REPUBLIQUE DU BENIN Fraternit Justice Travail MINISTERE DE

REPUBLIQUE DU BENIN ------Fraternité- Justice- Travail ------MINISTERE DE LA SANTE Performance-Based Financing in Benin: status and perspectives Workshop « West-Africa» organised by Performance-Based Financing Community of Practice Sénégal 18 th and 19 th March 2011 Alphonse AKPAMOLI, focal point Bénin Maud JUQUOIS, World Bank

Country specific constraints p Benin context: political stability for nearly 20 years p Health sector context n n Inputs globaly adequate (geographical accessibility and availability of health workers). No major cultural barrier to access health services: rate of assited delivery high (80% in 2006, DHS) Availability of drugs and equipment remains insufficient and high prices. Neonatal and maternal mortalities (MM: 397/1000 in 2006) decrease slowly Weak quality of care seems to be the main barrier 2

Human Resources for Health environment p Revenues of health workers seems low in Benin, even if it’s possible that bonuses compensate this situation and that salary structure is adequate. p Bonuses scheme is not linked to performance p Accountability mechanisms of health workers are very weak (lack of governance): absenteeism, corruption, drug pilfering, dual job holding and unresponsiveness to patient needs. 3

Salary at beginning and end of carrier in 4 countries Source: séminaire RHS de Cotonou (2008) 4

How to improve efficiency, accountability and governance? p Solutions to improve health system performance: n Give more power to patients/clients n Strengthen health workers motivation n Increase revenues and autonomy of health facilities

Benin contracting experience: are they payment for results? p Three experiences: n Performance contracts with 3 health districts (Banikoara, Aplahoué, sakété): Agreement on PTA and commitment from Mo. H to pay some expenditures and train actors on results p Problems to tranfer the funds and actors’ motivation p n Experience with Ménontin: Public-private partnership, p But not result-based payments. p n Ongoing experience in health district of Come (CTB)

RBF pilot scheme: main features Supply strengthen with focus on quality and utilization (equity) of health services (specifically maternal and child services) n With a community component for monitoring n Capacity building with international expertise, with an independent control role n Implement the reform in 8 pilot health districts (out 34), WB grant. n 7

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Benin RBF pilot scheme (1/5) • To continue contracting experience with health districts: p p Contracts between Mo. H and HF in the 8 pilot health districts : all public and private not for profit HF, health centres and hospitals. Fees for health services (18 indicators) focused on maternal and child health , and quality adjustment (checklist), quaterly payments • RBF unit to pilot the process inside Mo. H • International Technical Assistance for training and data control with capacity transfer, and 1 technical assistant in each RBF health district.

Benin RBF pilot scheme(2/5) A propice environment for Result-based management : • An increased autonomy for stakeholders: facilities (CSA, HZ, CHD) free to buy drugs and small equipments • An appropriate flow of funds • An intense communication with health staff and population

Benin RBF pilot scheme (3/5) Control and verification mechanisms: Measurement When ? Quantitative indicators (18) Monthly Qualitative Quaterly indicators (check -lists) Control By who? Health faciliy team When ? By who? Monthly Consistency check : EEZS and “district controller” Quaterly Verification : community based organizations. For HC : EEZS and Every 6 months « district controller » (random sample and For hospitals : peer unannounced visits) review and « district controller » Verification: Community based organizations and « district controllers »

Benin RBF pilot scheme(4/5) ACTIVITES ACTIVITÉS TRIMESTRIELL ES 6. Allocation du crédit FBR 5. Paiement du ACTIVITE SEMESTRIELLE crédit FBR 4. 7. Dépenses sur Détermination le crédit FBR 8. Contrevérification qualité du montant du ACTIVITES ANNUELLES crédit FBR 9. Audit 3. Mesure et comptable des vérification des dépenses FBR résultats FBR 1. Négociation 2. du contrat FBR Communication sur les contrats FBR 12

Benin RBF pilot scheme (5/5) Motivating rewards • Significant amount p p • around 200 millions FCFA (3. 8 Mio. USD) by district by year Depending on results Some freedom to use RBF credit, but without creating individualism p p A part of the credit is for staff incentives, the other part to buy small equipments, drugs, IEC activities… Staff bonus is proportional to the worker index (with a weighting in favor of small salaries)

Impact evaluation of RBF Benin pilot scheme p p p Research questions: RBF or additional budget unconditionned with results? Importance of health facilities’ management autonomy Thus, two interventions in cross-design: n 4 groups of HF(T 1 -2 -3 et C 1) and an additional control group(C 2), without additional budget. n Identification in the 8 districts, with random allocation of facilities between the 4 groups Baseline survey : health facility survey, staff survey, households survey, with diversified tools. 14

Impact Evaluation Design ADDITIONAL FUNDING FOR HEALTH FACILITIES ? YES CONDITIONAL ON RESULTS (RBF) MANAGEMENT AUTONOMY FOR HEALTH FACILITIES ? (500 HH and 50 HF) T 3 NO NO T 2 T 1 YES BUT NOT CONDITIONAL ON RESULTS (500 HH and 50 HF) 15 C 1 C 2 (500 HH and 50 HF)

Project Causal chain 16

Implementation agenda/Work plan p Impact Evaluation: n Baseline survey: Dec 2010 -Mach 2011 Questionnaires tested p Surveyors trained (began 1 st Nov) p n n n p Follow-up survey No. 1: Oct-Dec 2011 Follow-up survey No. 2: Oct-Dec 2012 Cost effectiveness analysis (2011) RBF Program : n n Effectiveness : Launch: 31 March 2011 April 2011 17

RBF Perspectives in Benin p RBF Norway and World Bank(4 years ) n n p World Bank: 7 millions USD Technical partnership p p Norway: 11 millions USD World Bank(8 ZS), CTB (5 ZS), 4 ZS with GAVI and 17 ZS with GF, so 34 ZS/34 ZS covered with experience sharing (tools et results) World Bank and UNICEF: traning support, drugs and equipements (Agreement letter between partners) Complement with other partners (GAVI, GF) Benin State

Questions p Technical sustainability: How can it be effectively ensured through knowledge transfer activities (transfer with progressive reduction of TA)? p Could RBF Financial sustainability be reached when donors will stop their support? (RBF cost will be US$1. 3/hab; for the government, it would represent 10. 1% health budget) p How to ensure effective monitoring with a local NGO? 19

Ensemble nos pays, avec la communauté internationale, le rêve sera une réalité