- Policy Dialoguing
- Quality of Care
- Health Management Information System
- Monitoring and Evaluation
- Health Service Delivery
- Financial Management and Procurement Procedures
- Some Observed challenges/gaps
- Existing gaps (Documents/further clarifications)
Objectives of the Study Tour
- The overall aim of the study tour is to understand the operations, challenges, and learn best practices in four major areas:
- PSC functionality, policy dialogue and influencing change in view of the adoption of RBF
- DHIS-2 RBF Database - inclusion of the QoC checklist
- Use of tablets in data collection, verification and reporting - linkages to RBF DHIS2 system
- General Project Data analaysis – data analysis framework
- Results Based Management (RBM) and Results Based Budgeting (RBB) creates an enabling environment for Results Based Financing (RBF)
- Autonomy in health care management and administration is decentralized to the provinces and districts
- Multi-sectorial involvement (NSC) of potential RBF partners to include national and International stakeholders and Provincial Medical Directors (PMD)
- Establishment of NSC sub-committees (with technical persons that are relevant taken on board for task implementation
- Non- inclusion of Permanent Secretaries in the NSC BUT the NSC reports to the PS-MoHCC
- There also exist a steering committee at district level
- A good understanding and ownership of RBF by SMT of MoHCC
- NSC functions:
- Oversee direction of policy formulation and implementation.
- Provide guidance to developing an institutional structure for an independent NPA mechanism based on the principles of Good governance and separation of functions.
- Present is the chairperson, vice chairperson with specific tasks
- Establishment of the Programme Coordination Unit (PCU) to take over Cordaid and Crown Agency functions
- Creation of a basket fund for RBF (Health Development Fund). This has been complimented by a gradual increase of the funds allocated to RBF by the MoF
Quality of Care
- The introduction of Continuous Quality Improvement (CQI).
- QI part of the mentorship program.
- Start small, Think Big (Geographical location and focus on few key indicators)
- Presence of a National Quality Improvement Strategy
- Presence of Quality of Care Pocket Guide
- QI initiative teams available at the facility, district, and provincial
- Display of guidelines and SOPs on the walls and availability of well stock emergency boxes
- Good interaction between health workers and clients
- Awarding best performing facilities: small token of gifts
- Clinical audits are done
- Innovation: use of cool boxes instead of fridges for vaccine storage
- Future: payment of quality of care will be delinked from the quantity so as to give equal weighting
- Use of the ‘carrot and stick’ approach for the quality of care (QoC score is rewarded differently according to category of scores
Data Collection - ODK System
- Use of Tablets/Smart Phones in administering the QoC checklist
- Use of Tablets/Smart Phones in administering the Client Satisfaction Survey
- Use of exit interviews and CCTSS interchangeably (Crown Agents)
- Data collected through ODK using tablets/Smart Phones that feeds into the DHIS2 via ONA for Cordaid and Data Collect for Crown Agent
- Contracting Individuals and not CBO as an institution to conduct the client tracing. The tracer should have a phone and be mobile. Payment is results focused according to number of questionnaires administered.
- Data quality has improved tremendously with the introduction of the tablets
Monitoring and Evaluation
- Integration of the QoC, CCTSS and remoteness bonus payments into DHIS-2
- Combining full, indicator based risk and facility based risk verification
- DHIS-2 system is locked after 6 months giving flexibility for the declared data to be corrected.
- Presence of Performance Based Dashboards at all levels (National, Provincial, District and Facility)
- The use of risk based monitoring for counter verification
- Use of data for decision making (in-depth analysis: weekly/monthly/quarterly report)
- Production of quarterly bulletins by the Local Purchasing Units
- Quarterly data analysis is not static or based on a data analysis plan
- No indicator targets set for hospitals
Health Service Delivery
- High involvement of the HCC in the management and administration of health facilities (community involvement)
- Inclusion of other indicators in the RBF package e.g. HIV , Malaria , TB and NCDs
- Well motivated staff with high sense of team work
- High professionalism and commitment of health cadres (Uniforms)
- Autonomy in operational planning at the facility (development and refurbishment of the facility)
- Incentives wisely invested to improve quality of services (eg. medicines, water supply, nutrition garden)
- PHE does NOT interfere in operational planning. But only supervises. The DHE does the technical guidance and direct supervision.
- Existence of urban payment voucher system
Finance and Procurement
- Operational planning - Plans are always adhered to.
- Pooled procurement at the district level through the DHE to address facility procurement challenges
- Hospitals contribute 10% towards the pool fund at DHE level
Some Observed Challenges/gaps
- Demand side RBF not adequately addressed
- Long queues mentioned by some nurses
- Competing programmes – verticalization
- Incinerators not available in some facilities
- Risk of over-sighting critical actions due to clinicians (nurses) highly involved in administrative work e.g. Financial management
- What is the criteria used in awarding best performing facilities?
- Clinical audits: who audits the clinic? What is audited? How often?
- Quality of Care Pocket Guide
- Cost effectiveness analysis report
- Use of tablets for quantity and quality verifications (Crown Agents). Cordaid is using tablets for quality and NOT quantity verifications. Ministry may need to harmonize this.