Report on the International Conference on Performance-Based Financing (PBF) Multi-Country Network Organised by Cordaid and COPED in collaboration with HDP and AEDES Rapporteur: Laurent Ntakarutimana Countries attending the Conference: Rwanda, Zambia, Burundi, Tanzania, Democratic Republic of Congo (DRC), Cameroon and Central African Republic (CAR)

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Report outline

1. Background of the Conference

2. Mission assigned to the Conference as soon as it was scheduled

3. Opening session of the Conference

4. Different presentations at the time of the Conference

Outline of the theme treated Recommendations or future prospects Questions and answers following presentations

5. Relevant observations made at the time of the closing of the Conference

1. Background of the Conference In January 2010, the Multi-Country PBF (Performance-Based Financing) Network was launched with the financial assistance of the European Union and Cordaid. In this Network of 7 sub-Saharan countries, namely Rwanda, Zambia, Burundi, Tanzania, DRC, Cameroon and CAR, PBF pilot projects are implemented and PBF-related experiences are shared to improve the health situation in the countries concerned. The following are the specific objectives of the Network:

1. To establish an international network for sharing experience among the seven (7) countries;

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2. To enhance new knowledge based on research- action in the following fields: community’s role in PBF, harmonisation of vertical and horizontal financing, collaboration between religious denominations and the State, institutional anchoring of the purchasing agencies, research on PBF’s impact on the human resource management;

3. To reinforce the capacities of partners and other stakeholders (local government and health professionals) to better manage a PBF programme;

4. To promote community participation with regard to both financing systems (PBF and mutual health insurance schemes) and to look for synergistic actions between mutual heath insurance schemes and PBF.

In February 2010, the launching Conference took place in Kigali and brought together the key stakeholders of the project coming from various countries. Besides the better understanding of PBF and the improvement of the knowledge of the EU’s guidelines for the implementation of the Project, the meeting also decided on follow-up actions, such as the launch of the Follow-up Committee and the organisation of its first meeting in November 2010 as well as the organisation of a Conference on experience sharing on PBF in February 2011. Cordaid’s partners, in the seven (7) countries concerned, are experimenting the PBF Approach in more than 20 different health districts, using several sources of funding (the World Bank, EU, the Dutch Government, Global Fund, USAID, earmarked funds, etc). However, each project is implemented in an autonomous way. Work tools and training modules are not shared at best. Even though trips are sometimes conducted for bilateral experience sharing, partners and countries do not sufficiently benefit from the lessons learned elsewhere. The purpose of the organisation of the current Conference is to promote PBF and experience sharing among the partners of Multi-Country PBF Network Project and other partners interested in PBF strategy. In addition, the project envisages annually organising a Conference to cover themes considered to be relevant to the development of the PBF strategy. 2. Mission assigned to the Conference as soon as it was scheduled This Conference intends to bring together varied participants: members of Multi-Country PBF Network, members of the Community of the Practice, Ministry of Public Health Delegates from the seven (7) countries concerned with the Project, the donor community and other PBF stakeholders in Burundi. Beyond principles and the theory, this Conference aims at highlighting the successes and limits of regional dynamics, and analysing the factors which contributed to these successes and failures. This Conference brings together professionals active in the purchasing function (purchasing of services or of performance) and in the function of the regulation of the health system. More specifically, the Conference aims at:

identifying lessons learned through various experiences in the region; identifying similarities in difficulties, differences in the search for solutions and

approaches; identifying problems where knowledge is still limited; consolidating the community of regional practitioners

A meeting bringing together stakeholders, decision-makers and donors, a meeting of experts.

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As French-speaking as well as English-speaking people attended the Conference, a simultaneous translation service was provided, bearing in mind that the language of communication of the Conference remains French. 3. Opening session of the Conference Cordaid Burundi’s Representative delivered an address for the occasion, greeted and welcomed guests on behalf of Cordaid and COPED. He reminded that the forum was favourable to sharing different experiences and facilitating research with a view to enhancing practices from this perspective of Performance-Based Financing accordingly. Cordaid Burundi’s Representative’s address was followed by that of the Multi-Country Network Coordinator. He stated that Cordaid is the pioneer of this PBF practice and that its experimentation started in 2002 in Rwanda. He added that there was no common formula applicable in all the countries, and that the specific context required experience sharing in an international network on the basis of research- action where, in this case, everybody was an expert. He said that participants were the holders not only of experience but also of expertise. He, therefore, called upon them to take advantage of the unique opportunity provided to them. As for he representative of the community of practice, he thanked the organisers for having extended the audience of the Conference by inviting other stakeholders in the areas concerned with these themes. He mentioned the case of Burundi, which made a rather difficult but firm reform. He said that the regional dynamics was considerable, and that, therefore, participants had to take up with humility the challenges before them and remain optimistic. Finally, Madam the Minister of Health in Burundi took the opportunity to warmly welcome guests coming from Africa, Europe and USA while expressing to them her wishes for the year 2011. She described the context of the organisation of this Conference. She indicated that PBF was a relatively recent practice in Africa, and that this explained the need for organising experience -sharing fora for implementation and reinforcement of the capacities of health stakeholders from the countries concerned. She said that it was within this framework that some experts’ networks, such as the Community of PBF practice and the Multi-Country PBF Network, were established. These networks aim, inter alia, for the sharing of research-action-based new knowledge, the reinforcement of stakeholders’ capacities and the promotion of community participation. She indicated that, after one successful experimentation period, Burundi decided to extend the experiment, consisting of the implementation of a strategy combined with the policy on free healthcare in favour of children less than five years of age and expectant mothers. She expressed her confidence that, even though there were still challenges, solutions would be found thanks to this research – action process. Considering that previous conferences set the tone and charted the way towards this experience sharing network, Madam the Minister urged the Conference to continue in the same vein and propose in-depth solutions. 4. Themes Various presentations on countries’ experiences The contents of the presentations were put at the disposal of participants in the form of CD. This report only highlights the main points of discussion, the governing idea, prospects and possibly recommendations.

