Project Information

Objective: The Improving Health Sector Performance Project seeks to improve the utilization and quality of maternal and child health services and communicable disease control programs (i.e., HIV/AIDS and tuberculosis) across Djibouti.
Status: Active
Date Effective: 07/27/2015 to 12/31/2018
Financing: HRITF $7 million and IDA $7 million
Other Financial Contributions: N/A

Photo credit: World Bank


Between 2002 and 2012, Djibouti has made significant progress in the health sector, particularly with regard to maternal and child health. The under-five mortality rate was almost halved going from 124 to 68 deaths per 1,000 live births; the maternal mortality ratio decreased from 546 to 383 deaths per 100,000 live births. Further, skilled deliveries doubled from 40 to 87 percent, and the proportion of children aged 12-23 months who were vaccinated with the diphtheria, pertussis and tetanus 3 vaccine before their 12th month increased from 45 to 93 percent. Despite such progress, health service delivery and management capacity continue to limit the quality of care as well as service utilization.


RBF Payments

The Improving Health Sector Performance Project uses results-based financing (RBF) to improve the quality of health services and improve health facility productivity. Under this supply-side scheme, the Ministry of Health–through its Performance Purchasing Unit (PPU)–contracts and incentivizes primary and secondary health facilities to deliver a predefined package of services.  Monthly RBF payments are contingent on increased service quantity and enhanced service quality, and include an equity bonus rewarding service delivery targeting the poor in rural and remote areas.


The RBF Verification function is led by the Performance Purchasing Unit (PPU). On a monthly basis, it assesses the quantity of services provided in health facilities under contract examining the level of agreement between data reported in the Health Management Information System and data contained in health facility registries.  On a quarterly basis, the PPU also verifies the technical quality of delivered services: it implements a quality checklist to measure the quality of care as well as the quality of health facility management. Conversely, the PPU contracts local associations to carry out community verifications, whereby they ascertain the delivery of reported services and also randomly measure patient satisfaction on a quarterly basis. The PPU has also contracted an external agency to implement quantity and quality-related counter-verifications.


Status and Achievements – Fiscal Year 2016

The Improving Health Sector Performance Project adopted a phased approach for its RBF component: it is endeavoring to gradually cover all primary and secondary health facilities in Djibouti’s five regions within 5 years.  The Project builds on lessons generated by the RBF pre-pilot experience implemented since June 2014. Further, it benefits from additional HRITF financing approved in March 2015.

Recently, additional emphasis was placed on capacity building to enhance stakeholders’ understanding of RBF and improve their performance with regard to the RBF verification function and to the management of the project’s features. This was particularly important given the appointment of a new minister and the establishment of a new management structure.  This capacity building was instrumental in engaging the government, which is now fully committed to RBF.

Lessons Learned

Although the specific context of Djibouti required some deviation from typical RBF project designs, it is clear that RBF principles should be respected when designing a RBF project.  A second lesson is to always include impact evaluation in the design: initiating system level reforms without accompanying mechanisms to quantitatively draw lessons learned is a missed opportunity.


The small number of health facilities in Djibouti precludes carrying out a randomized evaluation design. Nonetheless, the team is proceeding with an assessment of the autonomy of health facilities in the management of pharmaceutical revolving funds as well as in the management of user fees. This assessment targets eight of the 14 urban clinics located in Djibouti-Ville and two of the five hospitals located in the regions. This assessment uses multiple methods. 


Financing To Date


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