Ministry of Public Health and Fight Against Aids

REPUBLIC OF BURUNDI

MINISTRY OF PUBLIC HEALTH AND FIGHT AGAINST AIDS

REPORT ON THE IMPLEMENTATION OF PERFORMANCE BASED FINANCING IN BURUNDI

- April 2010 to March 2011 -

SEPTEMBER 2011

Table of contents

1.INTRODUCTION

1.1.History of the PBF in Burundi

1.1.Geographical distribution of PBF before the up-scaling.

1.2.Report objectives

1.3.Rationale and purpose of this report

1.4.Structure of the report

1.5.The team and methodoloy used

2.PBF OPERATING STRATEGY IN BURUNDI

2.1.PBF Institutional framework during early implementation

2.2.Public-private partnership

2.3.Separation of functions

2.4.Evolution of the institutional set-up of the PBF and some relevant contractual arrangements

2.5.Enlarged National Technical Unit Broad (enlarged CT-PBF)

2.6.Building missions of the CPVV

2.7.Strengthening the verification system

2.8.Utilisation of cross verification results

2.9.Management tools

3.MAJOR ACHIEVEMENTS UNDER THE PBF

3.1.PBF coverage of health facilities

3.2.PBF Capacity building of PBF stakeholders PBF

3.2.1.Training activities

3.3.Training on the PBF and Procedures Manual

3.4.Training based on PBF data

3.5.Recruitment of experts for technical assistance

3.6.Experienced NGOs accompanying provinces

3.7.Cross-verification and related results

3.7.1.Sample of health facilities to cross check

3.7.2.Sample of indicators to be cross checked

3.7.3.Sample of health beneficiaries for communal verification

3.7.4.Conclusions and recommendations spurred by the cross checks

3.7.4.1.Strengths

3.7.4.2.Weaknesses and recommendations

3.7.5.Vulgarisation of results and action undertaken

3.8.Contractualisation process of Central delivery units

3.8.1.Strategic options for the introduction of the PBS on the national level

3.8.2.Preliminary budget and contracting on the central level

3.8.3.Delivery units contracted at the central level during the first year of implementation of the PBF

3.8.4.Support delivery units helping with streamlining the organization and operation

3.9.Evaluation and review of the implementation of the PBF

3.9.1.Joint Evaluation Mission, September 2010

3.9.1.1.Results of the joint evaluation

3.9.1.2.

3.10.Fora for exchanges on Performance Based Financing

3.10.1.The exchange of inter-country experiences

3.11.Current developments for strengthening the health system through Performance Based Funding

3.11.1.Strengthening of community interventions

4.FUNDS MOBILIZED WITHIN THE PBF FRAMEWORK

4.1.Budgetary planning and monitoring tools for the implementation of the national PBF

4.1.1.Costing Model

4.1.2.The database

4.2.Comparison of budget forecast and actual expenditures at implementation of the PBF

4.2.1.Analysis by type of expenditure

4.3.Budget execution

4.4.Comparison of budget forecast and actual expenditures of health facilities

4.4.1.Analysis by province

4.4.2.Analysis by activity package

4.4.3.Analysis by free/non free indicator

4.4.4.Analysis by type of service

4.5.Comparison of forecast budget and actual expenditures of regulatory bodies

4.6.Co-financing the implementation of the PBF

PBF RESULTS WITH REGARD TO SUBSIDIZED INDICATORS

4.7.Evolution of utilization of PMA and PCA services

4.7.1.New curative consultations among persons 5 years and over

4.7.2.New curative consultations of children below 5 years of age

4.7.3.Births attended by trained personnel (excluding Caesarean section)

4.7.4.Fully immunized children

4.7.5.Old and new PF acceptant (implants et DIU excluded)

