanzania Alistidia Karaze Senior Research Officer -IHI85 Tanzania Khadija H Juma Nursing officer - MOHSW86 Tanzania Atuganile Adolph A/SECR87 Tanzania Madina Paulo PBF Coordinator88 Tanzania Valeria Tarimo AOA - CSSC89 Tanzania Mecklina Isasi Project Coordinator90 Tanzania Yuster Ngowo OMS91 Tanzania Linus Leonce Finance officer- CSSC92 Tanzania Titus A Mkapa PS-MoHSW93 Tanzania Dr Bernard Kephi Resident M.N.H94 Tanzania Prof. Mwafongo Specialist M.N.H95 Tanzania Hasr Hacliju Nurse M.N.H96 Tanzania Olivier Praz SDC97 Tanzania S.K.Runge CSSC-CC98 Tanzania Louis Tagwaba Interpreters99 Tanzania Renatus Sona Content officer - CSSC

100 Tanzania Michael Angulile DTSS - CSSC101 Tanzania Evan K DM CHAI102 Tanzania Ernest M Kulwa Protocol officer- MOHSW103 Tanzania Josephine Borghi IHI104 Zanzibar Michaelle Jacob Economist, MoH Zanzibar105 Zanzibar Abdul-latif Haji Director of Policy and Planning106 Zanzibar Mary Hadley Senior Health Advisor MOH107 Zanzibar Omar A Abdalla PBF Focal Personnel - MOH

Tanzania

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Annex 2. Agenda

Day/time Subject Speaker 6 March 08.00 Arrival and registration of guests 09.00 Opening ceremony and speeches

1. CSSC 2. Cordaid 3. Official opening by Tanzanian Authorities

Peter Maduki, Ex.Dir CSSC René Grotenhuis, Ex.Dir Cordaid Dr. Hadji Mponda, MOHSW Dr. Mohamed Gharib Bilal, Vice-President of Tanzania Rt. Jude Thaddeus Ruwa'ichi, Archbishop

10.30 Key note address PBF: State of the art; Evidence of impact, risks

Dr. Claude Sekabaraga World Bank

11.00 COFFEE BREAK 11.30 Presentation

PBF basic principles & Multi-country project

Christian Habineza, Multi-country programme

12.00 Presentation Health systems financing

Dr. Maximillian Mapunda World Health Organisation

12.30 Presentation PBF and gratuity

Sosthène HICUBURUNDI Dir Gen de Ressources MSP Burundi

12.50 Prepare questions for afternoon panel Discussion at group tables 13.00-14.00

LUNCH

14.00 -14.45

Panel discussion Questions on Health Financing, PBF, gratuity

Panel members: Claude Sekabaraga Maximillian Mapunda Christian Habineza Sosthène Hicuburundi

14.45 Presentation Real autonomy in practice

Dr. Nchilima Kaunda District health manager, Zambia

15.00 Presentation Role of Civil Society

René Grotenhuis, CORDAID

15.15 Presentation Public Private Partnership Tanzania

Dr. Adeline Kimambo, Ex-Director CSSC

15.30 Presentation Government perspective

Dr. Mung’ong’o - MOHSW Tanzania

15.30 Coffee/ tea 16.00 Group discussion on conference statement Led by moderator 17.00 Closing day 1 evening Reception; cocktail

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7 March DAY 2 08.30 Key lessons of decentralisation Claude Sekabaraga , World Bank 09.00 Decentralization policy in

practice.Democratic Republic of Congo Dr. Pierre Lokadi Permanent Secretary . MOH, DRC

09.15 Decentralization policy in practice Central African Republic

Mr. Jean Michel MandabaMinister of Public Health , CAR

10.30 Coffee/tea 11.00 Intrinsic and extrinsic motivation Dr. Kenneth Leonard

University of Maryland 11.15 Panel presentation by donor agencies

10 min. each speaker followed by Questions and Answers

EU: Edda Costarelli Bill&Melinda Gates Foundation: Margareth Cornelius World Bank: Claude Sekabaraga, Emmanuel Malangalila

12.45 PBF film

13.00-14.00

LUNCH

14.00 Tanzania donor basket Kirstine Noejgaard 14.30 Country experience Burundi

From pilot to national policy Sosthène Hicuburundi Dir Gen de Ressources Burundi

15.00 Country experience Zambia Collaboration State-ChurchDr. Dhally Menda. Christian Health Association Zambia 15.30 Coffee / tea 16.00 Adoption of Conference Statement

Led by moderator

16.30 Closing session Short video report Reading of Conference Statement Closing Remarks Official Closure

Dr. Fatuma, MOHSW Mr. Jean Michel Mandaba Mr. Ernest Schoffelen Dr. Fatuma

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