Interagency Working Group on Results-Based Financing

Meeting in Frankfurt/ Germany 7th May 2013

Dr Brigitte Jordan-Harder MD MPH

Results Based Financing Initiative for Maternal and Neonatal Health Malawi

What is the RBF4MNH Initiative?

Governments of Norway and Germany provide US$ 10 million (2011 -2014) Ministry of Health (RHU) / Options & BBA 4 districts, 18 facilities (MoH BEmONC and CEmONC) Supply side performance agreements Demand side cash transfers for pregnant women

RBF4MNH Outcome and Outputs

Increase in number of institutional deliveries of good quality in targeted health facilities 1. Increased quality of maternal and neonatal health services in targeted facilities 2. Pregnant women receive cash for transport to and staying at the facility 3. Increased staff motivation 4. Increased community members’awareness (women and men) of the importance of institutional deliveries

Contributing to reduced maternal and neonatal morbidity and mortality

Through

Performance incentives to motivate safe deliveries • Improved quality of reproductive health services • Increase of the number of quality deliveries at

health facilities And

Cash transfer to eligible women • For transport to and staying at the facility

Why focus on quality?

Maternal Mortality Ratio: from 770 (2000) to 675(2010) = minus 13% Institutional Delivery Rate: from 38% (2004) to 70%

(2010) = plus 84%

While the Institutional Delivery Rate almost doubled, maternal mortality remained high

Problems for provision of quality services

• Insufficient infrastructure • Lacking/ non-functioning equipment • Lack of/interruption of continuous provision of

essential medicines and consumables • Insufficient number and capacity of staff • Lack of staff motivation and commitment • Missing problem solving attitude of staff • Insufficient support and supervision by the DHMT

Obstacles faced by women for facility deliveries and timely access

• Distances and terrain • Lack of resources and ability to pay for

transport and stay at the facility after delivery

• Lack of decision making power of women • Traditional beliefs and poor awareness • Stigma (low age, unmarried)

The RBF4MNH components

Baseline assessment

RBF – Supply side RBF – Demand side Infrastructure & equipment

Independent evaluation

M & E Operational

Research

1) Empowering facilities to deliver quality care

Service providers and District managers as recipients of incentives:

1. Basic Emergency Obstetric Newborn Care (BEmONC)

2. Comprehensive Emergency Obstetric Newborn Care (CEmONC)

3. District Health Management Team (DHMT)

Selection of participating facilities

• CEmONC/BEmONC clusters • Possibility of referral • Coverage • Minimum quality of care available 24 hours delivery care Results of baseline assessment

Measuring Quality of Maternal and Neonatal Healthcare Delivery

12

Staff Medical Equipment Labour rooms Essential Drugs Data Money Knowledge

Structure

Supervision

Staff training

Equipment maintenance

Referral processes

Written procedures and Guidelines Service performance Patient feedback mechanisms Management meetings

Budget processes

Process

Safe equipment Increase in client satisfaction Improvements Based on Patient feedback Increased staff Motivation And problem solving Attitude Accurate reporting and Recording of data And use

Output

Increased numbers of institutional deliveries of good quality

Outcome

Supply Side Core Indicators and Targets-BeMONC

Core Indicators and Targets Weight /

Percent

1 Total number of facility based deliveries and number of referrals to CEmONC due to complications at the time of delivery increases by 5 percent from baseline every 6 months. 55%

2 100% maternal and newborn deaths properly audited according to national guidelines. 15%

3 100% of pregnant women who arrive at the facility for delivery with unknown HIV status who are tested and treated for PMTCT provided HIV test kits and ART are available. 10%

4 Accurately and completely filled HMIS reports submitted on time to the district health office. 5%

5 Up to date and complete stock cards of essential MNH medicines and commodities on the date of verification 5%

6 Accurate and complete RBF4MNH Initiative specific reports submitted to district health offices on time. 10%

Total 100%

Quality Deflators for BEmONC Quality Measures

1 Completely and properly filled partographs for all deliveries

2 Use of a uterotonic in third stage labor in all deliveries

3 Use of magnesium sulphate for control or pre-eclampsia and eclampsia when indicated

4 25% of women who deliver per month answer a patient satisfaction survey. At least one suggestion is selected by facility and implemented each quarter

5 Within 48hours after delivery administer Vitamin A to all newborns.

6 Broken maternity equipment reported to DHMT

7 Infection prevention and delivery quality checklist is implemented monthly and one documented action is taken to improve safety and quality each month

Supply Side Core Indicators and Targets for CEmONC

Indicators and Targets CEmONC Weighting

1 Completely and appropriately filled partographs according to national standards for all women who deliver in the facility

25%

2 All pregnant women who arrive at the facility for delivery with unknown HIV status are tested and treated for PMTCT, if they are HIV positive.

20%

3 Use of an uterotonic in third stage labor for all women who deliver in the facility

20%

4 Use of magnesium sulphate for control of pre-eclampsia and enclampsia for all women who show signs of pre-eclampsia or enclampsia who deliver in the facility

20%

5 Vitamin A administered to all newborns within 48 hours 15%

Total 100%

Supply Side Deflator Indicators for CEmONC

Indicators

1 Facility uses an infection prevention and delivery quality checklist once per month and documents at least one action taken each month to improve safety and quality delivery.

2 All maternal and newborn deaths must be properly audited according to national guidelines.

3 Each month, 25 percent of, or a maximum of 50 women, who have delivered, fill in a patient satisfaction survey administered by a person selected by the facility and at least one issue for improvement that is raised is selected, discussed and a solution proposed and documented.

