Allison Kelley

For the past year, experts from 12 Francophone African countries (1) have been working together on a project related to health financing fragmentation in their countries. In this blogpost, the first in a series, Allison Kelley (lead facilitator of the CoP Financial Access to Health Services) presents the main results from the first phase of this project, with a focus on cross-country findings. 


Last November on this blog, we introduced you to a collaborative project that two CoPs (Performance-Based Financing and Financial Access to Health Services) were launching on the challenge of Universal Health Coverage (UHC).

The project, financed by French Muskoka Funds and the NGO Cordaid, was a first for the CoPs: a chance to test our capacity to document a specific issue – health financing fragmentation – across a large number of countries. The hypothesis being that by their very nature and the size of the networks they represent (the PBF CoP has 1,500 experts, the FAHS CoP 800), CoPs could usefully complement the research and documentation activities being carried out by other actors (research institutes, aid agencies…) This first blog focuses on the results of the cross-country analysis from Phase 1 (2).

Universal Health Coverage: a big misunderstanding?

By its very definition, progress toward UHC means progress in three main dimensions: (1) the number of people covered (2) the comprehensiveness and quality of the package of services covered, and (3) the reduction of out-of-pocket payment at the point of service. How to move toward UHC, on the other hand, is sometimes misunderstood, with some thinking that it simply consists of introducing a single, universal, mandatory health insurance system.  In fact, the reality in all countries is that populations today are benefitting from some “coverage” through the various health financing schemes (HFS) that already exist. Moving toward UHC will be more a process of bringing order and efficiency to the HFS that already exist than it will be of introducing yet another one.

Mapping the situation in 12 Francophone countries

As a reminder, the objective of our project’s first phase was to carry out a mapping of HFS in 12 Francophone African countries, or almost a quarter of the continent. To reach a complex destination such as UHC, one must have a clear idea of the starting point!

The full Phase 1 report is now available (under the “resources” tab of this site). The cross-country analysis was drawn from the country documentation carried out by national CoP experts (3). Phase 1 produced useful lessons, and confirmed that we are indeed facing a tangle of HFS.

* Our study documented serious fragmentation in HFS in African countries today. Based on our method of counting, there are on average 23 HFS per country.

* Beyond simply counting the number of HFS (which was not easy in and of itself), carrying out this mapping exercise was more difficult than we had anticipated: in many countries, we encountered serious problems in accessing information on HFS. Financing information was frequently missing or unavailable. This lack of information not only hampers government leadership in piloting UHC, but also makes it difficult to get a sufficiently accurate understanding of what is a complex situation in each country, and so concrete suggestions for improving the coordination of HFS remain difficult to formulate.

* Our mappings show that in most countries there are both gaps in population coverage (people with little or no coverage) as well situations of overlapping coverage (certain population groups with coverage through multiple HFS). A common example is a civil servant already benefiting from health insurance who gives birth is a hospital with a fee exemption for deliveries. The vertical nature of the services covered and the narrow targeting of the population groups covered results in very “partial” coverage that often lacks continuity from a therapeutic perspective. 

* There is an alarming lack of coordination and continuity in terms of provider financing modalities among HFS; this is a serious obstacle to effective expansion of UHC.

* Our mapping shows a heavy dependence on external financing for health. This has a considerable influence on the structure of health financing and can exacerbate fragmentation not only in terms of the number of schemes, but also in terms of governance for health financing. The dramatic rise in vertical programs translates into not only a verticalisation of HFS and their respective benefits/services covered, but also a lack of centralised information at the Ministry of Health regarding these externally-funded HFS.

A shared challenge, but no common pathway to UHC…

The overall result of Phase 1 is thus to highlight a major challenge that all 12 countries are facing. The profusion of HFS, but also the current lack of coordination among them (as evidenced by the unavailability of centralized, transparent data), makes us conclude that significant progress toward UHC will be complex to achieve: order will have to be brought to the current tangle of HFS – some will need to be merged, others ended altogether….

And to bring order, many stakeholders will have to come together around the table – numerous Ministries and public agencies, the multiple programs and their various funders, private actors (like mutuelles), representatives of professional associations….

The bottom line is that no one solution exists for moving toward UHC. Each country’s path will be different.

Of one thing we are sure, and this is valid for all countries wanting to make serious progress toward UHC: governments, and Ministries of Health in particular, must develop significant, operational capacity to collect information, to analyse it, and to use it to guide decision-making. Knowledge management and the ability to analyse the situation - its strengths, constraints, opportunities, and threats – will be necessary conditions to achieve UHC.

As you’ll discover in an upcoming blog, these findings have had a major influence on the approach we’ve adopted for the second phase of this CoP collaborative project.


To access the report (in French, but with an executive summary in English), click here.


Notes :

1. Experts involved in this project ,In alphabetical order by country: H. Felicien Hounye  (Bénin), Maurice Yé (Burkina Faso), Longin Gashubije (Burundi), Isidore Sieleunou (Cameroon), Mamadou Samba (Côte d’Ivoire), Amadou Monzon Samaké (Mali), Mahaman Moha (Niger), Philémon Mbessan (Central African Republic), Ma-nitu Serge Mayaka (Democratic Republic of the Congo), Adama Faye (Sénégal), Salomon Garba Tchang (Chad), Adam Zakillatou (Togo).


2. In another blogpost, we will reflect on the lessons learned from this phase about the CoPs’ capacities.

3. To obtain information about country-level reports, please contact the experts directly (see Annex B of the cross-country analysis report).

Bruno Meessen

This blogpost introduces a multi-country research project looking at how at country level, Results Based Financing (RBF) schemes move from pilot to full integration into national health systems. The study is led by the Alliance for Health Systems and Policy Research and scientifically coordinated by the Institute of Tropical Medicine (ITM) and will be carried out by national research teams of eleven countries.




