Republic of Zambia  Ministry of Health   OPERATIONAL IMPLEMENTATION MANUAL  

 Republic of Zambia Ministry of Health OPERATIONAL IMPLEMENTATION MANUAL FOR RESULTS BASED FINANCING (RBF) IN PILOT DISTRICTS IN ZAMBIA Revised Final Version 14th November 2011 Preface This Project Implementation Manual (PIM) describes the operational policies, processes, and procedures for the Zambia Results Based Financing Scheme. It provides information on the objectives and policies of the components and gives instructive guidelines on the implementation of the Project and for the accompanying Impact and Evaluation. The PIM will ensure that there is consistency, transparency and accountability on the part of those involved in managing and implementing the project. The document may be updated or modified when need arises with the consent of all implementing agencies. i
Table of Contents 1. 2. 3. Introduction ..................................................................................................................................................................... 1 1.1 Addressing the Productivity Gap in the Health Sector ......................................................................... 1 1.2 Results and Performance Based financing ................................................................................................ 1 The Zambian RBF Context .......................................................................................................................................... 3 2.1 Health Vision and Reforms ............................................................................................................................... 3 2.2 Maternal and Child Health Outcomes .......................................................................................................... 3 2.3 Local PBF Experiences in Zambia .................................................................................................................. 4 2.4 Health Results Innovation Grant .................................................................................................................... 5 The Zambian RBF Model ............................................................................................................................................. 7 3.1 RBF Management Structure ............................................................................................................................. 7 3.2 Zambian RBF Principles .................................................................................................................................... 8 3.3 Methodology for Selection of Intervention and Control Districts .................................................... 8 3.4 Eligibility Criteria for participating in the RBF ........................................................................................ 9 3.5 Impact Evaluation .............................................................................................................................................. 10 3.5.1 Data Sources for the Impact Evaluation ................................................................................................ 12 4. Implementation: Role of Health Facilities, Districts, Provinces and National Level ........................ 13 4.1 Health Facility Level .......................................................................................................................................... 13 4.1.1 Role of Health Facilities under RBF ......................................................................................................... 13 4.1.2 Health Facility Business Plan ..................................................................................................................... 14 4.1.3 Performance Indicators ............................................................................................................................... 15 4.1.4 Key RBF Activities at a Health Facility ................................................................................................... 16 4.2 District Level ........................................................................................................................................................ 19 4.2.1 Role of the District Medical Office (DMO) .............................................................................................. 19 4.2.2 DMO Performance Contract ....................................................................................................................... 19 4.2.3 Monthly Quantity Audit by the DMO ....................................................................................................... 21 4.2.4 Quality Audit by the District or General Hospital ............................................................................... 21 4.2.5 Weights for the Quality Scores .................................................................................................................. 22 4.2.6 Steps for conducting a Quality Assessment ........................................................................................... 22 4.2.7 District RBF Steering Committee .............................................................................................................. 23 4.2.8 Determining Health Facility Payments .................................................................................................. 23 4.2.9 Consolidating and Transmitting Data for Payment .......................................................................... 24 ii
4.3 Provincial Level ................................................................................................................................................... 24 4.3.1 Role of the Provincial Medical Office (PMO) ......................................................................................... 24 4.3.2 Provincial RBF Technical Specialist ........................................................................................................ 25 4.3.3 Provincial RBF Steering Committee ........................................................................................................ 25 4.3.4 Consolidating and Transmitting Data for Payment .......................................................................... 26 4.4 National Level (Ministry of Health Headquarters) ............................................................................... 26 4.4.1 Roles of the Ministry of Health Headquarters ...................................................................................... 26 4.4.2 RBF Project Implementation Unit (PIU) ................................................................................................ 27 4.4.3 Purchaser Role of the MOH ......................................................................................................................... 28 4.4.4 Capacity Building and Training Programme ....................................................................................... 28 4.4.5 The National RBF Steering Committee ................................................................................................... 29 4.4.6 Zambia RBF Web Application Management System ......................................................................... 30 5. Fiduciary Arrangements ........................................................................................................................................... 32 5.1 Financial Management ..................................................................................................................................... 32 5.1.1 Disbursement of Funds ................................................................................................................................. 32 5.1.2 Managing Cash and Bank Accounts ........................................................................................................ 34 5.1.3 Initial Advances at Health Facilities, District and Provincial Levels ........................................... 35 5.1.4 Financial Reporting and Replenishment of Accounts ....................................................................... 36 6. 5.2 Procurement......................................................................................................................................................... 36 5.3 Capacity Building and Training in Financial and Procurement Management .......................... 37 The Technical Assistance Firm ............................................................................................................................... 38 6.1 7. Main tasks and specific deliverables .......................................................................................................... 38 ANNEXES 1‐30 .............................................................................................................................................................. 40 iii
List of Tables Table 1: List of Intervention and Control Districts ................................................................................................. 10 Table 2: Description of Groups for Policy Question One ...................................................................................... 11 Table 3: Description of Groups for Policy Question Two ..................................................................................... 11 Table 4: Description of Groups for Policy Question Three .................................................................................. 12 Table 5: Good Practice and Standards for a Business Plan .................................................................................. 14 Table 6: Core Indicators and Fees Schedule ............................................................................................................... 16 Table 7: DMO Performance Measures and Weights ................................................................................................ 19 Table 8: Weights attached to Quality Service Areas ............................................................................................... 22 iv
List of Figures Figure 1: Zambian RBF Model ............................................................................................................................................ 7 Figure 2: Business Plan Management Cycle ............................................................................................................... 15 Figure 3: Functional Linkages between the PIU and MOH Management ....................................................... 27 v
Acronyms and Abreviations ACM ‐ Annual Consultative Meeting AIDS ‐ Acquired Immuno Deficiency Syndrome ANC ‐ Ante‐natal care AZT ‐ Zidovudine BMI ‐ Body Mass Index BP ‐ Business Plan CBoH ‐ Central Board of Health CBOs ‐ Community Based Organisations CHW ‐ Community Health Worker CMR ‐ Child Mortality Rate CPs ‐ Cooperating Partners CSO ‐ Central Statistics Office DDCC ‐ District Development Coordinating Committee DMO ‐ District Medical Office D‐RBFSC ‐ District Results Based Financing Steering Committee EmONC ‐ Emergency Obstetric and Neonatal Care EPI ‐ Expanded Programme on Immunization FFS ‐ Fee‐For‐Service FP ‐ Family Planning GRZ ‐ Government of the Republic of Zambia HC ‐ Health Centre HF ‐ Health Facility HIV ‐ Human Immuno Deficiency Virus HMIS ‐ Health Management Information System HR ‐ Human Resources IE ‐ Impact Evaluation IMR ‐ Infant Mortality Rate IPT ‐ Intermittent Presumptive Treatment IT ‐ Information Technology MBB ‐ Marginal Budgeting for Bottlenecks MBP ‐ Malaria Booster Project vi
