Nigeria State Health Investment Project (NSHIP)

Transcription

1 Federal Ministry of Health Ondo, Nasarawa and Adamawa State Ministries of Health National Primary Health Care Development Agency Ondo State Primary Health Care Development Board; Nasarawa and Adamawa State Primary Health Care Development Agencies Nigeria State Health Investment Project (NSHIP) Performance-Based Financing User Manual Final version 14 December 2013 NPHCDA: Plot 681/682 Port Harcourt Crescent, Off Gimbiya Street, Area 11, Garki, Abuja. Tel: , , FMOH: New Federal Secretariat Complex, Phase III, Ahmadu Bello Way, Central Business District, Abuja FCT Nigeria, Tel: , Fax: , PBF portal:

2 TABLE OF CONTENTS TABLE OF FIGURES... 4 TABLE OF TABLES... 5 FOREWORD... 8 BACKGROUND... 9 NSHIP- PBF APPROACH PBF- PRE PILOT EXPERIENCE DEFINITIONS SERVICES AND FEE VALUES Health Service Packages: MPA and CPA Fee setting for services: Determining the Subsidies Household visit Service Protocol Reference Guide The Quality Checklists for Health Facilities The Performance Framework for the Local Government PHC Department Subsidized Care for the Indigents CONTRACTS Contract 1: Multilateral Contract for the LGA RBF Steering Committee Contract 2: Purchase Contract between the SPHCDA and the Health Provider Contract 3: Motivation Contract between the Health Center Management and the Individual Health Worker Contract 4: Contract between the SPHCDA and the LGA PHC Department Contract 5: Sub-Contract between the Health Provider and a Secondary Health Provider PERFORMANCE MANAGEMENT AT THE HEALTH FACILITY Business Plan Version _pbf_usermanual_ng-final Page 2

3 Indice Tool Framework for Individual Performance Evaluation MONITORING AND EVALUATION FRAUD: PREVENTIVE MEASURES AND PENALTIES Possible Fraud Fraud prevention Penalties for Fraud DATABASE PAYMENT CYCLE Rules of Use of the PBF Income Invoices CAPACITY BUILDING COORDINATION ANNEXES Annex 1: Multilateral Contract for the LGA RBF Steering Committee Annex 2: Purchase Contract between the SPHCDA and the Health Provider Annex 3: Motivation Contract between the Health Center Management and the Individual Health Worker Annex 4: Contract between the SPHCDA and the LGA PHC Department Annex 5: Sub-Contract between the Health Provider and a Secondary Health Provider Annex 6: MPA and CPA Annex 7: Service Protocol Reference Guides Minimum Package of Activities Complementary Package of Activities Annex 8: Quarterly Quality Supervisory Checklist for Health Centers Annex 9: Quarterly Quality Supervisory Checklist for General Hospitals Version _pbf_usermanual_ng-final Page 3

4 Annex 10: Monthly Health Facility Invoice Health Center General Hospital Annex 11: Quarterly Consolidated LGA Invoice Annex 12: Performance Framework for the LGA PHC department Annex 13: Business Plan for Health Centers Annex 14: Indice Tool for Health Centers Annex 15: Individual Performance Evaluation Template Annex 16: Column Headers for PBF Registers Annex 17: Terms of Reference for the Health Center Health Committee/General Hospital Governing Board Health Center: General Hospital: Annex 18: Terms of Reference for the Indigent Committee Annex 19: Indicative Indice Values for Health Center Staff Annex 20: Terms of Reference for the Health Center and General Hospital Internal Management Committee TABLE OF FIGURES Figure 1: The Nigeria PBF Administrative Approach Figure 2: Purchaser-Provider Split in the NSHIP-PBF Approach Figure 3: Image of the public frontend of the PBF web-enabled application Version _pbf_usermanual_ng-final Page 4

5 TABLE OF TABLES Table 1: An important note for the reader... 9 Table 2: December 2012 SWOT analysis for the PBF pre-pilot Table 3: An example of the application of a rural hardship weighting Table 4: Changing the weight for content of care Table 5: Weighting for the 15 Health Center Services in the 2014 Quality Checklist Table 6: Weighting for the 15 General Hospital Services in the 2014 Quality Checklist Table 7: Evaluations: ex-ante and ex-post Table 8: Penalties in case of more than 5% (up to 10%) untraceable clients Table 9: Penalties in case of more than 10% untraceable clients Table 10: Penalties in case of more than 10% unexplained discrepant results in quality counterverification of health centers Version _pbf_usermanual_ng-final Page 5

6 ACRONYMS AFB AIDS CPA DFF DLI DOTS DPM DRF EDL EDM FMOH HCWM HMIS HIV HRITF MDG M&E MySQL NAFDAC NSHIP MPA NPHCDA IBRD IC IDA LGA PBF PFMU PIM PBF-TSU PCN Acid Fast Bacillus Acquired Immunodeficiency Syndrome Complementary Package of Activities Decentralized Facility Financing Disbursement Linked Indicator Directly Observed Therapy for Tuberculosis Director of Personnel Management Drug Revolving Fund Essential Drug List Essential Drug Management Federal Ministry of Health Health Care Waste Management Health Management Information System Human Immunodeficiency Virus Health Results Innovation Trust Fund Millennium Development Goal Monitoring and Evaluation My Structured Query Language National Agency for Food and Drug Administration and Control Nigeria State Health Investment Project Minimum Package of Activities National Primary Health Care Development Agency International Bank for Reconstruction and Development Indigent Committee International Development Association Local Government Authority Performance-Based Financing Project Finance Management Unit Project Implementation Manual PBF Technical Support Unit, unit of the SPHCDA Pharmaceutical Council of Nigeria Version _pbf_usermanual_ng-final Page 6

7 PFMU PHC PHP PTB RBF RBF-TA SMOF SMOH SPHCDA SPHCDB SURE-P USD WB Project Financial Management Unit Primary Health Care Hypertext pre-processor Pulmonary Tuberculosis Results-Based Financing Results-Based Financing Technical Assistance Agency; staffing the PBF-TSU State Ministry of Finance State Ministry of Health State Primary Health Care Development Agency State Primary Health Care Development Board (Ondo State) Subsidy Reinvestment & Empowerment Program United States Dollar The World Bank Version _pbf_usermanual_ng-final Page 7

8 FOREWORD [Executive Director NPHCDA] Version _pbf_usermanual_ng-final Page 8

9 BACKGROUND Performance-Based Financing (PBF) for health services has been introduced in many developing countries over the past decade: for instance in Cambodia, Haiti, Afghanistan, Democratic Republic of Congo, Rwanda, Burundi, Cameroun, Central African Republic and Indonesia. 1 The approaches in various contexts differ; but they all aim at increasing the efficiency, effectiveness, quality and equity of health services offered to the population. The PBF approach generates interest from Ministries of Health who are looking for ways to reach the health-related Millennium Development Goals 1, 4, 5 and 6. Reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases are high on the agenda. PBF approaches have been especially successful in improving access to curative services, 2 and increasing the uptake of preventive services such as vaccination in children and pregnant mothers, voluntary counseling and testing for HIV, institutional deliveries and the use of modern family planning methods. While increasing the volume of services, PBF also increased considerably the quality of these services. 3 Table 1: An important note for the reader This is a long manual with a lot of information. We hope that managers and health workers will find it useful. We understand that managers and health workers will have to explain and teach difficult PBF concepts to their colleagues who might be too busy to study all details in this manual. To facilitate their task, we will create a separate executive summary which will attempt to explain in easy language the 10 most important issues from this manual. 1 By the end of 2013, there were over 32 countries planning, designing or implementing such PBF approaches. 2 Especially in areas where there were dysfunctional health services, see for instance: SOETERS, R., PEERENBOOM, P.-B., MUSHAGALUSA, P. & KIMANUKA, C. (2011) Performance Based Health Financing Experiment Improves Care in a Failed State. Health Affairs, 30, , or where there are dysfunctional free health care systems see for instance: MEESSEN, B., SOUCAT, A. & SEKABARAGA, C. (2011) Performancebased financing: just a donor fad or a catalyst towards comprehensive health care reform? Bulletin of the World Health Organization, 89, BASINGA, P., GERTLER, P., BINAGWAHO, A., SOUCAT, A., STURDY, J. & VERMEERSCH, C. (2011) Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. The Lancet, 377, Version _pbf_usermanual_ng-final Page 9

10 Although PBF approaches differ, they tend to have certain elements in common, they: increase managerial autonomy and decision making rights on resources; use non-governmental agencies for a purchaser role and management support; introduce a purchaser-provider split; Enhance monitoring and evaluation and data use; Use a fee-for-service-conditional-on-quality provider payment mechanism; Introduce performance frameworks at various levels of the health administration; Strengthen the community voice by requesting feedback from users and creating new governance mechanisms while strengthening existing ones. PBF usually starts with pilot projects after which scaling up to the national level is attempted. Such has been the case in Rwanda, where successful PBF pilot projects which were started in 2002 covering by 2005 about 40% of the health delivery network, which convinced the Ministry of Health of their effectiveness, after which PBF was scaled up to national level during Burundi was a similar case: pilot projects were started in 2006, expanded to cover 40% of the country by 2009, which were scaled up nationwide in April Conceptually, the Nigeria State PBF approach is a contracting in approach. Government, with technical and financial support from development partners, contracts-in technical assistance to purchase health services from public, and faith based health institutions. An internal market is created in which government purchases services from public, and private non-for profit and private for profit health providers. In this innovative PBF approach, the State Primary Health Care Development Agency (SPHCDA) is the purchaser of services. The SPHCDA contracts-in a technical agency the Results-based Financing Technical Assistance Agency (RBF-TA) - to carry out the purchasing function. The State Ministry of Health (SMOH) is the regulator. The Local Government Authority Primary Health Care Department is contracted to execute the quality supervisory function. The government through the State Ministry of Finance/Project Financial Management Unit (SMOF/PFMU) is the fund holder. This PBF approach allows multiple fund holders to purchase performance: they can be billed their share and pay facilities for performance directly. NSHIP- PBF APPROACH The Nigerian State Health Investment Project (NSHIP) is a USD$171million five-year program which will be implemented in Ondo, Nasarawa and Adamawa States. Of this amount $20M is a grant from the Health Results Innovation Trust Fund (HRITF), in addition to a $1M grant for an impact evaluation. The NSHIP has a 100% Results-Based Financing (RBF) focus. Version _pbf_usermanual_ng-final Page 10

11 Various Results-Based Financing components of this program aim at changing the incentive environment and the accountability and governance mechanisms at State level, at the Local Government Authority level, and at the health facility level. The NSHIP largely consists of the introduction of Performance-Based Financing (PBF) in the three States. This PBF manual details the institutional arrangements for the PBF approach. The operational details for the larger NSHIP can be accessed through the NSHIP Project Implementation Manual (PIM). This PBF manual is an integral part of the PIM. A PBF pre-pilot has been introduced in one select LGA in each State. This was done before scaling up in half of the LGAs in each State. Building local capacity for PBF and to adapt PBF to local realities was its purpose. See the next section for a summary of the experience so far. Rather than being a contracting-out model (an approach in which non-state actors are contracted to provide certain services), the NSHIP- PBF is a hybrid approach with a contracting-in in which contracted-in non-state actors and co-opted civil society strengthen Government services. This PBF approach effectively creates an internal market though which the SPHCDA purchases health services from public, private and faith based organization-managed health facilities. Performance-contracts are writing throughout the system. Performance frameworks exist for the Health Facilities, for the community client surveyors, and for the Local Government Authority (LGA) Health Team. 4 Figure 1 shows the administrative arrangements for PBF. Decentralized governance for PBF is done at the local government level through a formal steering committee. A purchaser-provider split: contracting and verification/counter-verification is done through a specific purchasing unit (with an embedded RBF-TA) from the SPHCDA. The LGA- PHC department verifies the quality at the health centers using a quantified quality checklist. 5 The SPCHDA through its purchasing unit through a defined protocol carries out community client satisfaction surveys. The SPHCDA organizes through a defined protocol regular counter-verifications of the reported quality of health centers and general hospitals. 4 Performance contracting is considered for the NPHCDA PBF-unit, and for the SPHCDA. 5 In Adamawa State the LGA-PHC department is directly managed by the SPHCDA. Version _pbf_usermanual_ng-final Page 11

12 Technical assistance, coordinated through state level extended team mechanisms is systematically provided. The community has a voice through the community client satisfaction surveys. Version _pbf_usermanual_ng-final Page 12

13 Figure 1: The Nigeria PBF Administrative Approach PBF- PRE PILOT EXPERIENCE The PBF pilots were started Dec 1 st, 2011 in three LGAs: Ondo-East LGA in Ondo State; Wamba LGA in Nasarwa State and Fufore LGA in Adamawa State. In June 2011, a two-week intense PBF training was held in Enugu. From June onward, three international PBF consultants were posted in the three LGAs one in each LGA, the tools were designed, fieldtested and adapted, and an intense training was provided towards the end of June 2011 on location in the three States. In December 2012, a review was done of the experience so far, using a SWOT approach see table 1. Version _pbf_usermanual_ng-final Page 13

14 Table 2: December 2012 SWOT analysis for the PBF pre-pilot Strengths Availability of drugs First quarter payment was done BP financing was done Commitment from the health workers (experienced) consultants were present all the time (in the field) Early impressive achievements in two states Community participation (ward health committees; local leaders) Health facility autonomy & fund availability High level political commitment Improved health infrastructure/equipment (due to availability of cash) Intense supervision (part of PBF intervention) Availability of champions in two States Pooling of staff in the intervention health facility (HR interventions) Web-application functional Opportunities Get the message out wider as there are results to be shared UN agencies and development partners would be supportive if they can see how it works Attract more support Engage civil society to strengthen accountability SURE-P program Saving one millions lives program Active media engagement Weaknesses Payment for performance for Q2-3 has not been done in two states, and Q1-3 was never paid in the third state Shortage of qualified staff in some facilities [absence of money led also to difficulties for verification; supervision and coaching] Overstaffing and wrong cadres Relative high salaries Nigerian health workers (and therefore low impact of the incentives through PBF) Administrative weakness (e.g. HRITF and PPF funds available for 1.5 years but not utilized) Absence of champions in one State Institutional structures are not yet established in the States (various steering committees and working groups) Threats Program needs to be scaled-up quickly Entrenched interests (e.g. central procurement of drugs) Centralized control Bottlenecks in disbursements can kill the program Lack of political will Transfer of staff Lack of understanding of PBF principles The pre-pilot PBF program showed remarkable results. Quantity and quality enhancements were quick and significant: The PBF pre-pilot has importantly shown that PBF as a concept works very well in Nigeria. There is room for even better Version _pbf_usermanual_ng-final Page 14

15 performance, and the SWOT analysis in table 1 brings out the lessons learned and some pointers at future system strengthening activities. Some things worked well, and some things less well: Things that worked very well: Introduction of the business plans and the investment units and thereby a rapid increase in quality across the board; Introduction of drug revolving funds (suggested during the training and picked up by all) and transparent pricing mechanisms led to an immediate access to essential reasonably priced drugs; Decentralized purchasing of drugs and medical consumables by health facilities themselves and thereby a rapid availabity of reasonsable quality drugs; Staff motivation and client receptiveness leading to much higher utilization of services by the community and quality of services provided; Counter-verification of the quantity and the quality was done and showed a very high level of correlation with reported results and this finding is important for the credibility of the much enhanced results. Things that worked less well: Fee-exemptions for the indigents were not implemented. The review after one year indicated that program managers were unsure of the post-identification mechanism (they had not implemented it), and did not see the need for it either. Protecting the poorest requires thinking and talking about how we can protect the poorest against high health expenditures, and to test and implement novel approaches that target the poorest. The service new latrine constructed did not take off, and it was stopped. The service impregnated mosquito net sold did not work well as there was interference by nationwide mosquito net distribution campaigns, it was stopped. Monthly and quarterly income-expense statements in the indice tool proved difficult for health facility managers and more effort would need to be put into capacity building and coaching for this essential management tool to ensure a more effective use of this indispensable management tool. Payments were delayed significantly in all three states (over nine months), and although payments were carried out in full eventually, it led to a drop in confidence by the health facilities (and a corresponding drop in results). Regular performance payments are a condition sine qua non of PBF. Areas of future system strengthening include and are not limited to: Version _pbf_usermanual_ng-final Page 15

16 Human resources for health will need radical reform. Whereas the total amount of health staff is probably sufficient, they are wrongly distributed and some lower cadres are in excess. Management of human resources would need to be decentralized to the health facility levels, which should be able to hire the staff they need (only). Demand side barriers to health service utilization need to be tackled to maximize utilization. Targets for such demand-side interventions are: (i) enhanced information campaign on patient rights; (ii) conditional cash transfer program (such as planned through the SURE-P); (iii) transport vouchers for maternal health services; (iv) enhanced output budget which would allow excempting the poorest of the poor to access essential services. Management of health facilities needs strengthening. The introduction of cash management, activity planning through business plans and investment units, individual performance evaluations and formal collaboration with the community has brought out weaknesses (and sometimes unexpected strengths). There is need for interventions such as (i) a professional stream of health facility managers who are selected and trained, and rewarded for their management of inputs and results; (ii) benchmarking of health facility managers; (iii) rewarding managers for good performance and (iv) intense coaching for the application of novel strategies to boost demand and supply of health services. The PBF output budget needs increasing. The PBF output budget which is around $2.7 per capita per year is too meager for the Nigerian context. States would do well by planning a higher amount (double to triple the current amount) for this output budget. A higher output budget combined with other reforms most notably comprehensive HRH reforms- would maximize results and Nigeria can afford it. The private-for-profit sector in urban areas needs engaging. Urban areas in the project States, just like in the rest of Nigeria house about half the population. Whereas in rural areas public providers are virtually the only qualified providers, in urban areas there is a booming private sector. The public service delivery network is insufficient to cater for the population in urban areas, and this is why it is important to engage with select private providers in urban areas to offer equitable access to health services for Nigerians. The poorest of the poor need protection. Whereas putting in place a post-identification mechanism has never been done before in Nigeria (but has been done successfully elsewhere) 6, this cannot be an excuse for not doing it. Until the time has come when a civil registration system works well, and a the poorest of the poor are pre-identified so 6 In many small PBF pilots there is experience with applying post-identification mechanisms. Increasingly, such post-identification mechanisms are built into large pilots, some with a specific research component to study its effect such as Burkina Faso and Congo. Version _pbf_usermanual_ng-final Page 16

17 that they can be exempted or charged a lesser fee when using health facilities, other mechanisms to reach the poorest have to be used. A post-identification mechanism is a reasonable method to do just that. DEFINITIONS Definition of PBF: services are purchased through Performance-Based Financing. The transaction is based on a purchase contract. Both service quantity and service qualities are rewarded. Services purchased are of a limited number (which typically are 15-24), while the quality consist of hundreds of data elements. The quality measure, through a quantified quality checklist, or balanced score card leads to a single composite quality value. A working definition of Performance-Based Financing (PBF) was elaborated in 2010 by the community of practitioners and knowledge institutions in the forefront of PBF development 7 : Performance-Based Financing is a health systems approach with an orientation on results defined as quantity and quality of service outputs. This approach entails making health facilities autonomous agencies that work for the benefit of health related goals and their staff. It is also characterized by multiple performance frameworks for the regulatory functions, the performance purchasing agency and community empowerment. Performance-Based Financing applies market forces but seeks to correct market failures to attain health gains. PBF at the same time aims at cost-containment and a sustainable mix of revenues from cost-recovery, government and international contributions. PBF is a flexible approach that continuously seeks to improve through empirical research and rigorous impact evaluations which lead to best practices (see footnote). 8 Definition of Results-Based Financing: Results-Based Financing (RBF) is a term which encompasses the entire family of incentive approaches, both on the supply-side, and on the demand-side. PBF is a sub-set of RBF, and is classified as a specific RBF strategy. 9 7 As discussed on the PBF googlegroups forum, a discussion forum of the African PBF Community of Practice, final consensus working definition as of 17 August PBF draws from micro-economic, systems analysis, public choice and new institutional economics theories. The effectiveness can be enhanced by demand-side interventions such as equity funds; conditional cash transfer programs, vouchers schemes and obligatory community based health insurance programs. Definition discussed and accepted on the African PBF community of practice discussion group, August Musgrove, P. (2010). Financial and Other Rewards for Good Performance or Results: A Guided Tour of Concepts and Terms and a Short Glossary. Washington DC. Version _pbf_usermanual_ng-final Page 17