Worldwide, more than 30 low or middle-income countries are today developing, within their health sector, experience with so-called RBF strategy. While a few of them have already moved to a full-fledged national policy, most of them are still in pilot stages. This large international movement is facilitated and boosted by a number of forces and positive synergies: political will, aid agencies’ leadership and financial resources, enthusiasm of experts, commitment of major stakeholders, pro-active knowledge management…

The main goal of every RBF scheme is to improve the performance of the health system (measured in terms of quality of the health service delivered, coverage rate…). The ultimate goal of every - successful - pilot scheme is to be scaled up. From a knowledge management perspective, though, a pilot scheme which failed to improve some target indicators is actually still a success if the operational lessons which have been drawn from the experience allowed stakeholders to improve the national health system. This is an outcome which matters for an RBF strategy, as many have argued that its transformative power is one of its key attributes. A key metric of the ‘success’ of an RBF experience should therefore be its ability, through the core principles it promotes, to reinvigorate the national health system. One can foresee transformations/scale up on many different dimensions.

Launch of a multi-country research project

The possible journey “from scheme to system” will be the main focus of a  multi-country research project coordinated by the Alliance for Health Policy and Systems Research and the Health Economics Unit of the Institute of Tropical Medicine. This research program is sponsored by NORAD, the Norwegian Aid Agency.

The call for proposals launched by the Alliance sparked quite some interest: 34 research teams submitted a proposal. Eleven countries have been selected – you can discover which ones by clicking here.(1) Selected research teams have been informed. The next step will be a protocol development workshop to which the principal investigators of the eleven countries will be invited. Together, we will explore the commonalities across the 11 cases and assess whether we can adopt a common framework and select a limited number of common research questions.

After approval of the protocols by ethical committees, each national research team will document how the journey from scheme to policy is going in their respective country (although among the 11 countries, we have also interesting stories of pilot schemes which did not materialize into national policies). While our sampled countries are mostly from sub-Saharan Africa (the most dynamic continent, as far RBF is concerned), we are happy to have also three experiences from outside Africa. In Africa, we will cover a nice mix of settings: a few post-conflict countries, some Francophone and Anglophone countries, a mix of small and big countries.

Our communication strategy

While the PBF Community of Practice is not formally involved in this research at this stage, we will make sure throughout this project to keep you informed about the progress being made. We are indeed very aware that moving from scheme to system is a challenge that some of you are already facing today. So you may learn from what we discover… but we also value the knowledge you will share with us. This interaction with you will take different forms, but our online forum and this blog will be major tools (do not hesitate, for instance, to contact us if you want to write a blogpost on the situation in your country or just share some reflections). We will also seize opportunities offered by face-to-face encounters to discuss on this topic with you (as we did already in Buenos Aires and as we will do again at the Cape Town symposium, in a satellite session co-organized with the World Bank).

This promises to be an exciting journey. We hope that you will be with us all the way long.

 
Note:
(1) We are very aware that some readers of this blog post are disappointed by the non-selection of their proposal. Proposals went through  a systematic appraisal system set up by the Alliance. Feel free to contact Mrs Maryam Bigdeli at the Alliance to know the reasons why your proposal has not been selected.

My first real encounter with the Plan NACER (now renamed “Programa SUMAR”, since the expansion of the target group and the benefit packages) (1) was in December 2013, at a donor meeting on RBF in Oslo. Martin Sabignoso, the Lionel Messi of Performance Based Financing (see picture), presented the Argentinian experience to us in a very convincing way. I was therefore happy to accept an invitation by the World Bank to attend its annual “Results and implementation workshop for RBF” (25 March – 1 April) in Buenos Aires. It was time to discover the experience in the country itself. Here are my own take home lessons (2).

Commonalities between SUMAR and PBF …

The Programa SUMAR and what we call Performance-Based Financing (PBF) in Africa, have many things in common. For a start, they both seem to work. In Buenos Aires, we had the chance to listen to Paul Gertler (Berkeley University). Paul is a big name in the research community: among many other things, he proved the impact of the Oportunidades scheme in Mexico and of PBF in Rwanda. He shared his findings on the impact of the Plan NACER on several key health outcomes. The figures are impressive: the Plan reduced the number of babies with a low birth weight, by increasing prenatal care use and quality; combined with better care for low birth weight babies, this led to a reduction in neonatal mortality among the scheme beneficiaries. One of the most interesting results is the reduction of the inequity in terms of health status across provinces: the poorest ones have caught up with the average in terms of infant mortality rates. The strategy is also very cost-effective.

Another similarity between NACER and PBF is the transformative power of the strategies – a feature which is growingly recognized as a key strength of such schemes. In Argentina, this could be seen at many levels. For instance, the program accelerated the adoption of ICT in the health system. Another nice example is the fact that NACER transformed the public health subsystem from one to which people were implicitly belonging (free health care) and implicitly covered (no list of health care services) into a system with formalization of the entitlement (people have to enroll in the program) and an explicit package of health services (Plan NACER Health Care Package). This has forced the public subsystem to collect names of people, which is seen as an important step in the development of a close relationship between the system and each eligible household. (3)

More fundamentally, it has demonstrated to the rest of the health administration the importance of focusing on results. During the field visit, I asked Claudio Scalamogna, general coordinator of the Programa SUMAR in the Province of Chaco, whether the new style of management brought by the Plan could one day penetrate other social sectors. He answered “This is my dream”.

A last similarity I want to highlight is the narrative used to present the scheme. When one listens to Martin, you get the impression you’re listening to a PBF champion. This is of course interesting, as both strategies developed in parallel and independently. I asked Martin how he explains this; his answer was straightforward: “Results Based Financing is about human beings, how human beings can improve their work, and how we, as policy makers, can empower the health workers towards a prioritized goal. Our assessment in Argentina was that in order to improve health of the under-covered population, we had to redesign incentives to health facilities, improve work conditions, give autonomy, provide opportunities for training and for greater participation in the health system. We think that is the secret and I am not surprised it applies to other countries as well”.