MCH ‐ Maternal and Child Health MDGs ‐ Millennium Development Goals MIS ‐ Management Information System MMR ‐ Maternal Mortality Ratio MOH ‐ Ministry of Health NGO ‐ Non‐Governmental Organisation N‐RBFSC ‐ National Results Based Financing Steering Committee PA ‐ Performance Assessment PBF ‐ Performance Based Financing PCA ‐ Principal Components Analysis PETS ‐ Public Expenditure Tracking Survey PIM ‐ Project Implementation Manual PIU ‐ Project Implementation Unit PMO ‐ Provincial Medical Office PMTCT ‐ Prevention of mother‐to‐child transmission of HIV P‐RBFSC ‐ Provincial Results Based Financing Steering Committee RBF ‐ Results Based Financing RH ‐ Reproductive Health SAG ‐ Sector Advisory Group SCs ‐ Steering Committees TA ‐ Technical Assistance TBIS ‐ Target Based Incentive System U5MR ‐ Under Five Mortality Rate UNICEF ‐ United Nations Children’s Fund UNZA ‐ University of Zambia WHO ‐ World Health Organization ZDHS ‐ Zambia Demographic and Health Survey vii
Definitions of Terms Buy Buyer Essential Design Elements Complementary Design Elements Contract Goods/services Motivation Performance Public Health Facilities Acquisition of Results Based Financing (RBF) relevant services. Anyone who buys RBF incentivised services or any other services relevant to the attainment of RBF goals and objectives. These are elements that are considered crucial for a national RBF system. These include for example; RBF relevant policy and strategy statements, dedicated Project Implementation Unit at MOH headquarters, strong national technical coordination platform dedicated to RBF, MIS system able to capture and feedback data efficiently and effectively, rigorous evaluations, routine data quality checks and validations, significant financial incentives through performance framework for the District Medical Office (DMO) and District Hospitals, functional District level RBF steering committee, civil society participation, performance framework targeting health facilities, regular bonus payments for health workers, and autonomy for the health facilities to manage resources and to make decisions. These are elements that are considered complementary to a national RBF system. They are judged as having potential to augment the impact of RBF on health services delivered. They include: Demand side interventions (conditional cash or in‐kind transfer activities); possible converting of once per quarter facility performance payment into monthly bonus instalments; introduction of ‘motivation contracts/agreement’ between health facilities and the individual health workers; implementing the ‘business plan approach’ in health facilities; and use of grassroots organizations in conducting community client surveys. A time bound convention by which commitments are made between two or more parties for the provision of specific RBF services. Any RBF relevant items and services agreed to be supplied or provided by the Supplier to the Purchaser under or pursuant to the Contract. State of mind, behaviour that pushes a person to act to achieve RBF objectives or results. The actual attained RBF results by a health provider as compared to the health sector standard results. All health facilities, either government‐managed or managed by a non‐governmental agency. In some cases, private for profit facilities can be sub‐contracted by primary recipients for certain RBF services, for instance curative care, or family planning services. viii
Purchaser Seller Specification The person(s), firm, company or organisation whose details are set out within the RBF contract for purchasing the Services from the Supplier/Provider pursuant to the contractual terms and conditions. Quality Quality Indicators Regulator Separation of Functions Anyone who sells RBF related services. The description of the RBF specific Goods/Products/Services/indicators set out in the contract or any other description of the RBF services/indicators agreed between the Parties in writing from time to time. Characteristic that gives a greater or lesser value to a RBF related product or service. These are a set of RBF quality‐relevant indicators constructed mainly from existing supervisory forms. The difference between ‘normal’ supervisory forms and the checklists created for use with RBF is that criteria have been made objectively verifiable within the limits possible, and they have been quantified. Each criterion has received a ‘weight’, as has each service. The resulting cumulative score is used in the performance framework. It therefore reinforces/strengthens and empowers the existing Performance Assessment (PA) structures and ensures services are delivered according to a set of national norms and standards. An agency that ensures the proper functioning of a RBF system through standard setting and ensuring compliance. It is a key principle in the design of a RBF system. It is a necessary condition in order to lessen conflict of interest situations. For example, in a situation where the control agency is at the same time the supplier of health services (i.e. it controls itself); b) when the purchaser is at the same time the provider, or c) when the regulator of quality (the district hospital) fulfils also the function of the quantity control the functional roles are "too close" and could lead to conflict of interest, collusion or fraud. Through the separation of functions, it becomes therefore possible for (i) creation of a quasi‐
market through internal contracts (i.e. to have sufficient separation between purchaser, provider and regulator); (ii) transparent district level RBF governance mechanism and (iii) the separation of “quantity audit” from “quality audit” through separate organizations. ix
1. Introduction 1.1
Addressing the Productivity Gap in the Health Sector One of the greatest challenges facing the Zambian health sector today is how to attain significant population‐level impact that would enable the country meet the Millennium Development Goals (MDGs) 4, 5, and 6. Over the past years, the per capita spending on health is estimated to have increased significantly though there have been no proportionate improvements in overall health status. Maternal mortality in particular remains high even for Sub‐Saharan Africa standards. Similarly, the burden of specific childhood diseases, incidence of non‐communicable diseases and the quality of service provision has continued to pose great challenges. This situation is partly attributable to the severe human resource constraints; i.e. workforce shortages, absenteeism, tardiness, poor morale and low staff productivity. The 2007 Public Expenditure Tracking Survey (PETS) (MOH/World Bank 2007) highlights the magnitude of the problem in detail: The percentage of vacant posts in rural health facilities is 42% and the rate of staff turnover is generally very high. Additionally, absenteeism and tardiness reduce the actual availability of staff already at post and clinical staff have the highest rate of absenteeism; 30.1% percent of doctors and 20.1% of clinical officers were not on site on the day of the study. This is due to low morale and the need for health staff to be engaged in various income‐generating activities in order to augment their salaries. The PETS analysis shows that if absenteeism and tardiness were fully eliminated, these losses would translate to a gain of 187 full‐time equivalent staff, enough to staff 21 rural health centres in Zambia. Furthermore, the productivity in the public sector is very low. An increasing portion of Ministry of Health (MOH) resources over the last years is going to administration rather than service delivery. The MOH, in conjunction with its cooperating partners, has explored and initiated various mechanisms for staff motivation and retention. The overall success of these initiatives is yet to be analyzed. It is however apparent that “productivity enhancement” has not been systematically in‐built in the initiatives. The emerging health policy consensus is that improvements in staff recruitment and retention need to be linked to purposeful strategies for performance/productivity enhancement in order for the country to reap benefits from its health sector investments. 1.2
Results and Performance Based financing Results Based Financing (RBF) can be a powerful approach in helping the Zambian health sector to address the productivity gap. RBF refers to a range of mechanisms designed to enhance the performance of the health system through the following: a) Focus on and accountability for results, b) Intensive use of evidence‐based decision‐making for service delivery, c) Systematic data (quality and quantity) verification, and d) Provision of incentives to facilities and staff. 1
However, RBF is an umbrella term that includes output­based aid, provider payment incentives, performance­based inter­fiscal transfers, and incentives to households for adopting positive health‐
promoting behaviours. What these mechanisms have in common is that a principal entity provides a financial or in‐kind reward, conditional on the recipient undertaking a set of pre‐determined actions or achieving a pre‐determined performance goal. By introducing incentives that reward results, RBF promotes greater accountability of service providers, improves management, improves efficiency and equity of service delivery, and strengthens health information systems. It can also facilitate greater involvement of the NGO and private sectors in health service delivery. An increasing body of evidence shows that RBF mechanisms are starting to work in Africa by strengthening health systems, stabilizing or decreasing costs of services, helping countries use limited resources effectively, improving staff motivation and morale (a proven incentive for staff retention) and empowering providers and beneficiaries. However, RBF requires strong commitment from the country and its partners and significant technical and financial resources for a sustained effort. If done well, this initiative has therefore the potential to transform the health landscape in Zambia and help to put the country on track to reaching the health MDGs. Performance Based Financing (PBF) is a component of RBF. A hallmark of PBF programmes is that individual health facilities are contracted and performance bonuses are provided for each defined service delivered. PBF can therefore be structured as Fee­For­Service System (FFS), Target Based Incentive System (TBIS) or a combination of both. However, the bonus payments under PBF are made subject to a “quality measure”, which either impacts negatively (therefore serving as ‘stick’) or positively (serving as a ‘carrot’) on the earnings. This attribute makes PBF fundamentally different from the ordinary FFS systems and TBIS. A characteristic of PBF is therefore an in‐built ability to deliver quality preventive and curative services. In addition, the bonuses reach the frontline health workers quarterly ‐ which can also be converted into a monthly bonus payment. Each member of staff’s bonus payment is further determined by the actual individual performance level in comparison to own staff “motivation contract”. 2
2.