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4.0 Presentation on Multi- Country PBF Project

This presentation was made by the person in charge of this Project at Africa level. The following is the presentation outline:

Name of the Project Background of PBF Network Partners to the Project Structure Objectives of the Project Duration and overall financing Points in common with other initiatives

The network is technically supported by Cordaid and co-financed by European Union (EU) and Cordaid. The Pilot Project started in Rwanda in 2002. And, in 2005, Cordaid Great Lakes Region extended experience sharing and established a discussion to set up a network. In 2007, the idea of the establishment of the network was successful with 2 English-speaking countries, namely Tanzania and Zambia, which also joined. The action occurs at two levels: each country tries to go at its own pace on the basis of PBF principles. Given that PBF is dynamic, it is essential that each country implements it according to its own context while keeping in mind the idea of advocating for a similar approach in implementing this scheme in different countries. Experience from Burundi presented by Dr. Jean KAMANA, Coordinator of the National PBF Technical Taskforce

a. Presentation outline:

Introduction: Institutional set-p Characteristics of Burundian PBF model Objectives Verification system Evaluation of the quality of services Main results Challenges Prospects Summary

b. Governing idea of the presentation The entire issue consists in knowing how to efficiently harmonise PBF with the new policy on free healthcare for children less than 5 years of age and expectant mothers, on the one hand, and with another measure issued by Presidential Order on the free treatment of all pathologies inherent in pregnancy and childbirth, on the other hand.

c. Prospects 2011

Review of the PBF Procedures Manual and of different PBF tools (March 2011) ; Redefining attributions and reinforcing the role of Provincial Committees for

Verification and Validation (CPVV) in PBF implementation;

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Undertaking the system of entering into contracts with service provision units at MSPLS central level;

Use of a new database on the Web to facilitate data management, the flow of funding and of communication in general (February 2011);

Undertaking reasonable measures to control the financing gap; Introducing or reinforcing reference and counter -reference framework within the

health pyramid; Attaching more importance to the quality of services; Reinforcing the support to field actors through supervision, training and other types

of logistic support. 4.2 Experience from Tanzania presented by Sule, T.Michael, PBF Area Coordinator, Rungwe Pilot Project

a. Presentation outline

Introduction Overall objective Specific objectives Expected results Project implementation Challenges and solutions Prospects

b. Prospects

Implementation of PBF second year Involvement of Government infrastructure and services in PBF Engagement in Research - Action

Tanzania has a PBF Training Institute. The other specificity of the practice in Tanzania is the harmonisation of the PBF Approach as practiced by the Government and that of religious denominations. Beneficiaries have a say in the matter. 4.3 Experience from CAR

a. Presentation outline:

Context Project presentation Some results Conclusion

b. Governing idea

The great innovation concerns the good delimitation of the areas of intervention.

c. Prospects The prospects appear as points requiring improvement:

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Correction of mistakes in the declaration of services Collaboration between medical workforce and COGES Role of COGES interface to support Health Facilities Health Facilities’ capacity to manage financial resources well Health Facilities’ capacity in planning and programming Campaigns for MIILD and JNV distribution Vaccines, contraceptives,…outage Follow-up of the activities

4.4 Experience from Zambia: CHAZ PBF

a. Presentation outline Background Objectives of the Project Results expected from the Project PBF Pilot Project Implementation Strategies CHAZ involvement Criteria for the selection of the pilot district PBF implementation structure Verification procedures Current situation

b. Prospects

Prospects appear as a sustainability plan for PBF Zambia Involvement of other important stakeholders (local purchasers, community

organisations, Ministry of Health, UNZA) Member of TWG-HCF and the National Piloting Committee Transparency in PBF financing for more equity Planning and integrated reporting for PBF Community involvement - possibility for the progressive introduction of pre-

financing structures Progressive introduction of PBF into the routine management of CHAZ

programs

4.5 Experience of Cameroon a. Presentation outline

General information about the country Administrative organisation: 10 areas Health system PBF situation

b. Governing idea

Cameroon’s experience shows the successful and very important role, which was played by the Catholic Church through its health centres. The experiment was so conclusive that it has already been extended to other regions of Cameroon.

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4.6 Experience of Rwanda presented by Dr. Joseph Ntibiringirwa from PBF Department, Ministry of Health

a. Presentation outline Health system in Rwanda PBF background in Rwanda Separation of roles in PBF Particularities of PBF Rwanda Some results Conclusions

b. Governing idea The system was regarded as a strategy to retain medical staff by preventing them from joining more remunerative structures. PBF began in 2002 under Cordaid’s initiative. In 2004, BTC adhered to the system and, in 2006, the Government institutionalised it. The system has already been adopted up to the community level. The only sector which is still being analysed is the adoption of the system in referral hospitals.

4.7 Experience of DRC

a. Presentation outline: Organisation of the health sector Financing of the health sector Reform of the health sector financing policy PBF interventions in progress Building on pilot experiments PBF as one of the tools of the reform Implementation of Multi-Country Project in DRC/Lower Congo Strategic areas of intervention Conclusion

b. Governing idea

Services streamlining and decentralisation The health sector is currently being reformed

c. Prospects Pilot experiments were made in all the regions and the assessment conducted in 2010. It is expected that the strategy will be used to define the national health policy. Indeed, the Ministry of Public Health is in the process of establishing a taskforce to develop and direct the scaling. PBF should, therefore, be a tool for the reform.