18 Definition of Decentralized Facility Financing (DFF): in decentralized facility financing or DFF in short, health facilities receive enhanced autonomy and once per quarter lump-sum cash transfer into their health facility bank accounts. All LGAs in the three project states have been randomly assigned to either DFF or PBF. This random assignment is part of an impact evaluation in which the Government of Nigeria is testing the effectiveness of PBF and DFF. The DFF facilities will get on average 50% of the cash that PBF facilities have earned. PBF facilities can use up to 50% of their income for paying performance bonuses, however DFF facilities cannot use their income for performance bonuses, only for spending on items and activities to increase quality or increase service production. DFF facilities will also get at least once per quarter a supervision from the LGA PHC department, where the LGA- PHC department will apply the quality checklist. The score of the quality checklist will not influence the earnings. Based on the results of the impact evaluation, DFF LGAs might transit to become full fledged PBF LGAs. Definition of the Provider: the provider is an institution contracted to supply services. Providers are health centers and general hospitals; public, quasi-public and private. Main PBF contract holders are allowed to sub-contract certain services. Sub-contracted Health providers can be public, private non-for-profit or private-for-profit. Sub-contracting is a strategy that is negotiated between the purchaser and the provider, through the business plan. Definition of the Regulator: the regulator is the State Ministry of Health. The SMOH has multiple levels of regulatory functions related to PBF. First, the SMOH participates in the design and continuous development of the quantified quality checklists: Quality checklists reflect the priority norms of the SMOH (such as for instance adherence to the national waste disposal guidelines); Priority norms are made operational through quality checklists; The regulatory role is made operational through performance contracting of the LGA PHC department by the SPHCDA; Quality supervisory checklists - applied by the local government health teams once per quarter to the PBF health centers - are based on National Health Service deliver norms. Quality checklists contribute to a quality bonus of a maximum of 25% on top of the quantity earnings of health centers. Second, the SMOH is closely involved in the peer-evaluations of the general hospitals; Version _pbf_usermanual_ng-final Page 18

19 General Hospitals are subject to a quality checklist once per quarter, using a transparent peer-review mechanism. Here also, a 25% quality bonus is at stake. Third, the SMOH is part of a tripartite quorum for the LGA RBF Steering Committee meetings: Without SMOH presence such steering committee meetings are unable to validate performance pay for the contracted health facilities. Fourth, the SMOH participates in the extended team mechanism. This is an implementation oriented coordination mechanism. Policy and strategy oriented coordination mechanisms are the State RBF steering committee and the RBF Technical Working Group. The SMOH, in close collaboration with the SPHCDA and partner agencies drafts policy and strategy related to PBF. Fifth, the SMOH s technical collaboration with the State office of the National Agency for Food and Drug Administration and Control (NAFDAC), the State office of the Pharmaceutical Council of Nigeria (PCN) and the SPHCDA on drugs and medical consumables: The State NAFDAC and the State PCN will work closely with the SMOH and the SPHCDA to certify three to four distributors in the State for selling generic drugs to PBF contracted facilities; PBF facilities are contractually obliged - guided by availability and best quality/price - to procure their inputs from one of these certified distributors and to stock generic drugs only; Compliance is checked and rewarded- through quarterly quality reviews; Providers paid through public funds will need good guidance on market prices and relative quality of drugs. Definition of the Purchaser: the Purchaser is the SPHCDA. The SPHCDA deploys verifiers, about 1 to 2 per local government authority. The SPHCDA roles are: Performance contracting of health facilities, both public and private; Negotiating targets and strategies through business plans; Contract management and strategic purchasing; Carrying out monthly or bi-monthly verification on the services produced; Once per quarter, the SPHCDA - through select members from grass root organizationscarries out community client surveys to: a. find out whether the clients have actually received the service (to avoid the phantom patient phenomenon ); Version _pbf_usermanual_ng-final Page 19

20 b. to get feedback from clients on their satisfaction and on their perception of the quality of care; c. Other information such as for instance how much money the clients paid; Assessing whether the local government health department deliverables have been met. This makes the SPHCDA a controller for an internal SMOH function (the correct execution of the regulatory function on behalf of the SMOH); In consultation with other stakeholders get agreement on the content of the service packages; Due diligence on validation procedures of the LGA RBF Steering Committees; Printing the quarterly invoice from the web-application and sending to the PFMU and eventual other fund holders for payment; Coordination and capacity building for PBF; Coaching of health facilities in enhancing performance. Definition of the Separation of Functions: separation of functions is a core concept of PBF. In the Nigerian PBF approach it is: primarily a separation of the purchaser from the provider; secondly, a separation between the regulator and the purchaser; Thirdly, a separation between the purchaser/verifier and the fundholder. An important concept is the purchaser-provider split. The purpose of this split is to avoid or reduce situations of conflict of interest or collusion. The SPHCDA is a para-statal, with its chief executive reporting to the Health Commissioner. A special purchasing unit will be created within the SPHCDA to reinforce this separation of functions. This Performance-Based Financing Technical Support Unit (PBF-TSU) will be staffed by a contracted-in technical assistance agency. The verifiers will be on the PBF-TSU pay-roll, including some key technical support staff. Direct line management of this unit - including several technical and support functions- will be through SPHCDA staff. The entire unit will be under a performance framework. This approach has been applied successfully in the Rwanda and Burundi PBF technical support units. When products/outputs/performance needs to be assessed, and are linked contractually to money, having an independent verifier, and credible checks and balances becomes important. See figure 2 below: Version _pbf_usermanual_ng-final Page 20

21 Figure 2: Purchaser-Provider Split in the NSHIP-PBF Approach Definition of the Purchaser-Provider Split: the purchaser-provider split is a concept which indicates that the purchaser (the SPHCDA) is not providing the services itself. Implicit in this definition is that the provider is not verifying itself but that the provider is verified by the purchaser, or by an agent hired by the purchaser. Description of the role of the Contracts: five contracts are used in the Nigerian PBF approach. These contracts are described in the section contracts and are annexed in full to this manual. Contracts are meant to clarify expected performance and to establish the new rules of PBF. It is vital that all working in PBF understand these contracts to a sufficient extent. Clarity in expected roles, and expected performance and transparency of control procedures and clear communication of results to all will contribute to lowering the risks, and implementation costs of PBF. A strong initial effort in rolling out PBF through well-designed training modules, and continued strong support to local government RBF steering committees, although costly and timeconsuming, will bear fruit in the mid to long term. Version _pbf_usermanual_ng-final Page 21

22 Definition of the Business Plans: 10 business plans in the Nigerian PBF approach are an integral part of the purchase contract between the SPHCDA and the health facility. Business plans are unlike action plans: action plans have a tendency to present overinflated targets which are never met. Business plans on the contrary are carefully negotiated between the SPHCDA and the health facility and are tied to the purchase contract. The health facilities have to indicate how they propose to get from A to B, and what interventions, and physical resources will be used to reach those targets. Definition of Investment Units: investments units, also called quality improvement units, are pre-defined lump sums of money which are part of the business plan approach. Investment units form part of the start-up of the PBF approach, and if necessary, will be used six-monthly during re-negotiations of the business plans. Health facilities, based on an approved business plan, can use their autonomy to implement their strategies using these investment units. SERVICES AND FEE VALUES Performance-Based Financing uses a mix of quantity and quality indicators to define the level of performance of a health institution. Performance frameworks are also applied to the health administration and contain process indicators. For PBF facilities the quantity performance is measured monthly or bi-monthly and the quality performance is measured once per quarter. Each defined service has a unit fee/subsidy and the quality carries a bonus up to 25% of the earnings. We will discuss in turn: 1. Health service packages; 2. Fee setting for services; 3. Quality checklists for health facilities; 4. Performance framework for the LGA health department; 5. The purchase of home visits; 6. Subsidized care for the indigents. Health Service Packages: MPA and CPA The PBF health service packages are carefully designed to respond to health problems facing the Nigerian population. The PBF service packages are based on 14 years of incremental experience gained on purchasing services through PBF. The services chosen have the highest potential to 10 Also called management plans Version _pbf_usermanual_ng-final Page 22

23 contribute to meeting the health related Millennium Development Goals. There are two types of health service packages: 1. Minimum Package of Activities (MPA): for the health center and community level, 2. Complementary Package of Activities (CPA): for the first level referral hospital. The MPA and CPA are listed in annex 6. Each defined service carries a variable unit fee. Fee setting for services: Determining the Subsidies The fees were modeled using a financial risk forecasting method commonly used in PBF projects. 11 Baseline data were drawn from the 2008 Demographic and Health Survey. As the three States have radically different baselines for the same services, the set of fees for each of the three States will differ over time. It is important to note the difference between a PBF fee, and a traditional fee-for-service provider payment mechanism. In PBF systems it is assumed that the costs for the services are already met (human resources; building; equipment and various recurrent expenses for vertical programs). However, these services do not move ; there is low output and a general lack of coverage for important public health services. Therefore in PBF we talk about subsidies. The PBF fee for a new outpatient consultation is not meant to pay for the cost of delivering this consultation. It is a subsidy for this service. Depending on local context, total subsidies for curative care can be around 20-30% of available PBF budget, the rest are subsidies for preventive services. The level of these PBF subsidies can change, depending on certain equity adjustments, local priorities and available budget. These variables are discussed below. The combined subsidies for all services are modeled at $1.8 per capita per year for the MPA and $0.9 per capita per year for the CPA. Within a State, policy makers can decide to allocate a certain equity weighting for local governments. Such weighting can be based on for instance: 1. distance in travel time to the State capital; 2. health worker population density; 3. Relative poverty measure. Such measures can thus lead to the allocation of a slightly higher per capita PBF output budget to certain local governments which are scoring lower on these measures. 11 Fritsche, G., Soeters, R., Meessen, B., Ndizeye, C., Bredenkamp, C., Heteren, van, G. (2014). PBF toolkit, Chapter 4: Setting the unit price and costing. The World Bank, Washington DC Version _pbf_usermanual_ng-final Page 23

24 Within a given local government area, the purchaser can allocate an equity weighting for relative destituteness of a facility ( rural hardship ). Contracted facilities are categorized in five categories 1 5; with a maximum difference in subsidy levels for individual services of 40%. See figure 3 below: the unit fees are illustrative only. The Cat3 column represents the average fee for that LGA. Table 3: An example of the application of a rural hardship weighting An equity calculator has been developed to assist in this calculation. However, the actual fee/subsidy setting will be done through the web-enabled application (the cloud computing see the section on the database). The local government health department will have to assist in categorizing its health facilities in these five categories. The health facility closest to the LGA administrative center would typically be a Category 1 health facility, while the health facility with the longest travel time to the administrative center, the furthest from the main road and some other metrics, would typically fall in a Category 5 category. The idea is that if one health facility is categorized as a Category 5 (+10% fee), that the health planners will have to find another facility to categorize as a Category 1 (-10%). Namely: the average fee for the LGA is the Cat3 column. Version _pbf_usermanual_ng-final Page 24

25 Higher subsidies for services in the most remote and destitute health facility are a way of providing that facility with the means to attract and retain qualified staff, and to compensate it for the higher costs of delivering quality health services in general. Fees/subsidies can be negotiated quarterly, if need be, depending on level of achievement/performance, and locally and communally perceived needs and targets; this requires a process of negotiation between the health facility and the purchaser. Household visit Performance-based financing (PBF) programs have, over the years, tried to engage with community-based activities. The basic purpose of these engagements was social marketing (attracting clients for services); the dissemination and use of Insecticide Treated Bed nets and the construction of Latrines. In rare cases, such engagements have led to innovative attempts to engage community health workers directly or indirectly through PBF approaches (Rwanda; Mali). In Ondo, Nasarawa and Adamawa states, some targeted community activities have also been tried in the PBF pre-pilot LGAs but to not much avail. Paying for distributing bed nets, in a context where large vertical programs already pay for these bed nets, including their distribution, or in a context where Ventilated Pit Latrines are not very common (rural remote Nigeria) such measures do not lead to an outright effect, or lead to perverse effects such as claiming the community based distribution of bed nets for payment. This early Nigerian experience is similar to those of a growing number of countries with such PBF programs, and the consensus is that something else needs to be done at the community level. There is an increasing tendency for mixing Results-based financing approaches which work on both the supply and the demand side. As an example: PBF programs combined with Conditional cash transfer programs (planned for Senegal; Nigeria; Republic of Congo); PBF programs combined with voucher schemes (planned for Yemen). In Cameroun, in the context of a PBF program in Littoral, there is an ongoing experimentation with the purchase of a house hold visit. This intervention is also planned in Burkina Faso and the Republic of Congo. This novel community based intervention is described below. Version _pbf_usermanual_ng-final Page 25

26 The purchase of a house-hold visit 12 In essence, the purchase of a house-hold visit is a demand-generating activity and a public health intervention at the same time. It is a paid visit, by a team of community health workers, or a grassroots organization, of a household, using a protocol. This protocol consists of the following: How does the household dispose of household waste? Do household members regularly wash their hands? What is the family planning status and reproductive choice of women aged in the house hold? Are children exclusively breastfed until 6 months? Is the latrine or toilet available, clean and utilized? Is the house hold using insecticide treated bed nets? Does the household have access to clean water? The process is as follows: 1 st, 2 nd and 3 rd house hold visit, according to protocol, each visit paid separately (in Burkina Faso for $2.40 per visit which in Burkina involves 16% of the total budget for PBF) During the first household visit the baseline situation in the household is reviewed, and recorded in a standard register. The team then discusses with the household on the specific actions to be taken during a 2 month period respectively by the household members, the health center staff and the local administrative authorities. The second household visit will be planned to monitor the actions and recommendations. Some recommendations such as on child vaccinations or family planning are voluntary while others are more binding such as that authorities will insist that the household must have a hygienic toilet or latrine in the house. The medical person may discuss behavioral changes while the person for household hygiene indicators provides more binding recommendations including in extreme cases penalties. If the results during the second household visit are satisfactory, this ends the inspection of that particular household. IF there are still problems during the second household visit, a third visit may be proposed. 12 This information was kindly provided by Dr Robert Soeters Version _pbf_usermanual_ng-final Page 26

27 Service Protocol Reference Guide Service protocol reference guides define further the PBF services and list the primary and secondary data collection tools. They are meant to be used by the health facility, the local government health authority and the purchaser. PBF uses defined primary registers for each service, and also has defined secondary registers. Primary registers are the ones in which the verifiers will be counting the services. Secondary registers are meant for deeper verifications in case of discrepancies, or when there is a counterverification exercise. Signing a purchase contract obliges the health facility contractually to use these defined primary and secondary data collection tools, according to their set formats. The formats for the column headers are listed in annex 16. If the primary and secondary data collection tools are not filled in completely and legibly, then in that case the service concerned will not be remunerated. Each PBF service line has, apart from identifying information and medical data, a column for the mobile phone number. If this column is not filled in- just like any other identifying information - the service provider will not get paid for that service. Clients will provide their personal mobile phone number and in case they do not have such, a number of a neighbor, a family member who lives close, or the village chief. 13 In the rare instance in which clients cannot provide a mobile phone number, they will have to sign next to the mobile phone column header. The service protocol reference guides can be found in annex 7. The Quality Checklists for Health Facilities The quality checklists for health facilities consist of a checklist for the health center, and a different one for the General hospital. These checklists have been developed from existing checklists in successful PBF projects, and adapted to the Nigerian context. The purpose of these checklists is to guide the health facility in delivering services according to prevailing norms. The focus of these checklists is predominantly on structural quality, although clinical processes (rational drug prescribing patterns and adherence to defined treatment protocols) are also measured and rewarded. 13 In Wamba LGA in Nasarawa State, the LGA decided to enumerate all households in the LGA. The household number was then used in case the client did not have a mobile phone number. Version _pbf_usermanual_ng-final Page 27

28 These checklists attempt to be as objectively verifiable as possible. Different people measuring the same thing ought to lead to the same scores. The health center quality checklist will be applied by the local government health authority once per quarter to each contracted facility. The local government health authority will be under a performance contract to carry out this important function timely and correctly. The local government authority PHC department performance framework can be found in annex 12. There will be a third-party counter-verification mechanism set up for this quality checklist: through a defined protocol, the scores provided by the local government authority will be counter-verified. The health center quality checklist can be found in annex 8. The General hospital will also be subjected to a quality checklist, once per quarter. A peerevaluation mechanism will be set up, whereby key technical and administrative staff from other hospitals, with representatives from the SMOH, SPHCDA and civil society, will peer-evaluate each other s performance. Also, a transparent counter-verification mechanism will be set-up. The General hospital quality checklist can be found in annex 9. Quality has various dimensions, and the PBF checklists can only measure some dimensions. Lessons from other PBF projects point at the importance of regular typically once per year - review of the quality checklists. New norms and guidelines can thus be incorporated as they come available. Feedback from the end users can inform the design. The quality bar can be put progressively higher. Table 4: Changing the weight for content of care The quality checklists have been modified since the 2011 pre-pilot experience and the revised checklists are included in this manual. The checklists have been changed to put a significantly larger weighting on actual content of care. Indicators that directly measure content of care, such as file reviews, provider knowledge on TB danger signs or observations of actual patient provider interactions, received a weighting of 25.6% (84/324) in the MPA and 38.4% (218/567) in the CPA. Version _pbf_usermanual_ng-final Page 28

29 Table 5: Weighting for the 15 Health Center Services in the 2014 Quality Checklist Nr MPA Service (2014) Points Weight_% 1 General Management % 2 Business Plan 9 2.8% 3 Finance % 4 Indigent Committee 2 0.6% 5 Hygiene and medical waste disposal % 6 OPD % 7 Family Planning % 8 Laboratory % 9 Inpatient Wards 6 1.9% 10 Essential Drugs Management % 11 Tracer Drugs % 12 Maternity % 13 EPI % 14 ANC % 15 HIV/TB 8 2.5% % Table 6: Weighting for the 15 General Hospital Services in the 2014 Quality Checklist Nr CPA Service Points Weight_% 1 General Management % 2 Business Plan 8 1.4% 3 Finance % 4 Indigent Committee 4 0.7% 5 Hygiene & Medical Waste Disposal % 6 OPD % 7 Family Planning % 8 Laboratory % 9 Inpatient Wards % 10 Essential Drugs Management % 11 Tracer Drugs % Version _pbf_usermanual_ng-final Page 29

30 Nr CPA Service Points Weight_% 12 Maternity % 13 ANC 7 1.2% 14 HIV/TB 8 1.4% 15 Surgery % % The Performance Framework for the Local Government PHC Department The local Government Health Authority has important functions related to the LGA PBF system. These functions are: (a) regular supervision of its health facilities; (b) application of the quality supervisory checklists once per quarter to each of the PBF health centers; (c) a capacity building role; (d) managing the HMIS; and (e) being the secretariat for the local government RBF steering committee. The local government PHC department is under a performance contract with the SPHCDA for its PBF supportive role. The SPHCDA Verifier will apply the performance framework, and present the results in the local government RBF steering committee. The performance framework can be found in annex 12. Subsidized Care for the Indigents The poorest of the poor face real problems accessing care. Free health care or selective free health care is not an option for Nigeria as available public funding is insufficient to pay for good quality and accessible basic health services. However, selective free health care could theoretically be subsidized through the PBF providerpayment mechanism, such as has been done for the Burundian SFHC/PBF mechanism. 14 Additional funding would have to be made available by the State to reimburse providers for such selective free health care. For improving access to health care by the poorest of the poor PBF will introduce a specific category called new consultation for an indigent patient. The poorest of the poor - the indigents- will be able to access curative and preventive services, without paying at the point of service. 14 Meessen, B., A. Soucat, et al. (2011). "Performance-based financing: just a donor fad or a catalyst towards comprehensive health care reform?" Bulletin of the World Health Organization 89: Version _pbf_usermanual_ng-final Page 30