The Zambian RBF Context 2.1
Health Vision and Reforms 2.2
Maternal and Child Health Outcomes Zambia’s vision for health is to “provide equitable access to cost‐effective quality health care, as close to the family as possible”. To achieve this, the government embarked on health sector reform in 1992. The main thrusts of the reform were the decentralization and delegation of planning, management and decision‐making of health services to the districts, overseen by the Central Board of Health (CBoH), which operated as a semi‐autonomous statutory board. The intention was to separate the functions of running the health sector, with MOH being responsible for policy formulation and regulatory functions, and CBoH responsible for policy interpretation and technical supervision of health service delivery at all levels. However, through the recent health sector restructuring process, implemented between 2005 and 2008, CBoH has been dissolved and the functions of MOH and CBoH have been merged. Following these changes, the management and control of public health facilities and services directly fall under MOH through Provincial Medical Offices (PMOs). In order to ensure continued public participation in the management of health services, the hospital and district health management boards have been transformed into Health Advisory Committees. Overall, attainment of the health sector vision has been a challenge more especially with regard to maternal and child health outcomes. Though the country has made significant effort to reduce maternal mortality ratio (MMR) and child mortality rates (CMR), the ratio and rates are still one of the highest in the world. Maternal mortality increased from 646 to 729 per 100,000 live births between 1996 and 2002. Since then, a downward trend has been observed and the results from the 2007 Zambia Demographic and Health Survey (ZDHS) show a MMR of 591 per 100,000 live births. Similarly, there has been significant reduction in the infant mortality rate (IMR) from 95 per 1000 live births in 2002 to 70 per 1000 live births in 2007 and under‐five mortality rate (U5MR) has decreased from 168 per 1000 live births in 2002 to 119 per 1000 live births in 2007 (ZDHS 2002 and 2007). The Neonatal Mortality Rate is estimated at 34 per 1000 live births for 2007. Even if progress has been made, these figures are still unacceptably high. The direct causes of maternal mortality in Zambia are known and treatable: Haemorrhage (25%), puerperal infection (15%), eclampsia (13%), complicated abortion (13%), obstructed labour (7%), malaria (5%), tetanus (1%), and non‐specific (21%). The indirect causes of maternal mortality are malaria, diabetes, anaemia and HIV/AIDS. In addition many contributing factors that predispose Zambian women1 are delays in accessing health facilities. Most maternal deaths in Zambia occur at home or on the way to the health facility. Malnutrition is a serious contributing factor to poor health status. As many as 13 percent of women of child‐bearing age have low Body Mass Index (BMI <18.5) and 50 percent of pregnant women are anaemic. On the other hand, under‐five mortality in Zambia is mainly attributable to neonatal causes (22.9%), pneumonia (21.8%), malaria (19.4%), diarrhoea (17.5%), HIV/AIDS (16.1%), measles (1.2%), and others (0.2%). The high rate of child malnutrition is also a key risk factor in childhood illness. It is estimated that 29.4 percent of children are underweight and 55 percent of children are stunted (2007 ZDHS). 1
HIV prevalence is 14.3% among adults aged 15-49 years (ZDHS, 2007). 3
The effective interventions to address maternal and child mortality are well known. Assisted delivery at birth contributes greatly to improvements in maternal health and interventions such as the use of insecticide‐treated bed nets, immunization, Vitamin A supplementation and oral rehydration therapy for diarrhoea have been shown to be among the most cost‐effective in reducing child mortality (Lancet 2003). The coverage of these critical interventions to improve maternal and child health is very low in Zambia, particularly in rural areas. For example, the proportion of institutional deliveries has been falling due to a shortage of trained midwives and weak referral systems. In 2007, only 47 percent of births were attended by a medically trained provider (in rural areas this figure is as low as 28%), and only 38.5 percent of pregnant women delivered in health facilities (MOH and CSO 2005). Birth by caesarean section – an indicator of the availability of appropriate obstetric care – is only 2 percent. For both these maternal health service indicators, Zambia ranks among the worst in East and Southern Africa. For those women who do avail themselves of the services provided by health facilities, the quality of care is often poor. For example, while on average, 93 percent of all pregnant women received at least one ante‐natal care (ANC) visit and at least 70 percent received four antenatal care visits (CSO 2003), less than two thirds have their blood pressure taken, an intervention that can help in management of eclampsia. These figures are much lower in rural areas. The 2007 Marginal Budgeting for Bottlenecks (MBB) exercise simulation model showed that the poor performance of the health sector in Zambia is caused by a series of bottlenecks in the service delivery chain which severely limit service accessibility, initial utilization of the services, timeliness and continuity of services, as well as effective (high quality) coverage (World Bank 2007). This analysis showed that the most important interventions to reduce maternal mortality and under‐five mortality would be to increase access to quality obstetric care, especially in rural areas. In addition, gains can be made through improved community and outreach services for antenatal care and timely referral. Given the above outlined situation, there is now an increasing awareness, commitment and action within the MOH to improving the health status of mothers and children. This commitment has translated into the development of a roadmap that describes the strategy of the GRZ to accelerate the attainment of MDGs 4 and 5 (MOH 2007). A number of interventions and actions provide evidence of this new emphasis. These include: the initiation of a national programme of Emergency Obstetric and Neonatal Care, the national scale‐up of Integrated Management of Childhood Illnesses, strengthening of family planning through emphasis on long‐term permanent methods of family planning and increased financial commitment towards maternal health through the creation of a separate budget line for reproductive health commodities. 2.3
Local PBF Experiences in Zambia Some local PBF initiatives have been designed and implemented in order to increase coverage of key reproductive and child health indicators in Zambia. One such example is the incentive scheme introduced by the District Medical Office (DMO) in Katete District. The activities for a PBF Scheme in Katete District were launched in 2003 to provide a coordinated approach to fight maternal and child mortality as well as to improve staff retention. One of the objectives of the incentive scheme in Katete District was to increase the percentage of pregnant women delivering in health facilities. In order to achieve this objective, a set of demand‐ and supply‐side PBF mechanisms were implemented and included the provision of “mama kits” (consisting of napkins, pins, soap and Vaseline gel) to new mothers at the delivery centre, gifts to the traditional birth attendants for each set of five pregnant women delivering in the health facility, food for antenatal 4
clients and US$ 285 for the best performing health centre. As a result, institutional deliveries increased overall from 55 to 85% between 2003 and 2006 in the district. Chavuma District also introduced demand side measures at the Mission Hospital. A “mama kit” was introduced, delivery waiting shelters built for mothers covering long distances from the facility, and family planning and other educational opportunities availed to the mothers. Consequently, the district has become one of the top 5 in both “facility deliveries” and “deliveries assisted by skilled personnel” in Zambia – outperforming many urban districts. There are also other incentive schemes such as the CORDAID financed PBF scheme in selected church health facilities and several NGO supported incentive schemes for disease specific programmes. The results of these interventions indicated that RBF can potentially be a highly effective mechanism to improve quality and coverage of core interventions in Zambia through increased demand for health services as well as increased motivation and productivity of health workers. 2.4