4.8 Sierra Leone’s experience cited as an example.

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PBF proves to be a strategy not only to ensure that services are accessible to the population but also to guarantee that medical staff improve services. The PBF Programme is in line with a large-scale programme, which will be financed by the World Bank. It was approved that 60% would be allocated to staff motivation and the remaining 40% used for the purchase of equipment. With decentralisation, supervision and verification are made at the level of grassroots communities. Sierra Leone defined the six axes of intervention of the PBF programme. The purchase of the performances is clearly defined and numerically established. All this was discussed at all the levels: the central level, the zonal or regional level. Supervision is done in synergy between the Ministry of Health and the Ministry of Finance at all levels: at local council, district or central level. Important roles and various responsibilities are clearly defined among various stakeholders to guarantee a good use of funds. The chain involves decision- makers and beneficiaries in the same process.

4.9 Questions and answers Questions regarding the case of Burundi There are many indicators, and PBF is in synch with the free health care system. At the same time, the issue of financing is raised. What is the solution? The answer and the solution lie in communities’ involvement. As regards the separation of duties, the Ministry of Health practically plays all roles: the same boss has control over everything. On which criteria are the sharing of funds and the financing allocated to the health sector based? Another observation is that the quality incentive is, at the end of the day, a sanction reinforcing those who are already strong and pushing down those who needed support. Can we have clarifications for this situation? The WHO Delegate expresses concern about the overestimation and validation of results by the incentive principle. There is a risk of manipulation because of this incentive. Are there, in other countries, criteria for the delimitation of performance thresholds? Answers regarding the case of Burundi The Ministry of Finance, and not the Ministry of Health, releases funds. Indicators are many, but what is more essential is showing everybody that the institutional set-up is coherent. And as free healthcare results from a national policy, it is not at this level that the review should be done. Mechanisms should be established, instead, to check whether the real beneficiaries really benefit from the provision of these services. Community verification is made by inviting tenders from local associations and shortlisting is done in transparency. Moreover, we see to it that the members of such associations have no direct relation with medical staff. There is no problem regarding verification staff since their shortlisting is objective: indeed, those who are eligible and all those who are not appointed by Decree or Order are requested to express their interest, and, once shortlisted, they are seconded in order to report to the President of the Verification Commission.

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The sharing of funds is done on the basis of clear agreements entered into with donors. The Government does not impose quotas. However, if some recognised health centres are not parties to these agreements with partners, it is the Government’s responsibility to cover the funds required. Questions about the case of Tanzania Is an experiment conduced in only one district sufficient to conclude that a system is successful? Another question concerned the relevance of the harmonisation of tools and approaches. Answers regarding the case of Tanzania Experiment in only one district is sufficient because, after this one- year experiment, all stakeholders, experts and decision makers will be convened to an evaluation workshop to think of a plan of extension to other health districts and even further. The harmonisation of approaches, as practised by the Government and religious denominations in Tanzania, is used to make these approaches credible and sustainable from the Government’s perspectives. Indeed, the Government hesitates to adopt PBF within the framework of the national health policy. The approach, therefore, consists in making a kind of advocacy in collaboration with the religious denominations having infrastructure and willing to convince the Government that the system can function. The Government’s scepticism is due to the fear of shaking up a health system, which functioned for years, by adding to it a new approach whose impact remains to be proven.

Questions about the case of CAR

The WHO Delegate expresses his concern about the overestimation and the validation of the results by the incentive principle. There is a risk of manipulation on account of this incentive. Answer for the case of CAR CAR’s experience showed, once more, the importance of checking well the relevance of the motivation incentive compared with the reality of the services. Indeed, it was found out that, actually, somebody who had stated to have conducted 2,000 HIV tests had hardly conducted one hundred and verification was made on the basis of supporting documents such as payment slips.

Questions about the case of Rwanda In connection with the separation of duties, to what extent have quality incentives contributed to staff retention? What is the impact of evaluations conducted unexpectedly? What are the differences between the results of the two evaluations used for? Are people reluctant to join the PBF system? Lastly, what is the Government’s strategy to remain within the budgetary limits?

Answers for the case of Rwanda

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As regards the separation of duties, the Ministry of Health deals with training while the Ministry of Finance releases the payment of the invoices after the evaluation of pre-defined indicators. Counter- evaluation is conducted by a private organisation. The evaluation is conducted at the qualitative level, and there are two types of evaluation: peer evaluation whereby health structure evaluates another for formative purposes. But there is also an evaluation by a central level structure, which, in fact, constitutes a counter- evaluation of the first evaluation. The first evaluation is assessed at 40% and the second at 60%. The structures concerned with peer evaluation know this in advance while the evaluation to be conducted by the central level can be unexpectedly conducted at anytime. Quantitative evaluation is monthly conducted, and it is under the responsibility of the district and qualitative evaluation under that of the hospital. Staff stabilisation is measured through requests for transfer. Until now, movements or tendencies to resistance have not yet been noticed with regard to the PBF system. Evaluation does not target staff because their evaluation falls within the ambit of the line authority. We, instead, evaluate the service.

Question about the case of Sierra Leone On which criteria were the incentives to the tune of 40% and 60% defined?

Answer for the case of Sierra Leone Out of seven (7) millions USD to be distributed among various health structures, proportionalities first depend on facilities. But, once distribution is made, each structure will have to maintain the ratios of 40 and 60%.

Questions about the case of Cameroon The project was implemented based on the health structures run by the Catholic Church. What was the mood of the health structures around? In general, what are the social effects of this system? The financing system by the Ministry of Health: what was reduced to be able to finance the PBF system?

Answer for the case of Cameroon There were, indeed, negative social effects, and some health district officers did not hesitate to qualify the project as discriminatory. Indeed, performances were obviously disproportionate between health structures applying the system and others that do not apply it.

Question about the case of DRC A concern regarding the system of supply in essential drugs when it is known that, particularly in some areas such as Bouma, the fraud of the drugs came from Angola?

