TERMS OF REFERENCE FOR A PERFORMANCE-PURCHASING AGENCY
DISCUSSION DRAFT: May, 2010
A. BACKGROUND
Background on PHC in Zimbabwe and the Bank project
General Approach: In order to strengthen the delivery of PHC services and strengthen the capacity of all service providers, the World Bank will enter into a contract with a performance-purchasing agency (PPA). The general approach for this contract is: (i) the PPA will act as a purchaser of services from individual health facilities, verify the validity of these services prior to pay and provide technical assistance for the implementation of a results-based financing (RBF) project a prescribed area; (ii) the PPA will strive, along with other actors such as the district health management team, to ensure that the performance of service providers improves and that tangible results (described in section H Performance Requirement below) are achieved; (iii) in order for the PPA to help achieve the expected results, the World Bank will provide it adequate and timely financial resources; (iv) careful and independent monitoring and evaluation will be carried out so that World Bank can be confident they are getting value for money, that learning is maximized, and that future implementation of RBF is based on clear evidence; (v) the PPA will implement RBF in line with the activities (described in section C Scope of Services); and (vi) the PPA will have the opportunity to implement the RBF project with sufficient managerial autonomy so they can flexibly respond to local conditions, introduce innovations aimed at achieving the stated objectives, and be held accountable for the results.
B. OBJECTIVES
The PPA will introduce and support the implementation of a RBF project which will:
(i) Strengthen the delivery of the basic package of services at a cost that is sustainable and replicable on a larger scale;
(ii) Increase the quantity of high impact clinical services provided and the population coverage of cost-effective preventive and promotive services;
(iii) Improve the quality of care provided in primary health care facilities;
(iv) Strengthen capacity of the Ministry of Health and other actors to implement the RBF mechanism, and;
(v) Reach the poorest members of the community with effective health services and increase equity in the access and use of both preventive and clinical services.
C. SCOPE OF SERVICES
The firm/organization selected to be the performance-purchasing agency (PPA) will act as a purchaser of services from individual health facilities, verify the validity of these services prior to pay and provide technical assistance for the implementation of a results-based financing (RBF) project in a prescribed area. The PPA will be responsible carrying out the following activities:
(i) Oversee the implementation of the agreed RBF project so that it accomplishes the specific objectives described above.
(ii) Work to ensure that the RBF project strengthens delivery of priority services in the minimum package of defined services as agreed to with the MOHCW
(iii) Provide dedicated technical assistance related to RBF operational procedures, including training to health workers, as described in the agreed manual of procedures.
(iv) Sign contracts with all participating health facilities/communities/districts/committees describing the performance framework as well as the roles and responsibilities in relation to RBF.
(v) Design and implement a system of external verification that effectively and efficiently validates the quantity and quality of services provided; ensuring that the services that are being paid for have actually been delivered.
(vi) Establish a district level RBF steering committee which meets at least quarterly to approve payment of performance invoices and oversee the overall governance and implementation of RBF. The committee will be chaired by the PPA and includes relevant representatives of the ministry of health, local government and civil society in the district.
(vii) Make timely payments (preferably using electronic transfers) to the health facilities bank accounts based on verified services delivered in keeping with the agreed manual of procedures.
(viii) Carefully maintain financial records such that they can be independently audited and also maintain a database that tracks the amount of services provided and the quality scores obtained by the health facilities.
(ix) Provide assistance to any health facility, where necessary in consultation with the District Medical Office, in the purchase of all items financed by the RBF funds earned by the health facility in accordance with approved MOHCW guidelines whereby thresholds for local purchases will be agreed
(x) Help with supervision to judge the quality of care provided in participating facilities using a standardized and quantitative checklist.
(xi) Consult regularly with RBF stakeholders. Ensure that the RBF manual of procedures are adjusted based on implementation experience.
(xii) Assist in special MOHCW activities such as national immunization days (NIDs) and other mass campaigns.
(xiii) Comply with existing MOHCW technical guidelines, procedures and those that are developed during the life of the contract.
(xiv) Facilitate the work of the 3rd party monitoring and evaluation firm reviewing PPA performance.
(xv) Maintain staff in the field to coordinate the overall RBF project in the country, which includes staff with backgrounds in Health, Finances, Management Information and Capacity Building. In addition, decentralized offices are to be established to support the programs in each district which include program managers for field operations officer as well as accountants.
D. LOCATION AND DURATION OF SERVICES
The successful firm/organization will support the implementation of the agreed RBF project in a defined area. A phased approach is proposed with the introduction of RBF in 8 districts (one in each of the provinces) followed by an additional 10-12 districts where RBF will be implemented. It is expected that the PPA contract will have a duration of two years, however this may be extended subject to the availability of funds.