31 We will first discuss the Drug Revolving Fund concept, and then the quality checklist. After this we will explain subsidized care for the indigents through PBF. A Drug Revolving Fund (DRF) will be introduced together with the PBF intervention. Rates for the drugs and medical consumables of the DRF are determined by the type of the drug, the source of the drug and the markup. The new rules for these Drugs are: They should be generic type; Figure on the Essential Drug List (EDL); They should be procured from the 3-4 certified distributors at the State level; Prescriptions should be used for all drugs and medical consumables, and prescriptions should be kept in the pharmacy; Modern pharmacy stock control measures will have to be implemented ( first in first out ; use of individual stock control cards, etc); Retail rates will have to be negotiated between the health facility management, the Health Facility RBF committee (its oversight committee); These negotiated rates will have to figure on the public bulletin board for clients to see. As a condition of the purchase contract all drugs and medical consumables sold from the health facility ought to be through this formal DRF. Informal DRFs or prescribing from private pharmacies will not be permitted. If the PBF facility breaks this rule it stands to get cautioned, receive a penalty or lose its purchase contract. The PBF intervention will be working closely with grassroots organizations to conduct client satisfaction surveys. Mobile phone technology will be used intensively, including testing a citizen s reporting through sms functions. The average costs of a prescription will therefore be known. Quality issues such as stock outs of drugs, or being sent to private pharmacies to buy drugs, will also be obvious. The quality checklists will be monitoring, and rewarding rational drug prescribing practices. The above measures are expected to bring down considerably the average variable cost of a curative consultation. However, these costs might still be too high for the indigents: the poorest of the poor. We will introduce a system of subsidized care for the indigents. This system will be piloted on a small scale so that we can see if it works. We will introduce a single case-based remuneration category, called new outpatient consultation for the indigent patient (MPA) and new outpatient consultation by a Doctor of an indigent patient (CPA). Basic rules are (see also annex 18): Version _pbf_usermanual_ng-final Page 31

32 Up to 5% of the total number of new outpatient visits can be claimed under this category the following month; There should be created an indigent committee, with members drawn from the Facility RBF committee and involving other community representatives appointed by the RBF committee (see annex 18 for its terms of reference); This indigent committee is responsible for verifying the accuracy of the application of the indigent category, especially related to perceived poverty; The health facility is encouraged to devise innovative methods to ensure accurate targeting. Such methods will be evaluated through focus group discussions. The PBF purchase contracts will make the care for the indigents an integral part of the MPA and CPA and therefore, just as for each of the individual services, adherence to the rules (such as the correct application of guidelines and procedures, and correct reporting), are a condition for continuing the purchase contracts. Purchase contracts are writing with one select health facility in each LGA, whereas there are more such health facilities in each LGA, and therefore, there is an element of contestability in each contract. The PBF contracts are not a right, but are conditional on continued good performance. The various strategies related to each of the services, including the care for the indigents, are negotiated in the business plans of each contracted facility. The financial risk forecasting model is set up to make an informed choice, within a given budget, a given baseline and hundreds of target assumptions, of the actual fee/subsidy paid for each category. These fees/subsidies can be renegotiated depending on target achievements or when certain services are overproduced whereas others are under produced (moral hazard). PBF uses the principle of cross subsidies; it is assumed that the case-based payment reimburses providers for the average variable cost of a curative treatment. In case the cost for an individual surpasses the actual reimbursement it is assumed that the health facility will cross-subsidize the actual variable costs through its other PBF earnings. In fact, curative care is the gateway for preventive services: one curative care case, such as an indigent, can lead to additional earnings for mother and child care services and other incentivized services. It should be quickly understood by health facility managers that attracting more patients (through offering good quality curative care and available drugs), leads to an opportunity to earn more through offering additional preventive services. Health facility managers in PBF projects frequently decrease the level of user charges in order to attract clients after which additional income can be gained through preventive care subsidies. Version _pbf_usermanual_ng-final Page 32

33 CONTRACTS Five contracts govern the Nigerian PBF approach. These contracts form the new rules and regulations of the PBF system. Its linked technical documents (quality checklists; performance frameworks and technical manuals) are part of these new rules and regulations. These contracts are: 1. A Multilateral Contract for the LGA RBF Steering Committee 2. A Purchase Contract between the SPHCDA and the Provider (health facility) 3. A Motivation Contract between the Health Center Management and the Individual Health Worker 4. A Contract between the SPHCDA and the Local Government Health Department 5. A sub-contract between the primary contract holder and a secondary health provider The contracts are described shortly below, and are annexed to this guide for more elaborate reference. Contract 1: Multilateral Contract for the LGA RBF Steering Committee The LGA-RBF steering committee is a core institutional aspect of the Nigerian PBF approach. It contains a formalized set of rules, in the form of a multilateral agreement between the members of the LGA RBF Steering Committee, and the LGA Chairman. The following organizations and position holders are members of this steering committee: The LGA Supervisory Councilor for Health The Primary Health Care (PHC) Coordinator The representative of the State Ministry of Health The Chief Medical Officer of the LGA General Hospital The representative of Health Facilities The representative of the SPHCDA The representative of Non-Governmental Organizations active in the LGA The Director for Local Government Administration (DLG) where available or Director of Personnel Management (DPM) or his/her representative The Pharmacy Officer The quorum is formed by (a) the LGA PHC Coordinator (or his/her deputy); (b) the representative of the SMOH and (c) the representative of the SPHCDA. If any one of these three position holders is not present then in that case the RBF steering committee meeting cannot be held, or when held, is not authorized to make any decisions. Version _pbf_usermanual_ng-final Page 33

34 Minutes of the steering committee meeting, together with a signed copy of the consolidated LGA PBF invoice for MPA and CPA, will need to be submitted to the SPHCDA prior to the 10 th of the fifth month. 15 Without these deliverables the SPHCDA and the PFMU cannot process the performance payments. The steering committee meets at least once per quarter and underscores the decentralized nature of PBF management. It is at the LGA level where the local actors know their health system best. It is here where performance data are submitted for scrutiny and validation and for subsequent action. The local government RBF steering committee contract is in annex 1. Contract 2: Purchase Contract between the SPHCDA and the Health Provider The SPHCDA who is the PBF purchaser - writes purchase contracts with select health facilities for the delivery of the MPA and the CPA. These purchase contracts are conditional on reaching an agreement on the business plan for each facility. See annex 13 for the business plan. The purchase contracts are writing for the duration of 12 months. They are conditional on continued satisfying performance which is defined as: (a) good performance and (b) continued good performance and (c) agreement on the strategies as laid out in the business plan. Purchase contracts can be writing with public facilities, with private non-for-profit facilities, with religious facilities and with private for profit facilities on a basis of non-discrimination. In principle, one main health facility per ward is contracted. For urban areas, other ratios might apply. Sub-contracting of other facilities by the main contract holder is allowed pending agreement on this strategy in the business plan. The fees/subsidies agreed in the purchase contract are valid for each 3 month period. They can be renegotiated by the SPHCDA in case: (a) the production is higher than expected; (b) the production is lower than expected; and (c) certain services are overproduced while others are under produced. 15 Months 1-3 are the performance months; by the end of month four latest the LGA RBF Steering Committee has to convene. The deliverables (minutes of this meeting; consolidated MPA and CPA performance data) have to arrive in original hard copy, carrying the appropriate signatures, at the SPHCDA prior to the 10 th day of the fifth month. Version _pbf_usermanual_ng-final Page 34

35 In case the SPHCDA does not issue a new amendment prior to the last working day of the quarter, the past quarter s fees/subsidies are automatically continued for a second 3- month period. Purchase contracts are not a right or an entitlement. The purchase contract can be found in annex 2. Contract 3: Motivation Contract between the Health Center Management and the Individual Health Worker The health facility management writes a motivation contract with each health worker in its facility. These motivation contracts indicate the rights and obligations of each health worker. It indicates the number of points the health worker is entitled to, when the health worker has carried out his/her job description and when his/her performance is 100% according to the individual performance evaluation (see annex 15). The management decides each quarter, based on the financial position of the health facility and the budget for the following quarter, which part of the budget will be allocated to performance bonuses. The budget for the following quarter is structured around procurement of drugs and medical consumables, maintenance of facilities/equipment and facility/equipment upgrade, payment of contracted medical staff, payment of sub-contracts, and performance bonuses. Performance bonuses cannot be more than 50% of PBF earnings of the facility. However, a lesser percentage can be allocated to performance bonuses if the facility decides to invest in its facilities first (to earn a higher performance score on the quality for instance, or to invest in equipment or infrastructure in order to provide more services). The performance bonus budget is then divided by the total number of points. The total number of points are the sum total of all points in all motivation contracts. Each health worker is thus entitled to its number of points * point value for that quarter (these point values can differ, depending on the health facility performance and the investment decisions taken by the management) * individual performance assessment %. The performance bonuses are paid once per month. 16 Motivation contracts are primarily meant to assist in the provision of good quality MPA and CPA services. In case of a mismatch between staff, for instance an overabundance of non- 16 Although the health facility is paid once per quarter, the management is expected to plan for monthly bonus payments to staff. Version _pbf_usermanual_ng-final Page 35

36 medical staff, and a shortage of medical staff, the health facility management is free to judge how much points it should allocate to non-medical staff as compared to medical staff. If for instance a health facility has 20 sweepers but only five medical staff, then it seems appropriate that the management considers how many sweepers and other non-medical staff it actually needs to ensure good hygiene and waste disposal and good patient registration. An internal health facility committee oversees the allocation of the performance budgets and ensures that the results of the performance evaluations are applied. Health workers, who are no longer working at the health facility, are not entitled to performance payments. See annex 3 for the motivation contract. Contract 4: Contract between the SPHCDA and the LGA PHC Department The SPHCDA writes a performance contract with the local government health department. This contract is meant to support the PHC department in its vital functions related to the LGA PBF system. The contract is an output-based contract with a performance framework linked to it. The SPHCDA Verifier will apply the framework once per quarter and present the findings in the quarterly LGA RBF Steering Committee meeting. In the LGAs which are classified as DFF, an adapted contract and framework will be introduced. The contract can be found in annex 4, and the performance framework can be found in annex 12. Contract 5: Sub-Contract between the Health Provider and a Secondary Health Provider The main PBF contract holder can sub-contract other facilities present in its ward, to provide some MPA services. Such a sub-contracting strategy should be indicated in the business plan and negotiated with and approved by the SPHCDA. It is assumed that such business plans are also vetted by the Facility RBF Committee and the local government health department. Sub-contracted facilities can be public, private non-for-profit, religious and private-for-profit facilities. The main contract holder is required to assure (a) adequate supervision; (b) quality norms related to the sub-contracted services; and (c) to ensure that the primary and secondary data collection tools are used for these sub-contracted services. Version _pbf_usermanual_ng-final Page 36

37 Typical services that can be sub-contracted include (a) curative services; (b) immunization services; (c) family planning services; (d) growth monitoring services, and (e) household visit as per protocol. The primary data collection tools ought to be present in the main PBF facility during the verification by the SPHCDA. The SPHCDA will also conduct community client satisfaction surveys under the sub-contractors. The primary contract holder will claim all services from the SPHCDA, merging his own production with the sub-contracted facility s production. The primary contract holder is entitled to a management fee of up to 25% of the sub-contracted PBF earnings. Other arrangements can include for instance remunerating traditional birth attendants to accompany women to deliver in the main PBF facility, or community health workers to ensure DOTS for TB patients. Such arrangements do not need a sub-contract and are typically managed through a tacit agreement between the PBF facility and the individual community health workers. See annex 5 for the sub-contract template. PERFORMANCE MANAGEMENT AT THE HEALTH FACILITY Performance Management is at the core of PBF systems. There are various levels to performance management. There is: (i) higher level performance management (strategic purchasing and coaching by the SPHCDA); (ii) performance management through supportive action by the local government health authority, and (iii) guidance through the LGA RBF Steering Committee. However, here, we explain shortly the three tools used in the facility level performance management. These tools are meant as an aid for the health facility management to focus their problem solving skills on the required quantity and quality performance. The first tool is the business plan; the second the Indice tool, and the third the framework for individual performance evaluation. Business Plan The business plan is used by the health facility management to explain the various targets and strategies it has devised to improve the coverage of good quality services. Close collaboration with the Facility s RBF Committee (drawn from key members of the Ward Development Committee) is required in its design. A valid business plan is necessary for the purchase contract Version _pbf_usermanual_ng-final Page 37

38 to take effect. It is also an integral part of the purchase contract: if the health facility does not do what it has set out to do, it faces a re-negotiation of its purchase contract. It might when poor performance continues lose its purchase contract. The business plan template can be found in annex 13. Indice Tool The indice tool is available in two forms; one is an excel spreadsheet for use in the General hospital, where there is IT equipment available. The other is a paper-based tool meant for use in health centers. The purpose of the indice tool is to manage health facility income in a holistic fashion. Cash income for the health facility is from: The Drug Revolving Fund (DRF); Eventual other charges (as determined by the health facility RBF committee); Income from PBF; Income from sub-contracting; Cash subsidies from the Government. The health facility will need to manage this income from various sources to pay for its expenses: Purchase of NAFDAC certified generic drugs and medical consumables from select certified distributors; Purchase of equipment; Rehabilitation of facilities; Pay contracted health staff; Pay sub-contractors; Pay community health workers (on a case by case basis when involved in PBF strategies); Pay performance bonuses to staff; Ensure a reasonable cash buffer. The paper based indice tool can be found in annex 14. Framework for Individual Performance Evaluation Health facility managers will use an individual performance evaluation framework, to distribute the performance bonus budget while managing individual effort. An example of such a performance evaluation framework is provided in annex 15. Health facilities are invited to expand this framework according to their local insights. Version _pbf_usermanual_ng-final Page 38

39 MONITORING AND EVALUATION Monitoring and Evaluation (M&E) permeate PBF approaches. PBF has a super M&E, in which data are monitored throughout the system and validated at various levels. Most importantly data are validated at the source (systematic Data Quality Audit) but also at other levels. In addition data are used intensively at all levels: at the health center level; LGA level; State level, and at the Federal level. In all, six levels of control/monitoring can be distinguished in the Nigerian PBF approach. Each of these six levels contributes to the reliability of the data and the subsequent performance payments. PBF systems are extremely thorough in the sense that each Naira paid for a service can be followed to the patient who received that service. Table 7: Evaluations: ex-ante and ex-post Structure Ex-ante Ex-post Frequency Health Center Quantity Quantity verification: Technical Support Unit (TSU)- SPHCDA As per protocol Community Client Satisfaction Surveys: CBOs Quantity verification: monthly Community client satisfaction surveys: sampling once per quarter Health Center Quality PHC-unit of the LGA As per protocol TSU- SPHCDA Quality verification: once per quarter Quality counterverification: sampling once per quarter General Hospital Quantity Quantity verification: Technical Support Unit- SPHCDA As per protocol Community Client Satisfaction Surveys: CBOs Quantity verification: monthly Community client satisfaction surveys: sampling once per quarter General Hospital Quality Multi-agency organized by TSU-SPHCDA with Hospital Board and As per protocol: Multiagency Quality evaluation: once per quarter Version _pbf_usermanual_ng-final Page 39

40 Structure Ex-ante Ex-post Frequency technical partners Quality counterverification: sampling once per six months LGA PHC department TSU- SPHCDA As per protocol: Multiagency Performance framework: once per quarter Performance framework: sampling once per six-months The first level of control is the purchase contract & its linked business plan. This purchase contract lays down the rules and regulations that govern PBF and include clauses that deal with fraud. This contract is writing between the health center management & its RBF committee and the SPHCDA. This first level of control ensures that data submitted in the monthly invoice (see annex 10) are true. These performance data have been compiled by the one responsible for the service department and have been signed off by the head of the health facility and also by the president of the Facility RBF committee. Health facilities already count their performance data many times prior to claiming them. Quality checklists are extensively utilized by the health facility management to measure progress on the various quality dimensions and to make clear what they expect from their staff. The second level of control consists of the monthly or bimonthly (depending on local circumstances) quantity control by the SPHCDA. The SPHCDA has a purchasing unit (the PBF- TSU), which employs its own Verifiers and has as task to verify health facility productivity. Verifiers count every single entry in the designated primary registers and sign off on the monthly invoice. Also, data elements that are the same for PBF and for the national HMIS system are triangulated during this process, thereby enhancing the reliability of key HMIS data at the source. The third level of control consists of community client satisfaction surveys. These community client satisfaction surveys are organized by the SPHCDA who selects grassroots organizations and selects and trains suitable surveyors among its members. These surveys are meant to answer Version _pbf_usermanual_ng-final Page 40

41 three questions: (a) is the client known in the community; (b) has the client actually received the service, and (c) what was the opinion of the client on the service received. The community client satisfaction surveys will also judge the reliability of the post-identification methods for the new outpatient consultation for an indigent patient category. The program will also experiment with mhealth (mobile phone technology through the sms function), to get qualitative feedback by community groups, which will be published on the RBF website. The fourth level of control consists of the local government health department carrying out the quarterly quality supervision using the designated checklist (see annex 8). Once per quarter, 15 service areas are checked in each health center. For the General hospital, a different quality checklist is used (see annex 9), and applied through a different mechanism. The summary data for each service are entered in the database. A maximum quality bonus of 25% of the quarterly earnings can be earned. The fifth level of control consists of the quarterly LGA RBF Steering Committee meetings. In these meetings, the monthly invoices are compared with the quarterly consolidated LGA PBF invoice (see annex 11), printed from the web-enabled database. The reason for comparing these two sets of invoices is to intercept data entry errors while at the same time having local stakeholders have a close look at the results. Furthermore, the quality score of the health centers is discussed and also the progress on the business plans. Results from the community client surveys are discussed and plans are drawn up to provide feedback to the authorities, health centers, and the communities. Minutes of these proceedings are sent to the SPHCDA, together with the approved quarterly consolidated LGA PBF invoice. The sixth level of control consists of the SPHCDA doing due diligence on procedures; the received minutes of the LGA RBF Steering Committee proceedings and the signed and approved consolidated LGA PBF invoices (for both MPA and CPA). Data are triangulated with data from the database. If all is found well a payment order is printed from the web-enabled database signed by the head of the PBF-TSU and his/her supervisor and sent to the PFMU (and eventual other fund holders). The PFMU will execute the payments to the contracted health facilities and the LGA PHC departments. Approved and executed payment orders will be published on the PBF website of the NPHCDA. Version _pbf_usermanual_ng-final Page 41

42 FRAUD: PREVENTIVE MEASURES AND PENALTIES Possible Fraud The introduction of PBF increases the risk for fraud as some providers or administrators inflate results to earn more money. Verification and counter-verification procedures mitigate the risk for fraud through measuring the difference between claimed (& paid for) performance and actual performance. This requires special attention to measures to detect fraud and to penalties applied in case of certified fraud. Fraud in PBF systems can be either intentional, or non-intentional. Intentional fraud relates to falsifying documents related to a service activity, falsifying register information, claiming services that had not been delivered, referring to acts of care that the user did not benefit from etc. Unintentional fraud (which is a rare occurrence) can be an error made by a verifier due to lack of comprehension of the indicators- on a quality checklist or it can be a misinterpretation of indicators by different verifiers (an effect known as inter-observer variability ). To avoid fraud - intentional or unintentional - there is need for incentives for good behavior, correct reporting and scoring, and disincentives for fraud. In all cases, possible fraud need to be substantiated quantitatively (the numbers and facts) but also qualitatively (a writing explanation as to what actual happened) as sometimes a case of non-intentional fraud can be based on a misinterpretation of an element of the quality checklist due for instance to a different sampling of a patient file, or be caused by different interpretations of the same event by different verifiers. However, once fraud is established based on quantitative proof, and supported by qualitative elements, strong actions needs to be implemented to discourage future fraudulent behavior. Fraud prevention The following preventive measures are implemented to decrease the risk of fraud, intentional or unintentional: Separation of functions, which helps to minimize fraud by avoiding conflicts of interest; Good quality ex-ante verification both of the quantity (SPHCDA) and quality (LGA-PHC departments); A clear manual, clear contracts and good training in the rules of the game; An effective reward and punishment system (and application of punishments in case of certified fraud); Good governance for PBF at the LGA level; Regular community client satisfaction surveys with feedback of the results at all levels. Version _pbf_usermanual_ng-final Page 42

43 If rules are transparent and known to all and actions are taken swiftly when fraud is detected while communicating such fraud and its consequences to all stakeholders, then the likelihood of fraud will be minimized. Penalties for Fraud When fraud is certified, the following actions are taken: Related to ex-post verification of the quantity (community client satisfaction surveys): If more than 5% (up to 10%) of the sample cannot be traced back in the community. This means that either the client exists but did not receive the service OR that the client does not exist. Verification is done through mobile phones and/or through household visits with certification that client does or does not exist as confirmed by the village head: o First offence: retention of 20% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website; o Second offence: retention of 50% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website; o Third offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA). Table 8: Penalties in case of more than 5% (up to 10%) untraceable clients First offence: retention of 20% of PBF earnings, no performance bonuses staff and repeat counter-verification Second offence: retention of 50% of PBF earnings, no performance bonuses staff and repeat counter-verification Third offence: stop the purchase contract, replace head of health facility. If more than 10% of the sample cannot be traced back in the community: Version _pbf_usermanual_ng-final Page 43

