The Ministry of Public Health and Sanitation of Kenya is developing a pilot Performance-Based Financing (PBF) project in Samburu Central district. Bruno Meessen met Dr. Rael Mutai, the lead person for the project, at a workshop organized by the World Bank in Livingstone, Zambia (May 29-June 1). 
 
BM: In this workshop you presented the Kenyan PBF pilot project. You mentioned a so-called Health Sector Services Fund. Can you tell us a bit more about this fund?

RM: Sometime in 2003, the Ministry of Health did a study to see what proportion of public funds allocated to primary level facilities actually made it to the facilities. It was found that hardly 30% of the funds that left the central government ever reached the small facilities. So the government came up with the idea to do a pilot of a direct funding of these facilities. The pilot was commissioned in the Coastal Province of Kenya. Over a period of 3-4 years, they were able to see these funds that had been channeled directly to facility account were having an impact. Based on that study, the government came together and decided to form the Health Sector Services Fund (HSSF). The HSSF is supposed to be rolled out to the rest of the country.

The strategy states that primary health facilities have to an open bank account and for the governance of the funding, to set up a health facility management committee. The head of the facility is the secretary of this committee; normally a person from the community acts as the chairman. Once that this is established, the whole facility committee is gazetted, so it is a legal entity. Then they are able to decide on their fund.

Are all health facilities eligible for the fund? Do all the health centers get the same amount or is it a formula taking into account, for instance, the population in the catchment area? Practically, how does it go?

The government has determined what to give on a quarterly basis per level of services  - dispensaries (serving population of up to 10,000) and health centers (serving population of up to 30,000) only. In this phase one of the project, the fund works with government facilities only. But in one year or two, once accountability rules are clarified, money will be given even to the faith-based facilities. Yes, there is a criterion that we used to determine which different sections of the country receive different amount. But there is more or less a baseline for a basic amount that all health centers (Ksh. 112,500 per quarter) must receive, there is a basic amount for the dispensaries (Ksh.27,500 per quarter) (1); It is only now that we are factoring in other equity parameters such as the accessibility or the poverty index.

The transfer to the health facility is organized in three components. The 1st component, which is the bulk of the transfer, is for operations and maintenance at the facility level; it covers basic recurrent costs including payment of casual laborers. The 2nd component is for the health facility to implement its Annual Operations Plan, which is broken into quarterly implementation plans listing activities the health facility will do (outreaches, a specific service in the area of maternal and child health, voluntary male circumcision…); health facilities define themselves what to do. The 3rd component is an incentive component, the PBF related part.

Can you indeed explain the link between the HSSF and PBF?

During the design of HSSF, it was envisaged that a proportion of funds would specifically be paid to incentivize the health facility. These incentives are to be given to the facility, but 40% is for investment and 60% is for the staff. This is just a general guideline, there is autonomy: the health facilities can decide that they even invest all so that they can attract more clients. But as it is in the pilot stage, we said 60% is for the staff, 40% is to be reinvested in the facility.

The way we decided our PBF, it is basically operationalizing the 3rd component of the HSSF. So we designed in such a way that the Health Sector Service Fund Secretariat remains the fund holder. They are the people who have been channeling the funds directly to the health facilities; in this new arrangement they will continue: they will be disbursing the performance incentives to the facilities, through their account. We do not even need to start saying which account is where: the Secretariat has the details, there is a master facility list; we will be able to able to track everything. For accessing the HSS fund, the facilities have already to submit a quarterly implementation plan. In PBF, we tell them it must be a business plan. So, what we do is just to modify the existing system.  Under the routine government system, certain things could not be entered in. For instance, if they are going to incentivize a traditional birth-attendant for them to bring a mother to the facility, in the business plan they can write it comfortably and there is no problem and the money will just be disbursed.

This system looks quite interesting. What is the benefit of bringing PBF to the HSSF?

 The general feeling of the country was that we have invested so much money into the health sector in terms of personnel, in terms of infrastructure, but we are not still meeting our target. It is in the process of trying to accelerate progress towards the Millennium Development Goals, the 4 and 5 specifically. The key asset of PBF is the human resource component.  You can post a staff member in a remote area, within no time he has left the place (very high turnover). We hope that by incentivizing them they might find some motivation to continue giving the services and to improve the quality.

 
(1)     1 Kenyan shilling = 0.0119 US dollars. This means that a dispensary gets around USD 0.13 per year per inhabitant.

25 years ago, between the 3rd and the 7th of August 1987, the WHO organized an interregional meeting in Harare. The meeting, which was about the implementation of primary health care (following up of the Alma Ata conference in1978), ended with a statement that is known (or forgotten!) today as the Harare Declaration. By establishing the health district model as a reference strategy to organize and develop health services, this event shaped health systems in many poor countries. This strategy particularly shaped health service provision in rural Africa.

A few weeks later, UNICEF organized another regional meeting in Bamako. It went down in history as the Bamako Initiative. Its content is better known: it marked the introduction (or formalization) of user fees and that of community participation in resource management, including essential drugs now sold to users.

Like the vast majority of policies, these proposals were based on pilot experiments or similar approaches already in place in some countries, for example, the "health shops" of Mali (cost recovery) or the experience of health zones in Zaire (health district strategy).