E. REPORTING
Quarterly Reports: The PPA will provide the World Bank, with a copy to the MOH through the Provincial Health Director, with quarterly reports related to activities undertaken in fulfillment of these terms of reference. The quarterly report will include the following sections: (i) progress in implementation of the RBF project; (ii) problems encountered and solutions undertaken; (iii) relations with stakeholders such as the provincial/district (health) authorities, the community, and other NGOs operating in the assigned areas; (iv) a financial statement; and (v) a summary of MOH HMIS forms with analysis; Such reports will be furnished within one month of the end of the quarter.
Financial Reports: The PPA will maintain a separate set of accounts for the project and provide an annual externally audited financial report to the World Bank. Such audit report will be furnished within three months of the end of the year. The cost of the audit will be borne by the NGO. The World Bank reserves the right to examine, or to have its designated agent examine, the accounts maintained by the PPA for these World Bank -financed activities.
F. DATA, SERVICES, AND FACILITIES PROVIDED BY THE GOVERNMENT OF ZIMBABWE (GOZ)
The GOZ will provide the PPA with the following inputs: (i) relevant available information about facilities, health-care status of population, and results of surveys and special studies, etc; (ii) access to all GOZ facilities in the areas of assignment; (iii) copies of technical guidelines and standard HMIS reporting and recording forms; (iv) access to MOH training courses; (v) copies of key reports and research carried out in Zimbabwe; and (vi) access to key GOZ officials for consultation and discussions.
G. AUTHORITY AND RESPONSIBILITIES OF MOH, WORLD BANK AND PPA OFFICIALS
Designated World Bank officials will have the authority to visit health facilities being supported by the RBF project at the discretion of the MOH to obtain such relevant information as to allow proper monitoring and supervision. The designated contract manager in the World Bank may convene a meeting with the management of the PPA at any mutually agreeable time to discuss and resolve issues related to this contract and its implementation.
10. Central MOH as well as provincial and district health officials will have the authority to review the quarterly report of the PPA and provide additional comments to the World Bank Provincial and district health officials will have sole discretion over resources provided through the regular GOZ budget. However, these officials will not refuse reasonable requests for the use of such resources by the PPA in implementing the RBF project. Provincial and district health officials will not seek from the PPA any payments, benefits, or other material resources for themselves, their staff, or their families.
11. The PPA will have full authority on hiring, firing, posting, remuneration, and customary managerial prerogatives over staff who have been recruited to implement these TORs. The PPA will only pay health facilities in line with the performance based contracts and not provide any payments, benefits, or other material resources to GOZ officials, their staff, or their families except with the written authorization of the contract manager and prior approval of the World Bank. The PPA will enjoy sole discretion in the procurement and use of office equipment, vehicles and materials needed to carry out these TORs. Where it is involved in procurement of drugs, medical supplies, and medical equipment, the PPA will also enjoy sole discretion provided it purchases medicines on the MOH’s essential drug list and ensures the drugs meet good manufacturing practices (GMP) and are of good quality.
12. The health facilities will be autonomous in the management of the health facility and the decision making in relation to resources received.
H. PERFORMANCE REQUIREMENT
Performance Indicators In order to gauge the success of the RBF project and the performance of the PPA, key indicators will be monitored.
Annual performance incentives will be awarded to the PPA based on progress made towards the selected indicators. Targets will be determined in line with relevant baselines and following negotiation with the organization selected for implementation. A bonus of 10% of the organization’s budget can be earned on an annual basis, depending on an assessment of progress against the annual performance indicators. The following annual performance indicators will be used:
Table 1: Annual indicators
Indicator / Approximate Target 1 / Means for Data Collection2 /1) Complete and timely quarterly reporting (progress, financial and HMIS data) to the World Bank/agent during the year
2) Number and percent of health facilities that received their quarterly performance payment on time during the year
3) Number and percent of health facilities that received payment of performance incentives in line with the fees for services and quality incentive formula set for the selected geographic area
4) Number and percent of health facilities where third party verification was carried out on both quantity of services reported and the quality of care index
5) Number and percent of health facilities where health workers received on a monthly/quarterly basis the designated % (as per manual e.g. 30%) of the bonus paid by the organization to the health facility
1 Targets should be seen as approximate rather than exact given the limits of precision in measurement of these indicators and uncertainties about the actual baselines at the beginning of the contract. What is important is statistically and programmatically significant changes in these parameters.
2 HMIS=health management information system, HH Survey = Household survey, HF survey = health facility survey, QSC=Quantitative supervisory checklist, Audit