Health Results Innovation Grant The MOH successfully applied for a grant from the World Bank (Norwegian Health Results Innovation Grant) to systematically pilot and expand on its RBF activities with focus on maternal and child health. In April 2008, Zambia was officially awarded the US$12.0 2million grant. The MOH will use the grant to implement RBF in order to catalyze the country’s efforts to aggressively reduce under‐five and maternal mortality in three years. This effort aims to change behaviour and strengthen systems in order to improve core maternal and child health outcomes. The project will strengthen the capacity of DMOs and participating health facilities in the target districts on a pre‐agreed core package of nine (9) facility based indicators, to rapidly expand the maternal and child health interventions at both health facility and community levels. The project will provide support to participating DMOs and health facilities to help them improve their planning, implementation, coordination and supervision capacities. The areas of support will include monitoring and evaluation and technical assistance. In this regard, an independent Technical Assistance firm will be hired to ensure that the objectives of the project and MOH at large are met. The overall activities supported by the project include:  Provision of incentive payments based on individual and institutional performance. A portion of the Incentive payments may be re‐invested to buy emergency drugs, recruitment of nurses and midwives on contract or temporal basis, cleaning materials etc;  Provision of a package of reproductive health commodities and equipment;  Support evidence‐based decision making by improving the availability and quality of data generated through the HMIS;  Support evidence‐based decision and documentation by evaluating the impact of the project through a scientific process before, during and after the end of the project;  Capacity building and training in the delivery of Reproductive Health services ‐ specifically Emergency Obstetric and Neonatal Care (EmONC); data management, analysis, reporting, and use; planning and budgeting; and financial and procurement management. The design phase involved an extensive two‐year design and preparation process (2008‐2010) led by the MOH with significant technical assistance from the World Bank. During this stage, the MOH 2
This amount has since been increased to US$ 17 million. 5
adopted Katete as an operational pre‐pilot district to inform both the process and content of the pilot activities. Katete had previous experience with local initiatives targeting staff retention and Maternal and Child Health (MCH) interventions (Section 2.3.). The introduction of RBF processes and tools in Katete during the pre‐pilot phase was therefore an opportunity to build on and leverage a local initiative. The RBF model and governance structures of the ten (10) pilot districts were finalized and agreed upon by the MOH, World Bank, and other partners during the National RBF Workshop held in Livingstone, Zambia January 24‐25, 2010 and follow‐up discussions in February and October 2011 (see Annex 1 for the list of selected districts). The model to be implemented in Zambia is a “fee‐for‐
service,” “performance based financing” through the public health sector and adheres to the principle of “separation of functions”. The pilot aims to test a scalable RBF model in Zambia. In this regard, a rigorous Impact Evaluation will help the country answer three (3) key policy questions to inform national expansion of the model (Section 3.5). The RBF tools have been introduced and tested in Katete. Further refinements were therefore possible and a robust set of standardized tools and operational procedures are now available for use in the pilot districts. A training Curriculum has also been developed for Health facilities, Districts and Hospitals. The Curriculum was tested in Chipata district after which more improvements were made in readiness for the commencement of the pilot. The Curricula includes training materials for Health facilities, Districts and Hospitals. For more information, see the Training Manual and Curriculum for the Zambia RBF Project. 6
3. The Zambian RBF Model 3.1
RBF Management Structure The RBF structure in Zambia is shown in Figure 1 below. It includes the national, provincial, district and health centre levels. Each level has a specific role to play as indicated in Figure 1 below: Figure 1: Zambian RBF Model 1. The national level is responsible for service purchasing in addition to RBF policy development, formulation of strategy, setting standards, development of tools, and ensuring oversight and financial control. The main actors at the national level are the MOH Headquarters (including the Project Implementation Unit), the National RBF Steering Committee and support institutions (including cooperating partners and NGOs). 2. The provincial level, specifically the Provincial Medical Office, is an extended arm of the MOH and plays a role in technical support. This includes a) RBF performance assessment of districts, b) provision of RBF relevant technical support to districts, hospitals and health centres, c) capacity building, and d) provincial level coordination of RBF activities. 7
3. The district level serves as the actual governance structure. The functions include consolidation and approval of health centre invoices (District RBF Steering Committee), provider contracting (DMO), supervision (DMO), quantity audit (DMO) and quality audit (District Hospital). 4. The health facility (provider) is the level where the health services are provided. Health centres, health posts and the community (through representation in the health centre committees) constitute this level. 3.2
Zambian RBF Principles 3.3
Methodology for Selection of Intervention and Control Districts The principles which underpin the RBF in Zambia are: i. Autonomy in management and planning of service providers; ii. Involvement of the population/community in managing the services; iii. Instruments: business plans, contracts, external verification, investment fund; and iv. Strengthen the organisation by separating functions of policy formulation, service delivery, and regulation (performance assessment, quality assurance, training and supervision). In order to effectively manage this institutional framework and ensure that the principle of “separation of functions” is adhered to, several contractual arrangements are required that specify the roles and obligations of the various actors. The following are the contracts that underpin the Zambian RBF model: 1. District Medical Office Performance Contract between the MOH/PMO and DMO (Annex 6) 2. Quality Verification Contract between the DMO and District/General Hospital or other contracted agency (Annex 8) 3. Health Centre Performance Contract between the DMO and Health Facility (Annex 7) 4. Motivation Contract For Health Centre Staff (Annex 9) 5. Motivation Contract for DMO Staff (Annex 10) 6. External Data Verification Contract between MOH/Project Implementation Unit (PIU) and a contracted agency Note: The management of contracts is a critical component of an effective RBF institutional management. This entails good routine management of contracts, accession to the clauses and the strict maintenance of all contractual documents by actors at all levels (see guide under Annex 11 for details). The pilot intervention will run for two years and there will be ten (10) full RBF Intervention districts which will receive additional financing through incentive payments and EmONC equipment. The incentives have been set up to interface between the organization and the health worker through predefined modalities for rewarding individual or group performances. In addition, ten (10) Control I districts will receive additional financing equal to the average RBF incentive payments in intervention districts as well as EmONC equipment. Ten (10) Control II districts have also been included as part of the pilot and these will not be provided with financial incentives and EmONC equipment i.e. they will operate normally or ‘business as usual’. See Annex 1 for the list of the respective districts. In all the Intervention and Control Districts, nine (9) key health facility indicators found in the HMIS and deemed as critical in improving maternal and child health services will be constantly monitored. 8