4.7.6.Voluntary screening for HIV/AIDS

4.7.7.New cases under antiretrovrirals

4.8.Quality of services

4.8.1.Average national score and its development over time

4.8.2.Technical quality analysis of the FoSAs

4.8.2.1.Technical quality analysis of the hospitals

4.8.3.Technical quality analysis of the CDSs

4.8.3.1.Analysis of quarterly average scores of perceived quality of CDS

4.8.3.2.Analysis of mean scores and rates of increase in technical quality, general and perceived, of the CDSs

4.8.3.3.Analysis of the differences between the scores of the technical quality of the CDSs

4.8.3.4.Analysis of the technical quality of the CDSs according to the level of PBF experience

4.9.Comparison between FOSAs regarding their average scores of the technical quality assessments

4.10.PBF and the strenghtening of the health system

4.10.1.Financial motivation in 2010

4.11.Professional motivation of health staff

4.12.Strengthening management, autonomy and the organization of health facilities

4.13.Strengthening of the SIS

4.14.The contribution of PBF to other reforms of the health system

4.14.1.Contribution to improving the implementation of the policy of free health care

4.14.2.PBF contribution to the support of the health district

5.LESSONS LEARNED AND RECOMMENDATIONS

5.1.Lessons learned

5.1.1.Strengths of the PBF in Burundi

5.1.2.Weaknesses of the PBF in Burundi

5.1.3.Opportunities to be exploited

5.1.4.Threats to prevent or mitigate

5.1.5.Recommendations

List of Graphs

Graph 1. Distribution of health facilities by contract according to their legal status

Graph 2. Breakdown of contract structures by province

Graph 3. Proportion of contracted health centers and public hospitals

Graph 4. Forecast budget versus actual expenditures (April 2010-March 2011)

Graph 5. Breakdown by type of expenditure as per forecast budget

Graph 6. Breakdown by type of expenditures by actual expenditures

Graph 7. Implementation rate of budget (April 2010- March 2011)

Graph 8. Budget execution rate for “regulation” (April 2010 to March 2011)

Graph 9. Monthly bills for the PMA and the PCA (April 2010 to March 2011)

Graph 10. Monthly increase rate of bills (April 2010 to March 2011)

Graph 11. % of actual expenditure per province versus forecast budget (April 2010 to March 2011)

Graph 12. Breakdown by activity package as per planned budget

Graph 13. Breakdown by activity package as per actual expenditure

Graph 14. Breakdown of free of charge/non-free of charge according to forecast budget

Graph 15. Breakdown of free/non free of charge against actual expenditures

Graph 16. Breakdown by free of charge/non-free of charge and by activity packages according to paid bills (April 2010 to March 2011)

Graph 17. Breakdown by type of service according to forecast budget (April 2010 to March 2011

Graph 18. Breakdown by type of service according to used budget (April 2010 to March 2011)

Graph 19. Breakdown by intervening entity according to forecast budget

Graph 20. Breakdown by intervening entity according to actual expenditures

Graph 21. Forecast breakdown of financing by funding source

Graph 22. Breakdown of paid bills to FOSA by funding source (April 2010-March 2011)

Graph 23. Monthly bills paid by funding source (April 2010 to March 2011)

Graph 24. Global evolution of PBA indicators

Graph 25. Global evolution of PCA indicators

Graph 26. New curative consultations among persons 5 years and over

Graph 27. New curative consultation of children below 5 years of age

Graph 28. Births attended by trained personnel

Graph 29. Evolution of the number of Caesarean births (April 2010 to March 2011

Graph 30. Evolution of the rate of cesarean sections compared to all deliveries between April 2010 and March 2011

Graph 31. Fully immunized children

Graph 32. Old and new PF acceptants

Graph 33. Voluntary screening for HIV/AIDS

Graph 34. New cases under antiretrovirals

Graph 35. Evolution of the average national score

Graph 36. Analysis of quarterly average scores of the technical quality of hospitals in the 2nd quarter of 2010 and the 1st quarter of 2011

