MODEL "GENERIC" PERFORMANCE FRAMEWORK for
Performance/Results Based Funding (P/RBF)
At Health Facilitylevel
Between the District Assembly, the CSO and the health staff of the Health Facility

Region:……..
District: ….. ...
Sub-District: ……...
Health Facility(Health Centre or DistrictHospital) of......

The following performance contract is stipulated between:

A. The District Assembly...... of...... , represented by its Coordinating Director

And

B. The Health staff of the Health Facility –hereafter called the Provider, represented by the facility manager,

And

C. TheDistrict Health Management Team – hereafter called the Regulator, represented by its district health director

And

D. TheCivil Society Organisation – hereafter called “CSO” represented by the responsible of its representation at district level

And

E. the District Mutual Health Insurance Scheme (DMHIS), represented by its Scheme Manager

PURPOSE OF CONTRACT: This contract covers the procedures and obligations of the two parties for results-based payments of health services to be provided by the Health Facility of ...... and listed in the article Part C of this contract.

This Performance Framework will be subject to an annual review.

PART A: GENERAL CONSIDERATIONS
Article 1: Performance Based Financing (PBF)

The contractual approach (CA) and its variant" Performance Based Financing” (PBF) aims to increase the performance of the Providers in terms of quantity and quality of care in to the populations living in its coverage area.

The objectives of the contractual approach are:
- Make health care financially and geographically accessible
- Provide people with good quality health care
- Involve the community in managing health care to ensure that health services are better responsive to people's needs
- Make health care more efficient and more equitable
Thestrategy of Performance Based Financing is consistent with the national strategic framework for growth and poverty reduction and the strategies in the health sector policy.

This strategy is consistent with the initiatives and the willingness of municipal authorities ...to make health care more accessible to the population and improve quality through the transparent and equitable utilization of available resources.

Article 2: Role and tasks of the stakeholders and their commitments

In General, the institutional set-up:

The stakeholders and organizations are:
- The health team of the Health Facility (HF), the “Provider” of quality care
- The District Assembly (DA) as the "purchaser" of quality care: it will (i) sign the quarterly contracts, (ii) allow the fund-holder to pay the Provider for the results to after verification;
- The District Health Management Team (DHMT), supported by the Regional Health Directorate (RHD), is the "regulator" whose tasks it is to (i) monitoring compliance to national norms, standards and policies and (ii) coach facilities in conceiving strategies to attain better results; (iii) train the Provider if needed to attain better results;
- The Civil Society Organization (CSO), will be responsible for (i) support the DA in priority setting between health results and holding Providers to account on results; (ii) verify of results concerning quality of care in the Health Facility; (iii) (counter-) verify results at household level;

- the District Mutual Health Insurance Scheme (DMHIS), will be (i) the Fund Holder, and will pay for results after the purchaser has given the order; (ii) verify quantitative results comparing report with facility registers;

- The Health Committeeof the District Assembly, which involves representatives of the District Assembly, the DHMT, DMHIS, and CSO has an oversight role and of arbitrage in case of conflicts between the contracting partners

More specific, for each contracting partner:

Contracting Party A: The Provider
The servicesProviderwill be held to account on producing results – hereto it will:

• The strategies for progressively achieving the targets of the MDG 4,5 and of the MPA (Minimal Package of Activities) are presented in a quarterly "results based plan" which precedes and accompanies this performance framework contract. The medical staff develops this "results based plan" based on (i) the national directives/guidelines for health, (ii) the results of technical analysis of the local health situation and (iii) the priorities expressed by the purchaser, the CSO based on their analysis of the health situation; (iv) the opportunities it identified to overcome bottlenecks to improve results.

• The Provideris committed to providing the minimum package of activities in accordance with the standards, providing quality health care to the entire population of the health area.

• TheProvidermust develop the necessary reports (SIEC,quarterly and annual reports) using data from the M/HIS (National Management/ Health Information System, like CHIMS)

• Utilization of RBF payments based on the audited results will be decided upon between the contracting partners and it will described in the contract which part will be used to finance the facility’s investments and operating costs and which part will be used as results-based payment of the facility team. The breakdown is proposed in the results-based plan.
Contracting Party B: The District Assembly(DA)
The DA commits to quarterly“purchase” results delivered by the Provider(see Article X) according to the following commitments:

For the last quarter
• Approve the reports of the Provider on the basis of the obtained and verified results;
• Pay the PBF motivations as agreed in the contract with the Provider