Answer for the case of DRC As regards the supply in drugs, we have the central purchasing agency and suppliers, who are beforehand approved and regularly assessed.

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5. Theme: PBF and free healthcare system, experience in various countries

For the second theme, we present facts according to specificities of various countries, which combine PBF and the free healthcare system. 5.1 Case of Burundi presented by Dr. Basenya Olivier Burundi presented its experience of synergy between PBF and the free healthcare system

Introduction The policy on free healthcare for targeted cases Performance- Based Financing (PBF) PBF integration and free healthcare system PBF Institutional set-up in Burundi First PBF results + free healthcare system Opportunities for implementation Factors favourable to PBF implementation + free healthcare Implementation challenges Conclusion

5.2 Case of Rwanda presented by Habineza Christian

Rwanda speaks about its experience on the capitalisation of PBF results

Background: PBF Rwanda Organisation of the Health facilities in the pilot phase Strategies implemented Results Fundamental changes since 2006 New directives and strategies Conclusion 5.3 Case of DRC, experience from the Southern Kivu The case of DRC is concerned with PBF and Vulnerability (displaced people and the destitute)

Introduction PBF and free healthcare targeting displaced people Various strategies of intervention in the same context PBF and free healthcare targeting the destitute Implementation process Modalities for providing healthcare services to the destitute Some results

5.4 Series of questions and answers for clarification

For the case of Burundi Questions:

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Does not the term “free healthcare” risk constituting a failure factor for the PBF system? What is the added-value of free healthcare integration?

Answer

PBF mechanisms were established to correct some cases of dysfunctioning in the application of the free healthcare policy. Some concerns are noticed at the level of hospitals where costs are exorbitant. It is necessary to try to find the best tariffs for free healthcare-related indicators. Otherwise, the integration of both is beneficial for the entire health system in Burundi.

For the case of Rwanda Questions:

Rwanda is so advanced in terms of autonomy that Health Facilities are left with a leeway to organise staff and payment. Despite this flexibility, tariffs are fixed by the Government. Is this a gap? Subscription to the mutual health insurance scheme is compulsory. Central purchasing agencies were abolished. So, where is the autonomy?

Answers:

The development of the mutual health insurance scheme and health insurance companies inevitably led to the negotiation of a tariff to constitute the basis for refunding. And revision is regularly done on the basis of the cost of drugs. Compulsory subscription to the mutual health insurance scheme is also in line with taxpayers’ sensitisation about the ownership of the system, as citizens’ healthcare cannot rely for ever on foreign subsidies.

6. Theme: PBF and Mutual health insurance companies/Health insurance

6.1 Introductory presentation The presentation was made by Dr. Reginald Moorels. He proposed some ideas regarding the financing of PBF health system compared with mutual health insurance schemes. Traditional financing with its advantages and drawbacks. The fundamental issue is to know whether a national mutual heath insurance scheme can become an overall strategy for the financing of the health system, integrating other strategies such as PBF.

6.2 Case of Burundi presented by Dr. Manassé NIMPAGARITSE a. Presentation outline:

Background of health financing Objectives of PBF in Burundi Community mutual health insurance scheme (Case of the Gitega Archdiocese

mutual health insurance scheme (MSAG) Analysis

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Avenues for solutions Conclusion

b. Governing idea The subscription to the mutual health insurance scheme should come to complement the PBF system

6.3 Case of Rwanda presented by Hakizimana Gaspard

a. Presentation outline Historical background Organisational structure Contribution and collection Advantages System of entering into contracts Caring for vulnerable groups Monitoring and evaluation Some results and progression of indicators Conclusion

b. Opportunities and Prospects

The presentation showed opportunities and prospects consist, inter alia, of the following: An introduction to a new approach of contribution based on households’ income A computerization of the management of the mutual health insurance schemes across

the board

6.4 Case of Southern Kivu presented by Pacifique MUSHAGALUSHA The presentation was meant to be more a questioning than concrete proposals since DRC is still trying to find itself in this field.

6.5 Questions and answers regarding various presentations 1st series

The mutual health insurance scheme as a complement to PBF or the mutual health insurance scheme as a financing of PBF?

For mutual health insurance schemes, one expects that, with 30 years of experience, there is more equity; but, the poor never contribute if contribution is made on voluntary basis. The combination between the compulsory medical insurance and PBF is efficient. Quality in Burundi improved and receipts in health centres increased. But there is still concern about financial access. Even the population is of the view that tariffs in health centres are reasonable since healthcare improvement is obvious. It is necessary to act now regarding the establishment of mechanisms to combine the mutual health insurance scheme and PBF for more equity. In this regard, mutual health insurance schemes should, indeed, be designed as a source of funding for the PBF system.

Is not the PBF system that should finance mutual health insurance schemes? Which donor is ready to support PBF over one long period from 15 to 20 years? PBF is a tool for the policy

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and not a policy in itself, is it? The question people should ask themselves is what would be the post-PBF situation. PBF should provide such sufficiently strong support that, even after the completion of the Project, dialogue could continue within a sufficiently balanced framework.

Who identifies the poor and on which criterion? And since this is about a changing situation, how is this reflected in the database?

Answers

PFB should remain a complement to the mutual health insurance schemes. Neither should constitute a source of funding for the other. It is good that indicators and receipts increase, but it is not obvious that this can impact on the reduction of tariffs. Within the framework of free healthcare, there is what is called the economy of means. Drugs are provided according to the money given: one drugs package given instead of both, for instance.

In Rwanda, when civil servants were obliged to contribute to the mutual health insurance schemes, they were reluctant. Two years later, however, even the private sector requested to adhere to this compulsory contribution to the mutual health insurance scheme.

The definition of the destitute is objective, especially that it is determined at the village level where people know each other. The updating of the database on the situation of destitution is done each year.