44 o First offence: retention of 50% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website; o Second offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA). Table 9: Penalties in case of more than 10% untraceable clients First offence: retention of 50% of PBF earnings, no performance bonuses staff and repeat counterverification Second offence: stop the purchase contract, replace head of health facility Related to ex-post verification of the quality for health centers (quality counter-verification of HC): both the LGA PHC department and the health facility are penalized as follows: If the discrepancy is larger than 10% and no qualitative explanation can be given for this discrepancy (average across the sampled services according to the protocol): o First offence: related to the LGA-PHC department: retention of 50% of LGA-PHC department performance earnings while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification. Writing warning to the responsible verifier; related to the health facility: retention of 20% of the total earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman. o Second offence: related to the LGA-PHC department: retention of retention of 50% of LGA-PHC department performance earnings while remaining earnings cannot be spent on individual performance bonuses PLUS warning in Version _pbf_usermanual_ng-final Page 44

45 writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification PLUS exclusion of responsible verifier from performance bonuses and from quality checklist assessments for a period of one year; related to the health facility: retention of 30% of the total earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman. o Third offence: Related to the LGA-PHC department: stop of the performance contract for the duration of one year (or until - for the SPHCDA - a satisfactory solution has been found) PLUS offering of quality supervision contract to another PHC pending resolution of the conflict. Related to the health facility: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA). Table 10: Penalties in case of more than 10% unexplained discrepant results in quality counter-verification of health centers First offence: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification. Health facility: retention of 20% of performance earnings, nil bonuses staff. Second offence: LGA-PHC department: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification plus exclusion of offending verifier from pool of verifiers. Health facility: retention of 30% of performance earnings, nil bonuses staff. Third offence: LGA-PHC department: stop the performance contract for the duration of one year. Health facility: stop the purchase contract. The ex-ante verification for the hospital quality is done by a multi-organizational team led by the SPHCDA, consisting of Hospital Board staff, third-party hospital staff and technical partner Version _pbf_usermanual_ng-final Page 45

46 agencies. The actual scoring for results is done by the SPHCDA with the others in observer status (i.e. not responsible for the actual scoring). DATABASE A web-enabled application forms the backbone of the Nigerian PBF administrative system. This time-tested solution has led to the successful scaling up of PBF nationwide in Rwanda and Burundi with near 100% data completeness, a high degree of timeliness, a very high level of data reliability and widely available data which are used at all levels of the health system. 17 A website will form the portal to the database. This website will also figure news, events, documents, information related to actors such as their contacts and websites and so on. The software used for this IT solution, WordPress, MySQL and PHP, are all open source. The database will offer preconfigured reports, such as the important consolidated quarterly LGA PBF invoices, but also interactive graphs and tables. A health facility table of all contracted Nigerian health facilities will be used, in which figures information such as their bank accounts. The health facilities will use unique identifiers which will enable them to be linked to other databases such as the HMIS. 18 The health facility table will also be updatable through the web application, for select administrators. The database can also be accessed through exporting data in Excel, and analyzing trends using the Excel Pivot or Graph option. Drawback from this approach is the limited internet connectivity in LGAs. However, SPHCDA staff which will be responsible for data entry will have fast internet access in its main and also zonal offices. LGA health staffs can use either internet cafes, or mobile 3G or 4G networks where available to access the web-enabled database. All performance information is accessible through the public frontend through ready-made graphs, and also through MS Excel tables that can be downloaded from the public frontend through the data-tab. 17 Similar systems have been designed for Zambia, and are in preparation for Chad, and DRC. 18 A DHMIS web-enabled platform is planned for Nigeria. Performance data can thus be linked in the cloud. Version _pbf_usermanual_ng-final Page 46

47 Figure 3: Image of the public frontend of the PBF web-enabled application 19 The database will have administrator, author, and editor and guest accounts. The SPHCDA will have various author accounts for its verifiers attached to each LGA (1-2 per LGA). These authors can only enter and modify data for their own LGA. Data from all health facilities are visible through not only the back-end, but also the public frontend. There will be select editor accounts for technical assistants from developing partners providing TA to the national PBF system and for certain core SPHCDA/PBF-TSU staff. These editor accounts allow for a larger range of editorial functions (accessed 5 December, 2013) Version _pbf_usermanual_ng-final Page 47

48 A few select users will have administrator accounts which confer the highest level of user account in which users can be added or modified, including their passwords. The administrators also have access to a log in which mutations in the database are recorded. Finally, all performance information is publicly visible, and allows website visitors to view dashboard information and to download data and carry out additional analysis without the ability to make changes in the database. PAYMENT CYCLE The payment cycle will be once per quarter. The following steps can be distinguished: (1) monthly health facility invoices are controlled and signed off by the verifier and brought to the SPHCDA where the data will be entered in the web-enabled application; 20 (2) The last such monthly invoices will arrive at the SPHCDA during month four prior to the end of week three (month one to three representing the quarter). The quarterly quality checklists are finalized for the health centers and the information will reach the SPHCDA latest by the end of the third week of month four; (3) Data entry through the web-application and printing of the provisory quarterly consolidated LGA- PBF invoice (one for the MPA; one for the CPA for each LGA); (4) The quarterly LGA- RBF Steering Committee meeting is held in which the quarterly consolidated LGA- PBF invoice is approved (or amended if necessary). During this process the original monthly invoices are compared with the quarterly consolidated LGA PBF invoice which has been printed from the database. After approval, the approved invoice together with the LGA RBF Steering Committee meeting minutes are sent as original hardcopies to the SPHCDA for which the LGA will receive a writing proof. All required documents ought to reach the SPHCDA/PBF-TSU latest the 10 th of the fifth month (months one to three being the quarter under consideration); (5) The SPHCDA has seven days to do its due diligence after which it produces a payment order (the payment order is generated through the web-application). The payment order is signed 20 Or for that matter entered through any functioning internet connection, which could be an internet café, or the personal 3G/4G mobile internet connection of the Verifier. Version _pbf_usermanual_ng-final Page 48

49 by the head of the PBF-TSU, by the SPHCDA supervisor of the PBF-TSU and sent to the PFMU; (6) The PFMU will process the payments within 14 days (i.e. before the end of the fifth month) and transfer the performance payments to the health facility bank accounts; (7) The payment orders will be published on the NPHCDA- PBF website. Rules of Use of the PBF Income PBF earnings are supposed to be used in a holistic manner taking into consideration all cashincome of the PBF facility from all combined sources. As a rule of thumb: a maximum of 50% can be allocated to staff performance bonuses from the PBF earnings. Invoices See annex 10 for a sample of the monthly Health Facility Invoice, and annex 11 for a sample of the quarterly consolidated LGA PBF invoice. CAPACITY BUILDING Capacity building and system strengthening are vital to a successful PBF program. Health Facilities need to be equipped with basic equipment and rehabilitated to a reasonable extent to level the playing field for service provision and to offer quality health services equitably. This will partially be achieved by introducing the business plan concept linked to retroactive financing. This will enable health facilities to upgrade themselves. A PBF training program will be devised. The institutional framework of the Nigerian PBF approach will be explained ending with the contract signing ceremonies. All actors at Federal, State, LGA, and health facility level will need to be trained. This is a major effort which will need excellent coordination between the FMOH, NPHCDA, SMOH, SPHCDA and development partners and operational and financial support from all to make this a reality. The level of effort required is much larger than any one single agency could undertake (administration; operations support and so on), therefore, such trainings will need to be decentralized to the different agencies that have operational capacity to do so. The PBF- TSU/SPHCDA will form the core of this coordination effort through its extended team mechanism. The following State level training strategy is proposed: Version _pbf_usermanual_ng-final Page 49

50 1. Employ a qualified international level master trainer; 2. Select a team of trainers from various agencies (SMOH, SPHCDA and development partners), a team of about per State would be necessary (cost born by partners for their staff); 3. Train the trainers in modern andragogic methods and approaches; 4. Create the training modules for the various target groups, with the trainers, create a manual for trainers; 5. Train (the first training can be a try-out, then the trainings can be simultaneous and in parallel); 6. Follow up. Creating a technical team, which collaborates horizontally to achieve the same mission (the implementation of the Nigerian PBF approach), tied to the SPHCDA/PBF-TSU (whose members are also part of this larger technical team) is deemed necessary. This is the so-called extended team approach. A window of opportunity opens by assembling a team of dedicated State level PBF trainers from various agencies. This extended team can also become part of the State technical resource pool which can and should be mobilized to offer technical support to the LGA RBF Steering Committees (where required) and the health facilities, to make PBF a reality (see below under coordination ). COORDINATION Coordination is of utmost importance for the successful introduction of the Nigerian PBF approach. Organizing technical assistants from all concerned State agencies and development partners engaged in the State PBF roll-out is most essential to a successful implementation. Such a team can be organized through the PBF-TSU/SPHCDA, and will contribute to a successful topdown policy implementation. The State RBF steering committee and Technical Working Group are the governing organs of PBF at the State level and double as an important forum for coordination and policy guidance related to PBF. Version _pbf_usermanual_ng-final Page 50

51 The web-enabled application and the website will contribute to making information accessible for all. Version _pbf_usermanual_ng-final Page 51

52 ANNEXES Annex 1: Multilateral Contract for the LGA RBF Steering Committee (..) State Ministry of Health (..) State Primary Health Care Development Agency AGREEMENT ON THE FUNCTIONS OF THE LOCAL GOVERNMENT RESULTS BASED FINANCING STEERING COMMITTEE THIS AGREEMENT is dated [ ] 201X BETWEEN: [ ], the LGA Chairman, representing [ ] LGA Dr. /Mrs. /Mr. And Version _pbf_usermanual_ng-final Page 52

53 The Members of the Local Government Authority Results-Based Financing (RBF) Steering Committee The LGA Supervisory Councilor for Health The Primary Health Care (PHC) Coordinator The representative of the State Ministry of Health The Chief Medical Officer of the LGA General Hospital The representative of Health Facilities The representative of the SPHCDA The representative of Non-Governmental Organizations active in the LGA The Director for Local Government Administration (DLG) where available or Director of Personnel Management (DPM) or his/her representative The Pharmacy Officer IT IS AGREED as follows: Purpose of the Agreement 1.1 The present Agreement aims at establishing the institutional framework and rules that govern the implementation of the Performance Based Financing (PBF) program at Local Government Level. 1.2 The Performance Based Financing strategy emanates from National Public Health policy. The Performance Based Financing User Manual (as published by FMOH/NPHCDA) serves as the principal reference document for all mechanisms agreed to herein and shall be referred to for further details and interpretation. 2. State Level Management of PBF : a Joint Responsibility of Key Stakeholders 2.1 The Statewide regulation of PBF shall be under the authorities of the State Ministry of Health (SMOH) and the State Primary Health Care Development Agency, in close collaboration with development partners and international agencies. 2.2 The SMOH will set up a State RBF Steering Committee that will review the implementation of PBF at state level, and provide general policy direction. The general objectives of the PBF program will be informed through collaboration with concerned Federal and International Institutions. The SPHCDA will provide the secretariat for this State level RBF Steering Committee. Version _pbf_usermanual_ng-final Page 53

54 3. State Level Management of PBF: The State Primary Health Care Development Agency (SPHCDA) 3.1 The day-to-day management of the PBF program shall be carried out by the SPHCDA. The SPHCDA shall be responsible for the following: (a) Facilitate the integration of other Statewide or LGA-wide health programs with PBF; (b) Purchase the minimum package of activities (MPA), and complementary package of activities (CPA) through direct purchase contracts with select public, faith-based institution, or non-for profit Health Facilities (one principal contracted health facility per ward; based on the principle of non-discrimination and best performance); (c) In collaboration with the local government health department, negotiate the business plan contents with the PBF facilities; (d) In collaboration with the local government health department, classify all contracted facilities in Categories 1 to 5 depending on the perceived rural hardship grading of these facilities (the health center closest to the LGA administrative centre will typically be categorized as a Category 1 ); (e) Do strategic purchasing of the MPA and CPA services. Define the subsidies for MPA and CPA services based on (i) results obtained; (ii) observed moral hazard and (iii) within the boundaries of a given PBF output budget; (f) Contract the local government health department for the quarterly quality supervision of the health centers; (g) Verify the monthly quantity production of the MPA and CPA services; (h) Verify the quarterly performance grid of the local government health authority; (i) Enter the MPA, CPA and quality checklist data in the PBF web-enabled database and produce the consolidated quarterly LGA PBF invoice for discussion in the LGA RBF Steering Committee; (j) Organize community client satisfaction surveys through local grassroots organizations using a defined protocol; (k) Perform due diligence on all quarterly LGA RBF Steering Committee deliverables (minutes of meetings; approved consolidated performance invoices), and facilitate the payment for performance without ado by the with the SMOH Project Finance Management Unit (PFMU); (l) Execute any contractual sanctions imposed by the PBF purchase contracts in case of non compliance or irregularities on the health facilities. 3.2 The SPHCDA may delegate some of these responsibilities through a writing agreement with a local government entity such as the Primary Health Care unit or to an external third party organization active at local government level. Version _pbf_usermanual_ng-final Page 54

55 4. Local government level management of PBF: The LGA RBF Steering Committee 4.1 The present agreement establishes a Local Government Results- Based Financing Steering Committee with the signatories as its members. 4.2 The LGA RBF Steering Committee shall ensure coordination of the PBF program and ensure that the applicable monitoring, control and sanction mechanisms are implemented within the geographical of jurisdiction of the LGA. The LGA RBF Steering Committee shall also be entrusted with devising local strategies to improve access and quality of care at the LGA health facilities. 5. Members of the PBF LGA Steering Committee 5.1 The Steering Committee is chaired by the LGA Supervisory Councilor for Health of the LGA, or his or her designated deputy. 5.2 Other members of the steering committee are the following: (a) the Primary Health Care (PHC) Coordinator; (c) the Representative of the State Ministry of Health ; (d) the Chief Medical Officer of the General Hospital, or his deputy; (e) one elected representative of the contracted health facilities; (f) The representative of the SPHCDA; (g) The representative of Non-Governmental Organizations active in the LGA (h) The Human Resources Management Officer; (i) The Pharmacy Officer 5.3 The Steering Committee chairman may propose additional members by writing request to the SPHCDA. Any additional members should be chosen for their active involvement in public health in the LGA and its communities. Non response or non-objection from the SPHCDA to a proposal from the Steering Committee chairman to add to the above listed members, within a month of the receipt of the request, shall be considered as a tacit approval. 6. Functioning of the LGA RBF Steering Committee 6.1 The Steering Committee shall meet at least once every quarter upon invitation to its members by the Committee chairperson. The Steering Committee shall validly meet and take resolutions if the minimum tripartite quorum of LGA leadership and representative from SMOH and representative of the SPHCDA are present. If any or all of these three parties are absent, the steering committee meeting will be invalid and any decisions or approvals taken in this meeting, notably: the approval of the monthly and quarterly performance figures will be invalid. The PHC coordinator shall act as the committee s secretary. Version _pbf_usermanual_ng-final Page 55

56 6.2 The chairman shall invite participants with at least 14 days notice, and will ensure that the next quarter s meeting will be planned during a current meeting. 6.3 The quarterly RBF Steering Committee meetings shall be held in the last week of the fourth month. 6.4 The minutes of the RBF Steering Committee meeting, signed by the chairman, and the consolidated quarterly LGA invoice, shall be sent in hardcopy to the SPHCDA. These deliverables ought to be received by the SPHCDA before the 10 th of the fifth month. 6.5 The minutes of the meeting should conform to the norms related to Agenda content and reporting format (see PBF user manual). 6.6 The Committee meetings shall have on their agenda at least the following areas of discussion: (a) PBF strategy: To present and discuss the data and information related to the PBF health facilities including activity level, quality of care level and other relevant information; to review the different strategies in place for the improvement of results and follow-up on previous decisions of the committee. (b) PBF dialogue: To give opportunity to every member of the committee and representatives of the health facilities to express any challenges or difficulties in implementing the program or their own strategies; to address disputes that are referred to it by members or stakeholders. (c) PBF invoice validation: To review, discuss and eventually approve the final consolidated quarterly invoices of PBF health facilities prior to transmission to the SPHCDA. This validation process needs to ratify every single original monthly PBF invoice, and all the quality scores, with the consolidated quarterly LGA PBF invoice. The latter invoice is drawn from the PBF web-enabled application: verifying whether the data match (the physical evidence with the data in the database) is an important validation function. (d) PBF management support/evaluation: To review and discuss the performance of the LGA PHC department: the LGA PHC department is under a performance contract to carry out certain functions related to the well-functioning of the PBF system, in a timely and correct manner. The SPHCDA Verifier has scored the performance using the performance evaluation tool. The results are discussed in the plenary. (e) Care for the indigents: curative care for the indigents is introduced as a pilot mechanism. The steering committee is required to follow up on the functioning and appropriateness of the developing targeting mechanisms whether they target the poorest of the poor and the near poor -, and to ensure the Indigent committees are functioning appropriately. Version _pbf_usermanual_ng-final Page 56

57 6.7 Monitoring of the LGA RBF Steering Committee 6.8 The SPHCDA shall monitor the Steering Committee and is authorized to access the committee s minutes and any other relevant documents related to committee s activities. 6.9 Receiving the steering committee minutes, created according to strict guidelines, conjointly with the quarterly consolidated LGA PBF invoice, is a pre-condition for the SPHCDA and the PFMU to process the performance payments The SMOH, upon advise from the SPHCDA, may review the modalities of the Committee s operations and/or dissolve it appears that irregularities may have compromised the PBF system in the LGA. 7. Role of the Heath Facilities representative The LGA s PBF health facilities are represented by one of the Health Facilities heads. He/She has been elected by the in-charges of the other facilities, during a plenary meeting. She/he shall have responsible with bringing to the committee s attention the concerns of the different facilities managers. She/he shall also responsible to inform accurately to the other heads of facilities about the decisions of the Committee. His/her tenure is 12 months, with the possibility of one times re-election. 8. Role of Chief Medical Officer of the General Hospital The Chief Medical Officer of the General Hospital will be part of the RBF Steering Committee. The first level referral hospital has important functions related to (i) the referral system; and (ii) training and capacity building. 9. Role of the LGA PHC Department The LGA PHC Department, hereby represented by its coordinator, shall be responsible of the following: (a) General supervision of health facilities within the LGA to ensure that the PBF program is being implemented according to agreed strategies and policies; (b) Apply the quality checklist to each PBF health facility, once per quarter and submit these checklists to the SPHCDA Verifier linked to the LGA, prior to the 20 th of the third month; (c) Organize the quarterly LGA RBF Steering Committee meetings prior to the end of the fourth month. Invite members at the least 15 days prior to the steering committee meeting. The LGA PHC department will function as the secretariat of this steering Version _pbf_usermanual_ng-final Page 57

58 committee. Agenda setting will need to be agreed between the SPHCDA designed LGA Verifier and the local government health director or his designated PBF coordinator; (d) Manage financial and human resources diligently towards the achievement of the recommendations and strategies set by the LGA Steering Committee, the SPHCDA and the SMOH. (e) All other functions normally attributed to the department as part of its day-to-day mission in the LGA. 10. Role of the NGO representative The NGO representative represents civil society. The NGO representative is chosen among civil society organizations active in the health or social protection sectors in the local government area. 11. Dispute resolution 11.1 In the case of dispute relating to the interpretation of the present contract, both parties agree to refer to the current Performance Based Financing User Manual In case of unclarity of certain PBF system elements, the Steering Committee might request higher level SPHCDA technical support for clarifying certain matters In the case of dispute relating to the implementation of the present contract, both parties agree to refer to the matter to the arbitration of the State RBF Steering Committee which acts as the regulator of the PBF system in the State. The arbitration decision in the matter shall be final and binding towards all parties The SPHCDA is under no obligation to write a purchase contract for MPA or CPA with any health institute. Its primary drivers for contracting are (a) good performance and (b) continued good performance. Past performance budgets or performance fees/subsidies are no guarantee for future fees/subsidies. 12. Duration of the Contract The present contract is signed on ( ) for a period of 12 months until ( ). It shall be renewed tacitly for an additional 12 subject to the terms stipulated in section 1 of the present contract. SIGNED BY Version _pbf_usermanual_ng-final Page 58