Discussions conducted during the design phase were that each province was to have at least one RBF Intervention district, a Control I district, and a Control II district – giving a total of 3 in each province. However, Lusaka province has not been included because of the existence of several other RBF initiatives in the province. Given that the low coverage rates of maternal and child health interventions are predominantly in rural areas, GRZ decided to focus the RBF pilot interventions on rural areas in order to enhance the efficient targeting of resources. In this regard, as part of the selection criteria, district remoteness and geographical constraints to service provision were taken into consideration. The criteria of matching were therefore extended to include a district deprivation score – with the exclusion of Lusaka Province. In addition, after further consultations with several stakeholders, it became apparent that the pilot RBF interventions in Lusaka Province would greatly overlap with the other RBF initiatives in the province and make it difficult to conduct the Impact Evaluation described in Section 3.4 below. This implies that only 8 provinces have been included in the pilot phase with Northern and Southern Provinces each having 2 intervention districts, 2 Control I districts, and 2 Control II districts. The administrative capacity of the district is expected to play an important role in determining the success or failure of the RBF scheme. For this reason, GRZ decided to implement the pilot interventions in a district representative of the average capacity in the DMOs for that province. This is because focusing on exceptionally high (or exceptionally low) capacity districts would overstate (or understate) the estimate of a national scale‐up for the RBF. Thus, the administrative capacity of the district is measured as an index derived from a Principal Components Analysis (PCA) based on the following three measures of performance at the DMOs:  The average facility level stock‐out rate of key commodities over the years 2006 and 2007.  The average supervisory visit rate from the DMO to all facilities over the years 2006 and 2007.  The rate of under‐5 population covered by immunization campaigns in 2006 and 2007. All three of these measures reflect different aspects of capacity at the DMOs. Two districts at or near the provincial median index score derived from these measures were selected and then randomly assigned to treatment/RBF pilot or control status, following the evaluation design described in the Impact Evaluation section in 3.4 below. 3.4
Eligibility Criteria for participating in the RBF Pursuant to 3.3 above, the other aspect of administrative capacity at the health facilities is the availability of qualified health workers and the skills mix. These are critical elements in determining the success or failure of the RBF scheme. For this reason, only health facilities with AT LEAST ONE QUALIFIED health worker will be eligible for inclusion on the RBF from the targeted pilot districts and health facilities. If a health facility does not have one trained staff by the end of the first quarter of 2012, it will no longer be eligible for participating on the RBF. 9
3.5
Impact Evaluation Operational Impact Evaluation (IE) is a tool to determine the causal impact of policy innovations and hence can help guide policy decisions by assessing the effectiveness and cost‐effectiveness of competing policy options. Hence, a rigorous impact evaluation will accompany the pilot to help the MOH answer key policy questions to inform national expansion of the model. The Impact Evaluation will be conducted alongside a qualitative research. The RBF as implemented in Zambia is by definition a district level scheme that will be implemented in 10 pilot districts thus limiting the scope of evaluation methodologies available for use. Given this limitation, three districts in each province (except for Lusaka which has none and Northern and Southern which have six districts each) were purposively selected and then each randomly assigned to a Treatment group, Control group I, and Control group II). The overall evaluation of the effectiveness of the RBF scheme will be quasi‐
experimental through the matching of facilities across paired treatment and control districts. Three (3) primary research questions will be addressed in the impact evaluation aimed at ascertaining policy interest with regard to the potential future scale‐up of the RBF scheme. The Impact Evaluation questions will be evaluated in the districts/health facilities through the three (3) Research Arms (Intervention, Control I, and Control II) as outlined above. These are shown in Table 1 below. Assignment of the districts to the respective research arms was based on triplet‐matched randomization. Table 1: List of Intervention and Control Districts INTERVENTION Mumbwa Lufwanyama Lundazi Mwense Mporokoso Isoka Mufumbwe Siavonga Gwembe Senanga CONTROL 1 Kapiri Mposhi Masaiti Nyimba Kawambwa Chilubi Nakonde Mwinilunga Namwala Itezhi‐tezhi
Kalabo CONTROL 2 Chibombo Mpongwe Chadiza Milenge Chinsali Mpulungu Chavuma Mazabuka Kazungula Shangombo i. What is the causal effect of the Zambian RBF on the population health indicators of interest? In order to answer this question, inputs will be assigned to the three reeasrch groups as follows: (a) The Intervention group will be receiving EmONC equipment and RBF incentives; (b) The Control I group will be receiving EmONC equipment and the equivalent of the average RBF incentives in the Intervention group; and (c) The Control II group will receive nothing. This is shown in Table 2. In the Control I group, there will be a separate account at district level to cater for these funds which will flow based on the normal GRZ guidelines. 10
Table 2: Description of Groups for Policy Question One Intervention Control 1 Control 2 EmONC equipment +RBF incentives EmONC equipment +Average RBF incentives Business‐as‐usual ii. Do higher incentive payments in rural/remote areas result in increased health outcomes and greater retention of staff? In order to answer this question, the health facilities in the Intervention and Control I groups will be further randomized in two different groups (rural/urban and remote) based on national classification. In this regard, the Cabinet Office classification of districts into urban, rural, or remote for purposes of determining the level of hardship allowances for civil servants will be used. This classification takes into account the different levels of development within a district by designating certain parts of a district as urban (mostly the district administration centre), others as rural (outside a 20KM and 15KM radius of the administrative centre in cities and municipalities, respectively), and the rest as remote (the periphery of a district). The Cabinet Office classification of districts will be complemented by the MOH’s labelling of districts into four categories, namely A, B, C and D, which defines them in terms of ‘urban’, ‘rural’ and ‘remote’. Based on the above, the total number of remote facilities in the Intervention and Control I districts were identified. From the total number, a smaller number of remote facilities in both the Intervention and Control I groups (106 to be precise) were selected using stratified random sampling. The sampled remote facilities will receive a 25% higher incentive payment above the incentive payments due to each respective group. This means that all the other remote, rural and urban health facilities in both the Intervention and Control I groups that were not selected will receive the normal incentive payments due to each respective group. This is illustrated in Table 3. Table 3: Description of Groups for Policy Question Two Intervention Group 1 (Rural, Urban and Remote Facilities not sampled) EmONC equipment +RBF incentives Group 2 (Remote Facilities sampled) *EmONC equipment +RBF incentives plus 25% more of RBF incentives Control I Group 1 (Rural, Urban and Remote Facilities not sampled) Group 2 (Remote Facilities sampled) EmONC equipment
+Average RBF incentives *EmONC equipment +Average RBF incentives plus 25% more of Average RBF incentives Note: *The full list of the higher incentive remote facilities is attached as Annex 2. 11