When a question regarding best achievements by the Government of Rwanda is asked at random to some intellectual citizens, all mention the mutual health insurance scheme, among others. 2nd series

Is not the operation of mutual health insurance schemes in Burundi based on unilateral

decisions since the members of a mutual health insurance scheme never meet to decide to increase or reduce contribution charges?

What is the viability of the mutual health insurance scheme when very expensive free healthcare is introduced?

Before starting the mutual health insurance schemes in Southern Kivu, were the risks measured?

The three (3) main functions for a good operation of a health financing system: Resource mobilisation, risk pooling and resource allocation. In this line, could mutual health insurance schemes be regarded as purchasing agencies?

Should mutual health insurance schemes be self-sufficient? Answers For the moment, external contribution proves to be necessary because, in the case of MSDG, contributions are voluntary, bearing in mind that some people are not in a position to pay their subscription fees. This explains the support from the Government. The establishment of these mutual health insurance schemes, sometimes with the support of private agencies, requires the definition of a common policy whereby contribution is compulsory as is the case for Rwanda. A good policy helping to identify temporary or permanent destitute people is also needed. Of course, everything depends on the capacity to sensitise local communities about the massive subscription to mutual insurance systems. In so doing, viability is possible.

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Even when contribution is compulsory, mutual health insurance will always require contributions from people and the State contribution to be deducted from social contributions. Members of mutual health insurance schemes and PBF advocates all say that they aim for a system of solidarity and equity. Now, the poor have access to quality healthcare. And credit should go to the PBF system. There was no quality healthcare when there was free healthcare without PBF. The notion of the loss of profit had produced perverse effects. The example was that of a Caesarean section which represented a loss of profit to the tune of USD 250. As a result, any delivery was subjected to a Caesarean section. Now this was reduced to USD 60.

7. Theme: Community PBF/PBF and communities 7.1 Introductory presentation by Jean Benoit Falisse

Community participation is a questionable concept in the sense that the community is difficult to delimit and its participation not clearly defined. It is, therefore, necessary to strive to know the reality on the field, based on research with questions and a methodology. A crucial question on causal relation: do people take interest in the system because it generates more money or because the system creates performance? What is PBF’s contribution? Emphasis is laid on planning. The major role is entrusted to health committees. The remaining question concerns governance. People do not agree on what health committees should be, are and will be regarding their role in the health system management. Besides, there is the role of local associations. Ultimately, there are 3 parties: Health Committees Community health staff Community- Based Organisations / Associations

7.2 Presentation on the experience of Makamba, one of the provinces of Burundi, by Dr. Canut

a. Presentation outline:

• Short outline of the component of the Multi-Country Project implemented in Burundi • Some results after one year of implementation • Community health within the framework of the seven (7) PBF member countries • Institutional set-up

b. Prospects or Actions in pipeline

CAP study conducted with the population and community health staff Development of a training programme intended for ASC Action plan and negotiation of contract Monitoring/Coaching community health staff Documentation and sharing of ASC actions

7.3 Presentation of Rwanda’s experience by Dr. Ludwig De Naeyer Outstanding ideas:

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Communities were contacted to involve them in the transfer of women for childbirth. It is not right to pay people based just on reports. The technical quality of services and precise quality indicators were taken into account. Health co-operatives operate thanks to the funds provided by the Government and the donor community, on the one hand, and through income generating activities, on the other hand. It should be noted, however, that co-operatives also ask for some contributions from beneficiaries/ patients. Gaps mainly lie in the lack of equipment and wages. With the introduction of PBF, all co-operatives submit their reports regularly.

Questions to presenters

1. Can one develop more HIV integration into PBF? 2. What is the role of Health Committees while it is

known that preference is given to community health staff even at the training level? How can Health Committees be more involved?

3. The package of activities carried out by ASC. The preventive component is put at a disadvantage in our countries. Should not we think of involving them in the prevention sector? The example is the use of mosquito nets.

4. What is the level of education required for a community health agent to be recruited?

5. Rwanda: There is a discrepancy at the level of community health staff. How are they monitored?

6. How to combine community health staff’ work with confidentiality, particularly regarding HIV/AIDS?

7. Community staff’s participation in the operation of health centres. Should not this system be abandoned to mention involvement instead of community participation outside the operation of health centres?

8. The community is not a homogeneous block. One notices that there is need to explore other components apart from COPSA and community health staff. Otherwise, there will always be excess of work/ heavy workload. Answers and feedback from presenters The number of ASC remains an estimate. Actually, there are about 2000. The increase in the incentive plays a major role in this situation. In Rwanda, some staff follow up people in their residence; this is real involvement, indeed. As regards heavy workload, this is not the case for Rwanda, since each staff is in charge of 2 to 3 children and about 5 expectant mothers. We have not yet reached the point of heavy workload. As for the question of knowing whether maternal health was taken into account while integrating HIV, the answer was ‘yes’ because we have the indicator regarding the screening of expectant mothers. Moreover, the agency effects payment after counter-evaluation We start from the principle of the community’s ownership of the health system. The health committee, in this situation, cannot be a service provider since the mission entrusted to it is service monitoring.

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The community health agent acts beyond the health system. Indeed, he or she acts in sanitation, nutrition etc. As for confidentiality, the health community staff is employed in the recovery and transfer of cases with which touch is lost, in cases of abandonment; and, in this situation, he or she is not informed about the reason of the visit. Other questions Was the Makamba Pilot Project ever based on already existing data? Is not there any risk of double payment for TB indicators since this is also in the world fund programme? The Ministry of Health initiated the harmonisation of community health staff services. Is there any collaboration with your Pilot Project of Makamba? Rwanda: TB indicator within the community: what is the communities’ contribution? Do you give incentive to found out to be TB positive or to all transferred cases? Why is not demographic explosion mentioned in the strategies proposed? It is also necessary to consider the management autonomy for health areas. Otherwise, how can you manage a village health structure from an urban structure?