4 On the day of the verification visit all broken maternity equipment is reported in writing to the DHO.

5 Stock Cards of essential MNH drugs and commodities (see Annex 14 for list) are up-to-date and complete on the date of verification

6 Completely filled HMIS reports are submitted on time, no more than 5days after the end of each month.

7 Accurate and complete RBF4MNH Initiative specific data reports submitted not later than 5 days after the end of each month.

DHMT Performance Indicators

Indicators Weighting

1 Sum of all institutional deliveries across the district meets or exceeds number in previous performance period 60%

2 At least one month supply of essential MNH drugs and commodities available at all facilities in the district 15%

3 On the day of verification a list of essential equipment (agreed with MOH) is in operating condition in RBF facilities 15%

4 Complete HMIS reports are transmitted to Central MOH in time 10%

Deflator Indicators for DHMTs The total incentive payment for DHMTs is deflated by the performance score of the RBF facilities in each district, which is calculated as: Sum of all performance payments achieved by facilities in the District (MWK) Maximum performance payments available (MWK)

A further 25% (4.2% per month) can be deducted from the DHMTs incentive payment for every month that an identified RBF facility in the district does not participate in the Initiative

Allocation of Payment

• BEmONCs: entire Facility team (70%); investment in service improvement/living conditions (30%).

• CEmONCs: 40% to invest in entire hospital; 60% to maternity ( 70% for maternity staff, 30% to investment in the maternity ).

• DHMTs— 60% for the entire DHMT team 40% for investments and operational costs

Verification

• 6-monthly verification of - reports submitted by the facilities and DHMTs by visiting - all involved facilities and District offices and countercheck with respective records - randomly selected number of women who delivered at the participating facility

Strengthening District Health Systems Incentives paid by the RBF Initiative strengthen district health systems: • District governance and management through incentivising

their performance and aligning DHMT targets with facility targets promoting supportive supervision

• Logistics through incentivising district teams for improved drug supply to HFs and better equipment maintenance

• Health Information System at all levels through incentivising improved data collection, reporting and use at HF and district level

Strengthening District Health Systems cont' Incentives paid by the RBF Initiative strengthen district health systems: • Promoting an enabling environment for health

service providers’ motivation, productivity and responsiveness to clients and working as a team

• Improved referral system (contribution of cash transfer)

2) Supporting pregnant women to reach HF in time through

Provision of cash for • Transport • Delivery related costs • Coming early enough before delivery • Staying long enough after delivery

Which women are eligible?

• Women 15 to 49 years old • Pregnant women who register at ante natal care

services • Women who deliver at participating health facilities • Women who stay recommended 24/48 hours after

delivery

Targeting Process

Registration at Health Facility

Health Surveillance Assistants verify

Health Facility Data Compilation

Submission of List to District Health

Office

District Health Office Approval and

Record Keeping

Financial Management • Each participating health facility will be required to

manage the funds provided • Each participating health facility will have an

operating bank account • Signatories will be decided by each health facility • The District Council will assign some accounts clerk

to work closely with health facilities • RBF Initiative will be managing the funds at central

level

Financial Flow • RBF Initiative based on delivery estimates per

month transfers funds into the bank account of the health facility

• Health Facility RBF Initiative Officers are informed of the transactions

• Health Facility RBF Initiative Officers prepare vouchers and cheques

• Cheques cashed, copies of the transaction sent to District RBF Initiative Coordinator

Financial Flow Chart RBF Initiative

transfers funds into Heath

Facility

Health Facility RBF Initiative

Officers informed

Health Facility RBF Initiative

Officers prepare cheques

Funds withdrawn by

the Health Facility ready for payment

Health Facility prepares

reconciliation and financial

requests ready for submission

Cash Transfers Cost compensation for transport, food and buying delivery related items like plastic sheets, chitenje…

Distance Band (KM)

Transport (MK) Delivery Related (MK)

Postnatal Upkeep (MK)

0-5 100 1,800 1,500 ( 750 every 24 hours)

>5 - 10 300 1,800 1,500 ( 750 every 24 hours)

>10 - 15 500 1,800 1,500 ( 750 every 24 hours)

>15 - 20 700 1,800 1,500 ( 750 every 24 hours)

>20 1,500 1,800 1,500 ( 750 every 24 hours)

Monitor, Review, Revise, Document

• Rewarded indicators • Processes of demand and supply side component • Environmental factors influencing project progress

and changes • Factors influencing maternal mortality • Possible unintended consequences

Operational research and evaluation Operational Research: • Workload assessment • Barriers for assessing services and patient streams External evaluation by University of Heidelberg Germany, College of Medicine Malawi, Harvard University USA, Bergen University Norway Impact of RBF on quality Information available for the initiative Reaching the poor Client satisfaction Community awareness

Lessons learnt so far • Availability of critical inputs have to be assured and up front

improvements financed • Complexity of the approach requires substantial time and

resources for design and preparation - shortening time for implementation

• No one fits all design- must be flexible to adjust to local circumstances

• Improved quality is essential – but finding verifiable indicators for rewarding quality a difficult task

• It takes time for health workers to understand and adopt the RBF concepts – requiring intensive supervision & support

Lessons learnt so far cont’

• Building district level support into the design is crucial to enable continuous support

• Embedding the approach in government systems can bring early gains and enhances ownership

• Involvement of all levels of government in all steps of the design is time consuming but initiates already a change of mind set and action for change

Timeline RBF4MNH

Preparation Phase 10/2012 – 03/2013

Facility Rehabilitation and supply-side component

Cash transfer begins 07/2013

First incentive payments to

facilities 10/2013

Performance Agreements signed 1/04/2013

Second incentive payments to

facilities 04/2014

Rehabilitation of Nkwhazi BEmONC