But the differences are even more interesting…

A first difference: Argentina is a federal state and the Programa SUMAR reflects this reality. The program rests on a two-tier contractual system: there’s one contract between the national level and each province and another one between the province and health facilities. The contract between the central government and the province has two components: 60% is paid on a capitation basis (in 2013, around 2.6 US$ per person who has registered for the SUMAR– but existing enrollees count only if they used at least one health service during the last 12 months), 40% is performance-based using tracer indicators (see below). Initially, the whole funding was coming from the national level (with money from a loan granted by the World Bank). But since 2009, the provinces have also been co-financing the program, up to 15% nowadays. This share is expected to grow further. Martin told us that an efficient trick to keep control over such a two-level system is to use the national funding to remunerate the provincial unit teams. This allows the central level to define the profiles of members of the provincial units and to have a say on recruitment by provincial units.

The national government maintains some key decision rights: it defines the list of health services that are covered under the program (the benefit package) and the categories of costs which can be covered at facility level with the revenue collected from the program. But the rest is under the control of the province. For instance, each province defines the fee to be paid to the health facility for each service. While the program´s rules stipulates that facilities are allowed to allocate to staff incentives up to 50% of the program revenue, it is up to  each province to decide whether that percentage will be 0 or 50. Of course, below the province, the health facilities are also granted key decision rights: thus the facility has the final decision on what to purchase (but with a variable degree of autonomy across provinces, as we could observe during our visit). We were told that in general, health facilities are prioritizing training opportunities, equipment and infrastructure improvements.

A second difference: more complex payment formulae

The National government puts the emphasis on 14 key interventions scientifically proven to have an impact on priority health problems. As quality is key for the effectiveness of these interventions, a lot of stress is put on fulfilling quality conditions. According to this principle, a province receives more resources as long as its performance is above defined targets. For example, if the province manages to give a first prenatal check-up before the 13th week to at least 29% of the eligible pregnant women, it will receive additional resources. The higher the percentage of women with early check-ups, the higher the retribution (It is a continuous payment function). Each tracer has a mandatory set of information regarding the quality of the health service to be reported for every case. For our example, the province must report – along with the name of the woman and her ID number – the  date of the first check-up, the week of gestation, the date of the last menstrual period, the probable date of birth and, of course, the name of the health facility that provided the health care.

The contract between the Province and the facilities is simpler. They are paid on a fee-for-service basis (a price per quantity, as in PBF systems). For a selected set of health services they have also an incentive to match some standards for quality. All of this is subject of ex post verification (see below). Additionally, some provinces are using higher prices for health services that fulfill the quality matrix. In this case, they are extending the sanction scheme post verification in order to penalize the cases that do not match these criteria.

I  discussed this approach with Gyuri Fritsche (World Bank). He reminded me that this approach – to pay for an output only if it has some key attributes of quality – was the initial strategy of the Belgian Technical Cooperation project in Rwanda (except that the BTC verified the fulfillment of quality attributes ex ante). This model had not been adopted for the scale up in Rwanda and elsewhere in Africa, as it was considered too difficult to bring to scale: collecting quantity and quality indicators separately was seen as much easier to implement – the former being collected monthly, the latter quarterly. The Argentinian system is indeed much more demanding in terms of routine data collection, but as we know, there is an ICT revolution going on. This is something we may have to reconsider in the future.

A third difference: allocation of the RBF revenue to individual bonuses is not the dominant model. Only seven out of twenty four provinces allow their facilities to pay incentives to the personnel. Martin told us that several reasons explain this heterogeneity. Some provinces do not want it for legal reasons, others because they don’t think direct incentives to personnel will bring better results; some also doubt they would be able to sustain a bonus scheme in the future. As a matter of fact, in the health centre we visited, the transfer received from SUMAR represented just 4% of the health centre wage bill. Not sure this would be enough to induce a dramatic change.

We were of course curious to know whether there was a difference in performance between the provinces which have allowed facilities to pay a bonus with the funding and those that haven’t. I asked the question to Paul and Martin. Paul explained that the outcome variables he used to prove the effectiveness of the NACER plan were very rare events; the sample sizes unfortunately did not allow to ascertain a possible positive contribution of individual bonuses. He is about to check this possible determinant with another data set. Martin’s assessment was that the main determinant of the surge in performance has been the  expansion of autonomy at facility level: to have resources and be free to allocate them. As he put it nicely: “Health facilities have set up collective management approaches. RBF represents a real change in the culture of the health system, including at health facility level. For the first time health staff are participating in allocation decisions. This is also incentivizing!” The staff of the health centre we visited gave us another (complementary) explanation: the economic crisis of 2001 was really terrible and the health system experienced a collapse. The reinjection of funds brought by the NACER plan and the fact that the health facility staff had decision rights was a relief and created a new dynamic.

A fourth difference: a more important role for external verification. In PBF schemes, external verification is mainly there as a mechanism to reassure sponsors about the reliability of the verification system; it is henceforth called ‘counter-verification’. The External Concurrent Audit in Argentina is more integrated in the general functioning of the RBF scheme. For instance, the information gathered by the external audit firm feeds into the supervision program of the internal auditors. The permanence of the external audit allows the internal audit to focus on supervision, coaching and problem solving. This is something very valuable as this allows the program supervisor not to be perceived as controller. In Argentina, the external audit’s decisions have biding authority: if a discrepancy from the rules is found, no interference by authorities is possible: the penalty will have to be paid. This external audit is costly, but interestingly enough, the fines it charges to health facilities are nearly covering the full cost of doing the external audit.

A fifth difference: the management of Programa SUMAR involves a lot of people. Olivier Basenya (Ministry of Health, Burundi) and I were a bit shocked by the numbers mentioned when we heard them for the first time in Oslo: 150 staff at the national office of the program and 700 for the whole country! Compare:  Burundi’s central level PBF team counts only 7 ministry of health staff and 3 staff affiliated to partners. Are too many people involved in SUMAR management?

As explained by Martin: “Our job is to develop the strategic planning, to provide support and to supervise the 7,000 health facilities involved in the program. We are also administrating the 24 legal performance contracts. Our team is therefore multidisciplinary: we have economists, physicians, lawyers, social psychologists, experts in communication, experts in information technology, accountants… Health progress is multi-causal, so you need to build multiple solutions, multi perspective solutions. We are always fine-tuning the strategy, trying to learn what the reality is saying to us. We are also very committed to training the provincial teams. SUMAR is also a program that integrates all other substantial programs. We are working with more than 30 health programs in our Ministry of Health”.