iii. How does the likelihood of audit/external verification of results affect the accuracy of reported data? In order to answer this question, external verification will be done periodically over the implementation period. Only the facilities in the Intervention group will be used and these have been randomized into three groups to receive notice of a varying likelihood of performance audit. One group will confront a 100% likelihood of audit, the second group a 30% likelihood of audit, and the third group a 10% likelihood of audit. This is shown in Table 4. Letters specifying the likelihood of audit will be distributed during the cascade training. This will enable the health facilities to know which group they belong to and the regularity of audits. The assignment of facilities to the three groups of varying audit intensity is listed in Annex 3. Table 4: Description of Groups for Policy Question Three Intervention 1 Intervention 2 Intervention 3 100% likelihood of audit 30% likelihood of audit
10% likelihood of audit
3.5.1 Data Sources for the Impact Evaluation Maternal and Child Health interventions are outcome‐driven programmes and thus the project will need systematic and regular aggregate data from the health facilities to assess the status of the overall process, to introduce programme changes as needed, and to make policy recommendations. As such, information that will be used for the evaluation of the Zambia RBF will be derived from numerous sources including the Health Management Information System (HMIS), surveys, qualitative research, and project implementation reports. HMIS: Since incentive targets and payments are facility specific, the HMIS will play a key role both in setting these targets and assessing the success of facilities in reaching these targets. Utilizing the HMIS is critical during the pilot phase that wishes to formally test a scalable policy option. Currently, facility level HMIS information is collected at the district level and then summarized before reporting up the chain. The Impact Evaluation team will utilise the HMIS in the selected pilot districts to ensure that the facility‐reported information is entered in an appropriate electronic format and delivered to the PIU. External verification of HMIS: The achievement of district and facility RBF indicators, and consequent reward payments, will be determined through a set of self‐reported indicators. For this reason, it will be necessary to minimize the incentive to misreport through external audit and sanctions given any evidence of misreporting. This component will be financed through an independent contract with a specialized local or international firm. Facility and household surveys, qualitative research will all be employed in the collection of the various data. This component will be financed through independent contracts with specialized local or international firm/consultant to capture the ongoing learning in the design and implementation of the RBF pilot programme. Qualitative research aimed at assessing the effect of the program on health workers and communities will also be used. 12
4. Implementation: Role of Health Facilities, Districts, Provinces and National Level 4.1
Health Facility Level 4.1.1 Role of Health Facilities under RBF The health facility, specifically the health centre, is the key actor in the RBF model. All other levels of the health system support the health centre in delivering quality health services. Health facilities are responsible for the following RBF relevant activities:  Developing a business plan (that outlines the strategies and resources required to reach the targets set for the selected RBF indicators)  Mobilizing and managing of resources for service delivery  Actual provision of the relevant health services to clients  Undertaking any other (facility and community level) interventions that enhance access to and quality of the delivered services  Invoicing for the delivered services  Facilitating access to information for audits and verification exercises  Decision making on utilisation of bonus payments in accordance with the general RBF stipulations.  Progress reports to the DMO on a monthly basis  Ensuring complete compliance to RBF procedures and full accountability for all received RBF resources. A quarterly performance contract will be signed between each participating health facility (provider) and the DMO (who is the representative of the Ministry of Health as the purchaser). The contract specifies the terms and conditions for RBF involvement (see Annex 7). The health centre in‐charge and the chairperson of the health centre committee are co‐signatories to the contract ‐ with the District Medical Officer signing on behalf of the DMO. The two co‐signatories have therefore specific roles to play in overall contract management for the health facility; i.e. they should:  Thoroughly be acquainted with the contents of the contract;  Ensure strict compliance with the contractual terms and conditions;  Ensure that health facility staff and health centre committee members are fully aware of the contractual implications and opportunities; and  Represent the health facility in key RBF interactions (including settlement of disputes) with the DMO. Copies of the contract document, together with other RBF support documents and templates should be filed and safely stored in an office or location that allows smooth retrieval and referencing. 13
4.1.2 Health Facility Business Plan Each health facility will develop a quarterly "business plan" as an integral part of the RBF contract (see Annexes 12 and 13). The plan will be attached to the performance contract signed with the DMO and should be updated quarterly. The plan must be completed, discussed and approved (by the DMO) in line with the schedule for the development of the district annual action plan. Once complete, it must be signed by the in‐charge of the health facility together with the chairperson of the Health centre Committee. The absence or failure to develop such a business plan may result in the termination of the performance contract. The elements of a business plan are the following: (a) Calculations of quarterly target per indicator; (b) problem analysis as to why output and quality targets are not achieved; (c) strategies proposed to solve the problems; (d) the human resources required and how to motivate staff; (e) the infrastructure and equipment requirements and (f) the financial planning. For a template of a business plan see Annex 12. Through the business plan, the health facility therefore specifies strategies and targets to increase the quantity and quality of the incentivised health services. A business plan, though initially developed for a year, turns out to be quarterly work plan due to the updates. Updating a plan every three months allows more flexibility, will accelerate improvements and timely flag serious problems in a health facility. The plan helps to identify problems in the catchment area such as why health service objectives and targets are not achieved and proposes realistic strategies for a three months period. Table 5 shows the recommended good practice and standards for a business plan. Table 5: Good Practice and Standards for a Business Plan 1. Business Plan should be updated quarterly and the latest copy made accessible The DMO verifies the current/updated business Plan 2. Business Plan should be prepared with key stakeholders
This includes all key health centre staff, health centre committee members, representatives of outreach posts and health posts, Community Health Workers (CHWs), representatives of subcontracted private clinics (if applicable), NGOs and other Community Based Organisations (CBOs) providing health services in catchment area. 3. Business Plan should contains convincing geographic coverage plan Clear strategies for various zones, outreach activities and demand generating initiatives(including social marketing where applicable) 4. Business Plan should analyse the Human Resource (HR) situation
Health Facility (HF) addresses this subject in the Business Plan (BP) including a strategy for optimising the use of available staff 5. Business Plan should project revenue and expenditure BP outlines expenditure for delivering the incentivised indicators as well as the relevant revenue 4.1.2.1 Business Plan Management Cycle The business plan management will undergo a cycle involving four stages (see the following diagram). During the first stage of the contracting process, the DMO invites the health facility to develop a “business plan”. The second stage concerns the implementation of the business plan by the health care providers. During the third stage, the DMO, district hospital and the external verifier strictly control 14