25 years have passed. Globalization and new information technologies have profoundly changed the environment. The structural adjustments of the 80s are long gone. Today the continent is experiencing the strongest economic growth. Some countries have been able to exploit this new phenomenon for major changes in their health system and its financing. Rwanda has shown that the goal of universal coverage is not insane. But the continent is far from being homogeneous. HIV / AIDS is ravaging southern Africa. For the Horn of Africa to Central Africa and a fraction of West Africa, these 25 years have been plagued by armed conflicts. These shocks, coupled with the effects of the global economic crisis of the 80s, have been particularly harmful to health care systems. Many would argue that the potions that were administered to patients (structural adjustment programs, privatization, introduction of user charges...) have not helped, moreover, had long-term side-effects on health systems.

In the coming months, several communities of practice affiliated with “Harmonization for Health in Africa” (in 25 years, agencies have also realized the need to coordinate better!) will collaborate to develop a collective reflection on the Harare Declaration and Bamako Initiative. Several organizations have already indicated their willingness to be partners in this endeavor (if you work for an agency or an international organization and would like to help, please contact us). Like us, they believe that the issues identified in Harare and Bamako 25 years ago are still valid, although some updating is required.

We hope that this process can lead to a regional event in 2013. In the meantime, our intention is to tap our different technology platforms, especially this blog and our online discussion groups, to progress in the reflection.

This text is more than just an announcement of things that we will be producing. It is primarily a call for your contribution and input. They can be modest, such as helping us to widely spread our debates and discussions to people you know, or more ambitious, such as writing an article or a blog post or conducting an interview.



We count on your enthusiasm!

                                                                    Bruno Meessen

Il y a 25 ans, les 3-7 août 1987, l'OMS organisait une réunion interrégionale à Harare. La réunion, qui s’inscrivait dans le fil de la conférence d’Alma Ata (1978) en faveur des soins de santé primaire, se clôtura par une déclaration aujourd'hui connue ( ou oubliée!) comme la Déclaration de Harare. Cet événement a marqué les systèmes de santé de nombreux pays pauvres en établissant le modèle du district sanitaire comme stratégie de référence pour organiser et développer les services de santé. Cette stratégie a été particulièrement structurante pour l’Afrique rurale.

Quelques semaines plus tard, l'UNICEF organisait une autre réunion à Bamako. Elle est passée dans l'histoire comme l'Initiative de Bamako. Son contenu est plus connu: elle marqua l’introduction (ou la formalisation) de la tarification des soins, celui de la participation communautaire dans la gestion des ressources, notamment les médicaments essentiels désormais vendus aux usagers.

Comme la très grande majorité des politiques, ces propositions reposaient sur des expériences pilotes ou des approches analogues déjà en place dans certains pays (par exemple, les « magasins-santé » du Mali pour ce qu’il en est du recouvrement des coûts ou sur l’expérience des zones de santé au Zaïre pour ce qui est de la stratégie du district sanitaire).

Vingt-cinq ans ont passé. La mondialisation et les nouvelles technologies de l’information ont profondément changé notre environnement à tous. L’Afrique des ajustements structurels des années 80 a laissé place à un continent en forte croissance économique. Certains pays réussissent à exploiter ce nouveau contexte pour apporter des changements majeurs à leur système de santé et à son financement. Le Rwanda a ainsi montré que l’objectif d’une couverture universelle n’était pas insensé. Mais le continent est loin d’être homogène. L’épidémie du VIH/SIDA ravage l’Afrique Australe. Pour la Corne de l’Afrique, l’Afrique Centrale et une fraction de l’Afrique de l’Ouest, ces vingt-cinq dernières années ont été affligées par les affrontements armés. Ces crises, ajoutées aux effets de la crise économique mondiale des années 80, ont été particulièrement nocives aux systèmes de santé. Beaucoup diront que les potions qui ont été administrées aux malades (programmes d’ajustement structurel, privatisation, introduction de la tarification des soins…) n’ont pas aidé ou ont eu, en tout cas, également des conséquences à long terme sur les systèmes de santé.

Dans les mois qui viennent, plusieurs communautés de pratique de « Harmonization for Health in Africa » (en 25 ans, les agences ont également pris conscience de la nécessité de mieux se coordonner!) vont collaborer pour mettre en place une réflexion collective sur la Déclaration de Harare et l’Initiative de Bamako. Plusieurs organisations ont déjà signifié leur volonté d’être partenaires dans cette entreprise (si vous travaillez pour une agence ou une organisation internationale et souhaitez nous aider, n’hésitez pas à nous contacter !). Comme nous, elles sont convaincues que les enjeux identifiés à Harare et Bamako il y a 25 ans restent d’actualité, même si une certaine mise à jour est à faire.

Nous espérons que ce processus pourra aboutir à un événement régional en 2013. D’ici là, notre intention est d’animer au mieux la réflexion via les différentes plateformes technologiques dont nous disposons, en particulier ce blog et nos groupes de discussion en ligne.

Ce texte est plus qu’une annonce de choses que nous allons produire. C’est avant tout un appel à vos propres contributions. Des plus modestes, comme la large diffusion des produits de nos débats et réflexions ou la participation à nos échanges, aux plus ambitieuses, comme la rédaction d’un article, d’un blog ou la conduite d’un interview.

En espérant pouvoir compter sur votre enthousiasme, bonne participation à tous !