We also noticed  many medical doctors in the health center we visited (well, most were absent, but they were reported as members of the team). So, it is possible that the relatively large team of the SUMAR program partly reflects a context-specific reality, but we agree that some PBF national units in Africa could be strengthened.

A last difference:  the system is steered more dynamically

A big danger with a PBF system is self-satisfaction:  you set up the system and then you run it more or less in a routine way. At the workshop, I checked with Olivier Basenya about his main take home message, and he duly agreed: “the Argentinian national unit steers its RBF system in a more dynamic way than we do”.

To conclude

Argentina was a refreshing experience for many PBF experts. Let’s keep in mind that RBF is not about implementing a single standard model. Although there are principles and good practices, there might be even better practices out there that we still have to discover. We learned a lot from Argentina during our stay in the country. Conversely, the Argentinian team is also eager to learn from other country experiences, so don’t hesitate to invite Martin.

(1) In this text, I refer to “NACER” when I refer to the initial scheme. I use “SUMAR” when I refer to what is in place today.

(2) I express my sincere gratitude to the SUMAR team, and particularly Mrs Jesica Azar who kindly answered my numerous questions on the way to the health center.

(3) I find this idea interesting and could be considered in some African countries. Let’s illustrate the concept with the case of Burundi. Each child under 5 would still receive treatment for free, but the health centre would be reimbursed by the national PBF scheme only if the health centre can provide for each utilization by a child his ‘free health care’ number. The great benefit of such a model is that it incentivizes health facilities to enroll families in the program, a way to develop a stronger bond with them. I also imagine that our ICT/PBF colleagues could develop solutions to provide information on utilization by enrollees to health centres (lost in follow-up, etc) to improve continuity of care.

Bruno Meessen

You are international health expert and you distrust the strategy of community health workers, hate performance based financing and don’t believe in community participation anymore? Press on the key “Rwanda” for an update!

In August 2013, during a visit in Burundi, I had the opportunity to discover a pilot experience of community PBF. That experience, led by the ONG IADH overcame the reluctances I had so far, as many others, regarding the strategy of community health workers. I knew that this strategy was already applied countrywide in Rwanda, the neighboring country. I benefited from a recent request from the Government of Rwanda and the United States Government’s Integrated Health Systems Strengthening Project (led by Management Sciences for Health) to learn more about it. My conviction was strengthened: we are facing a breakthrough.

Development of community PBF in Rwanda

The Rwanda’s experience in community PBF occurred in two times. The first experience- since 2006- thoroughly played the game of decentralization: the local government had transferred the budget for the community health workers to the local authorities (the administrative district). That approach, the G2G (government to government), to some extent, failed in its early stage. As Dr. Claude Sekabaraga, who I met again in Kigali, reminded me, the money didn’t reach the beneficiaries and was sometimes used by the decentralized administrative structures to fund other activities (infrastructures…) that seemed to be a higher priority. The second experience - started in 2009 - has been funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Because of the donor's rules, the funds for the community health workers  have been transferred through the health centres.

The originality of the Rwandan model lies in the organisation of the community health workers (CHWs). The MOH opted for the setting of cooperatives of CHWs. Cathy Mugeni, who leads, since the beginning, the program at the MOH in Kigali, explained that this choice was, among others, due to the national political context: in comparison to an 'association' (like in Burundi), the cooperative is an institutional formula that permits more easily an economic activity, additional to the support to routine community health activities - it was more conform to the country’s objective to progress towards a lesser dependency to external aid for the funding of its health sector.

I was of course curious to discover the strategy on the field. By chance, my stay in Rwanda coincided with that of a delegation of the Lesotho’s Ministry of Health. I was thus able to join them for a visit of the Gikomero health center (1).

Lessons

The community health workers must henceforth be recognized as an integral component of the health system. I say “henceforth” because it was not and is still not the practice in most CHW programs: in many countries, the strategy of CHWs has been impeded for longtime by its fragmentation (each vertical program having its own CHWs); it had also been accused of paving the way for apprentice doctors, uncontrollable once equipped with drugs. I can’t take position for each context, but what I’ve seen in Rwanda, what told me different informants and what I’ve read besides convinced me: ignoring the CHWs is depriving ourselves of a true accelerator for numerous health objectives that are dear to us, especially those under the MDGs 4,5 and 6.

Dr. Michel Gasana, National Director of the National Tuberculosis Control Programme, thus explained me that CHWs played henceforth a key role in the identification and referral of persons suspected of having tuberculosis. They also play a role in the administration of the treatment (DOTS). At Gikomero, the CHWs showed us a lot of their activities, including the integrated management of childhood diseases (fever, diarrhea and pneumonia) at the community level, the promotion of the use of family planning services, the delivery of contraceptive methods and drugs to manage tuberculosis, the behavior change communication, and the community-based nutrition program: all high impact interventions. We also appreciated the quality of their different tools.

As many health system experts, my attention these last years has been drawn to the health facilities. Our first concern was to reinforce them so they may be able to deliver their health package. What stroke me at Gikomero was the very high integration that exists between the activities of CHWs and those of the health center. If the CHWs provide some services (e.g. treatment of diarrhea with ORS and Zinc, treatment of pneumonia, treatment of malaria), a good part of their contribution is the promotion of the use of the health center (they also are permanently in touch with the health center and the Ministry of Health thanks to mobile phones that permit to lead fast interventions to save lives at the community level). The key advantage of the CHW is that he/she lives in the village. He/she is trusted by the community and is thus welcomed in each household. Later, the same day, we visited, in another district, the Rutongo hospital. In the pediatric ward, we were able to interview a mother with her baby who has kwashiorkor. She told us her journey: her notice of a change in the behavior of her baby, her contact with 'her' CHW, the decision to go together to the health center (despite that the anthropomorphic measures were in the “green”),  and after the diagnosis of a severe malnutrition by the health center, the immediate referral to the hospital (using an ambulance).