Graph 37. Analysis of differences between the scores of the technical quality of hospitals

Graph 38. Score assessments of technical quality of hospitals by level of seniority of the PBF provinces

Graph 39. Analysis of quarterly average scores of the technical quality of the CDSs

Graph 40. Average scores of perceived quality of the CDSs

Graph 41. Mean scores regarding technical quality, perceived and general of the CDSs

Graph 42. Annual growth scores of technical and perceived quality of the CDSs

Graph 43. Differences of technical quality scores of the CDSs

Graph 44. Average technical quality evaluation scores of the CDSs

Graph 45. Average score of the FOSAs during the technical quality evaluations by province (3 quarters of 2010)

Graph 46. Evolution of the average performance score of BDS by province

List of Tables

Tableau 2. People trained in PBF

Table 3. The accompanying NGOs and their provinces of support

Table 4. Drawing the four rounds of cross verification

Table 5. Recommandations made by the joint evaluation mission, 2010

Table 6. Average monthly premiums of the District Hospitals

Tableau 7. Primes mensuelles moyennes au niveau des Centres de Santé

Table 8. Analysis of the average monthly financial incentive in USD for health personnel in comparison with the average monthly salary in the early career category of staff

1. INTRODUCTION
2. History of the PBF in Burundi

The General Assembly of Health held in 2004 showed that the health sector in Burundi is facing a high burden of neonatal, infant and maternal morbidity and mortality as well as a resurgence of communicable and non-communicable diseases. Moreover, the performance of the health system is weak. This has led to a low quality of services and care provided to the population and is an obstacle to achieving the health-related MDGs by 2015.

To cope with these constraints, the Ministry of Public Health has developed a National Health Development Plan (PNDS) 2006-2010 which focuses on the fight against the disease and strengthens the performance of the national health care system with the aim of accelerating the achievement of the MDGs. In addition, the main objectives of the NHDP are included in the Strategic Framework for Economic recovery and the fight against poverty (SFFP).

Recognizing that the fight against the disease and the achievement of the MDGs could not be done without a functioning health system, the PNDS has adopted strategies including the decentralization of the health system with the establishment of health districts and the use of contracting in the health sector.

In 2006, the Ministry of Public Health developed a National Contracting Policy which serves as reference for establishing contractual arrangements between all actors in the health system, knowing that the State remains the guarantor of the process of contracting in the health sector being the primary responsible of public service. One of the contracting options is the performance-based health financing (PBF).

In 2006, the Ministry of Public Health of Burundi adopted its National Contracting Policy with the approach of performance-based financing (PBF) as one of the strategic pillars of health development. The same year, the Government of Burundi declared free delivery and curative care for children under five.

Performance-based financing pilot projects were implemented in three provinces from 2006 on, and the positive results of these led the Ministry of Health in 2009 to extend this approach to 9 of the 17 provinces in Burundi.

Cordaid and Health Net TPO have been accompanying PBF from the start by initiating pilot projects in different provinces starting in Bubanza, Cankuzo and the health District of Kibuye in the Gitega province. The implementation of the perfomance-based financing approach by Cordaid in the provinces of Bubanza and Cankuzo began in November 2006 with funding from the Dutch Government (DGIS).

Since January 2008, the operation has been pursued in Bubanza and been co-financed by the EU and Cordaid for a period of two years (end of 2009). At the same time, PBF implementation activities were performed for one year thanks to Cordaid funding (2008), before that province was integrated in the Health Plus (santé plus) project. This project started in January 2009 for a period of two years and additionally covers the provinces of Ruyigi, Rutana and Karuzi.

In 2008, with ECHO funding, the implementation of the contractual approach began in the Health District of Rumonge in Bururi province and in the Nyanza-lac of Makamba province. With ECHO funding, the intervention was extended to cover the Health District Rumonge for the whole 2009.

