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Discussion The results from the comparisons between RBF and non-RBF districts reveal a rising trend in utilization services in RBF districts. For some MNCH services (deliveries, ANC, high-risk perinatal referrals and growth monitoring) these trends are statistically significant. In the RBF districts, the reliability of HMIS data and quality of care increased since the introduction of RBF. The study also points at externalities that influence behaviour of health service providers. Utilization figures for OPD, syphilis RPR test and IPT2 show a positive trend before the intervention in both RBF and control districts, while this trend is no longer significant after the intervention. This may for instance be caused by stockouts of drugs and supplies. Literature about the mechanisms through which RBF contributes to better performance is limited. This is also referred to as “the black box of RBF implementation”. 7 It is generally imagined however, that the pecuniary incentives which are earned by providers and are contingent and proportional to their productivity, motivate them to perform better. 8 The qualitative study revealed practices in RBF districts which are not being followed in control districts. In this section, the ways in which these could be contributing to improved performance are discussed. First, because the contracting approach clarifies what is expected of actors in terms of results, 9 the use of RBF contracts stipulating the obligations of the NPA, health facilities, DHEs/PHEs and CBOs has enabled the DHEs/ PHEs to execute their supervisory role by removing role ambiguity and ensures that communities’ opinions are regularly collected through CBOconducted surveys. The relative autonomy enjoyed by health facilities in RBF districts is not a characteristic of governance in non- RBF districts. With active involvement of staff and HCCs, RBF facilities take responsibility for operational planning and implementation. In the non-RBF (control) districts, operational planning was a paper exercise because facilities had no control over the user fees they collected; they relinquished them to the DHE. Due to lack of funding to execute the planned activities, the same plans are submitted every year. Facility staff in RBF districts also have increased (not absolute) autonomy over procurement. So it is likely that they are able to demonstrate allocative efficiency and innovation, by acquiring supplies which are necessary to solve specific operational problems at their particular facilities. Community involvement has always been a strong aspect of the Zimbabwean public health system, premised on the primary health care concept and philosophy. With RBF funds, HCCs have been re-activated and are committed and take ownership of the health services. In addition, the patient satisfaction surveys by CBOs, which were a feature in RBF districts only, gave communities a voice and likely motivated health service providers to take the preoccupations of the community into account in their operational planning. Financial incentives, such as applied in the Zimbabwean RBF project, have been argued to crowd out intrinsic motivation of health workers. However, achievements in the first nine months of the scaled up RBF project in Zimbabwe (March 2012 to December 2012) must be attributed to intrinsic motivation of staff and HCCs since, as alluded to earlier in this paper, personal incentives for frontline health workers in RHCs and district hospitals were only introduced after in 2013. A major contributing element to the success of an RBF intervention concerns the efforts made in relation to training and capacity building. In the first two years of the programme around 10% of the total project budget was invested in training for national level decision makers, district staff and facility staff. Conclusion In general, the RBF programme in rural Zimbabwe has shown positive intermediate results. It has succeeded in the removal of user fees for MNCH services, a finding confirmed through client satisfaction surveys, as well as compensating health institutions for the foregone income. Utilization figures increased in districts which implemented RBF, indicating that accessibility has effectively increased. While the results are inadequate for a conclusion regarding the statistical significance of the overall impact of the RBF project in Zimbabwe, this research found several elements only prevalent in the intervention districts, that may have contributed to the positive results in service utilization and quality improvements in RBF districts since the project commenced. These are: Use of contracts to clarify what is expected of each actor for payments to be made; Community involvement in the provision and planning of health services; Autonomy for primary health care facilities in planning and procurement; and Intrinsic motivation of staff, demonstrated by improved utilization statistics even before personal staff incentives were introduced in the project. p References 1. WHO. Trends in Maternal Mortality: 1990 to 2008. Geneva: World Health Organization 2010. 2. Zimbabwe National Statistical Agency. Poverty and Poverty Datum Line Analysis in Zimbabwe 2011/12. Harare: Zimbabwe National Statistical Agency 2013. 3. Ministry of Health and Child Care. The Health Investment Case. Harare: Ministry of Health and Child Care 2010. 4. Ministry of Health and Child Care. The National Health Strategy 2009–2013. Harare: Ministry of Health and Child Care 2009. 5. Government of Zimbabwe. Zimbabwe Agenda for Sustainable Socio-Economic Transformation Document. Harare: Government of Zimbabwe 2013. 6. Lagarde, M. How to do (or not to do) . . . Assessing the impact of a policy change with routine longitudinal data. Health Policy Plan 2011; 1–8. 7. Torsvik G. Researching PBF: Time to open the black box. 2013 Available from: http://performancebasedfinancing. org/2013/06/02/researching-pbf-time-to-open-theblack-box/ [accessed on 11 June 2015]. 8. Basinga P et al. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: An impact evaluation. Lancet 2011; 377(9775):1421–1428. 9. Eldridge C, Palmer N. Performance-based payment: Some reflections on the discourse, evidence and unanswered questions. Health Policy Plan 2009; 24(1):160–166. 36 <strong>AFRICAN</strong> HEALTH MONITOR • OCTOBER 2015
