Gambia, The

Project Information

Objective: To increase the utilization of community nutrition and primary maternal and child health services, the MCNHRP combines a supply-side performance-based financing (PBF) mechanism with a community-based results-based financing (cRBF) mechanism and a conditional cash transfer (CCT) for antenatal care to foster stronger links between communities and health facilities. The cRBF also aims to improve adoption of health and nutrition behaviors that go beyond service utilization. 
Status: Active
Date Effective: 05/20/2014 to 07/31/2019
Financing: HRITF $5 million and IDA $8.68 million
Other Financial Contributions: N/A

Photo credit: World Bank

PROJECT RATIONALE

The Maternal and Child Nutrition and Health Results Project (MCNHRP) was designed to respond to the concurrent supply-side and demand-side barriers highlighted by a wide range of national and external surveys as well as by pre-pilot process evaluation that used mixed-methods.   Most of the demand-side constraints occur at the household or community level (except for provider attitudes) and include cultural obstacles; cost; inconvenience; as well as an inadequate understanding of the risks and benefits associated with the adoption of a particular behavior.  On the supply-side, the reasons for poor outcomes stem from the health system experiencing insufficient financing; inconsistent infrastructure, equipment and supplies; inadequate training and motivation of health providers; and inefficiencies resulting from verticalization of the health sector.

RBF AT A GLANCE

RBF Payments        

On the supply-side, the Ministry of Health and Social Welfare (MOHSW), as the purchaser, contracts health facilities to improve coverage and quality of services delivered.  Health facilities are paid by the National Nutrition Agency (i.e. the fund holder) for achieved and verified results: 60 percent of PBF payments are typically used to improve infrastructure, procure equipment and supplies, increase outreach activities as well as cover operating costs; and 40 percent are used as performance incentives for healthcare personnel. These incentives are also supplemented by a quality bonus.  

On the demand side, existing community structures are contracted by the MOHSW to impart health information, support behavioral change (for nutrition, health, hygiene and sanitation) and refer all pregnancies to the nearest health facility. In each target community, the Voluntary Development Committee (VDC) and Village Support Group (VSG) are contracted by the MOHSW.  The VDC coordinates and oversees the achievement of predefined performance thresholds as agreed upon in the quarterly community business plan. The VSG – composed of village members, including the community birth companion and village health worker –delivers health and nutrition promotion, counselling and referral services. The RBF payments are made to the community once results are both achieved and verified: 70 percent is used by the VDC to cover operating costs, support community mobilization and invest in community development projects, and 30 percent is used to provide VSGs with performance-based incentives.

The MOHSW – including the Regional Health Directorate – leads the RBF regulation function, ensuring compliance with RBF objectives and principles and alignment with national health promotion norms and guidelines.

VERIFICATION

Under the supply-side PBF scheme, the verification of the quantity of services delivered is carried out by NaNA monthly through a review of health facility registries and payment claims.  Conversely, the verification of the quality of care is led by the MOHSW – represented by the Regional Health Directorate – which carries out quarterly verification using the quality checklist to ensure proper adherence to set protocols and standards of care.  Further, an independent Community Client Tracer and Satisfaction Survey Agent is contracted by the National Nutrition Agency (NaNA) to check the authenticity of the clients reported by providers and to evaluate client satisfaction (i.e. a sample of clients are traced and administered a client satisfaction survey questionnaire). An Independent Verification Agency (IVA) performs technical and quality assessment at all operational levels from central to community level.

Under the cRBF scheme, the verification of quantity is carried out monthly through the implementation of surveys using lot quality assurance sampling (LQAS) – a random sampling methodology – which is then compared to target proportions set in the cRBF contract. The LQAS is implemented by Community Based Organizations contracted by NaNa.  The verification mechanism also builds on community registries and reports, detailing the number of outreach activities carried out and the number of “at risk” patients referred to the nearest health facility.  Furthermore, an external verification agent is contracted to perform bi-annual random technical and quality spot checks to ensure the validity and accuracy of implemented verifications. This counter-verification is carried out on a sample of beneficiaries.

IMPLEMENTATION

Status and Achievements – Fiscal Year 2016

The MCNHRP became effective in May 2014. Piloted in the North Bank West Region until December 2014 and leveraging additional financing in April 2015, the project was gradually scaled-up to four additional regions, namely Central River, North Bank East, Lower River and Upper River regions. The MCNHRP is currently being implemented in five of The Gambia’s seven health regions, covering all the rural areas of the country.

The RBF mechanism enabled policy dialogue on health system strengthening, including the quality of care, updating of the HMIS, drug supply chain challenges, staff motivation, and efficiency.  Progress has been seen in trends pertaining to antenatal care, postnatal care, and family planning services. Quality scores and health center earnings overall have also experienced increases.  Furthermore, ownership and satisfaction has improved.

Partners such as UNICEF have seen the benefits of the project and are now considering building on the system that has been established through the MCNHRP.

The management of community contracts (i.e. large numbers) remains a challenge, requiring a decentralization of management functions. It is important to note, however, that social sectors are experiencing difficulties, given the overall fiscal and political challenges the country faces.

Lessons learned

The separation of RBF functions facilitates innovative collaboration between Government institutions, including the Ministry of Health and Social Welfare, the National Nutrition Agency, the Ministry of Agriculture and the Ministry of Finance and Economic Affairs.

EVALUATION AT A GLANCE

The impact evaluation is exploring the synergy between demand- and supply-side incentives. The overall approach for the evaluation is a randomized and phased-in 2 x 2 design. The principal empirical strategy for the evaluation is to compare changes in communities reached early by the interventions to changes observed in communities reached in later phases of the project. The evaluation uses a mixed methods approach with an embedded process evaluation which will not only enable measuring impact but also explaining the “how” and the “why”.

The baseline survey was implemented in 2014: data was analyzed and incorporated in a report that was disseminated in December 2015.  Midline data was collected in July-August 2016 with data analysis ongoing.  Endline data will be gathered in January-February 2018.