From September 2009 on, the two districts of Bururi and Matana are covered through GAVI-HSS funding. The GAVI-HSS intervention was extended to incorporateHealth District of Rumonge, covering the whole province of Bururi up until December 2010.

For the province of Makamba, Cordaid implemented the PBF with funding from the EU / Cordaid for the period of 2009-2010.

The significant results of the pilot experiences measured through a household survey and a Cordaid quality of care surveyin 2008, led the MSPLS to consider scaling them up from April 2010. However, these pilots, although based on the same principles,were implemented by different NGOs with different institutional arrangements, a variable care package to sign contracts for and variable bonuses for performance in the provinces.

Within the framework of reimbursement of medical free treatment by the Government, several problems including the delay of repayment of care structures, the overcharging of medical procedures, the intense workload of health personnel and the lack of drugs and equipment caused problems and prevented an optimal implementation of this measure. To cope with these difficulties, the MSPLS opted to fund the free healthcare package through a system of funding based on production of improved quality care. In addition, for efficient implementation of the policy of free health care for pregnant women and children under five years, the MSPLS decided to finance this free package through the PBF strategy.

The Ministry of Public Health and Fight Against AIDS, the Ministry of Finance and the technical and financial partners made a strategic agreement in March 2009 to capture the synergies between these two approaches and adopted the idea of merging the two strategies.

By funding, projects, technical assistance or participation in technical meetings, many technical and financial partners showed their support for these two strategic options.

It is in the context of a harmonized implementation of the PBFand reimbursement of the free care package at the national level that the MSPLS developed a procedural manual which is a reference tool for PBF. This manual describes in detail how the purchase will be completed as well as the financing of services, control, verification, counter verification, validation, and delivery of health care services and community participation in the entire process.

The table below describes the evolution of PBF initiatives in different provinces and before the up-scaling process which started on 01/04/2011.

Table 1: Evolution of PBF initiatives before scaling-up

N° / Province / District / PBF Partner / Time period of PBF support intervention
Start / Expected end
Bubanza / Bubanza / Cordaid / 2006 / 2011
Mpanda / Cordaid / 2006 / 2011
Bujumbura Town Hall / Bujumbura Nord / NON PBF
Bujumbura Centre
Bujumbura South
Bujumbura Rural / Isale
Kabezi
Ijenda
Bururi / Bururi / Cordaid/Gavi/Santé plus / Sept.2009- / June 2011
Rumonge / Cordaid/Gavi/Santé plus / 2008- / June 2011
Matana / Cordaid/Gavi/Santé plus / Sept.2009- / June 2011
Cankuzo / Cankuzo / Cordaid / Nov.2007-2008/Jan.2009- / June 2011
Murore / Cordaid / Nov.2007-2008/Jan. / June 2011
Cibitoke / Cibitoke / Italian Cooperation / March 2009 / 2011
Mabayi / Italian Cooperation / March 2009 / 2011
Gitega / Gitega / TPO-Gavi / Oct.2009 / 2010
Kibuye / TPO / Nov.2006 / 2010
Mutaho / TPO-Gavi / Oct.2009 / 2010
Ryansoro / TPO / Feb.2009 / 2010
Karuzi / Buhiga / Cordaid-santé plus / Jan.2009 / June 2011
Nyabikere / Cordaid-santé plus / Jan.2009 / June 2011
Kayanza / Kayanza / NON PBF
Musema
Gahombo
Kirundo / Kirundo
Mukenke
Vumbi
Busoni
Makamba / Makamba / Cordaid-santé plus / 2009
Dec 2010 / Jan 2011-June 2011 (Santé Plus)
Nyanza Lac / Cordaid / 2009
Dec 2010 / Jan 2011
June 2011 (Santé Plus)
Muramvya / Muramvya / NON PBF
Kiganda
Muyinga / Muyinga
Giteranyi
Gashoho
Mwaro / Kibumbu
Fota
Ngozi / Ngozi / Swiss Cooperation / 2008 / 2012 (risk of disengagement)
Kiremba / Swiss Cooperation / 2008 / 2012 (risk of disengagement)
Buye / Swiss Cooperation / 2008 / 2012 (risk of disengagement))
Rutana / Rutana / Cordaid-santé plus / Oct.2008 / June 2010
Gihofi / Cordaid-santé plus / Oct.2008 / June 2010
Ruyigi / Ruyigi / Cordaid/Santé plus / 2009 / June 2011
Kinyinya / Cordaid/Santé plus / 2009 / June 2011
Butezi / Cordaid/Santé plus / 2009 / June 2011