One of the great strengths of the Makamba experience in Burundi and the one from Rwanda is the establishment of a joint entity to all the CHWs of one health center.  Firstly, this removes the previous problem of fragmentation of the strategies using CHWs (each program having his). This also greatly facilitates the communication with the health center; this permits for example passing at the scale of a strategy in a quicker way. More fundamentally, the existence of an association of a cooperative permits to pass from a model where the CHW is strictly instrumental to a model that really favors a collective decision- which is, for me, the real stake of the community action.

For that, it was needed to create a stake for collective decision. Our hypothesis is that community PBF, with its injunction of funds into these self-managed entities (associations or cooperatives), creates that involvement. Because if the community PBF envisages that the joint entity will have to remunerate each CHW for its own contribution, the payment by the Ministry of Health is high enough for the group to put a part of its revenue aside. With that money, investment decisions can be made. 

At Gikomero, Ms. Concessa Kiberinka, CHW and accounting of the CHWs cooperative, presented us the different activities led by the cooperative: a piggery, a banana plantation, real estate investments… She also told us about their future project: to build a production unit of pork! In business management schools, this is called to move up the value chain…

I asked her if there was no risk that the economic success of the cooperative corrupts the project, whose first finality was health. We could for example imagine that in the future, the candidates to the post of CHW are “opportunists”, mainly interested by the economic gain.  She explained me that each village chose, democratically, its CHW, and that criteria were the dedication for the village, the integrity, the ability to gain the trust to visit households… (2). It’s difficult to describe, but during the different oral interventions of CHWs during our visit, all these values emanated from them.

Emergence of a model

So there is a model extremely well designed and structured that emerges: CHWs, democratically elected by the community, trained on an effective health interventions package, working collectively and under the supervision of a health center, locally organized into a cooperative, itself remunerated by a PBF and fostered to launch economic activities, all of that in a context of strong political mobilization.

One can predict that the next Demographic and Health Survey (2015) will confirm the health impact of that global strategy. Some will ask which component will have been the most determinant. Dr. Ina Kalisa Rukundo (School of Public Health of Kigali), who is coordinating a study in the impact of the community PBF funded by the World Bank told me: “Between the baseline and the final assessment, three years have passed. In Rwanda, everything goes very fast. There has been a very strong mobilization of the national and local authorities in favor of CHWs. It is also a small country and the good ideas are quickly shared. Our study tries to isolate the effect of PBF, but we would not be surprised if finally, the study reveals that the different arms of the study have similar results”. It is also probable that the numerous beneficial effects related to that policy (especially in terms of governance and economic impact) will never be well identified.  This is the case for societies in rapid transformation.

A renewed vision

One must of course be careful with the experiences from Rwanda and Burundi. Factors like the high density of population, the democracy at the village level, or the high implication of women in the collective action could be elements more difficult to find in other contexts. It is also possible that more that the “what” to do, it is the “how” to do it that matters. It is by the experimentation elsewhere that we will know it.

This shows a more general lesson, surely valid for the academic world engaged in global health: it is greatly time to review some of our dogmas and mental categories. We live in a world in permanent change, in Africa as well. What was unimaginable yesterday can happens tomorrow… and is already occurring in Rwanda! In public health, many of our references are based on a static, or even worse, wrong reading of the societies. As teachers, we must have the humility to recognize that part of our teaching is shaped by our past experiences and determined by analysis frameworks maybe conceptually elegant, but out of phase with the reality.

Notes

(1)    Thanks to Health Development Performance and to the School of Public Health for having accepted us as visitors for this visit!
(2)    The cooperatives include 2/3 of women; as a man, I see there a very wise decision (moreover, not surprising for Rwanda).

Bruno Meessen

Vous êtes expert en santé internationale et vous vous méfiez de la stratégie des agents de santé communautaire, détestez le financement basé sur la performance et ne croyez plus en la participation communautaire ? Tappez sur la touche « Rwanda » pour une mise à jour !

En août 2013, lors d’une visite au Burundi, j’avais eu l’occasion de découvrir une expérience-pilote de FBP communautaire. Cette expérience menée par l’ONG IADH avait vaincu les réticences que j’avais jusqu’alors, sans doute comme beaucoup d’autres, vis-à-vis de la stratégie des agents de santé communautaire. Je savais que cette stratégie de FBP communautaire était déjà mis en œuvre à l’échelle de l’ensemble du pays dans le pays voisin, le Rwanda. J’ai profité d’une récente sollicitation dans le cadre du  « Integrated Health System Strengthening Project »  du gouvernement du Rwanda et du gouvernement américain (mise en œuvre par  Management Sciences for Health) pour en savoir plus. Ma conviction en sort renforcée : nous sommes face à une avancée pleine de promesses.

L’expérience du Rwanda en matière de FBP Communautaire s’est faite en deux temps. La 1° expérience – dès 2006 – s'est faite sur financement public. Elle a joué à fond le jeu de la décentralisation : le gouvernement central avait fait passer les budgets à destination des agents de santé communautaires par les autorités locales (le district administratif). Cette approche – G2G (« government to government ») a, dans sa phase initiale, été un échec relatif. Comme me l’a rappelé le Dr Claude Sekabaraga, que j’ai retrouvé à Kigali, l’argent n’atteignait pas les bénéficiaires et était parfois utilisé par les structures administratives décentralisées pour financer d’autres activités (infrastructure…) qui leur semblaient plus prioritaires. La 2° expérience -à partir de 2009 - s'est faite sur financement du Fond Mondial de la Lutte contre le SIDA, la tuberculose et le paludisme. A cause des règles imposées par le bailleur, les fonds à destination des agents de santé communautaires ont alors transité, non par le district administratif, mais par les centres de santé.(1)

L'originalité de l'expérience rwandaise réside dans l'organisation des agents de santé communautaires (ASC). Le Ministère de la Santé a opté pour la mise en place de coopératives d'ASC. Cathy Mugeni, qui conduit, depuis le début, le programme au Ministère de la Santé à Kigali, nous a expliqué que ce choix était entre autre dû au contexte politique national : la coopérative des ASC est une formule institutionnelle qui permet plus facilement l’activité économique en plus du soutien aux activités de santé communautaire de routine – elle était plus conforme à l’objectif du pays de progresser vers une moins grande dépendance vis-à-vis de l’aide extérieure pour le financement de son secteur santé. 