Issue of community health staff’s positioning so that s/he is not always considered as a branch of the health structure. How are non-medical staff members managed, particularly in terms of remuneration? If the community health staff works on a voluntary basis, s/he is demolished in terms of the health structure. And if he is trained and equipped for services, it is tempted to dissociate itself from the community to become a salaried employee. But whose employee is he or she? The organisational set-up should pay attention to the role given to the community health staff so that s/he does not become one salaried employee with no contact with the community. Was the community health staff trained on ethics so that the principles of confidentiality are inculcated in him? Community participation is often conceived in terms the health centre. It is good to refer to Rwanda’s experience in family planning, malaria, sanitation and others. This is, therefore, multidisciplinary; it is beyond one health system only. There are other social determining factors and other influences to be taken into account. Even though PBF is an important driving force, one wonders whether it is enough so that all these social life sectors are covered. Who is the real representative of the community? Is it a community health staff or a Health Committee? At the end of the day, all these interventions show us how important it is to develop clear indicators to be submitted to these Health Committees and community health staff, keeping in mind that the ultimate goal is the improvement of healthcare services. Answers: TB cases are dealt with by community health staff. The concern is that the number risks being higher regarding real suspicious cases. As regards autonomy, the preventive aspect was neglected in the role assigned to ASC. Community participation, therefore, should be reinforced but with the training precondition.

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I wonder which type of indicators one can submit to the community level. For instance, you will not ask people to wash their hands whenever they come from the toilet. This is difficult to verify. Coming back to management autonomy, it is true that the mission entrusted to a Health Committee could differ from one country to another. There are specific tasks for community health staff and health Committees, but neither can do everything. Who has to do what? Moreover, there is the issue of remuneration, which dissociates the community staff from his or her community. Obviously, there are other forms of incentives, which are not necessarily called salaries. The Makamba Pilot Project was based on former trained community health staff. Cordaid and the Council for Education and Development (COPED) do not evolve alone in PBF integration. All is done in agreement with the Ministry. A study will be conducted and validated by the Ministry in order to have clear tools enabling to know who does what. If we agree that the Burundian health system has 4 levels, why should not we agree that the fourth level, namely the community level, be also financed like the three others? Regarding gifts, this means that when there will no longer be gifts, the work will not be performed.

8. Theme: Interaction among PBF stakeholders (regulators-service providers-users) 8.1 Presentation on the case of Cameroon, Batouri Diocese by Dr. J P Tsafack

The Bishop in charge had refused to accept incentives because he was of the view that medical staff were paid to do this work. Consequently, people started leaving in great numbers for public Health Facilities. Only inexperienced staff applied for a job in these Catholic Health Facilities. Finally, the Bishop was obliged to reverse his decision.

8.2 Presentation on the separation of duties by Peter Bob Peerenboom The separation of duties should be done in a way that safeguards the power balance among the regulator, the service provider and the purchaser. The principle is not new in the health field, and it is not an innovation from PBF. The separation of duties cannot be perfectly carried out because there is a complex reality involving other family, professional, political, economic aspects, etc. Questions/comments

1. It is true that research – action is still needed, but this applies more to the pilot phase. Public-private partnership and the combination of both prove, therefore, to be indispensable.

2. It is necessary to distinguish public from private. All pilot projects start with the private model. But one cannot do without the public for a long time. For the private model, it is easy to involve purchasing agencies in competition. It is also noticed that the public model is bureaucratic in the negative sense of the term. But, would not it be good to have public - private collaboration, instead of saying that the normal evolution necessarily leads to the public model. The only advantage for the semi-public system is that it is acceptable for the Ministry of Health. But the latter is not the only partner or interlocutor in the development or set-up of the health sector.

3. In this interaction, doors should remain half-open among the three stakeholders since, besides each party’s independence, the donor’s requirements come into play. Indeed, technical support implies some regulations.

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4. It is desirable that the Ministries of Health gets space for negotiation of organic texts before they are adopted. Indeed, Ministries of Health operate, most of the time, based on the texts that were not the subject of negotiation. This is an obstacle.

Answers There is no scientific evidence of the relevance of a model. This is negotiated among different stakeholders and from several perspectives: economic, political, etc PBF systems currently operate with purchasing agencies. Why should not they, for instance, be combined with mutual health insurance schemes? It is also necessary to raise the question about the proliferation of private stakeholders. Burundi made so much progress with the only private partner, namely Cordaid. But this is likely to create dependency. It is necessary to recognise the advantage of diversifying private partners. The antinomy between the public and private sectors should be grasped by intelligence since the private sector is not the model of what goes smoothly and the public sector the opposite. The cases of Burundi and Rwanda, which adopted public models with private partnership, should be supported in this direction without denying that whoever would like to start another approach could do it. This, undoubtedly, could bring another textbook case. The case of Burundi and Rwanda in the centralization of the payments should not pose any problem since, in a combination, what matters is the separation of duties and each party’s independence in its duties. It is beneficial to add to this public-private couple an associative component, particularly within the framework of community health. It was noticed, in some places, that Health Committee members are at the same time community health staff. The separation of roles would help all stakeholders to better play their part. Another line of thinking would be mechanisms of representativeness in the bodies and different structures. Thus, the vulnerable could be represented and have their voices heard.

Another series of questions - Some think that an external organisation could conduct counter-evaluation while others

are of the view that the health inspection Department can do it. What do you think about it?

- Are results, which are observed, attributable to PBF only or should other determining factors to be taken into consideration be analysed before adopting either system?