59 [.] LGA, hereby represented by the Chairman of [.] LGA Dr. /Mrs. /Mr Signature And The Members of the Local Government Authority Performance Based Financing (PBF) Steering Committee 1. The LGA Health Director 2. The Primary Health Care (PHC) Coordinator 3. The Representative of the State Ministry of Health 4. The Chief Medical Officer of the LGA General Hospital 5. The representative of Health Facilities 6. The representative of the SPHCDA 7. The representative of Non-Governmental Organizations active in the LGA 8. The Director for Local Government Administration (DLG) where available or Director of Personnel Management (DPM) or his/her representative 9. The Pharmacy Officer Version _pbf_usermanual_ng-final Page 59

60 Annex 2: Purchase Contract between the SPHCDA and the Health Provider ( ) State Primary Health Care Development Agency PERFORMANCE BASED FINANCING (PBF) CONTRACT FOR THE PURCHASE OF HEALTH SERVICES No THIS CONTRACT is dated [ ] BETWEEN: The State Primary Health Care Agency ( SPHCDA ) represented by its Executive Chairman Dr. /Mrs. /Mr. : And [.] Health Centre, herein referred to as the facility or HF Represented by: Mrs. / Mr. [ ] Head of [ ] Health Centre Mrs. / Mr.: [.] Chair [...] Facility RBF Committee Version _pbf_usermanual_ng-final Page 60

61 IT IS AGREED as follows: 1. Principles of Performance Based Financing 1.1 The present contract is a performance contract between the SPHCDA and the Health Facility in the context of the State Performance Based Financing (PBF) program. 1.2 The goal of PBF is to increase the provision of quality Basic Health Services to the population by increasing health facilities decisional rights on the management of their own operations. 1.3 The Performance Based Financing strategy emanates from National Strategic Health Development Plan and NEEDS and Vision 20/20/20. The SPHCDA reserves the right to amend the applicable policies that serve as the basis of its support to the health centres prior to the expiry of the present contract. 1.4 The Performance Based Financing User Manual (as published by FMOH/NPHCDA) serves as the principle reference document for all mechanisms agreed to herein and shall be referred to for further details and interpretation. 2. Duration of the Contract 2.1 This purchase contract is valid from [.] for a period of [12] months until [ ]. 2.2 This contract may be revoked by the SPHCDA unilaterally at anytime, in case of fraud, or continued underperformance. The annexes and Business Plan (as stipulated in Section 13 herein) form an integral part of the present contract. 2.3 The SPHCDA reserves the right to re-negotiate the service fees each 3 month period, however, the SPHCDA can also decide to keep the fees at their current levels. If such amendment is not produced on the last working day of the end of the quarter, the current fee set will be used for the following quarter. After re-negotiation, an amendment with a new set of negotiated fees will be produced, including a new business plan. 3. Purpose of the Contract This contract defines the rights and obligations of both parties within the context of the PBF system: The Health Facility, as the provider of health services and the SPHCDA, the purchaser of Health Services. Version _pbf_usermanual_ng-final Page 61

62 4. Performance Payments 4.1 The SPHCDA shall make Performance payments to the HF according to a fee for service / case based provider payment mechanism, which is also conditioned on the quality of care. The services that are purchased and corresponding unit fees are listed in Annex The payments received by the Health Facility under these terms may be used as incentives in the form of salary bonuses to its staff members and as reinvestments in activities, equipments, commodities or infrastructure that contribute directly to the attainment of improved performance targets and enhanced quality of care to the population. 4.3 The maximum that the HF may budget for worker s bonuses is 50% of its profits. Violation of this basic rule may lead to the termination of the present contract by the SPHCDA. 4.4 Any bonus payments by the facility to its workers shall be spread over a period of three months, in the sense that each entitlement is received monthly by the workers. 4.5 In consideration of the fact that non-medical staff are in general over-supply, and essential medical staff in undersupply, it is agreed that it is up to the HF management, and its Facility RBF committee, to decide on how many of the non-medical staff it needs to incentivize to keep basic hygiene, the waste disposal according to applicable norms, and cleanliness of the premises. 4.6 The HF may decide to forfeit bonuses for a limited period and to invest in its infrastructure or equipment. The HF may choose to invest part of its earnings in expanding its health workforce through local labor contracts, and invest also in fringe benefits to attract and retain qualified health staff. 5. Organs of the Health Center 5.1 The Health Facility shall be jointly represented by the Head of the Facility and the Chairman of the Facility RBF Committee. 5.2 The Health Center in-charge shall put in place an Internal Management Committee to review individual staff performance and distribution of the funds generated through PBF and the present contract. This Internal Management Committee shall use (a) the indice tool for integrated financial management and performance bonus payments; (b) a motivation contract writing with each employee in which its part (proportion) of each quarterly bonus budget is indicated; and (c) minutes to document its proceedings. See the latest PBF manual for further details. Version _pbf_usermanual_ng-final Page 62

63 6. Mission of the Health Facility 6.1 The Health Facility must ensure that funds generated through PBF are managed in the general interest of the health centre and, in general, contribute to the improvement of public health in the community. 6.2 In doing so, the health facility (HF) hereby commits to undertake the following: Develop strategies designed to achieve the overall goals of Performance Based Financing at HF and community level; Avoid any activities in contradiction with national health policies and/or accepted medical ethics; Inform the Primary Health Care (PHC) Department at the Local Government Authority of any change in HF personnel, technical skills and equipment at the facility that which could hamper its capability to render the Services remunerated by the present PBF contract; Ensure the permanent availability of all data recording registers and all management tools at the HF, and ensure that such documents are accessible to the SPHCDA, LGA PHC department and research companies during the execution of the present contract; Report in writing any case of fraud or attempted fraud committed by HF staff members to the SPHCDA and the PHC Department; Ensure complete transparency and access to information relating to the use of funds generated through PBF and all others sources; Distribute part of the revenues generated through PBF and the present contract its staff in the form of bonuses and in accordance with set guidelines. The indice tool will assist to direct resources to core essential medical staff; Allocate part of the revenues generated through PBF and the present contract to operational expenditure (other than personnel remuneration and trainings). 7. Procurement and Prescription of Drugs and Medical Consumables 7.1 The Heath Facility shall procure all drugs and medical consumables with PBF - Certified Distributors. The State Agency of the Pharmaceutical Council of Nigeria (PCN), in collaboration with the SMOH will issue a list of 3 to 4 PBF - Certified Distributors in the State. The HF shall, at all times, be expected to conform to the list of Certified Distributors as updated from time to time by the State PCN. In choosing the distributors, availability of drugs, best price and quality should be the guiding principles. 7.2 The facility shall only procure essential drugs (as listed in the approved essential drug list) and medical consumables in generic form. Procurement of non-essential (not listed in the essential drugs list) of non-generic drugs (expensive brands drugs while cheaper Version _pbf_usermanual_ng-final Page 63

64 generic drugs are available) is not allowed. Non-compliance with this obligation may lead to the termination of the present contract by the SPHCDA. 7.3 Procurement of drugs and or medical consumables from non- PCN/PBF - Certified Distributors will be considered a violation of the purchase contract and may lead to immediate termination of the present contract by the SPHCDA. 7.4 The facility shall keep records of drugs and consumables procurement accessible at the pharmacy, and in-depth audits will need to show a match of stock-in and stock-out. 7.5 The facility shall ensure that all drugs and medical consumables prescribed in the HF are prescribed through a prescription, which shall be maintained and accessible at all times for control at the pharmacy. Prescriptions should indicate (a) the name and age of the patient; (b) the date; (c) clearly legible listed generic drugs with quantities; (d) name and signature of the prescriber. Prescription of drugs should strictly follow protocols (types of generics and recommended quantities) as mentioned in the treatment guidelines. Irrational use of drugs leads to a high cost to the population. Systematic non-adherence to these treatment guidelines could therefore lead to loss of this purchase contract. 7.6 Drugs and medical consumables available at the health facility should be clearly listed and accessible at the public notice board and at the pharmacy and should: (a) list the unit price; (b) list the number of items for a typical course, and (c) the unit price (the retail price ) should not exceed the whole sale price + a reasonable markup as negotiated with the community and ratified by the Facility RBF Committee. 7.7 The existence of informal drug schemes managed by the facility or by its staff is strictly forbidden under this contract and it may lead to immediate termination of the contract by the SPHCDA. 8. Quantity audits and provisional PBF invoices The SPHCDA verification teams shall conduct monthly or bi-monthly Quantity audits by reviewing all entries made in the designated registers. They will compare their review with the provisory monthly invoice as prepared by the HF management (see annex 2). Such monthly quantity control shall be conducted not later than the 15 th day of each month, or in some instances bi-monthly depending on local conditions. 9. Data Collection Registers 9.1 For the purpose of the present contract, each PBF Data Collection Register and its contents/entries register constitute a financial records document and will be treated as such. Non-adherence to strict registration norms herein, non-completeness or non- Version _pbf_usermanual_ng-final Page 64

65 legibility of the data in the columns, will lead to non-remuneration of the concerned services. 9.2 The Facility shall adhere to the norms for Primary and Secondary Register Column Headers as described in the applicable Performance Based Financing Manual. In the event pre-printed PBF registers are not available, the health facility shall design handwriting registers using the available office stationery according to the above mentioned norms All numbering, in all registers, from the first day of the PBF contracting, shall start with a 1, and continue for the remainder of the calendar year. The following calendar year, the numbering should start with a new 1, etc. The end of the month should be clearly indicated through a line. The numbering should continue into the following month, until the end the calendar year. 9.4 Routine Health Management Information System (HMIS) data shall align with data from the PBF registers. 10. Quality audits 10.1 In order to ensure that the services performed by the HF meet satisfactory quality standards, specific Quality Indicators (as described in the latest PBF manual) will be assessed every quarter by the LGA PHC department The results of these Quality Audits will be factored in the calculation of the overall performance of the HF and the final PBF invoice as follows: a. 25% of the total claimed earnings over the preceding months shall be added as quality bonus if the quality score for that quarter is 100%. b. If the HF s quality score is 49% or less, the quality bonus is automatically 0 for the evaluated quarter. c. A quality score between 50% and 99% will be prorated as follows: Quality Bonus = % Quality Score * (total earnings for all contracted services over the past three months) The quality audits shall be counter-verified regularly by an independent third party to be determined by the SPHCDA. If fraud is detected with the quality score, the present purchase contract may be terminated immediately by the SPHCDA. 11. Validation of the Quarterly Consolidated PBF invoices Version _pbf_usermanual_ng-final Page 65

66 11.1 The LGA PBF Steering Committee shall, on a quarterly basis, validate the Health Facility s monthly PBF invoices and the quality score obtained The LGA PBF Steering Committee shall determine the amount earned by the Health Facility on the basis of the scores obtained in both the quality and quantity controls conducted respectively by the LGA PHC Department and the SPHCDA verification teams as described in Section 9 herein. 12. Terms of payment The amount of each Quarterly Validated final PBF invoice shall be paid into the Health Facility bank account not later than 60 days after the quarter in which they were earned. For that purpose, the Health Facility shall operate autonomously its own bank account in which the funds will be transferred. Guidance on the management of the bank account is available in the PBF manual. 13. Utilization of funds received through PBF, and through all other sources 13.1 The utilization of funds earned through PBF, and through all other sources, and the present contract shall be at the discretion of the Health Center Management Committee within the limits fixed in Section 4 of this contract Against this background the health center, shall ensure that all documents are well secured. All payments made to staff and other beneficiaries should be clearly signed or thumb printed. Fraud in financial management will be dealt with according to applicable State Laws. Fraud in financial management may lead to immediate termination of the present contract by the SPHCDA. 14. External Counter-verification and Misreporting 14.1 A third party organization shall be contracted by the SPHCDA to conduct random counter-verifications at community level (the so-called community client satisfaction surveys) on a periodic basis in order to confirm the Facilities results. In that event, the Health Facility hereby agrees to grant full access to the relevant records as may be required In case of any irregularities discovered in the course of such counter-verification (including, but not limited to, inaccurate reporting and ghost patients), the Health Facility shall be subject to the penalties as detailed in the PBF user manual and annex 3 of this contract. Version _pbf_usermanual_ng-final Page 66

67 15. Business Plan Within three months upon the signature of the present contract, the HF shall submit a Business Plan for the following twelve months of activities (see format in the PBF manual). The Business plan will outline the strategies considered in order to increase the quantity and the quality of its services. The Business Plan shall then be reviewed and approved by the SPHCDA and form an integral part of the present contract. The absence of Business Plan or the non-compliance with its strategies may lead to the termination of the present contract by the SPHDCA. 16. Care for the Indigents 16.1 The Health Facility may allocate a maximum number of 5% of the curative consultations of the previous month under the reimbursement-category new outpatient consultation for an indigent patient for the current month. When allocated to this category the patient shall not pay any fee. Patients allocated under the new outpatient consultation for an indigent patient cannot be allocated under new outpatient consultation (see annex 1) The monthly sum of the number of new outpatient consultations and the number of new outpatient consultations for an indigent patient shall form the monthly new outpatient consultations provided by the Health Facility. However, a new outpatient consultation for an indigent patient client or new outpatient consultation client can consume other PBF services. In this case, the additional service shall also be counted under the additional PBF service The reimbursement for a new outpatient consultation for an indigent patient category is based on the cost of an average curative care consultation in the Nigerian context according to modern treatment guidelines. The reimbursement is also based on the principle of cross-subsidization: this means that in case the treatment for the indigent client surpasses the actual treatment costs incurred by the HF, that the HF cross subsidizes this treatment from other sources of income The new outpatient consultation for an indigent patient category is meant for indigents, the poorest of the poor. This category shall be recorded using a separate register, and any other such tools that the facility management, its Facility RBF committee, or its indigent committee have put in place The appropriate use of the new outpatient consultation for an indigent patient category will be verified through the routine verification and through the community client satisfaction surveys A specially designated Indigent Committee shall meet regularly to review the appropriateness of the post-identification mechanisms. This indigent committee is drawn Version _pbf_usermanual_ng-final Page 67

68 from three members of the Facility RBF Committee and select members of the community not related to any of the health facility staff. This indigent committee reviews each month the appropriateness of the allocations (ref PBF user manual). 17. Sub-contracting for defined services in the minimum service package 17.1 The Facility may sub-contract with select providers for defined services in the MPA will be allowed. The sub-contracts including the proposed services - will need to be proposed in the business plan, vetted by the LGA PHC department and approved by the SPHCDA. Sub-contracting can be with public, private non for profit and private for profit providers All sub-contracted services shall be verified by the SPHDA verification teams, and counter-verified by an independent agency through community client satisfaction surveys in the same manner as non sub-contracted services. The Health Facility, as principle contract holder, shall use the approved sub-contracting template (see PBF manual), shall be responsible for the filing and accessibility of all signed sub-contracts, and ensure secondary registers are in conformity with applicable norms in the same manner as the primary registers The Facility, as principal contract holder, is responsible for the appropriate quality standards of care in the sub-contracted facility which is under its direct supervision. It may use up to 25% of the earnings of its sub-contracted facility for its own administration costs provided that it is agreed upon in the sub-contract document between both facilities. Done at.. On./ /201.. For The State Primary Health Care Agency Mrs. / Mr. Signed And Chairman of the Ward Health Committee Mrs. /Mr./Dr Head of the Health Facility Mrs/Mr/Dr Signed Signed Version _pbf_usermanual_ng-final Page 68

69 Annex 1: list of Minimum Package of Health Services for the PBF purchase contract. Note: fees are valid for the first three months only and subject to possible re-adjustment by the SPHCDA. Previous fee/subsidy levels are not a guarantee for future fee levels. No MPA Service Fee (Naira) 1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital 5 Completely Vaccinated Child 6 Growth monitoring visit Child Tetanus Vaccination of Pregnant Woman 8 Postnatal consultation 9 First ANC consultation before four months pregnancy 10 ANC standard visit (2-4) 11 Second dose of SP provided to a pregnant woman 12 Institutional Delivery 13 FP: total of new users of modern FP methods 14 FP: implants and IUDs 15 VCT/PMTCT/PIT test 16 PMTCT: HIV+ mothers and children born to are treated according to protocol 17 STD treated 18 New AFB+ PTB patient 19 PTB patient completed treatment and cured 20 Household visit per protocol Version _pbf_usermanual_ng-final Page 69

70 Annex 2: Provisory Monthly PBF Invoice Provisory Monthly Invoice for MPA Services LGA: Health Center: Month: Year: Service 1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital 5 Completely Vaccinated Child 6 Growth monitoring visit Child Tetanus Vaccination of Pregnant Woman 8 Postnatal consultation 9 First ANC consultation before four months pregnancy 10 ANC standard visit (2-4) 11 Second dose of SP provided to a pregnant woman 12 Institutional Delivery 13 FP: total of new users of modern FP methods 14 FP: implants and IUDs 15 VCT/PMTCT/PIT test 16 PMTCT: HIV+ mothers and children born to are treated according to protocol 17 STD treated 18 New AFB+ PTB patient 19 PTB patient completed treatment and cured 20 Household visit per protocol Grand Total for the month Quantity Produced Unit Fee Sub- Total Naira The current invoice for the month of [ ] Naira of..health Center is totaled at Date. Health Center RBF Committee Members: The HC in charge: The verifier: Version _pbf_usermanual_ng-final Page 70

71 Annex 3: Fraud FRAUD: PREVENTIVE MEASURES AND PENALTIES Possible Fraud The introduction of PBF increases the risk for fraud as some providers or administrators inflate results to earn more money. Verification and counter-verification procedures mitigate the risk for fraud through measuring the difference between claimed (& paid for) performance and actual performance. This requires special attention to measures to detect fraud and to penalties applied in case of certified fraud. Fraud in PBF systems can be either intentional, or non-intentional. Intentional fraud relates to falsifying documents related to a service activity, falsifying register information, claiming services that had not been delivered, referring to acts of care that the user did not benefit from etc. Unintentional fraud (which is a rare occurrence) can be an error made by a verifier due to lack of comprehension of the indicators- on a quality checklist or it can be a misinterpretation of indicators by different verifiers (an effect known as inter-observer variability ). To avoid fraud - intentional or unintentional - there is need for incentives for good behavior, correct reporting and scoring, and disincentives for fraud. In all cases, possible fraud need to be substantiated quantitatively (the numbers and facts) but also qualitatively (a writing explanation as to what actual happened) as sometimes a case of non-intentional fraud can be based on a misinterpretation of an element of the quality checklist due for instance to a different sampling of a patient file, or be caused by different interpretations of the same event by different verifiers. However, once fraud is established based on quantitative proof, and supported by qualitative elements, strong actions needs to be implemented to discourage future fraudulent behavior. Fraud prevention The following preventive measures are implemented to decrease the risk of fraud, intentional or unintentional: Separation of functions, which helps to minimize fraud by avoiding conflicts of interest; Good quality ex-ante verification both of the quantity (SPHCDA) and quality (LGA-PHC departments); A clear manual, clear contracts and good training in the rules of the game; An effective reward and punishment system (and application of punishments in case of certified fraud); Good governance for PBF at the LGA level; Version _pbf_usermanual_ng-final Page 71

72 Regular community client satisfaction surveys with feedback of the results at all levels. If rules are transparent and known to all and actions are taken swiftly when fraud is detected while communicating such fraud and its consequences to all stakeholders, then the likelihood of fraud will be minimized. Penalties for Fraud When fraud is certified, the following actions are taken: Related to ex-post verification of the quantity (community client satisfaction surveys): If more than 5% (up to 10%) of the sample cannot be traced back in the community. This means that either the client exists but did not receive the service OR that the client does not exist. Verification is done through mobile phones and/or through household visits with certification that client does or does not exist as confirmed by the village head: o First offence: retention of 20% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website; o Second offence: retention of 50% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website; o Third offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA). Box 1: Penalties in case of more than 5% (up to 10%) untraceable clients First offence: retention of 20% of PBF earnings, no performance bonuses staff and repeat counter-verification Second offence: retention of 50% of PBF earnings, no performance bonuses staff and repeat counter-verification Third offence: stop the purchase contract, replace head of health facility. Version _pbf_usermanual_ng-final Page 72