7 Piloting a performancebased financing scheme in Chad: Early results and lessons learned Joël Arthur Kiendrébéogo, i Olivier Barthès, ii Matthieu Antony, ii Louis Rusa ii Corresponding author: Joël Arthur Kiendrébéogo, e-mail: jarkien@gmail.com SUMMARY—The Ministry of Health of the Republic of Chad decided to introduce a performance-based financing (PBF) strategy as a pilot project in eight districts of rural areas, from October 2011 to May 2013. Based on both qualitative and quantitative data collected during the implementation of the scheme, this study aims to reflect on the early results of the scheme and draw valuable lessons to inform future scaling up of the strategy. Despite some methodological limitations, the results show that overall access to health services and quality of care improved in the period considered, even though some indicators reacted less. These positive results resonate with the findings of our qualitative interviews that highlighted changes in ways of providing care as well as managing health facilities and regulating the health system. However, results vary substantially between regions (north and south) and between facilities. Moreover, the short duration of the project leaves the sustainability of these changes in question. In conclusion, our study stresses the need for evaluations and an evidencebased discussions in order to tailor the design of PBF scheme to the context, and to better inform policy-making decisions on PBF schemes, both at pilot stage and when considering their rollout nationwide. Voir page 71 pour le résumé en version française. Ver a página 71 para o sumário em versão portuguese. Performance-based financing schemes for health facilities have been attracting increasing attention in most sub-Saharan Africa countries and some experts believe that the strategy could serve as an entry point to address several structural weaknesses constraining health systems. 1,2 In October 2011 Chad adopted this strategy as a pilot project for 20 months with the overarching objective to improve uptake and quality of health care. Based on the quantitative data made available by the PBF data verification process and on qualitative data collected specifically, the present study aims to document the experience gained from field implementation in order to present the early results of the scheme and reflect on the drivers of behavioural change within facilities and in the wider health system. This could supply valuable lessons for a possible future PBF scheme in Chad and provide a perspective on scaling up. It could also stimulate critical reflections from stakeholders and be helpful for other countries facing similar challenges. Context From a health and demographic perspective, Chad is a complex and difficult environment. The country’s health indicators are very low, particularly those related to maternal, newborn and child health. According to the Multiple Indicator Cluster Survey (MICS, 2010), 3 under five mortality ratio was 175%, infant mortality ratio 106%, contraceptive prevalence 4.8% and skilled birth attendance 22.7%. Chad’s maternal mortality ratio is one of the worst in the world, at 1 100 per 100 000 live births in 2010. 4 The PBF scheme included four regions (out of 23 in the country) and eight districts (out of 72) with two districts per region. There were a total of nine district hospitals and 102 primary health centres (PHCs). The population covered was estimated at 1 650 000 (Chad’s total population estimate is 11 million). The selection of areas for the project was based on three criteria: 5 Districts where maternal and child health performance indicators were below the national average; The poorest districts, according to national levels of poverty; and Districts where support from donors was less important. Two of the regions were located in the north of the country (Batha and Guéra, with 46 PHCs in total) and two in the south (Mandoul and Tandjilé, with 56 PHCs in total), with completely different characteristics. Population density is higher in the south and health facilities, particularly faith-based ones which are usually credited with better organization and management, are more numerous. By contrast, populations in the north are more scattered and nomadic, spending a good part of the year outside their enumeration area. Moreover, there are geographical accessibility issues with long distances from villages to nearest facilities, with some PHCs being more than 200 km from the district hospital. Low levels of education and sociocultural constraints are also more marked in the north. The project was designed to be consistent with the National Health Policy elaborated for the period 2007–2015, which identified some problems in health-care provision, particularly: low coverage – health facilities in difficult locations, low technical equipment, i Centre MURAZ, Burkina Faso ii Agence Européenne pour le Développement et la Santé (AEDES), ISSUE 20 Brussels, • SPECIAL Belgium ISSUE ON UNIVERSAL HEALTH COVERAGE 37
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