Performance-Based-Financing was introduced more than four years ago in Sierra Leone to complement the Free Health Care Initiative targeting pregnant and lactating women and children under 5. At the height of the Ebola outbreak, PBF facilities and payments were mobilized to support the response. For example, the small team administering the scheme made a decision to continue payments during the Ebola crisis. Due to the state of emergency, payments to facilities were based on unverified data, with the understanding that any overpayments would be addressed once the Ebola crisis was over and independent verification of facility-reported data carried out.
Sierra Leone’s PBF program also includes two tertiary hospitals. Quarterly verification continued and they were paid based on their performance. The money they received helped to establish holding centres, where suspected Ebola cases could be safely isolated. Both Medical Superintendents expressed their appreciation of the PBF team’s commitment to ensuring continuity of payments, especially as the cash helped to increase their Infection and Prevention Control mechanisms before the international community response was on track and running.
Another small Maternal and Child Health facility in Gbongboma, Bo district, built an isolation “room” out of palm trees, as a simple means to protect themselves. The nurse-in-charge explained that 60 percent of the facility’s income comes from PBF, which helped with service continuity. The remaining income comes from consultation fees for non-Free Health Care services and selling cost-recovery drugs.
Mary Thullah 20-year old mom comforts her daughter Fatmata Turay after she received vaccinations at the Princess Christian Maternity Hospital on March 10, 2015 in Freetown Sierra Leone. Photo © Dominic Chavez/World Bank
As in other countries, Facility Management Committees, consisting of community members, decide in partnership with facility staff and management how to invest the PBF funds. As a result of the PBF, the facility documented discussions and decisions on how funds would be spent. Health worker enthusiasm of nurses working in the PBF scheme is also high. PBF is one of the few approaches that give an important voice to the community – and hence to the patient. This way, they can prepare themselves and their community for other epidemics and do not need to wait for the central level Ministry to intervene.
It is worth highlighting that the PBF scheme in Sierra Leone invests 50 Cents per capita annually, significantly below the international standard of USD 3-4. It speaks for the Sierra Leonean culture and possibly also the absence of alternatives that the largely underfinanced PBF scheme still managed to improve motivation among health care workers. This fact was also noted in the external verification exercise completed in 2014, which especially highlighted the motivation of health care workers and the relatively high patient satisfaction score of 7.2 out of 10.
PBF in Sierra Leone offers an example of the potential impact even when underfinanced, in sometimes weakly governed and low capacity contexts. One might wonder what kind of change is possible when PBF is implemented in an enabling environment with full separation of functions, adequate financing, and strong supervision and governance. Sierra Leone might have an answer to that soon – with testing of an improved PBF PLUS scheme underway in one district. The new design addresses most of the issues identified in the existing PBF scheme and increases the per capita payments up to international standards. Initial results are expected in 2016.
Bringing market approaches to the health sector doesn’t make it evil: it is a necessary move to make it more efficient, effective and transparent. All attributes that are much needed in the Sierra Leone context. The existing PBF scheme has already contributed to improvements in those areas. Challenges also remain, with the total funding needed for the post-Ebola recovery estimated to be up to US$1 billion. Although the existing PBF scheme invests about US$ 3.2 million directly through participating facilities, that seemingly ‘small’ money can have a big impact for the receiving facilities. Some of the results have been discussed above and are further outlined in the 2014 Annual Bulletin.
 According to the external verification conducted in 2014 by Cordaid, main limitations of the current PBF scheme include important differences between internal and external verification figures for PBF indicators used to determine incentive payments received by facilities, late payments to the facilities, limited separation of functions and lack of involvement of the facility management committees in verification and investment decisions.