73 If more than 10% of the sample cannot be traced back in the community: o First offence: retention of 50% of total PBF earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman with automatic inclusion in a next round of community client satisfaction surveys, publication of fraud on public website; o Second offence: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA). Box 2: Penalties in case of more than 10% untraceable clients First offence: retention of 50% of PBF earnings, no performance bonuses staff and repeat counterverification Second offence: stop the purchase contract, replace head of health facility Related to ex-post verification of the quality for health centers (quality counter-verification of HC): both the LGA PHC department and the health facility are penalized as follows: If the discrepancy is larger than 10% and no qualitative explanation can be given for this discrepancy (average across the sampled services according to the protocol): o First offence: related to the LGA-PHC department: retention of 50% of LGA-PHC department performance earnings while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification. Writing warning to the responsible verifier; related to the health facility: retention of 20% of the total earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman. o Second offence: related to the LGA-PHC department: retention of retention of 50% of LGA-PHC department performance earnings while remaining earnings Version _pbf_usermanual_ng-final Page 73

74 cannot be spent on individual performance bonuses PLUS warning in writing to the Director of the LGA-PHC department with a copy to the LGA chairman with automatic inclusion in a next round of quality counter-verification PLUS exclusion of responsible verifier from performance bonuses and from quality checklist assessments for a period of one year; related to the health facility: retention of 30% of the total earnings from a next payment while remaining earnings cannot be spent on individual performance bonuses PLUS warning in writing to the health facility RBF committee with a copy to the LGA chairman. o Third offence: Related to the LGA-PHC department: stop of the performance contract for the duration of one year (or until - for the SPHCDA - a satisfactory solution has been found) PLUS offering of quality supervision contract to another PHC pending resolution of the conflict. Related to the health facility: stop of the purchase contract until administrative action has been taken (replacement of the head of the health center by a suitable candidate whose candidacy is endorsed by the SPHCDA). Box 3: Penalties in case of more than 10% unexplained discrepant results in quality counter-verification of health centers First offence: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification. Health facility: retention of 20% of performance earnings, nil bonuses staff. Second offence: LGA-PHC department: LGA-PHC department retention of 50% of performance earnings, nil bonuses staff and repeat counter-verification plus exclusion of offending verifier from pool of verifiers. Health facility: retention of 30% of performance earnings, nil bonuses staff. Third offence: LGA-PHC department: stop the performance contract for the duration of one year. Health facility: stop the purchase contract. The ex-ante verification for the hospital quality is done by a multi-organizational team led by the SPHCDA, consisting of Hospital Board staff, third-party hospital staff and technical partner Version _pbf_usermanual_ng-final Page 74

75 agencies. The actual scoring for results is done by the SPHCDA with the others in observer status (i.e. not responsible for the actual scoring). Version _pbf_usermanual_ng-final Page 75

76 Annex 3: Motivation Contract between the Health Center Management and the Individual Health Worker Health Facility Worker Motivation Contract This Contract is dated [ ] 2011 Between: (Official name) Health Centre, herein referred as the facility or HF Represented by: Ms/Mrs. / Mr. [.] Head of [...] Health Centre, and Mrs. / Mr.: [..] Chair person of the [.] Facility RBF Committee And Dr/Ms/Mrs/Mr [names of HF worker], [Job title] herein referred as the worker IT IS AGREED as follows: 1. Principles of Performance Based Financing 1.1 The present contract is entered between the worker and the facility within the context of the Performance Based Financing (PBF) program and the Performance Based Financing Contract for the Purchase of Health Services signed between the facility and the State Primary Health Development Agency (SPHCDA). 1.2 The payment of workers motivation bonuses emanates from National Public Health policies and as such the Government reserves the right to unilaterally amend applicable policies prior to the expiry of the present contract. Version _pbf_usermanual_ng-final Page 76

77 1.3 The motivation contract institutes a mode of additional remuneration to the worker, by way of individual bonuses according to his or her personal work performance with respect to his or her Job Profile. 2. Validity of the contract: Motivation contract and employment contract 2.1 The Job Profile of the worker (in annex 1) including the details of his/her tasks at the Facility form integral part of the present contract. 2.2 The motivation contract does not supersede or replace the existing worker s employment contract. In the event the worker s employment contract is terminated, the present motivation contract shall automatically be terminated without notice. 3. Validity of the contract : Motivation Contract and PBF contract The existence of this contract is strictly subordinated to the existence and the duration of the PBF Purchase Contract between the facility and the State Primary Health Development Agency (SPHCDA). In the event the PBF Purchase Contract is terminated for any reasons, the present motivation contract shall automatically be terminated without notice. 4. Covenants of the parties 4.1 The Facility worker The worker shall use reasonable effort in promoting access of the population to better quality Health Care, working in collaboration with other facility workers The worker commits his/herself to safeguarding the transparency and veracity of information regarding the Facility s operations The worker agrees to be held accountable for fraud or negligence committed by him/her during the execution of his/her duties. 4.2 The Health Facility a) The Facility management commits itself to evaluate monthly, in an objective and transparent way, the performance of the worker in light of his Job Profile and tasks which were assigned to him. b) The Facility management commits itself to pay to the worker a performance bonus on a monthly basis, if the general financial position and the performance income permit, and according to the terms of the present contract. Performance bonuses are the result of a mix of productivity and quality of the health facility. If this productivity is low, there will Version _pbf_usermanual_ng-final Page 77

78 be less money available for performance bonuses. The health facility management and the RBF Health Committee might propose, to invest in upgrading the physical infrastructure and the equipment first, to gain more performance payments in the future. Such a strategy will be communicated to the staff. Therefore, the performance bonuses might be forfeited by management, to invest in the health services offered to the population, but which might, in the middle term, lead to higher performance rewards by the health facility and its workers. c) The Facility management commits itself to put all reasonable effort in providing the worker with the resources necessary for the successful completion of the tasks assigned to her/him and within the limits of the resources available to the facility. 5. Amount and Calculation of Salary Bonuses 5.1 The payment of individual bonuses shall be approved by the RBF Committee upon proposal from the Facility Internal Management Committee (IMC) using the result of Monthly Individual Evaluation and the index corresponding to his/her professional category as determined by the IMC. 5.2 Important: the management of the health facility, in conjunction with the RBF Committee, may decide to forfeit part or all of the bonus payments for a given quarter, in order to invest in increasing the quantity and quality of care. Individual performance bonuses might, therefore, fluctuate considerably each quarter. 5.3 The amount payable to the worker shall be calculated as follows: The Indice value corresponding to his/her professional position, which is hereby fixed at points. 5.4 The individual performance award is calculated by multiplying the individual indice value with the monthly point value with the individual performance evaluation. The proportion of the Facility s profits allocated to the payment of facility worker s bonuses is determined quarterly by the Facility s RBF Committee. See the PBF manual and the indice tool for further guidance. 6. Payment of PBF workers bonuses The PBF bonuses shall be paid to the workers retrospectively on a monthly basis. 7. Individual performance evaluation The Internal Management Committee of the HF shall, on a monthly basis, evaluate the worker s performance in accordance with the tasks assigned to him. The IMC shall keep individual Version _pbf_usermanual_ng-final Page 78

79 performance score cards that will record the worker s performance. These individual score cards shall be kept accessible for transparency and audit purposes. 8. Temporary suspension of the motivation bonuses In the event of fraud, record falsification, or any other serious irregularity, the RBF Committee may decide to suspend salary bonuses of all HF Workers for a maximum period of three (3) months. 9. Resolution of disputes In the event of any disputes relating to execution of the present contract, either party may resort to the arbitration of the Facility RBF Committee. All parties hereby agree that such arbitration shall be final and binding towards all parties. 10. Duration and amendment of the contract The present contract is valid from [ ] for a period of [.] month until [...] and it shall be tacitly renewed for as long as the worker s employment contract remains in force. Done at.. On./ /201 The Worker Ms/Mrs. / Mr. Signed And Chairman of the RBF Committee Ms/Mrs. /Mr. Head of the Health Facility Ms/Mrs./Mr. Signed Signed Annex 1: Job Profile Version _pbf_usermanual_ng-final Page 79

80 Annex 4: Contract between the SPHCDA and the LGA PHC Department ( ) State Primary Health Care Development Agency PERFORMANCE BASED FINANCING (PBF) CONTRACT FOR THE QUALITY SUPERVISION OF HEALTH SERVICES No THIS CONTRACT is dated [..] 2011 BETWEEN: The State Primary Health Care Agency ( SPHCDA ) represented by its Executive Director Dr. /Mrs. /Mr. : And The [.] Local Government Authority Primary Health Care Department Represented by: Mrs. / Mr.: [ ] Primary Health Care Department Coordinator Mrs. / Mr.: [.] Chairperson of [ ] Local Government Version _pbf_usermanual_ng-final Page 80

81 IT IS AGREED as follows: 1. Principles of Performance Based Financing 1.1 The present contract is a performance contract between the SPHCDA and the Local Government Authority Primary Health Care Department (PHCD) in the context of the State s Performance Based Financing (PBF) program. 1.2 The goal of PBF is to increase the provision of quality Basic Health Services to the population by increasing financial incentives for health workers and by increasing health facilities decisional rights on the management of their own operations. 1.3 The Performance Based Financing strategy emanates from National Public Health and Poverty Reduction policies. The SPHCDA reserves the right to amend the applicable policies that serve as the basis of its support to the PHCD prior to the expiry of the present contract. 2. Purpose of the Contract 2.1 The purpose of this contract is to establish a performance contract for the LGA PHCD to undertake Supervision of the Quality of Care at the LGA s PBF contracted Health Facilities based on the applicable Performance Framework (see attached in annex 1). 2.2 Part of the payments received under these terms may be used by the PHCD department to pay for incremental expenses directly related to the Supervision and Control Activities, including, but not limited to, per-diem for supervision team members, office equipments and consumables, maintenance and repair of vehicles and communication costs. 2.3 Part of the payments received under this performance contract may be used to pay performance bonuses to staff involved in the supervisory activities. 3. Mission of the PHCD within the PBF System 3.1 The Primary Health Care Department (PHCD) shall ensure that Health Facilities in the LGA provide adequate quality health care services in the general interest of improvement of public health in the community. 3.2 In doing so, the PHCDA hereby commits to undertake the following: Conduct timely quarterly quality supervisions of the Health Facilities contracted through PBF contracts with the SPHCDA (as stipulated in Section 4 herein); Investigate at facility level any activities in contradiction with national health policies and/or accepted medical ethics and solve these, and bring these to the attention of the LGA RBF Steering Committee if necessary; Version _pbf_usermanual_ng-final Page 81

82 Supervise the Health Facilities regularly (as stipulated in Section 4 herein), investigate and document for the LGA RBF Steering Committee any change in HF personnel, technical skills and equipment at the facility that which could hamper its capability to render the Services remunerated by the present PBF contract; Investigate and Report in writing any case of fraud or attempted fraud committed by HF staff members to the SPHCDA and the LGA RBF steering committee; Ensure complete transparency and access to information relating to the use of funds received from the SPHCDA in relation to the present contract. 4. Quality audits of the PBF contracted Health Facilities 4.1 For the purpose of this contract, the term PBF facilities shall refer to all health facilities that are contracted and remunerated by the SPHCDA through PBF purchase contracts; 4.2 The PHCD verification teams shall conduct Quarterly Control audits by applying the applicable PBF Quality supervisory checklist (see template in annex 2). This checklist is updated regularly, typically annually, and the PHCD should use the latest version as developed and approved by the NPHCDA/SPHCDA; 4.3 Such Quarterly Quality supervision shall be conducted at all PBF facilities no later than the 15 th of the fourth month following the quarter and must contain all quality scores for review and validation by the LGA RBF Steering Committee; 4.4 The original of all quality supervisory checklists shall be sent to the SPHCDA, and arrive there no later than the 20 th of the fourth month (the month following the quarter). 5. Business Plans 5.1 The PHCD shall review on a quarterly basis the level of implementation of the Business plans developed by the HFs and part of their PBF purchase contracts. The Business Plans evaluation shall form part of the PBF Quality Verification checklist as described in annex 2; 5.2 The PHCD may, as a result of the review, suggest changes to the business plans in close collaboration with the Facility RBF Committees and Heads of facilities. The PHCDA has an important technical supportive and advisory and capacity strengthening role in this aspect; 5.3 In relation to 5.2, it is ultimately the SPHCDA which will have to agree on the proposed business plan contents, and which consists of a negotiation between the health facility management and the SPHCDA directly. 6. Performance Remuneration of the PHCD Version _pbf_usermanual_ng-final Page 82

83 6.1 The budget ceiling for this contract is Naira (N ). The level of remuneration shall be directly proportional to the score obtained by the PHCD in accordance with the performance framework tool (as detailed in Annex 1 of the present contract); 6.2 For instance, if the PHCD obtains 75% score in a given quarter, the PHCD shall receive 75 % of the total available performance budget for that quarter. 7. Evaluation of the PHCD Performance 7.1 The SPHCDA Verifier shall evaluate the PHCD s performance every quarter, not later than the 15th day of the month immediately following each concerned quarter and using the Performance Assessment Framework; 7.2 The SPHCDA Verifier shall sign 1 original of the quarterly performance assessment, the original will go to the SPHCDA HQ for filing and entry in the web-enabled application; a copy will remain at the PHCD and will be presented during the following RBF steering committee meeting; 7.3 In case of systematic underperformance, such as not carrying out the quality supervision in a timely and complete manner, or in the case of fraud with the quality assessments, the SPHCDA retains the right to unilaterally stop this contract, and to provide this contract to another party. 8. Terms of payment 8.1 The SPHCDA shall directly pay the PHCD by way of bank transfer in the designated PHCD bank account in quarterly installments; 8.2 Payments will be executed along with the performance payments for health facilities, and will follow the same system of validation, due diligence and approvals (validation in the LGA RBF Steering Committee; submission of minutes of the meeting and invoices to the SPHCDA; due diligence of the SPHCDA on the deliverables; payment for performance by the PFMU); 8.3 It is hereby agreed, as a critical pre-condition to the present contract, that the PHCD shall have direct access and control of the designated bank account. 9. Dispute resolution 9.1 In the case of dispute relating to the interpretation of the present contract, both parties agree to refer to the most current applicable Performance Based Financing User Manual, and attempt to resolve the issue in the LGA RBF Steering Committee meeting; Version _pbf_usermanual_ng-final Page 83

84 9.2 In the case of dispute relating to the implementation of the present contract, both parties agree to refer to the matter to the arbitration of the State RBF steering committee which acts as the regulator of the PBF system in the State. The arbitration decision in the matter shall be final and binding towards all parties. 9.3 However, in case of systematic underperformance, as documented in section 7.3, the SPHCDA retains the right to stop the current contract unilaterally and to contract with another party. 10. Duration of the Contract The present contract is signed on [date] for a period of 12 months. It shall be renewed tacitly for an additional 12 months subject to the terms stipulated in section 1 of the present contract. Done at.. On / /2010 For The State Primary Health Care Agency Mrs. / Mr. Signed And Chairperson of the Local Government Authority LGA PHCD Coordinator Mrs. /Mr. Mrs. /Mr. Signed Signed Annex 1: LGA PHC Department performance framework Annex 2: Quality Supervisory Checklist for Health Centers Version _pbf_usermanual_ng-final Page 84

85 Annex 5: Sub-Contract between the Health Provider and a Secondary Health Provider PERFORMANCE BASED FINANCING (PBF) SUBCONTRACT Subcontract No. Between Health Center (Principal Facility) in [.] State; [.] Ward, [ ] LGA And Health Center/Health Post (Subcontractor) 1. Purpose of the contract The present contract is a performance contract between the Principal Facility and the Subcontractor for the remuneration of health services provided by the subcontractor on a case based payment basis. 2. Services delivered The Health Services provided by the subcontractor and their remuneration are as follows: No Service Fee 1 New Outpatient Consultation 2 Fully Vaccinated Child 3 FP new or existing user of modern FP methods 4 Growth monitoring visit child 5 Household visit as per protocol The Fee has been adjusted to reflect the administrative overheads that the principal PBF contractor is allowed to levy on each service of the sub-contractee. This administrative overhead is meant to pay for the efforts of the main PBF contractor to (a) manage the sub contracting Version _pbf_usermanual_ng-final Page 85

86 process; (b) ensure quality services delivered by the sub-contractor; (c) coaching on the use of registers; (d) coaching in the use of advanced strategies employed to boost productivity. The administrative overheads can be up to a maximum of 25% of the Fee value claimed by the main PBF contractor, from the SPHCDA. It can be a lesser percentage, but not a higher percentage. 3. Principal contract The existence of this contract is subordinated to the existence and the duration a Principal PBF Purchase Contract between the Principal Facility and the State Primary Health Development Agency (SPHCDA). In the event the Principal Contract is terminated for any reasons, the present subcontract may automatically be terminated without notice. 4. Interpretation and reference Both parties agree to refer to the most current applicable Performance Based Financing User Manual and the Principal PBF Contract between the Principal Facility and the State Primary Health Development Agency (SPHCDA) for any matter relating to the interpretation and execution of obligations inferred by the present contract. 5. Duration, validity and termination The present contract is valid for a period of [ ] months from [Date.] to [Date ] subject to satisfaction of both parties. Either party may terminate the contract at any time. It shall be renewed automatically for additional 12 months periods in the absence of writing notice to the contrary emanating from one of the party prior to the end date. 6. Dispute resolution Both parties agree to refer any dispute relating to the present contract to the Facility RBF Committee. In case of unresolved conflict, the issue will be referred to the LGA RBF steering committee, whose decision will be final. SIGNED on By Head of Health Center And Head of Health Center/Post Contractor Sub-contractor Version _pbf_usermanual_ng-final Page 86

87 Annex 6: MPA and CPA 1. Minimum Package of Activities (MPA) No MPA Service 1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital 5 Completely Vaccinated Child 6 Growth monitoring visit Child Tetanus Vaccination of Pregnant Woman 8 Postnatal consultation 9 First ANC consultation before four months pregnancy 10 ANC standard visit (2-4) 11 Second dose of SP provided to a pregnant woman 12 Institutional Delivery 13 FP: total of new users of modern FP methods 14 FP: implants and IUDs 15 VCT/PMTCT/PIT test 16 PMTCT: HIV+ mothers and children born to are treated according to protocol 17 STD treated 18 New AFB+ PTB patient 19 PTB patient completed treatment and cured 20 Household visit per protocol Version _pbf_usermanual_ng-final Page 87

88 2. Complementary Package of Activities (CPA) No CPA Service 1 New outpatient consultation by a Doctor 2 New outpatient consultation by a Doctor of an indigent patient 3 Counter-referral slip arrived at the Health Center 4 Minor Surgery 5 Major Surgery (ex CS) 6 Normal delivery 7 Assisted Delivery 8 CS 9 Inpatient Day 10 Inpatient Day for an indigent patient 11 Postnatal consultation 12 First ANC consultation before four months pregnancy 13 ANC standard visit (2-4) 14 FP: total of new users of modern FP methods 15 FP: implants and IUDs 16 FP: vasectomy and bilateral tuba ligation 17 VCT/PMTCT/PIT test 18 PMTCT: HIV+ pregnant mothers and children born to are treated according to protocol 19 STD treated 20 New Client put under ARV treatment 21 New AFB+ PTB patient 22 PTB patient completed treatment and cured Version _pbf_usermanual_ng-final Page 88

89 Annex 7: Service Protocol Reference Guides Minimum Package of Activities No Name MPA Service Description Primary Data Collection Tools 21 1 New outpatient consultation Any new curative care visit during the past month 2 New outpatient consultation of an indigent patient During the past month, indigents who have been consulted as an outpatients. Indigents are locally identified. Maximum of 5% of all new curative consultations during the previous month. 3 Minor Surgery Any new minor surgical intervention during the past month. Minor Surgery defined as (i) Suture; (ii) incision and drainage; (iii) minor excisions. Curative Care Register Indigent outpatient register Minor Surgery Register Secondary Data Collection Tools 22 Original prescription for drugs dispensed kept at the pharmacy which includes cost of drugs. Drugs register and stock cards conform. Proceedings indigent committee Community Client Satisfaction Survey: postidentification questionnaire application Original prescription for drugs and medical consumables dispensed kept at the pharmacy which 21 See Annex Primary Data Collection Tool Column Headers. These registers ought to be well-legible with filled all columns filled in. The PBF column header formats are mandatory. If information is lacking, automatically this service is not remunerated/validated. The Verifier can use a red pen to cross out the service and or to make annotations. If the mobile phone number is not recorded, the service risks not being remunerated. In case of absence of mobile phone number the client can provide any number, i.e. from a family member, the neighbor, or the village chief. But a recorded number is mandatory. In the unlikely case that the client has no number at all to provide, the patient will need to sign the register s column header. 22 The secondary data collection tools can be partially at the health facility, partially with the client. They can be subject to scrutiny during either the routine data verification exercises, and or during the community client satisfaction surveys. In case there is no trace of such services rendered in the secondary data collection tools, then the service might be considered not rendered ex-post, and sanctions will be applied as per contract.