J’étais bien sûr curieux de découvrir la stratégie sur le terrain. Par chance, mon séjour au Rwanda coïncidait avec celui d’une délégation du Ministère de la santé de Lesotho. J’ai donc pu me joindre à celle-ci lors de la visite au centre de santé de Gikomero.(2)

Leçons

Les agents de santé communautaire doivent désormais être reconnus comme une composante à part entière du système de santé. Je dis « désormais » car ce n’était pas gagné d’avance : la stratégie des ASC a longtemps pêché par son morcellement (chaque programme vertical entretenant ses propres ASC) ; elle a aussi été soupçonnée de faire le lit d’apprentis-docteurs, incontrôlables une fois dotés de médicaments. Je ne peux pas me prononcer pour chaque contexte, mais ce que j’ai vu au Rwanda, ce qu’on m’ont dit différents informateurs et ce que j’ai lu par ailleurs m’a convaincu: ignorer les ASC, c’est se priver d’un vrai accélérateur pour de nombreux objectifs sanitaires qui nous sont chers, en particulier ceux repris sous les OMD 4, 5 et 6. Le Dr Michel Gasana, Directeur national du programme national de lutte contre la tuberculose, m’a ainsi expliqué que les ASC jouaient désormais un rôle-clé dans l’identification et le référencement des personnes suspectées d’être infectées par la tuberculose. Ils jouent aussi un rôle dans l’administration du traitement (DOTS). A Gikomero, les ASC nous ont présenté leurs nombreuses activités, notamment :la prise en charge intégrée des maladies de l’enfant (fièvre, diarrhée et pneumonie) au niveau communautaire, la promotion de l’utilisation des services de planification familiale, la fourniture de méthodes contraceptives et des médicaments de prise en charge de la tuberculose, la communication pour le changement  et le programme de nutrition à base communautaire) : toutes des interventions à haut impact. On a aussi pu apprécier la qualité de leurs différents outils.

 Comme beaucoup d’experts « système de santé », mon attention ces dernières années a été orientée vers les formations sanitaires. Notre premier souci était de les renforcer pour qu’elles puissent prester leurs paquets d’activité. Ce qui m’a frappé à Gikomero c’est la très grande intégration qui existe entre les activités des ASC et celles du centre de santé. Si les ASC prestent certains services (ex : traitement de la diarrhée par SRO-Zinc, traitement de la pneumonie, traitement du paludisme et suivi nutritionnel de l’enfant malade), une bonne part de leur contribution passe par la promotion de l’utilisation du centre de santé (ils sont aussi en contact permanent avec le centre de santé et le Ministère de la Santé grâce à des téléphones mobiles qui permettent de mener des interventions rapides pour sauver des vies au niveau communautaire). L’avantage-clé de l’ASC c’est qu’il réside dans les villages. Il bénéficie de la confiance de la communauté et est ainsi accueilli dans chaque foyer. Plus tard, le même jour, nous avons visité, dans un autre district, l’hôpital de Rutongo. Dans la salle de pédiatrie, nous avons pu interviewer une maman d’un enfant avec un kwashiorkor. Elle nous a raconté son parcours : son observation d’un changement de comportement de son bébé, une prise de contact avec son ASC, la décision d’aller ensemble au centre de santé (en dépit que les mesures anthropométriques étaient dans le ‘vert’) et après diagnostic d’une malnutrition aiguë par le centre de santé, la référence immédiate à l’hôpital (avec recours à l’ambulance).

Une des grandes forces de l’expérience de Makamba au Burundi et de celle du Rwanda, c’est la mise en place d’une entité commune à tous les ASC d’un même centre de santé. D’une part, cela évacue le problème antérieur de la fragmentation des stratégies recourant aux ASC (chaque programme ayant les siens). Cela facilite aussi grandement la coordination avec le centre de santé ; ça permet par exemple des passages à l’échelle d’une stratégie de façon plus rapide. Plus fondamentalement, l’existence d’une entité autogérée permet de passer d’un modèle où l’ASC est strictement instrumental (comme relais des programmes) à un modèle mobilisant réellement la décision collective – ce qui à mon sens, est le vrai enjeu de l’action communautaire.

Pour ce faire, il fallait créer un enjeu pour la décision collective. Notre hypothèse est que le FBP communautaire, par son injection de fonds dans ces entités autogérées génère cet enjeu. Car si le FBP communautaire prévoit que l’entité commune devra rémunérer chaque ASC pour sa contribution individuelle, le paiement par le Ministère de la Santé est suffisamment élevé pour que le groupe puisse mettre une partie des revenus de côté. Avec cet argent, des décisions d’investissements peuvent être prises.

A Gikomero, Mme Concessa Kiberinka, ASC et comptable de la coopérative des ASC, nous a présenté les différentes activités économiques que la coopérative menait : un élevage de cochons, une bananeraie, des investissements immobiliers… Elle a aussi partagé avec nous leur projet futur : construire une unité de production de viande de porc ! Dans les écoles de gestion, on appelle cela progresser le long de la chaîne de valeur…

Je lui ai demandé s’il n’y avait pas un risque que le succès économique de la coopérative corrompe le projet, dont la 1° finalité était sanitaire. On pourrait imaginer par exemple que les candidats au poste d’ASC dans le futur soient des ‘opportunistes’ surtout intéressés par le gain économique. Elle m’a expliqué que chaque village choisissait, démocratiquement, son ASC et que les critères qui comptaient étaient le dévouement pour le village, l’intégrité, l’aptitude à gagner la confiance pour visiter les foyers… (3) C’est difficile à décrire, mais durant la réunion avec les ASC, toutes ces valeurs émanaient des ASC qui ont pris la parole.

Emergence d’un modèle

Voilà donc, un modèle extrêmement bien pensé et structuré qui émerge :  des ASC, sélectionnés démocratiquement par la communauté, formés à un paquet d’interventions efficaces, travaillant en coordination et sous supervision du centre de santé, organisés localement en une coopérative, elle-même rémunérée par un FBP et encouragée à lancer des activités économiques, le tout dans un contexte de forte mobilisation politique.