the results declared by the health facility in terms of "quantity" and "quality". The fourth stage of the cycle involves the examination of this feedback, renegotiation and the renewal of contracts. Figure 2: Business Plan Management Cycle Phase 1: Contracting Phase 2: Health service provision Phase 3: Verification  Service providers develop a business plan  District Medical Office “buys” the incentivised services.  Service providers implement their strategies.  Service providers utilise resources as deemed appropriate.  District Medical Office verifies results  District Hospital audits quality  Local community groups or contracted agency verify patient satisfaction DISTRICT MEDICAL OFFICE AND SERVICE PROVIDERS SERVICE PROVIDERS IMPLEMENT PAYMENT for good quality services Higher “performance” means higher bonus pay Phase 4: Contract renewal Annual renewal based on the quarterly feedback concerning quantity, quality and satisfaction of population. 4.1.3 Performance Indicators The Zambia RBF model is a “Fee for Service” model that is initially targeting 9 key health facility indicators found in the HMIS and deemed as critical in improving maternal and child health services. The selection of these indicators was discussed at length and agreed upon by the MOH and its partners. The indicators are:  Curative consultations  Institutional deliveries by skilled birth attendant  ANC prenatal and follow up visits  Postnatal visit  Full immunization of children under 1  Pregnant women receiving 3 doses of malaria IPT  FP users of modern methods at the end of the month  Pregnant women counselled and tested for HIV  Number of HIV pregnant women given Niverapine and AZT Based on these indicators (whose definitions are provided in Annex 16), a health centre fee schedule as outlined in Table 6 has been developed. This consists of the core indicators, an index (weighting) attached to each indicator and the respective fee. In arriving at the index, due consideration was accorded to the significance of the indicator, i.e. the associated result in attaining the MCH national and programme goals as well as the level of complexity in conducting the requisite intervention. For 15
example; a curative consultation has an index of 1, where as an institutional delivery is accorded 20 – indicating that a delivery is assumed to be 20 times more complex (i.e. with regard to time taken, level of skill, drugs and supplies utilised, equipment used and immediate post delivery services) than an average curative consultation conducted. Table 6: Core Indicators and Fees Schedule3 No 1 2 3 4 5 6 7 8 9 Indicator Curative Consultation Institutional Deliveries by Skilled Birth Attendant ANC prenatal and follow up visits Postnatal visit Full immunization of children under 1 Pregnant women receiving 3 doses of malaria IPT FP users of modern methods at the end of the month Pregnant women counselled and tested for HIV Number of HIV pregnant women given Niverapine and AZT Index 1 20 5 10 7 5 2 Fee (Kwacha 1,000 32,000 8,000 16,500 11,500 8,000 3,000 9,000 10,000 In order to avoid a situation where these incentivized indicators become the centre of attention and improve at the detriment of all other health indicators, the non‐incentivized indicators will also be routinely monitored. The aim is to ensure that improvements in indicators are comprehensive and not biased towards the incentivized ones. Therefore, if non‐incentivized indicators fall below 80 percent of the expected trend (based on historical data) at any time during the RBF implementation period, the facility must meet with the DMO to review the situation and define corrective measures. If the downward trend continues, the DMO reserves the right to nullify the performance contract. 4.1.4 Key RBF Activities at a Health Facility Some of the key RBF activities for a health facility include monthly reporting, quarterly invoicing, facilitating the calculations of incentive payment, decision making on the utilization of incentive payment and (factual) reporting. 4.1.4.1 Monthly Reporting An essential activity at the health facility is ensuring that that the services that have been reported have actually been delivered. Accurate reporting therefore becomes an essential part of this model. Each month the health facility will be required to fill out a monthly report, i.e. a provisional invoice (see Annexes 14 and 15) that summarizes the number of services delivered under each incentivized indicator as recorded in each of the corresponding HIMS facility registers.  Child health register  Safe Motherhood register 3
Higher incentive remote facilities will receive 25% more than the regular price per indicator. The full list of the higher incentive remote facilities is attached as Annex 2. 16




Family Planning register Outpatient register Postnatal register Prevention of mother‐to‐child transmission of HIV (PMTCT) register The health facility will be required to have the registers ready for evaluation during the monthly internal data audits to ensure that the data in the RBF activity summary report matches the data in the HMIS registers. The RBF activity summary report is an auditable document that also serves as an invoice. Considering the importance of the HMIS registers and RBF activity summary report for the payment of incentives, it is important to check entries and avoid errors. Lack of quality in these documents (e.g. if the data in the monthly RBF activity summary are not matched with the data in the HMIS registers) may attract penalties. A gap of more than 5% may result in the non‐payment of incentives for the concerned indicator. Note: One copy of the Monthly RBF Activity Summary Report must be kept at the health facility and another one stored at the DMO. The copies must be kept for at least 5 years for auditing purposes. 4.1.4.2 Quarterly Invoicing On the basis of the monthly RBF activity summaries, an invoice for incentive payment will be prepared for a quarter. This is a critical activity that must be completed by the 7th day after the end of the quarter. The Health Centre In‐Charge and the Chairperson of the Health Centre Committee will append their signatures to the invoice and submit it to the DMO. It is important that the submission date is strictly adhered to as many other subsequent activities in the RBF chain depend on it (see Annexes 17 and 18 for the deadlines of critical activities). Note: The actual quarterly incentive payment that will eventually be received by the health facility is determined by two factors:  Monthly quantity audits by the DMO who will review the entries in the designated registers and compares them to the numbers entered in the invoice.  Quarterly quality audit conducted by a Hospital contracted by the DMO. This is to ensure that the services delivered meet the agreed upon quality standards. Thus, the incentive payment is calculated in the following manner: Amount to be paid = Total Quantity amounts attained in 3 months multiplied by Quality Score 4.1.4.3 Distribution of Incentive Payments at Health Facilities The incentive payment received by the health centre for each quarter will be divided in the following manner:  Staff performance bonuses/incentives: No greater than 75% of the total performance incentive earned for a quarter should be used for staff motivation among the health centre staff.  Reinvestment: A minimum of 25% of the total performance incentive earned for a quarter will be used for reinvestment towards activities that contribute directly to increasing the quantity 17