For the coming next quarter:
• Analyse the results reported by the provider in order to establish, together with the CSO,the priority health results to be achieved during the next quarter;
• Communicate in written its health priorities to the Provider to enable it developing its results-based plan;
• Negotiatenext quarter’s results with the Providers, based on their results-based plan
• Co-sign the performance contract with the Provider
• Prepare the contracts for verification of the Provider’s results with the DMHIS (quantity at facility level) and the CSO (quality of care at facility level) and counter-verification at household-level

Contracting Party C: the CSO
The CSO will support the District Assembly in its role of Purchaser, and will be contracted to verify results as reported by the Provider.The CSO are the DA results negotiating instance. As such, it will:

(i)support to the purchaser

• Support the District Assembly in analyzing health data of the SIEC and in establishing the priority health results to be achieved with the DA;
• Communicate established health priorities to the Provider before developing their results-based plan;
• Based on the Provider’s results-based plan, the CSO prepare contract negotiations on behalf of the District Assembly;
• Facilitate, once a year, adopting of the Provider’s annual summary report by the Coordinating Directors office of the District Assembly;
• Facilitate defining the distribution of results-based payments between the Provider’s personnel in accordance with the agreed repartition in the contract;
• Hold the provider to account on proper management and use of resources deriving from the PBF payments and its accordance with the norms and procedures, and as stipulated in the contracts.

(ii)Support the Provider

•The CSO may contribute to developing the results-based plan, ensuring the inclusion of the DA priorities in this plan, and taking into account the contractual obligations of the parties as agreed in this Performance Framework;

(iii)Verification of results as reported by the Provider

•the CSO will participate in the DMHIS’ verification of quantitative results in the facility;
•the CSO will carry out the verification of the quality of care according to the RBF scoring list;
•the CSO will carry out the counter-verification of the quantitative results at household level;

Contracting partner D. the fund-holder: the DMHIS

The DMHIS will have two major roles to play: it will be the local fund-holder for all funds related to results-based payments – as such, it is an implementing agency of the DA. Secondly, it has a role in the verification of the results that were reported by the provider.

(i)the local fund-holder:

• The DMHIS will receive RBF funds from NHIA Head Office – which will “front-load” the DMHIS to ensure timely payments;
• The DMHIS will pay the Provider quarterly according to the prices per results as stipulated in the related contract, immediately after receiving the positive decision made by the purchaser;
• The DMHIS will take care of the book-keeping and administration of all results-based payments on behalf of the Purchaser;

(ii)verification of results:

•The DMHIS will verify the results as reported by the Provider at facility level by comparing these with the corresponding data in the Facility’s registers;
•The DMHIS will participate in verifying the results in terms of quality of care, according to the RBF scoring list, performed by the CSO;

Regulator: The District Health Management Team (DHMT)
Regulation is assured by the representative of the Ministry of Health at the operational level, the District Health Management Team (DHMT).Regulation consists of

(i)supervising if the provider respects the national policies, norms and standards (like quality of care assurance);

(ii)bringing the contracting parties to respect their commitments under the contractual terms agreed in the CA/PBF;

(iii)to coach and to support the "provider", during supervision and on the job training,in its attempts to realize a better performance.

The District Assembly will sign another performance-based contract with the DHMT to ensure supervision takes place, according to well specified criteria and results verification.

The Steering Committee: The District Assembly’s Health Committee
In the steering committee the four main actors of this Performance Framework participate: the District Assembly, the CSO, the Facility managers, the DHMT and the DMHIS, and regional level representatives such as the Regional Health Directorate (RHD, chair) and the Regional Office of the NHIA.The Health Committee is the consultative body having the ability ofa priori determining the strategic outline and at posteriorisolving any disputes between the contracting parties.

(i)Outlining a priorithe contracts of the different facilities

• on an annual base, defining the strategic outline of all contracts to be signed with the different providers;
• on an annual base, defining the strategic outline of all contracts to be signed with the different providers;
• validate the methodology of verification to be implemented by DMHIS and CSO.

(ii)Oversight at posteriori of implanting the contracts

• solving any disputes between the contracting parties if they would arise and can’t be solved between them;
• monitoring process by ensuring the administrative and legal aspects of the contract;
• Assess the advancing status of the CA / PBF in the Communes by analyzing the results from the monitoring system, the verification, and the supervision
• monitoring that supervision activities of ECDS are correctly and timely performed;
• Organize at convened deadlines, meetings and their minutes
• Consider misunderstandings: It is also a platform that offers the opportunity to complain and solve problems.