Answers

External verification by an independent organisation is the formula applied in Burundi and Rwanda. But one can imagine a contract between the regulator and a purchasing agency since both agree on the objectives to be achieved and on the indicators of verification. Such is, indeed, the case of Cameroon where the World Bank funds allocated to this programme are given to non-profit-making organisations, purchasing agencies. Some contributions, therefore, always need to be considered before concluding that either system is appropriate or inappropriate.

Theme 9: Public-private partnership in the PBF system (Collaboration between religious denominations and the State)

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After a series of presentations on the cases of CAR, Cameroon, Zambia, Tanzania and Burundi, participants had the opportunity to ask questions or make comments.

Series of question-comments

1. Taking into consideration all presentations, a fundamental question arises: when funds come from the public sector to the private sector, people find this abnormal. However, when it comes to investments in roads and other sectors, the question is solved through tenders where nobody is interested in knowing whether the bidder is a non-profit-making organisation or not.

2. The secret behind the collaboration between Catholics and Protestants. Is this the result of pressure from the donor or not?

3. There are preferential tariffs for recognised hospitals but not for health centres. Why? 4. The system of entering into contracts in Cameroon: Could the State have transferred to

you some hospitals for management? 5. Most of private healthcare structures are built by private individuals, but the

management is entrusted to the State. How has Tanzania succeeded in managing all these healthcare structures?

Answers

1. In Cameroon, there is no framework unifying religious denominations. Each religious

denomination is left with a leeway to organise itself to be able to enter into partnership with the State?

2. In Zambia, it was noticed that whenever a private organisation approaches the State, the problem was always the same, namely duplication. This obliged them to work together.

3. In Tanzania, the best health facilities were built by religious organisations, particularly inside the country. And human resources in the health sector are not sufficient. The Government, therefore, felt the need to collaborate with the private sector even at the level of sharing human resources. Despite this initiative, there is still a shortage of human resources.

4. The issue of high funds is persistent because funds are still insufficient. In the meantime, the Government agreed to inject some funds into the health facilities belonging to religious denominations.

5. In Cameroon, even when the State agrees to entrust to us the management of health facilities or to entrust the management of schools to private sector, we only take the facilities we are in a position to manage.

Another series of questions/answers and/or comments

1. PBF should constitute an argument to convince the Government to grant the same

facilities on the basis of performance. 2. In Cameroon, there is currently a programme for the rehabilitation of private health

facilities, financed by France to the tune of USD 27 millions. It does not matter whether Catholics, Protestants and Moslems are grouped together or not. It is only after the

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completion of this rehabilitation programme that we will see those who are eligible for PBF.

3. PBF advocates for non- discrimination against private individuals and this produced results in Rwanda. In Burundi, in a meeting that took place last year, it was difficult to have the idea approved, but today we understand that the Burundian Government is open for the reconsideration of this non-discriminatory treatment. However, it is clear that, in the provision of services, the population has preference for the private sector over the public sector when there is no issue of financial means. Therefore, all public and private structures should receive equal treatment in terms of advantages and sanctions as well.

4. Regarding the issue of financing private sectors, the situation, in Tanzania, developed so much that a Department in charge of public private collaboration was established in the Ministry of Health. Why should not mechanisms of integration be established to ensure that such private sector’s involvement is no longer considered as a favour done to it?

5. This kind of competition between the public sector and the private one exists because, instead of asking the genuine question regarding how the population can be assisted to have access to quality health care, most Governments are concerned with knowing how their services can operate. Yet, everybody knows that in most cases, the private sector is more effective and efficient. PBF provides a unique opportunity to bring closer both approaches around the same vision, namely the improvement of pubic health through the improvement of healthcare quality.

6. An observation regarding the presentation of the Burundian case: why does a public sector stakeholder present public-private partnership? Does this mean that you could not find a private sector representative?

Theme 10: PBF and healthcare quality (Minimum package of activities and Complementary package of activities)

The objective is that of seeing:

- How to comprehend the “medical production” quality, particularly at the level of district hospitals?

- How to integrate this quality aspect within the framework of payments?

Questions -Comments

1. Dr. Michel, Head of Cordaid Mission in Burundi, wished to know whether there are no other experiences from elsewhere, which could serve as a source of inspiration?

2. What is the role of customers or patients in the definition of quality? 3. Need for having a consensus on the standards in order to develop a tool which is

evolutionary in time. It would be interesting to reflect on the indicators to be financed in research- action so that hospitals do not focus only on quantity but also concern themselves with quality.

4. Service quality or healthcare quality?

Answers

- Both are needed: service quality and healthcare quality. Healthcare quality evaluation requires tools and prerequisites, protocols which should not necessarily be standardized but adapted instead. On the other hand, criteria of accreditation may be standardised.

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- It is important to take into account service and healthcare quality evaluation by customers, beneficiaries.

- The distinction between quality and quantity does not seem obvious since quantity is, at the end of the day, the volume of quality health care. Indicators on the regularity of the service provision should be checked instead.

- Quality evaluation by peers may be biased because people are prepared for it. People know in advance that evaluation will take place. But when you go there one or two weeks thereafter, the situation is awful.

- In Burundi, the scores given to technical quality and perceived quality are respectively 40 and 60%. The question is to know which should have greater weighting.

- In Rwanda, they propose evaluations conducted unexpectedly. The problem is that all this requires teams, resources and sometimes it is not obvious that the entire logistics is in place. Having said that, peers are experienced people, who can easily notice the quality of a hospital. A hospital is not something which goes from good to poor performance overnight.