On peut prédire que les données de la prochaine Enquête Démographie et Santé (2015) refléteront l’impact sanitaire de cette stratégie globale. Certains se poseront la question de quel aura été le composant le plus déterminant. La Dr Ina Kalisa Rukundo (Ecole de Santé Publique de Kigali), qui coordonne une étude d’impact sur le FBP communautaire financée par la Banque Mondiale m’a répondu : « Entre l’étude de base et l’étude finale, trois ans se seront écoulés. Au Rwanda, tout va très vite. Il y a eu une forte mobilisation des autorités nationales et locales en faveur des ASC. C’est aussi un petit pays et les bonnes idées sont vites partagées. Notre étude essaie d’isoler l’effet du FBP, mais ne serions pas surpris si au final, l’analyse finale révèle que les différentes branches de l’étude ont des résultats similaires ». Il est également probable que les nombreux effets bénéfiques connexes de cette politique (notamment en termes de gouvernance et d’impact économique) ne seront jamais bien identifiés. C’est le lot des sociétés en transformation rapide.

Une vision renouvelée

On doit bien sûr être prudent avec l’extrapolation des expériences du Rwanda et du Burundi. Des facteurs comme la forte densité des populations, la démocratie au niveau du village ou encore la grande implication des femmes dans l’action collective pourraient être des éléments plus difficiles à retrouver dans d’autres contextes. Il est aussi possible que plus que le ‘quoi’ faire, c’est le ‘comment’ faire qui compte. C’est par l’expérimentation ailleurs que nous le saurons.

Cela indique une leçon plus générale, certainement valide pour le monde académique engagé en santé internationale : il est grand temps de revoir certains de nos dogmes et catégories mentales. Nous vivons dans un monde désormais en changement permanent. Ce qui était inimaginable hier est peut-être envisageable demain… et déjà en œuvre aujourd’hui au Rwanda! En santé publique, beaucoup trop de nos prescrits sont basés sur une lecture statique, ou pire datée, des sociétés. Comme enseignants, nous devons avoir l’humilité de reconnaître que notre enseignement est façonné par nos propres expériences passées et déterminé par des cadres d’analyse peut-être conceptuellement élégants, mais en décalage avec la réalité.

Notes :
(1) Les deux systèmes co-existent encore actuellement. Jusqu'à récemment les fonds publics arrivant au niveau du district administratif étaient utilisés par ce dernier pour couvrir les coûts que l'action communautaire entraînait à son niveau (supervision, réunions...). Suite à une forte réduction du financement du Fond Mondial, les financements publics vont désormais également servir à rémunérer (à la performance) les activités des ASC.  
(2) Merci à Health Development Performance et à l’Ecole de Santé Publique de Kigali pour nous avoir accepté comme participant à cette visite !
(3) Les coopératives comptent 2/3 de femmes ; comme homme, je vois là une décision très sage (du reste, peu surprenante au Rwanda).

Designing and implementing a Performance Based Financing (PBF) scheme is an art. Isidore Sieleunou interviews an  artist who is happy that his latest piece of art finally saw the light : Gyuri Fritsche from the World Bank. Gyuri introduces the freshly released PBF Toolkit to us. You can access the full document here.

Could you tell us the main motivations that led to the production of this Toolkit? 

The main motivation for creating this toolkit was a sense that although there was a massive interest in PBF, the knowledge on PBF approaches was very limited and confined to a few early PBF pioneers. The idea was to make such knowledge which is based on years of experimentation, widely available to other experts. There was a sense (and such a sense still exists) that many ‘PBF’ projects were started that had significant design and implementation flaws while such design and implementation experimentation had been done previously, and lessons had been learned on the ‘how to’ (the ‘science of delivery’) already. Our credo was therefore: ‘make mistakes, but make original mistakes and do not repeat those that have been made before’. I believe there is a strong demand for the experiential knowledge contained in this toolkit which comprehensively rehashes the experience from key pioneers over the past, say, 15 years.

Three years ago, some authors wrote that the PBF strategy underestimated important constraints to its implementation. Do you agree with this assessment?

First, what is a ‘PBF strategy’? There is no such thing as a “PBF strategy”, there are various PBF approaches, and these approaches evolve continuously. Second: if PBF were easy, it would have been done before. So PBF is not an easy fix, but it is a set of principles that are adapted to each specific context. PBF is unpredictable as a ‘strategy’ in a specific context, as there are so many variables that will influence whether it will succeed or not. The best that one can do as an implementer is to apply as much as possible all elements of PBF approaches that are known to be linked positively with some effect. It is not an exact science, but I guess this is the best advice I can give. The most important constraint is having effective local champions that advocate for the approach. It is a health reform and because it is a reform, we need to appreciate that it has political economy aspects. PBF is not a technical fix, or some sort of vertical program; it is a systemic multi-layered intervention. And this is exactly why we wrote this toolkit: to ‘demystify’ PBF, to describe what worked best and how, and also, what failed.

So far, knowledge on how to implement a PBF scheme has largely been disseminated through the mobility of experts, with a massive involvement of experts from Africa – something remarkable if we compare with previous practices. Still the support from implementing agencies from the North has remained important. Which evolution do you expect in the close future? Any role to be played by the toolkit?  

I expect Southern experts to play even more important roles in the future. Already, the most effective local champions are those who move from their own contexts to other contexts. Quite a few are very effective experts. This toolkit will enable these experts to access knowledge held previously by a few pioneers and to become even better experts. Also, this toolkit is not a final product, but rather a look back in time, up to plus or minus the current period, and say: this is what has been done, this is how it was done, and this is what seemed to work better and this is what was tried and did not work well. In this sense, this toolkit is a benchmark: experts will need to get acquainted with its content, and then move on and build on the knowledge contained in it (and produce a next version). Northern technical assistants will have to adapt to these changing realities: they will have to devise business models that will focus on creating local capacity and be flexible and nimble.  

Some experts, including within the PBF community, are a bit afraid that on some aspects, we move too quickly towards a doctrine. This could create rigidities or too much ‘cut & paste’ of solutions. How does the toolkit deal with this risk?