Part B: The P/RBF management cycle

Article 3: the P/RBF process:

InformationThe process starts by between the contracting parties analyzingthe health data from the SIEC based on the H/MISto set priorities to be achieved in health. Based on this analysis the District Assemblyand the CSO communicate their priorities to the Provider for developing the results-based plan.
The Results-based Plan This is in P/RBF programs elsewhere known as the ‘business plan”.The Provider defines its results-based plan on (i) the national guidelines for health, (ii) the results of its technical analysis of the local health situation, (iii) the priorities expressed by the District Assemblyand the CSO, and (iv) opportunities they identified to overcome bottlenecks at the demand-side. The DHMT will support the Provider at least once a quarter in reviewing the last results-plan and in developing the new one.
NegotiationNegotiating the performance contract takes first place between the Provider and the CSO on behalf of the Purchaser to ensure that the plan will respond to the needs and demand of the population,on the basis of the results-based plan. The District Assemblywill finalizethe negotiation before signing the contract.
Signing thecontractEach quarter the contract willbe signedbetween the Purchaser and the Provider.
The implementation of the contract The Provider will performthe activities based on the strategies outlined in the results-based plan, adopted in the contract. The results will be reported to the Purchaser. The different types of verification (see Article 4) are then carried out. The District Assembly makes relatedresults payments after verification of the reported results.
Every 3 months the P/RBF process restarts.

Article 4: Reporting

The Health Team sends a signed monthly report (SIEC) which declare the quantitative results of the Provider.
The verification reports (see Article 5) of the DMHIS and the CSO are submitted to the District Assembly with a copy to the ASACO
The supervision reports of the DHMT are forwarded to the District Assembly with a copy to the Health Committee.

The DMHIS provides a quarterly report of P/RBF payments made to the Purchaser

The Provider provides a quarterly report to the Purchaser on payments made with the P/RBF funds received

Article 5: Verification

The Coordinating Director of the District Assembly must be reassured of the validity of results that were reported by the Provider. Hereto, four types of verification of results will be carried out:

A. At least once a quarter, quantitative results will be checkedat Facility level by the NMHIS, supported by the CSO, through the control of registers comparing these with the reported results.

B. At least once a quarter, results in quality care at Provider level will be checkedby the CSO, supported by the DHMIS, using an established standard quality-score grid.

C. Quarterly verificationby independent actors at household level, interviewing individuals who were reported to have benefited from care at the Provider’s level. This is to ascertain whether the health service has actually been offered, while a questionnaire will be used to assess the level of customer satisfaction. This in addition to the population-based impact studies to assess client satisfaction with the services of the Provider.

D. An external audit of expenses incurred in connection with AC/PBF will be conducted annually. The report of this audit will be presented to the contracting partners with a copy to the Steering Committee.

Article 6: Payment of the service delivery

The payment for service delivery is made after the quarterly verification of the Provider’s report mentioned in Article 5 of this contract. The Coordinating Director of the District Assembly will proceed to the payment of premiums under part C of this contract following the favorable results of the verification.The total amount payable is equal to the amount of acts carried out multiplied by the unit cost multiplied by the percentage of quality score achieved. The amount is paid by bank transfer (or by transfer in a microcredit account) carried out by the Local Fund-Holder (DMHIS)on the name of the Provider.

The District Assemblywill notify by letter the Facility Manager of the payment ordered to DMHIS. The DMHIS will notify the Facility Manager of the amounts paid to the Facility’s bank account. To this notification letter of payment shall be attached, a copy of the payment invoice established on the basis of verified performance and a copy of the quarterly report.

Following the transfer of money in their account, the Facility Manager must confirm reception of funds to the District Assemblywith a letter stating the date and exact amount credited to his account.

The Facility manager transfers, according to management procedures stipulated in the contract, the amounts due to the Facility team, and signs all expenditures made on P/RBF payments. The Facility Manager will specify the amount transferred and the amounts for different categories of expenditure.
Article 7: Deadlines

The Facility Manager presents theresults-based plan to the District Assemblyand the CSO during the period starting from the last ten days of the current quarter until the sixth day of the first month of next quarter.

The signing of the contract between the actors concerned takes place on the same day after adoptingthe results-based plan.

The Provider must submit its report on P/RBF results no later than the 05th of each following month, which will be signed by the secretariat of theDistrict Assembly immediately after reception of the report.

Upon receipt of the report, the Coordinator Director’s office has two weeks to conduct the verification (see Article 5)

Payment will be made within seven days after presenting the verification report (See Article 4).

In return the other party (Provider) must acknowledge receipt of the funds within a period not exceeding a week.