90 No Name MPA Service Description Primary Data Collection Tools 21 4 Referred patient arrived at the General Hospital Counter-referral slip available at the Health Center. Fully filled in by the MD. The number of valid counter-referral slips is counted. 5 Completely Vaccinated Child Child less than 12 months old which has received all vaccines according to the national protocol (BCG; DTP3; Measles) 6 Growth monitoring visit Child Any new quarterly growth monitoring visit of a child less than five years old during the past month. These growth monitoring visits ought to be monthly according to the protocol, however, here, Tetanus Vaccination of Pregnant Woman a quarterly visit is remunerated. Each second to fifth TT vaccination of a pregnant woman during the past month 8 Postnatal consultation A post natal consultation held within 48 hours after giving birth, during the past month. 9 First ANC consultation before four months pregnancy A first ANC consultation occurs before 4 month s pregnancy, during the past month. Version _pbf_usermanual_ng-final Page 90 Original of counter-referral slip available at the Health Center. Vaccination Register Under-five clinic/nutrition Register ANC register Individual Card kept at the HF Delivery register ANC register Individual Card kept at the HF Secondary Data Collection Tools 22 includes cost of drugs/consumables. Drugs register and stock cards conform. Copy of the counter-referral slip available at the General Hospital. Referred patient registered in the outpatient s department register. Under-five card with vaccination records, held by the mother. Under-five card with growth curve plotted, held by the mother ANC card held by the mother Vaccination register Partogram or inpatient form ANC card held by the mother 10 ANC standard visit (2-4) Any 2-4 th standard visit according to the ANC register ANC card held by the

91 No Name MPA Service Description Primary Data Collection Tools Second dose of SP provided to a pregnant woman focused antenatal care visit schedule and approach. Second visit between weeks; third visit at 32 weeks and the fourth visit at 36 weeks. During the past month. The second dose of SP (IPTp), according to the protocol, during the past month. 12 Normal delivery A delivery attended by a trained attendant at the health facility during the past month. 13 FP: total of new and existing users of modern FP methods Any new or existing user of injectable contraceptive or oral contraceptive pills, during the past month. An injection represents three month s protection and a FP visit for OAC should provide three month s worth of pills. 14 FP: implants and IUDs Any new user of implant or IUD, during the past month. Individual Card kept at the HF ANC register Individual Card kept at the HF Delivery Register FP register Individual Card kept at the HF FP register Individual Card kept at the HF Secondary Data Collection Tools 22 mother Medical prescriptions for Ferrosulphate, Vermox and SP kept at the pharmacy. Drugs register and stock cards conform. ANC card held by the mother; medical prescription for SP kept at the pharmacy. Drugs register and stock card conform. Partogram; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs Version _pbf_usermanual_ng-final Page 91

92 No Name MPA Service Description Primary Data Collection Tools VCT/PMTCT test Any new VCT or PMTCT test carried out during the past month. 16 PMTCT: HIV+ mothers and Any new HIV+ mother and newborn children born to are treated child treated according to the PMTCT according to protocol protocol, during the past month. 17 STD treated Any new STD treated according to syndromic treatment protocol, during the past month 18 New AFB+ PTB patient A new AFB sputum positive Pulmonary Tuberculosis patient diagnosed, at the facility, during the past month. 19 PTB patient completed treatment and cured A former AFB+ PTB patient completed DOTS, and cured after treatment proven by negative sputum examinations, during the past month. 20 Household visit per protocol A household visit as per protocol, using a defined list of questions/issues and ending with a business plan for each household related to water&sanitation; FP/RH; vaccinations and growthmonitoring visits. VCT register ARV register; delivery room register Curative Care Register Tuberculosis register Tuberculosis register Household visit register Secondary Data Collection Tools 22 register and stock cards conform. Laboratory register; stock records PMTCT register; laboratory register; stock records. Drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Laboratory register. Slides kept for counterverification/quality assurance. Laboratory register. Slides kept for counterverification/quality assurance. Drugs register. Version _pbf_usermanual_ng-final Page 92

93 Complementary Package of Activities No Name CPA Service Description Primary Data Collection Tools 23 1 New outpatient consultation by a doctor 2 New outpatient consultation by a doctor of an indigent patient Any new curative care OPD visit attended by a Doctor during the evaluated month Any new curative care OPD visit by an indigent patient attended by a Doctor during the evaluated month. Indigents identified according to local norms. Maximum of 20% of all new curative consultations and or admissions during Curative Care Register Indigent register Secondary Data Collection Tools 24 Original prescription for drugs dispensed kept at the pharmacy which includes cost of drugs. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams. Proceedings Indigent committee Community Client Satisfaction Survey 23 See Annex Primary Data Collection Tool Column Headers. These registers ought to be well-legible with filled all columns filled in. The PBF column header formats are mandatory. If information is lacking, automatically this service is not remunerated/validated. The Verifier can use a red pen to cross out the service and or to make annotations. If the mobile phone number is not recorded, the service risks not being remunerated. In case of absence of mobile phone number the client can provide any number, i.e. from a family member, the neighbor, or the village chief. But a recorded number is mandatory. In the unlikely case that the client has no number at all to provide, the patient will need to sign the register s column header. 24 The secondary data collection tools can be partially at the health facility, partially with the client. They can be subject to scrutiny during either the routine data verification exercises, and or during the community client satisfaction surveys. In case there is no trace of such services rendered in the secondary data collection tools, then the service might be considered not rendered ex-post, and sanctions will be applied as per contract. Version _pbf_usermanual_ng-final Page 93

94 No Name CPA Service Description Primary Data Collection Tools 23 3 Counter-referral slip arrived at the Health Center the previous month. A counter-referral note filled by the MD, sent to the health center, during the evaluated month. The feedback must at least mention the diagnosis and treatment received. The carbon copy of the referral note is only remunerated when it is accompanied by a short note with name, date and signature of the health center incharge. 4 Minor Surgery Any new minor surgical intervention during the evaluated month. Minor Surgery defined as (i) Suture; (ii) Herniotomy; (iii) Subcutaneous cyst removal; (iv) I&D; (v) amputation of a finger/toe 5 Major Surgery (ex CS) Any new major surgical intervention during the evaluated month. Major surgical intervention defined as a laparatomy for any cause (bar CS), or amputation of a large limb. Carbon copy of the original referral slip, filled in by the MD. Minor Surgery Register Theater register Secondary Data Collection Tools 24 Original prescription for drugs and medical consumables dispensed kept at the pharmacy which includes cost of drugs/consumables. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams. Original referral slip available at the Health Center Original prescription for drugs and medical consumables dispensed kept at the pharmacy which includes cost of drugs/consumables. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams. Original prescription for drugs and medical consumables dispensed kept at the pharmacy which includes cost of Version _pbf_usermanual_ng-final Page 94

95 No Name CPA Service Description Primary Data Collection Tools 23 6 Normal delivery A normal delivery attended by a trained attendant in this facility, during the evaluated month. 7 Assisted delivery An assisted delivery attended by a Doctor in this facility, during the evaluated month. 8 CS A CS carried out at this facility during the evaluated month. 9 Inpatient Day One day admission of an admission of a minimum of three days duration and discharged alive, during the past month. Delivery register Delivery register Delivery register or theater register General admission register for each department Secondary Data Collection Tools 24 drugs/consumables. Drugs register and stock cards conform. Lab/radiology register contains proof of requested exams. Partogram and inpatient file; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Partogram and inpatient file; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Partogram and inpatient file; eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register In patient form kept at the health facility Version _pbf_usermanual_ng-final Page 95

96 No Name CPA Service Description Primary Data Collection Tools Postnatal consultation A post natal consultation held within 48 hours after giving birth, during the past month. 11 First ANC consultation before four months pregnancy A first ANC consultation occurs before 4 month s pregnancy, during the evaluated month. 12 ANC standard visit (2-4) Any 2-4 th standard visit according to the focused antenatal care visit schedule and approach. Second visit between weeks; third visit at 32 weeks and the fourth visit at 36 weeks. During the evaluated month. 13 FP: total of new users of modern FP methods Any new or existing user of injectable contraceptive or oral contraceptive pills, during the past month. An injection represents three month s protection and a FP visit for OAC should provide three month s worth of pills. 14 FP: implants and IUDs Any new user of implant or IUD, during the evaluated month. 15 FP: vasectomy and bilateral tuba ligation A vasectomy and bilateral tuba ligation carried out at this facility, during the evaluated month ANC register ANC register ANC register FP register FP register Theater register Secondary Data Collection Tools 24 ANC card kept at the health facility ANC card kept at the health facility. ANC card kept at the health facility. Medical prescriptions for Ferrosulphate, Mebendazole and Fansidar kept at the pharmacy. Drugs register and stock cards conform. Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Eventual drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Family Planning Register Version _pbf_usermanual_ng-final Page 96

97 No Name CPA Service Description Primary Data Collection Tools VCT/PMTCT/PIT test Any new VCT or PMTCT or PIT test carried out during the evaluated month. 17 PMTCT: HIV+ pregnant Any new HIV+ mother and newborn mothers and children born to child treated according to the PMTCT are treated according to protocol, during the evaluated month. protocol 18 STD treated Any new STD treated according to the syndromic treatment protocol, during the evaluated month 19 New Client put under ARV treatment Any new patient (pediatric or adult) HIV positive who started ARV (Antiretroviral therapy), including transferred in, during the evaluated month. 20 New AFB+ PTB patient A new AFB sputum positive Pulmonary Tuberculosis patient diagnosed, at the facility, during the past month. 21 PTB patient completed treatment and cured A former AFB+ PTB patient completed DOTS, and cured after treatment proven by negative sputum examinations, during the past month. VCT/PMTC register ARV register; delivery room register Curative Care Register ART Register Tuberculosis register Tuberculosis register Secondary Data Collection Tools 24 Laboratory register; stock records PMTCT register; laboratory register; stock records. Drugs and medical consumables dispensed through the prescriptions kept at the pharmacy; drugs register and stock cards conform. Patient files Laboratory register: Slides kept for counterverification/quality assurance. Laboratory register: Slides kept for counterverification/quality assurance. Drugs register. Version _pbf_usermanual_ng-final Page 97

98 Annex 8: Quarterly Quality Supervisory Checklist for Health Centers [.....] MOH/[....] PHCDA Quarterly Quality Review of Health Centers version 14 December, 2013 Date: Name Supervisor: LGA: Ward: Medical Staff Total: HF: Population: Non-Medical Staff Total: 1 General Management [max 21 points] YES NO 1.1 Presence of map of health facility catchment area Health map of the health area available and on the notice board of the health facility showing villages, main roads, natural barriers, special points and distance 1.2 HMIS reports - business plan - minutes of meetings and patient cards (OPD, ANC, Partographs, FP and Bed head tickets) well stored In cupboard and in box files and accessible by the duty manager 1.3 Staff duty roster available and well displayed up to date for current month and visible for staff and patients 1.4 Technical meetings with staff conducted monthly and minutes available Each monthly minutes contains at least: (i) date of the meeting; (ii) signed list of participants; (iii) follow-up of decisions taken during the previous meeting; (iv) there is a list of developed recommendations or decisions taken; (v) each month the monthly financial balance is discussed; (vi) minutes of the meeting are signed by the chair. For every meeting report that contains the above = 2 p. (max 3 reports) 1.5 Standard Sheets for referral available At least 10 standard sheets are present during the evaluation Availability of communication radio or dedicated mobile phone for communication between health facility and general hospital Radio or mobile phone functional with batteries and/or call credit and contact details on the phone (e. g: Medical Director CH, HF Staff, LGA PBF HFs OICs, PHC Dept. PBF Team and SPHCD PBF Team, etc.) HMIS reports are filled, updated and transmitted to the LGA on schedule 3 0; 1;2 5 0

99 Remark s Transmission of HMIS report is after verification of the SPHCDA of the monthly MPA invoice (including those of subcontracted HFs if applicable) and a signed receipt of acknowledgement is available HMIS data analysis report for the quarter being assessed concerning priority problems Five priority health problems are followed each quarter and data have been updated up to the month prior to the supervisor's visit (all or nothing) Health Facility RBF Committee meetings conducted monthly and minutes available Each monthly minutes contain: (i) date of the meeting; (ii) signed list of participants; (iii) follow-up of decisions taken during the previous meeting; (iv) there is a list of developed recommendations or decisions taken; (v) each month the monthly financial balance is discussed; (vi) minutes of the meeting are signed by the chair. Each report according to norms = 1 p (maximum 3 points) Total Points (21)../21 (0; 1; 2) Date: Signature of the Name of Supervisor: supervisor: 2 Business Plan [max 9 points] YES NO 2.1 Quarterly business plan for the current period made and accessible Valid and renegotiated for the current quarter (Section 2: Business Plan) 2.2 Business plan prepared with key stakeholders Facility RBF Committee Members involved (Chairman (president) signed off on the plan) Representative (s) of subcontracted private clinics or health posts involved (if applicable) 2.3 Business plan contains convincing geographic coverage plan Strategies for sub-contracts (e.g. villages at more than one hour by foot) are elaborated Mobile strategies (EPI, FP; ANC, household visits per protocol) are used and planned Business plan analyses presence of untrained informal practitioners in catchment area HF treats this subject in the BP, and suggests a strategy for dealing with informal practitioners Business plan analyses presence of trained practitioners operating without any permission Version _pbf_usermanual_ng-final Page 99

100 2.5.1 BP may suggest to include them or to discourage if quality conditions are not met 2.6 Business plan shows a plan to assure financial accessibility for the population Business plan shows negotiated rates between HF, committee and community Business plan shows planning for care for the indigents Remarks Total Points (9)../9 Date: Name of Supervisor: Signature of the supervisor: 3 Finance [max 15 points] YES NO 3.1 Financial and accounting documents available and well kept Monthly financial report available and correctly filled Theoretical balance of cash-book corresponds to liquidity in cash Document available (Indice Tool) to show that quarterly calculation of incomes, running costs, investments and variable performance subsidies are done This document guarantees running costs: = salaries, purchase of drugs and equipment, subcontracts, petty cash from small expenditures, social marketing, maintenance and rehabilitation This document calculates the performance bonus according to the formula: performance bonuses = income of the quarter - running costs Contract salaries and benefits + performance bonuses do not exceed 50% of total HF income through PBF Existence of monthly performance bonus system is known by staff Take a random staff member and ask what the performance bonus was last month, and what his or her individual performance % was. If both are explained then 4 points. Total Points (15)../ Version _pbf_usermanual_ng-final Page 100

101 Remarks Date: Name of Supervisor: Signature of the supervisor: 4 Care for the Indigents [max 4 points] YES NO 4.1 Planning for Care for the Indigents expenditures % of curative consultations of the previous month: documented quantity in monthly management meetings 4.2 Indigent committee meets monthly Remarks The Indigent committee meets monthly to review the Care for the Indigent Category use. Each monthly minutes contain: (i) date of the meeting; (ii) signed list of participants; (iii) follow-up of decisions taken during the previous meeting; (iv) there is a list of developed recommendations or decisions taken; (v) each month the monthly financial balance is discussed; (vi) minutes of the meeting are signed by the chairman. Each report according to norms = 1 p 3 Total Points (4)../4 0; 1; 2 Date: Signature of the Name of Supervisor: supervisor: 5 Hygiene and Sterilization [max 31 points] YES NO 5.1 Fence health facility available and well-maintained Fence exists, can be closed at night and there are no holes 5.2 Availability of a garbage bin in the courtyard Bin with lid accessible to clients which is not full 5.3 Presence of sufficient latrines/toilets which are well-maintained At least two functional latrines/toilets Version _pbf_usermanual_ng-final Page 101

102 5.3.2 Floor without fissures with single hole and lid Recently cleaned without visible fecal matter Door lockable from the inside, super structure with roofing, without flies and no smell Smells of disinfectant Presence of sufficient showers which are well-maintained At least one bathing facility (with floor without fissures, Door lockable from the inside, super structure with roofing) Bathing facility with running water, or container with at the least 20 L of water Evacuation of the waste water in a sanitation pit Waste pit for Health Care Waste is available and according to the norms Waste disposal pit minimum 2 meters deep, lined with clay, concrete or brick or plastic, it is fenced and has a bright flag. The waste pit is a minimum of 15 meters from the health facility, minimum of 50 meters from a household, and 100 meters from a water source Health Care Waste is not visible (covered by at the least 10 cm of soil or lime) The health facility maintains a register indicating the date of the creation of the pit(s), and the location (s) 5.6 Courtyard clean No waste or medical waste in the courtyard 5.7 Sterilization according to norms using a pressure sterilizer Sterilizer functional Sterilization protocol available and utilized (medical personnel present can explain the protocol or demonstrate the process) 5.9 Hygienic conditions assured during wound dressing and injections Yellow and Red Bins for medical waste with lid and foot pedal, lined with bag Security box for needles well positioned, and used (and not full) (Section 5: Hygiene) Needle cutter available and used Container/bowl with lid containing disinfectant used for putting used instruments 5.10 Disposal of Health Care Waste according to National Norms Waste disposal of non-contaminated waste in Black Bin with lid and foot pedal, lined Waste disposal of contaminated HCW in Yellow Bins with lid and foot pedal, lined Waste disposal of organically HCW in Red Bins with lid and foot pedal, lined Protective gear for personnel managing HCW available; boots, plastic shorts, thick plastic/rubber gloves Remarks Total Points (31)../ Version _pbf_usermanual_ng-final Page 102

103 Date: Name of Supervisor: Signature of the supervisor: 6 Curative Consultations [max 97 points] YES NO 6.1 Good conditions in waiting area Sufficient benches and or chairs protected against sun and rain and waiting area is not inside the consultation room 6.2 Unit fees of drugs displayed to the public Easily visible in the consultation room waiting area, updated, with (i) unit price per item; (ii) price for a standard treatment of the drug Drugs are all generics 6.3 Existence and use of waiting card system with numbers 6.4 Consultation room in good condition Walls with durable materials well painted, floor paved with cement without fissures, undamaged ceiling Consultation room and waiting space separated assuring confidentiality Windows with curtains Functional door with functional lock Running water (tap or water dispenser) with soap and clean towel available and used between patients 6.5 Consultation room (where emergencies are received) has 24/7 light Electricity or solar light or functioning high pressure kerosene light present 6.6 Consultations are done by skilled staff Identification of consulting staff in register (names, rank and signature) 6.7 Consulting staff is well-dressed Clean blouse and footwear 6.8 Correct numbering of registers Correct numbering and closed at the end of the month 6.9 Service availability 7/ Supervisor verifies entries in register for the last three Sundays 6.10 Malaria protocol put on wall and accessible for staff National protocol for diagnosis and treatment of simple and severe malaria Version _pbf_usermanual_ng-final Page 103

