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Gambia Debriefing Presentation

Presentation Outline

  • 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

Policy Dialoguing

  • 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
  • Future:
    • 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

Existing Gaps


  • What is the criteria used in awarding best performing facilities?
  • Clinical audits: who audits the clinic? What is audited? How often?

Materials/Documents Required:

  • 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.

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