- The highest weighting should be put on technical evaluation. - Rwanda’s practice consists in entering into contracts with private agencies to ensure

cleanliness and hygiene in hospitals. - As for community surveys, the problem that occurs is that some people stay at home and

fill in the form or the evaluation questionnaire. - Should not several approaches be combined for evaluation purposes to ensure the

reliability of the quality evaluated? - Regarding the evaluation of perceived quality, it is true that standards are difficult to

define. It is important to lend an ear to healthcare beneficiaries. An example is that of a hospital in Cameroon where, in childbirth services, women said that they would like to be treated by a female medical doctor. After this request was met, attendance and receipts rates increased by more than 35%.

- It is important to notice that all these considerations on perceived quality, community evaluation are more valid for first-level institutions than large hospitals.

- It was noticed, particularly in the case of Burundi, that it is of course necessary to evaluate quality, seeing to it that all the managerial and logistic aspects are not neglected. Efforts still need to be made as regards quality evaluation. Indeed, evaluation is currently conducted on a half-yearly basis while, as a rule, it should be conducted on quarterly basis. All parameters should be taken on board before coming up with a final proposal.

- PBF does not finance actions or the real costs of the services. The example that had been given to Burundi concerned the Caesarean section, but it is not true, because PBF only contributes to the tune of 10% only. The problem is that costs are not recovered. Consequently, a part of the population unable to pay is held hostage in hospitals. Other alternatives and other mechanisms to recover costs are needed within the framework of this free healthcare policy. It is necessary to imagine other means of financing or increase the means of operation. Otherwise, this phenomenon of economy of means will persist.

- Yes, PBF tools should be dynamic. But at which pace should we revise these tools? If tools and grids are performing, they should be maintained, but if weaknesses or gaps are noticed at the level of results, revision is a must. What matters is to know that these tools should not remain fossilized. They should, instead, be revisited from time to time to measure their performance.

Topic 11: PBF and the Health Information system

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The working group proposes the following: 1. Product 1: PBF non-technical specifications 2. Tools developmental perspectives: ■ PBF computer management tools meant for purchasers (Performance purchasing agency, Health services purchasing agency, Public utility institution, Funds channelling organ, Special Fund for health promotion, Ministry of Public Health …) ■ Development of an open HIS software accessible on Internet and combined with a PBF module (On the basis of Rwanda’s experience?)

11.1 Feedback from the working group on PBF and payment by Nicolas de Boorman.

The following are the conclusions and recommendations from this group:

• PBF is a supplement and not the main source of financing • PBF should guarantee quality instead of covering the real costs of the services • The tool should be dynamic • Grid weighting: ≥ 50% on clinical activities (output indicating that prerequisites are in

place) • The score in itself is used to allocate the budget: evaluating in details indicators and

progress is important

Questions - Comments

- Actually, the problem is not the link between both tools. What matters is to avoid double work. If indicators collected through PBF and HIS are the same, the link is clear. There is a noticeable shortage of staff, who would process data at the central and district levels. This explains the tendency to remove them.

- People say that HIS does not operate smoothly in Rwanda. This is due to the fact that they wanted to replace it by another simpler system, but there is no output so far. Indeed, the problem posed by a complex system processing 1,000 data cannot be solved by a simple system, which is expected to deal with more data.

- In my opinion, emphasis was laid on the data from health centres. What will be done with data from hospitals?

- PBF contributes to the reliability of HIS data, but this remains to be proven by mechanisms insisting particularly on the validation system.

- PBF produces data, which can be audited, because money is at stake. The danger for Governments is to rely only on PBF data concerning 24 financial indicators, which will finally account for only 5% of the performance, once they are not reinforced by HIS data.

11.2 Presentation of PBF management tool/a purchasing agency from Burundi:

Quality evaluation should support PBF without necessarily being integrated into it. The Burundian system easily allows each actor to define the priorities to be financed. PBF is calculated on the basis of indicators recognised as possible and having been tested for their reliability. The result probably provides a series of 40, 50 and 60 indicators at most.

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Theme 12: PBF programmes mapping

There is a form to be completed in groups per country.

Each country represented chose a contact person for information sharing. The same exercise is done in other countries applying PBF in order to have, in the end, one PBF mapping covering the entire Africa.

Theme 13: Africa Performance Based Financing Community of Practice and Perspectives by Nicolas

The presentation was made and Websites addresses were given for more documentation and information sharing. See PowerPoint presentations

Theme 14: Training on the drafting of scientific articles

By Maria Bertone & Jean Benoit Falisse The main objective of the presentation was to help trainees understand terms and jargon used in the field and harmonise them. The second aspect of the presentation, besides the drafting techniques as such, concerned the use of visual aspects and other small things requiring attention in handling figures and percentages.

5. Relevant observations made at the time of the Conference closing

• Participants expressed optimism that the Conference constitutes a step towards other opportunities to work together within the framework of the Multi-Country PBF system.

• The Conference is an opportunity to learn about the stages of implementation of this large-scale project financed on a line other than health. This initiative is strategic for the EU, which, according to Cotonou Agreements, was accustomed to entrusting the funds to Governments. This initiative provided EU with a good opportunity to collaborate with Non-State Actors.

• The participation is extended to the community of practice. It is certain that people will continue to think about each country’s specificities to ensure progressive improvement in the implementation of the PBF system

• When coming to the Conference, participants think that they know a lot. But, they later realise that they still have a lot of things to learn. Various participants’ expertise will enable to conduct research to see what is appropriate in different countries to make sure that the PBF mission is extended in the spirit of healthcare quality improvement.

Official closing address

The representative of the Burundian Minister of Health thanked all those who contributed to the success of this Conference, namely the donor community, the organisers and various participants from the seven (7) countries, pointing out that, without everybody’s participation, the Conference would not have been successful.

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A cultural party where a drink was served to celebrate the friendship among countries having attended the Conference was organised in an atmosphere embellished by the famous Burundian drummers as well as cultural troupes. Rwanda, Zambia, Burundi, Tanzania, Democratic Republic of Congo (DRC), Cameroon and Central African Republic (CAR)