104 6.11 Simple malaria correctly treated Register see last five cases of simple malaria and review treatment acc protocol (one point for each correct treatment according to protocol: max 5 points) WHO flow diagram for ARI put on wall and accessible for staff 6.13 ARI protocol applied See last five cases of ARI and review treatment acc protocol; register mentions Temp; RR; cough yes/no; diagnosis (one point for each correct treatment according to protocol: max 5 points) WHO protocol for Diarrhea put on wall and accessible for staff 6.15 Diarrhea protocol applied See last five cases of Diarrhea and review treatment acc protocol (each correct treatment one point; max 5 points) 6.16 Proportion of consultations treated with antibiotics <30% See last 100 cases in register, check diagnosis and calculate the rate (< 30 cases) (Section 6: OPD) Treatment guidelines available in consultation room 6.18 Knowledge of tuberculosis danger signs and criteria for referral Select any available qualified medical staff, and ask the question on TB dangers signs Answer must contain at least 4 of the following signs: (i) weight loss; (ii) loss of appetite; (iii) fever; (iv) cough of more than 15 days duration; (v) night sweating Stethoscope and BP machine available and functional Let nurse check BP and review measure 6.20 Thermometer available and functional 6.21 Otoscope available and functional 6.22 Examination bed available with mattress Non-torn, plastic cover, specific for the OPD consultations only 6.23 Weighing scale available and functional Inspect in comparison with known weight of supervisor: after weighing, the balance should return to zero 6.24 Integrated Management of Childhood Illnesses strategy is applied Protocol is available in the consultation room The last five IMCI cases are traced in the register and comply with the IMCI strategy (all five) 6.25 Determination of nutritional status Determination of nutritional status of all children under 5 who come for consultation (check ten children under five through a random sampling method: take a random number between 1 and 3 and using this sampling interval check five consultations) Version _pbf_usermanual_ng-final Page 104

105 Determination of nutritional status of all women with a sick child under 6 months of age (as above) Screening record of nutritional status available, up to date and properly filled out Direct observation of three consecutive children under five (each child maximum 14 points; max 42 points) Ask about fever and IF FEVER ask about (i) since when; (ii) persistent or intermittent Ask about cough and IF COUGH ask about since when Ask for diarrhea IF DIARRHOEA then ask (i) since when; (ii) how often per day; (iii) consistency - water or mucus or bloody; (iv) vomiting GENERAL IMPRESSION: awake or tired? FIRST - COUNT RESPIRATION RATE (observe before touching child!!!) Temperature (measure) Skin pinch (in case of diarrhea) OR chest auscultation (in case of cough) 2 0 Remarks Total Points (97)../97 Date: Signature of the Name of Supervisor: supervisor: 7 Family Planning [max 22 points] YES NO 7.1 At least one qualified staff trained in Family Planning Confidentiality in consultancy room assured Room with closed doors, curtains at windows or non-transparent glass Family planning methods available and visible in demonstration box for potential users Condoms; OAC; Injectable; Implant; IUD; are available in the demonstration box (all five items) Penis model available on the desk; box with condoms available with at the least 50 condoms Staff correctly calculates number of clients expected monthly for oral and injectable contraceptives For example for population (target is entire ward catchment pop) = * 22.5% * 25%/12 * 4 * 90% (assuming 25% unmet need; 22.5% target population; 90% of oral/inject AC at HC level. Ask any medical personnel involved in care for clients to 2 0 Version _pbf_usermanual_ng-final Page 105

106 explain this target calculation. 7.5 Business plan contains strategy to achieve FP targets (Section 7: FP) Collaboration with public sector, private sector and social marketing, mobile strategies, advocacy among local leaders etc (explicit mention in the BP) Involvement of HF staff in strategies (explicit mention of this in the BP) 7.6 Stock of oral and injectable contraceptives in adequate for example for pop 72 doses of oral (3 month cycles) and injectable methods combined 7.7 IUD available and staff trained to use it at least five IUDs and at the least one staff trained to use it 7.8 Implant method available and staff trained to use it at least five implants available and staff trained to use it Strategies available for transfer of persons to hospital seeking permanent FP methods Referral system worked out - strategy to reduce prices; mobile strategy for surgery? 7.10 FP individual cards available and filled according to the format Remarks Check at least five cards for BP, hepatomegaly, varicose veins, weight (all cards; all elements checked) Total Points (22)../ Date: Signature of the Name of Supervisor: supervisor: 8 Laboratory [max 17 points] YES NO 8.1 Laboratory technician or technologist available 8.2 Laboratory is open every day of the week Supervisor verifies the last 4 Sundays in laboratory register 8.3 List of laboratory examinations visible for the public with fees Version _pbf_usermanual_ng-final Page 106

107 8.4 Results recorded correctly in laboratory register and match with results in inpatient sheets or OPD examination cards Supervisor verifies last five results 8.5 Availability of parasites demonstrations On plastic paper, in a color book, or put on wall Blood smear: Vivax, Ovale, Falciparum and Malariae Stools: Ascaris, entamoeba, ankylostoma and schistosome 8.6 Microscope available and functional functional objectives; immersion oil available, mirror or electricity blades, cover glass, GIEMSA available 8.7 Malaria rapid tests available At the least 20 tests available in the laboratory; non-expired Centrifuge available and functional 8.9 Waste evacuation correctly carried out Organic waste in a bin with lid with disinfectant Security box for sharp objects available and destroyed according to waste disposal guidelines Personnel adequately washes dirty pipettes in containers with disinfectant 8.11 Laboratory equipment for testing for PTB Remarks (Laboratory) Reagents for AAFB testing; stock control car for reagents is available and lists stock; at the least 30 non-recycled slides available for testing External Quality assurance protocol for PTB testing available and implemented: slides sampled and sent for quality control according to protocol, and latest report, as per protocol, is available and shows results as per cut-off point of the protocol Total Points (17)../ Date: Name of Supervisor: Signature of the supervisor: 9 In-patient Wards [max 6 points] YES NO 9.1 Guard duty roster clearly visible for staff and followed up Supervisor verifies guard duty's report - names and signatures match Version _pbf_usermanual_ng-final Page 107

108 9.2 Furniture available and in good state Each bed has a (i) non-torn plastic covered mattress, (ii) mosquito net, (iii) clean sheets, (iv) night table 9.3 Patient comfort and hygiene The wards are clean: no debris on the floor; and wards smell of disinfectant Space between the beds is at the least one meter Each ward has access to drinking water Each ward has running water or water dispenser with water, soap and a clean towel 9.4 Light available in each ward Electricity; solar light or rechargeable battery lamp 9.5 Confidentiality Women in separate ward from men; the inside of the wards are not visible from the outside 9.6 In patient register available and is well maintained check identity and hospital bed days 9.7 Recording forms for hospitalizations available and well filled and well stored At least 10 blanks; supervisor verifies 5 filled forms Weight, temperature, and eventual laboratory exams recorded Treatment monitoring checked Remarks Total Points (6)../ Date: Name of Supervisor: Signature of the supervisor: 10 Essential Drugs Management [max 20 points] YES NO Staff maintains stock cards for ED showing security stock levels = monthly average consumption (MAC) * 2 (two months monthly average consumption) 4 0 Supply in register corresponds with physical supply: random sample of three essential drugs Health facility purchases drugs, equipment and consumables from the Pharmaceutical Council of Nigeria certified distributor, approved by SMOH/SPHCDA 3 0 Version _pbf_usermanual_ng-final Page 108

109 Latest Pharmaceutical Council of Nigeria certified distribution center list for the State available Last procurement list is shown which shows the certified distributor which sold the drugs All drugs and medical consumables are (i) NAFDAC certified and (ii) Generic 10.3 Main pharmacy store delivers drugs to health facility dispensary according to requisition Supervisor verifies whether quantity requisitioned equals quantity served Drugs to clients are uniquely dispensed through prescriptions. Prescriptions are stored and accessible Drugs and medical consumables prescribed, are all in generic form 10.4 Drugs stored correctly Clean place, well ventilated with all drugs on cupboards, labeled shelves Drugs and medical consumables stored on alphabetical order, first in - first out basis 10.5 Absence of out of date drugs or drugs with unreadable labels Supervisor verifies randomly three drugs and 2 consumables Out of date drugs well separated from stock Destruction protocol for out of date drugs available and applied Remarks Total Points (20)../ Date: Name of Supervisor: 11 Signature of the supervisor: Tracer Drugs (min. stock = Monthly Av. Consumption times 2) [max 20 points] YES > MAC x Paracetamol 500 mg tab 11.2 Ibuprofen 200 mg caps Chlorpheniramine 2 mg 11.4 Oxytocin 10IU/ml vial 11.5 Mebendazole 100 mg tab 11.6 Ferrous Sulfate 325 mg tab 11.8 Amoxicillin 500 mg caps NO < MAC x 2 Version _pbf_usermanual_ng-final Page 109

110 11.9 Amoxicillin 125 mg/5ml suspension Co-trimoxazol 480 mg tab Co-trimoxazol 40mg/200mg - 5ml susp Doxycycline 100 mg caps Erythromycin 250 mg tab Co-artemeter 20/120 mg tab (1; 2 3 and 4) Sulfadoxine/pyrimethamine 500 mg tab ORS sachet Condom Metronidazol 200 mg tab Sterile gloves Venflon 18G Min stock = 10; MAC applies only when higher than Venflon 22G Min stock = 10; MAC applies only when higher than IV giving set Min stock = 10; MAC applies only when higher than Ringers lactate 1L Min stock = 5L; MAC applies only when higher than 5L Dextrose 5% 1L Min stock = 5L; MAC applies only when higher than 5L Syringe 5ml Syringe 10ml Scalp vein needle Remarks Total Points (20)./2 0 Date: Name of Supervisor: Signature of the supervisor: 12 Maternity [max 24 points] YES NO Version _pbf_usermanual_ng-final Page 110

111 12.1 Sufficient water with antiseptic soap and liquid antiseptic in delivery room A functioning water source or at the least 20L 12.2 Light in delivery room 24 hours Electricity, solar light or rechargeable battery lamp or kerosene lamp filled with kerosene 12.3 Waste from Maternity correctly handled Bin with lid and lining and safe needle disposal container, specific for the maternity room use only 12.4 Delivery room is well-maintained Walls with durable materials and painted (Section 12: Maternity) Curtain between delivery bed and door Delivery room smells of disinfectant Floor level cement, without fissures and ceiling not damaged Windows with curtains and functional door 12.5 Availability and use of the Partographs At the least 10 forms available for use Verify three randomly selected Partographs whether filled according to the norms 12.6 Deliveries performed by skilled personnel Identification of the skilled provider from names in the register Availability of scales for weight/length, an obstetrical stethoscope and an aspirator Tape to measure length Scale to measure weight (check functionality) Aspirator plunged into a non-irritating disinfectant or functional manual/electric aspirator 12.8 Availability of at the least 10 pairs of sterile gloves 12.9 Availability of at the least 2 sterilized obstetrical boxes Content at the least 1 pair of scissors, 2 pliers and one needle holder Availability of at the least one episiotomy box One sterilized box with needle holder, needles, 1 anatomical plier and 1 surgical plier Catgut and nylon sutures; antiseptic, local anesthetics, sterile swaps Delivery table in good state Table in two parts with removable non-torn plasticized mattress and two functional leg supports Available equipment for care of the newborn Sterile tying string or clip for umbilical cord Version _pbf_usermanual_ng-final Page 111

112 % tetracycline eye ointment non-expired Adequate in-patient rooms Mattress covered in impermeable plastic Sheets, blankets and mosquito nets on each occupied bed Remarks Total Points (24)../24 Date: Name of Supervisor: Signature of the supervisor: 13 EPI and Pre-School Consultation [max 20 points] YES NO 13.1 Personnel calculates correctly target for fully vaccinated children Target = population * 4.8% / 12 : asked from any medical personnel dealing with care for clients The target population concerns the ward population (or the defined catchment pop in case ward has more PBF primary contract holders) 13.2 EPI fridge Presence of a fridge - temp form available, filled twice a day including the day of the visit Temperature remains between 2 and 8C in register sheet Supervisor verifies functionality of thermometer Temperature between 2 and 8C also according to the thermometer 13.3 Chemical Temperature Indicator Presence of a chemical temperature indicator (this is a specific piece of paper different from the thermometer) which shows temperature acc to the norms 13.4 Appropriate storage of vaccines Freezing compartment: Measles Non-freezing compartment: BCG, Penta + HepB, TT, thinners Absence of vaccines which are expired Readable labels on all vaccines 13.5 Appropriate stock of vaccines BCG, Penta, Polio, Yellow Fever, HBV, Measles, Tetanus (Section 13: EPI) Presence of stock control cards for all vaccines; concordance paper and physical stock verified 4 0 Version _pbf_usermanual_ng-final Page 112

113 13.6 Cold Chain maintenance If kerosene fridge: stock of at the least 14L Kerosene; if solar fridge: battery not damaged 13.7 Cold packs are well frozen At the least Syringes available Auto-blocking at least 30; for dilution - at least Waste collection availability of safe disposal box Stock of U5 growth cards available At the least Child immunization register well maintained System is capable of identifying drop outs and Fully Vaccinated Children Conditions in waiting area for immunization services Sufficient benches and or chairs, protected against sun and rain Patients receive numbered waiting buttons according to their arrival Baby weighing scale available and in working condition Balance calibrated to zero + pants available, clean and in good condition Group IEC/BCC Group meeting held before vaccinations (check the schedule of health education sessions) Existence of updated IEC report with (a) topic, (b) number of participants, leader of activity, (d) date and (e) signature Existence of a system to recover drop-outs Schedule, record of appointments, classified invidual charts Remarks Total Points (20)../ Date: Name of Supervisor: Signature of the supervisor: 14 Antenatal Care [max 12 points] YES NO 14.1 Business plan contains convincing strategies to effectively conduct ANC for all pregnant women in catchment area Version _pbf_usermanual_ng-final Page 113

114 Fixed strategy; and advanced strategy for distant villages: catchment area covers entire ward or defined catchment population if multiple PBF primary contract holders 14.2 Weighing scale present, functional and calibrated to zero 14.3 ANC form for HF available and well filled in: last five forms verified All: Examinations: weight - BP, Uterus height, Parity, Date of last menstruation All: Laboratory: albuminuria, glucose All: Obstetrical examination done: Fetal heart rate, Uterine height, presentation, Fetal movement recorded ANC form shows the administration of Ferrous Sulphate/Folic Acid and Mebendazole and SP (for the last five forms above) ANC cards for mother available: at least 10 in stock 14.6 ANC register available and well filled in Complete identity, state of vaccinations, date visit, whether high risk pregnancy or not/danger signs All columns well filled including the identification of problems if any, and actions taken 14.7 ANC conducted by qualified personnel Nurse; midwife CHO or CHEW, verified on ANC cards 14.8 Group IEC/BCC Group meeting held before FP consultation (check the schedule of health education sessions) Existence of updated IEC report with (a) topic, (b) number of participants, (c) leader of activity and (d) date and (e) signature 2 0 Remarks ANC: Total Points (12)../12 Date: Signature of the Name of Supervisor: supervisor: 15 HIV/TB [max 8 points] YES NO 15.1 Well-equipped HIV counseling room ensuring privacy: Plastered and painted wall of solid material Smooth cement floor Ceiling in good condition Windows with glass and curtains Doors that close Version _pbf_usermanual_ng-final Page 114

115 15.2 Availability of IEC/BCC material related to HIV Penis model on the table A box of condoms on the table which has at the least 50 condoms 15.3 Existence of a VCT/PMTCT counseling register and lab register acc norms 15.4 Staff trained in counseling At the least one staff trained as a councilor All counseling done by a trained councilor 15.5 Referral system and follow up for HIV clients Individual client cards available; planning for CD4 cell counts 15.6 Referral system and follow up for TB patients Each AAFB+ PTB patient has a person attached to him/her who supervises DOTS: proof of in register; mobile phone number of such a supervisor is registered Each PTB patient has a contact address and/or phone number in both the register and the individual card 15.8 Availability of anti-tuberculosis drugs (for at least three new clients) Rifampicine-isoniazide-pyrazinamide : cp mg Etambutol tabs 400 mg Remarks Total Points (8)../8 Date: Name of Supervisor: Signature of the supervisor: Nr Service Max P % 1 General Management 21 2 Business Plan 9 3 Finance 15 4 Indigent Committee 2 5 Hygiene 31 6 OPD 97 7 Family Planning 22 8 Laboratory 17 9 Inpatient Wards 6 10 Essential Drugs Management Tracer Drugs 20 Version _pbf_usermanual_ng-final Page 115

116 12 Maternity EPI ANC HIV/TB 8 Total 324 Name Supervisor Signature: Name Head of Clinic/Staff Date: Signature: Final Score: Version _pbf_usermanual_ng-final Page 116

117 Annex 9: Quarterly Quality Supervisory Checklist for General Hospitals [...] MOH/[...] PHCDA Quarterly Quality Review of General Hospitals version 14 December 2013 Date: Name Team Leader Evaluation: LGA: Medical Staff Total: CH: Population: Non-Medical Staff Total: 1 General Management [max 24 points] YES NO 1.1 General Hospital RBF Committee meets once per month. Each complete report is worth 1.5 points; max 3 reports Date of the meeting Agenda Signed list of participants Follow-up of the decisions taken during the previous meeting In each issue section there is a description of the problem In each issue section there is a list of developed recommendations or decisions taken In each issue section there is a deadline to solve the issue In each issue section there is a responsible named Each month the monthly financial balance is discussed Minutes of the meeting are signed by the chairman (minutes should be separate documents) HMIS reports - business plan - minutes of meetings well stored In cupboard and in box files and accessible by the administrator 1.3 Staff duty roster 24/7 available in all units and well displayed up to date and visible for staff and Version _pbf_usermanual_ng-final Page 117

118 patients 1.4 Management Team Meetings conducted Monthly and minutes available. Each complete report is worth 1.5 points (max 4.5 points); max 3 reports Date of the meeting Agenda Signed list of participants Follow-up of the decisions taken during the previous meeting In each issue section there is a description of the problem In each issue section there is a list of developed recommendations or decisions taken In each issue section there is a deadline to solve the issue In each issue section there is a responsible named Each month the monthly financial balance is discussed Minutes of the meeting are signed by the chairman (minutes should be separate documents) Availability of communication radio or dedicated mobile phone for communication between General Hospital and health centers Radio or mobile phone functional with batteries and/or call credit and contact details of all PBF/DFF facilities (e. g: Medical Director CH, Head of Units, PBF HFs OICs, PHC Dept. PBF Team, HSMB Key Officer and SPHCD PBF Team, etc.) List of phone number of health facility in-charges available and up to date 1.7 HMIS reports are filled, updated and transmitted to the HSMB/SMOH After verification of the SPHCDA of the monthly CPA invoice Completely filled according to the prevailing formats HMIS data analysis report for the quarter being assessed concerning priority problems Ten priority health problems are followed each quarter and data have been updated up to the month prior to the quality evaluation visit Through a chart, follow up on monthly (i) average length of stay; (ii) average bed occupancy rate, (iii) Bed turnover rate and (iv) income/expenses statements 1.9 Ambulance available and functional Vehicle log book available and maintained/filled Version _pbf_usermanual_ng-final Page 118

119 1.9.2 Vehicle maintenance register available and filled Ambulance available and functional Remarks Total Points (24)../24 2 Business Plan [max 8 points] YES NO 2.1 Quarterly business plan for the current period made and accessible Valid and renegotiated 2.2 Business plan prepared with key stakeholders Hospital RBF Committee involved Business plan analyses Hygiene and waste management HF treats this subject in the BP (toilets; showers; medical and nonmedical waste disposal; safe sharps disposal practices; general cleanliness; infection prevention), and suggests a strategy for improvement 2.5 Business plan analyses Quality of Medical Care Remarks BP may suggest to include them or to discourage if quality conditions are not met (Section 2: Business plan) 2 0 Business plan shows a plan to assure financial accessibility for the population Business plan shows negotiated rates between HF, Indigent Committee and community Business plan shows the mechanism how the GH identifies indigents, and how it assesses eligibility, and how it deals with decision making on difficult cases Business plan shows planning for the resources available for financing care for the indigents Total Points (8)../8 Version _pbf_usermanual_ng-final Page 119

120 3 Finance [max 42 points] YES NO 3.1 Financial and accounting documents available and well kept Monthly report of treasury available and correctly filled Theoretical balance of cash-book corresponds to liquidity in cash Document available to show that quarterly calculation of incomes, running costs, investments and variable performance subsidies are done This document guarantees that running costs: = salaries, purchase of drugs and equipment, subcontracts, petty cash for small expenditures, food for patients, maintenance and rehabilitation and financial buffer This document uses the MS Excel- based 'indice tool' for its information. The 'indice tool' is shown and the calculations for the coming quarter are explained This document calculates the performance bonus according to the formula: performance bonuses = income of the quarter - running costs 3 0 Contract salaries and benefits + performance bonuses do not exceed 50% of total HF income through PBF 2 0 Existence of monthly performance bonus system is known by staff Take a random staff member and ask what the performance bonus was last month, and what his or her individual performance % was. If both are explained then 4 points. Total Points (42)../ Remarks (Financial Management) Version _pbf_usermanual_ng-final Page 120