I am not too afraid of this ‘cut and paste’ labelling. The toolkit was written with a keen eye on this theoretical danger of being labelled as a ‘cookie cutter approach’ and I believe sufficient care has been taken to present a balanced view wherever possible. Nevertheless; this is a TOOLKIT and some degree of advice is necessary and also expected from a toolkit. I will give an example. If for instance you decide to disregard the element of health facility autonomy in your PBF design, do not be surprised if you do not find any effects of PBF in the near future. Even worse, sometimes designs are framed as ‘Rwanda/Burundi type of PBF’ whereas there are major departures from that design. The issue in my opinion is a misunderstanding or lack of knowledge on the contexts where these PBF approaches have evolved so successfully. And this is why this toolkit is so important: the toolkit tells many stories about many different design and implementation elements, which, if pieced together and read as a whole, tell a much more comprehensive story on PBF approaches and especially, on how to make them more effective.

A challenge obviously is that the knowledge on PBF is evolving very quickly. If you had to add a new chapter, let’s say, next year, which new topic would you cover?

Information and Communication Technology (ICT) is an area which evolves rapidly. For instance, the development of tablet based software for the quality checklists with automatic uploads to a web-based platform/dashboard. Also the web-enabled applications through OpenRBF are evolving as we speak, with major work being done in inter-operability with other ICT solutions such as DHIS2. Another area is the increasing interest in moving towards process elements of quality, such as for instance the use of criterion based medical audits or vignettes (case-studies). Furthermore, the issue of urban PBF, where public funds are used to contract private for profit providers through PBF will be a major growth area. Also, the area of equity, of how we target the poor, is evolving really fast. In the World Bank we now work systematically hand in hand with our social protection colleagues, and there is a fair amount of cross-fertilization here.

In the foreword, Tim Evans reminds us that delivering services is important to push the frontier of knowledge forward. Some people think that when the World Bank adopts a new idea, trickle-down effects swiftly follow. So when Jim Kim, the Bank’s President, announces that ‘the science of delivery’ will be a hallmark of his tenure, this raised a lot of expectations among practitioners. Should we interpret this important document as the sign that the World Bank gets serious about implementation issues?

I cannot speak for the World Bank, but I agree that there is a general wave inside the Bank to become much more focused on the poor and to become more effective and efficient in what we do for the poor. This toolkit does just that. If you look at our health portfolio in Africa for instance, you will see that PBF is BIG. And it is set to become even bigger in Africa, while it is slowly taking off in Central and South-East Asia, and trickling into the Arab world and Latin America too.

Do you agree with the view that the experts of the PBF Community of Practice (PBF CoP) should contribute to the next edition? Do you have any plan in this respect?

This is a toolkit written by experts from the PBF – CoP. The way it was done, will enable adding tools to on-line folders in the appropriate chapters which will remain accessible through the links in the e-book, and through the WB website. In the near future I believe that various chapters will need updating and this can be done in various ways. It is my hope that this toolkit, which will be produced in three languages (EN; FR and SP), will be used by our PBF-CoP colleagues who will further enrich and expand it. 

The Alliance for Health Policy & Systems Research, a global partnership hosted within WHO, is about to launch a new implementation research programme focused on results-based-financing (RBF). A few experts of the Performance Based Financing Community of Practice (CoP PBF) attended a preparatory meeting in Geneva on 23-24 January. In this blog post, they report on the two-day event.

 The Alliance for Health Policy & Systems Research is known for its commitment to enhancing the dialogue between researchers and research users, policy makers in particular, in developing countries. As readers of this website know, the Harmonization for Health in Africa communities of practice fully embrace this agenda. Late December, several of us were contacted by Joe Kutzin (WHO, Geneva - Department of Health Systems Governance and Financing) and Nhan Tran (Alliance) to join them, together with other RBF and provider payment reform experts, for a consultation meeting to prepare a new call dedicated to implementation research on RBF. Olivier Basenya, Por Ir, Bruno Meessen and Laurent Musango made the trip to Geneva.

Participants were asked to assist the Alliance in identifying main implementation research questions related to the scale up and integration of RBF initiatives into national health systems and policies, and in identifying priority countries where such research would have a greater impact. After two days of intense interactive deliberations, it was decided that the research program will focus on the enabling factors and barriers for RBF (pilot) schemes to be scaled up and integrated into national health systems and  policies, taking into account RBF design features and implementation process, health systems characteristics, and socio-economic and political context. We agreed that the importance (extent) of the scaling-up and integration would  be assessed on several dimensions such as population and service coverage, institutionalization, financial integration in the public budget and so on. While some countries have been relatively successful in making progress on this multidimensional scale, others have been encountering quite serious obstacles in doing so.We are hopeful that this research program will bring interesting insights into how one needs to successfully navigate the policy process, combining efficiency with ownership and a sufficiently inclusive process, with the aim of strengthening health system and moving towards Universal Health Coverage (UHC). We know from previous meetings that national PBF champions are looking for guidance in this respect.

All participants made relevant contributions, with some as delicate as the tiny paper cranes produced by Professor Winnie Yip from Oxford University (picture illustrating this blog post). Others (like ourselves),  conveyed their message in a more straightforward way. One of the things we emphasized was that it’s vital to ensure that the research process involves country health authorities in such a way that it allows them to reflect on the extent to which they have actually achieved health systems strengthening via the integration/scale up of their pilot schemes – a shift from scheme to system and policy.

Interestingly enough, the research program will not have a purely instrumental aim. Eligibility criteria will also allow applications by research teams willing to document processes which were wrong from the start, e.g. a pilot project with insufficient or no (government) ownership,  or one that failed to be scaled up. It was suggested that the research areas should be a mixture of countries that have advanced in RBF implementation at national level, countries in pilot experiences phase and some others with a demand side component. 

The planning of the Alliance is ambitious. We expect the call to come out soon, so keep an eye on their website (ourselves, we will of course inform CoP experts through our online forum). We hope that many of you will apply and submit letters of intention as this is a research program fully in line with priorities pursued by the PBF CoP.