Photo credit: Alexis Boyoko/PDSS II
Despite some moderate improvements, reproductive, maternal and child health indicators continue to perform poorly in the Republic of Congo. The maternal mortality ratio remains high with 426 deaths per 100,000 live births; the total fertility rate increased from 4.8 to 5.1 children per woman between 2005 and 2012, and the adolescent fertility rate reached 147 per 1,000 in the 15-19 age group in 2012 (DHS, 2012). In parallel, the under-five mortality rate is at 68 deaths per 1,000 live births, and undernutrition persists with 24.4 percent of children under five being stunted (DHS, 2012). Further, heavy reliance on out-of-pocket health expenditures – coupled with poor service quality, neglected community-based health delivery systems and deep economic disparities – continues to constrain health service utilization, particularly among poor and marginalized populations.
RBF AT A GLANCE
The second Health Sector Development project uses a supply-side performance-based financing (PBF) to increase the quality and utilization of maternal and child health services. Under this scheme, the Ministry of Health and Population (MOHP) contracts and incentivizes health centers and first level referral hospitals to respectively expand the coverage and improve the quality of both the minimum package of activities (MPA) and the complementary package of activities (CPA). Particularly targeting the poor, this scheme contracts both public and private health facilities – including for-profit facilities. The Directorate for Financial Management makes quarterly PBF payments: facilities are paid based on quantity and quality-related indicators, and health workers receive bonuses based on individual performance. This PBF payment mechanism also includes penalties to discourage fraud.
In parallel, the Project is also piloting a demand-side PBF scheme: the Rainbow Project. Under this scheme, PBF health facilities contract and incentivize community relays – composed of health facility staff and community health workers from the community – to support households in adopting positive behaviors. Through household visits, these community relays impart health information, assess the health status of household members, and establish an action plan that lists the changes the family will implement throughout the project to improve their health (e.g. vaccination, curative care, contraception, nutrition, hygiene and sanitation, prenatal care, and malaria prophylaxis). Each action included in the action plan is matched with a color-coded voucher, and this voucher can either be redeemed to access free health services or to benefit from priority access (e.g. reduced waiting time). Quarterly, community relays receive a portion of facilities’ PBF payments, based on performance and on the allocative structure chosen by the facility based on the indice tool.
The MOHP leads the PBF regulation function, ensuring compliance with PBF objectives and principles and alignment with national norms and guidelines.
The ex-ante verification (i.e. prior to payment) is led by the Contract Development and Verification agents. These are CDV agents are National Non-Governmental Organizations contracted by the MOHP to carry out a quarterly assessment of the quantity of services delivered. This assessment determines performance levels by combining a quality score derived from a quantified quality checklist, and project outputs extracted from monthly activity reports. Community client satisfaction surveys are managed through grassroots organizations selected and supervised by the CDV agencies. Data is collected using tablets and mobile applications. In addition, there are a host of transparent internal assessments for the performance of the district and departmental health administration and a handful of central ministry of health departments, including the unit managing the PBF scheme which are also under performance contracts.
Conversely, the ex-post verification (i.e. after payment) is led by a third party agent contracted by the MOHP to ensure the reliability of ex-ante performance assessments, including the community client satisfaction surveys. Specifically, this verification agency focuses on counter-verifying the quantity of services provided, using Lot Quality Assurance Sampling; quality assurance of the client satisfaction surveys at community level; assessing the reliability of quality checklists in a sample of health facilities, and the validity of the performance frameworks of the decentralized and central Ministry of Health departments.
Status and achievements
The project was introduced in seven Departments covering 86 percent of the national population, with a particular focus on urban areas and public-private partnerships (i.e. 75 percent of contracted providers in the large urban centers of Brazzaville and Pointe Noire are private providers).
The PBF supply-side intervention was rolled out in August 2015. The implementation of the demand-side intervention, the ‘Rainbow Program', was initiated at the end of August 2016. In collaboration with Lisungi the social protection program, identification of 25% of the poorest households has been done during 2016, and in the first quarter of 2017, fee exemptions of these poorest households is being rolled-out in selected districts and selected health facilities.
Due to the strongly decreased oil price with public budgets heavily relying on oil income, public budgets have been slashed and the project might need to take into account lesser government contribution in the near future.
- Strengthening local capacity is vital for the PBF approach to succeed.
- Effectively lobbying decision makers to create a fiscal space for health is a key strategy for sustainability.
- PBF is becoming an important strategy for engaging and regulating the private sector in urban areas.
EVALUATION AT A GLANCE
The impact evaluation examines the combination of performance-based financing, community-based targeting and subsidization of health services provided to the poor and household visits, according to an established protocol. PBF is implemented at the district level (with control districts in the same departments) and the demand-side interventions are randomized at the health facility level.