It should be noted that most of the support has been extended beyond 2011 except those provinces supported by Cordaid whose projects ended in June 2011. Support for these provinces should continue through the Amagara Meza project funded by the European Commission. It is expected to start in the last quarter of 2011.

1.1.Geographical distributionof PBFbefore the scaling-up

Beforescaling-up, PBFsupportswasdistributed as follows

• 9 out of 17health provinces(52.9%) were receivingsupport froman external PBF partner;
• 8 out of health17 provinces(47%)did not havethe supportof an external PBFpartner. Among them,two(Cibitoke andKirundo) have subsequentlybeen supportedrespectivelybythe Italian Cooperation andthe Belgian Technical Cooperation;
• 22 healthdistricts out of 45(48.9%) did not havesupportfroman external PBF partner. Among them, 6 (Cibitoke Mabayi, Kirundo, Busoni,andMukenkeVumbi) have subsequentlybeen supported bydifferentTFPPBF;
• 2 healthprovinces, the province ofBubanza(Districts Bubanza andMpanda) and the province of Ngozi(health districts NgoziBuyeandKiremba) faced therisk of ending support of external PBFpartners(Cordaid Bubanzaand the SwissCooperationfor Ngozi) following thecompletion of their projects.Bubanzareceived an extensionuntil June2011 andin Ngozi, only the fundingof regulatory bodiesandverification activitiescontinued.

It should be notedthat the financingof the ItalianCooperation inCibitokedid notcontinuewiththe introduction of thenationwideimplementationof the strategy,due tosome donor conditionalitywhichappeared to conflictwiththe fundamental principles ofPBF. It wasagreed to divert these funds toother activities inthe sameprovince including therehabilitation and equippingof health facilities, support for regulatory bodiesandverification activities.

1.2.Report objectives

This report describesthe implementationof PBFin Burundibetween April 1, 2010(start dateofnationallyscaling up)and March 31, 2011.

Itcovers boththe technical aspects ofimplementation and the results by presenting various stakeholdersin the system,the lessons learned fromthe implementationin terms of strengths, weaknesses, opportunities to capitalizeand / orthreats to avoid.

Itis thereforenota simplereportingof the findingsoractivities, buta thorough analysisof the approachas itwas carried out to theinduced changes inthehealth system inBurundi. PBFhascontributed to the achievementof these results andto improve thehealth care systembut these results areof courseto be interpretedin context.They werealsopossible thanks tootherreformssuch asthe establishmentof health districts, improving health coverageandhealth care provisionin terms ofinfrastructure and equipment, the development of a reference and counter-reference between health centers anddistrict hospitals, reform of the drug procurementsystemandother inputs.

1.3.Rationale and purpose of this report

After thefirst 12 months ofimplementationof the strategy ofPBF, it is a good moment to preparea reportthat provides information onthe first steps ofthelifeof the saidstrategy.

Thisfirstreport servesas a reference forsimilar exercisesin thefuturesincethis type ofperiodicreportingon an annual basiswillbe systematicallyrigorousto adequately and progressivelydocument the evolutionof the approach.

Moreover,recommendations to bemadeto correctthedeficienciesand to capitalize onthe strengthsgenerated by the systemarelikely toserve as a guidefor those involved inimplementationintheir efforts to improvetheir mode ofaction.