and quality of services delivered. This is a key feature of the model as health facilities will be able to use these resources for activities that they deem appropriate. The DMO will not prescribe the investment activities to be implemented at the health centres but will discuss the activities with the health centre during the development of the health centre Business Plan. 4.1.4.4 Staff Motivation Contracts and Individual Staff Performance Assessment In order to ensure that each staff commits oneself to the expected service level, a “motivation contract” will be entered into between the Health Facility and each individual member of staff (see Annex 9). The motivation contract institutes a mode of conditional remuneration to the employee, dependent on individual performance and his/her official job title. Bonus payments are therefore linked not just to the overall institutional performance, but also to the individual performance. In order to assess the employee’s performance, a scoring card (Individual Evaluation Form for Health Facility Staff) has been specifically developed for this purpose (see Annex 22). Each member of staff will be assessed out of a possible maximum score of 100 for conscientiousness to work, team spirit, technical skill and adaptability to work, personal development will, and contribution to overall institutional performance during the quarter. The attained score (say 95%) is then multiplied by the total amount available for staff bonuses and the individual staff index. For the Health Centre In‐charge, he/she will not be assessed by anyone as he/she is the head of the institution. The quality score for the health facility as assessed by the District/General hospital will be the score for the In‐Charge. 4.1.4.5 Distribution of Performance Bonuses to Individual Members of Staff at Health Facilities The total amount available for staff performance incentives/bonuses (after deducting the amount for re‐investment) will be divided amongst the individual health facility staff based on the employees’ individual staff index (which is derived from his/her basic salary) and the percentage score from the individual performance evaluation (see sub‐section 4.1.4.4 above). The formula is: Individual Staff Motivation Bonus = (Staff Index) X (Total Amount Available for Staff Performance Incentives) X (Percentage Score from Individual Evaluation) An example of how to calculate Individual Staff Performance Bonuses is provided in Annex 30. Once all the members of staff have been paid, the remaining amount from the total available for staff performance bonuses should be used for re‐investment. 4.1.4.6 Data Quality Controls Internal data quality controls are an integral part of the health facility functions under RBF. The health facility staff has to ensure that data entry is complete and accurate at all times. The health centre in‐
charge must check all registers on a weekly basis and ensure that all registers are up‐to date and correctly entered. Note: If any irregularities are discovered in subsequent periods, bonuses must be repaid and all missing money must be returned. Irregularities include items such as stealing, or falsification of records. Subsequently, the health facility will be barred from the incentive scheme for a period of 12 months. 18
4.2
District Level 4.2.1 Role of the District Medical Office (DMO) Under the RBF arrangements, the DMO is responsible for the following:  Overall technical coordination of RBF at the district level  Supervision of health facilities  Signing financing agreements with the health facilities  Conducting monthly data quantity audit  Contracting the hospital or any other appropriate agent to conduct quarterly quality audit  Procurement of larger items and ensuring that the necessary resources (e.g. equipment, drugs) which healthcare workers will need to perform their duties are made available.  Preparation of quarterly progress reports to the MOH – a standard short reporting form will be provided for this purpose, and  Documentation of challenges and successes 4.2.2 DMO Performance Contract A performance contract between the DMOs and MOH/PMO will be entered into in order to hold the district accountable for results (Annex 6). The contract is accompanied by a performance framework that emphasizes 11 process measures ‐ which are derived mainly from the existing DMO tools and supervisory functions (see Table 7 and Annex 19). As shown in Table 7, each indicator/measure has a weight attached and a specific fee/bonus. At the end of each quarter, the PMO comes up with a synthesis that assesses and scores the performance of the DMO in all the 11 core areas. The synthesis forms the basis for calculating the payments due to the DMO. The maximum amount of money that the DMO can get as Performance Incentive is K30,000,000 (Thirty Million Kwacha) per quarter but this can be lower depending on the actual performance achieved. For example, a score equivalent to 80% will mean that the DMO can only receive 80% of K30,000,000 which is equivalent to K24,000,000. Table 7: DMO Performance Measures and Weights No. District Indicator/Performance Measure 1.
100% of Health Centres have been supervised at least once per quarter based on the recommendations from the RBF Quantity and Quality audits, and Performance Assessment 2.
Health Centres with 100% of qualified clinical health workers according to Health Centre establishment 3.
At least one Meeting with Health Centres Staff held during the past quarter 4.
At least one half hour training on one specific topic, during the quarterly HC staff meetings 5.
Organize quarterly Health Centre RBF Quantity audits
6.
Quarterly quality assessment of the Health Facilities in the district conducted by the District/General Hospital 7.
Monthly HC RBF and HMIS data entered in the RBF and HMIS databases and printed before the 7th day after the end of the month 8.
Participation in the Quarterly District RBF Steering Committee Meetings
9.
Management of the District Pharmacy
10. Quarterly Performance Assessment of the Health Centres done
11. Communication equipments with health facilities
Weight 20
10
10
10
15
10
20
15
25
20
19
4.2.2.1 Distribution of Performance Incentives at DMO The Performance Incentive payment received by the DMO for each quarter will be divided in the following manner:  Staff incentives: A maximum of 75% of the total Performance Incentive earned for a quarter will be divided among the DMO staff.  Re‐investments, monitoring, D‐RBFSC meetings, and other activities: A minimum of 25% of the total Performance Incentive earned for a quarter will be used for reinvestment towards activities that contribute directly to increasing the number and quality of services delivered in the district. This includes undertaking RBF quantity audits, follow‐up supervisory visits, holding of D‐RBFSC meetings, and other activities deemed necessary to the effective implementation of the RBF in the district. 4.2.2.2 Staff Motivation Contracts and Individual Staff Performance Assessment at DMO The Performance Incentive at the DMO is linked to the overall performance of the institution but also to the individual performance. Thus, in order to ensure that each staff commits oneself to the expected service level, a “motivation contract” will be entered into between the DMO and each individual member of staff (see Annex 10). The motivation contract institutes a mode of conditional remuneration to the employee dependent upon individual performance and official job title. In order to assess the employee’s performance, a scoring card (Individual Evaluation Form for DMO Staff) has been specifically developed for this purpose (see Annex 23). Each member of staff will be assessed out of a possible maximum score of 100 for conscientiousness to work, team spirit, technical skill and adaptability to work, personal development will, and contribution to overall institutional performance during the quarter. The attained score (say 90%) is then multiplied by the total amount available for staff performance bonuses and the individual staff index. In this case, an employee will be entitled to 90% of the total maximum amount due to him/her. For the District Medical Officer, he/she will not be assessed by anyone as he/she is the head of the institution. In this case, the overall score from the DMO RBF Evaluation by the PMO will be his/her score. 4.2.2.3 Distribution of Performance Bonuses to Individual Members of Staff at DMO From the total amount that the DMO will get for performance incentives, it will first deduct a minimum of 25% for re‐investment purposes, the remainder of which should be regarded as the total amount available for staff performance incentives/bonuses. This money will then be divided amongst the individual members of staff at the DMO based on the employees’ individual staff index (which is derived from his/her basic salary) and the percentage score from the individual performance evaluation (see sub‐section 4.2.2.2 above). The formula is: Individual Staff Motivation Bonus = (Staff Index) X (Total Amount Available for Staff Performance Incentives) X (Percentage Score from Individual Evaluation) An example of how to calculate Individual Staff Performance Bonuses is provided in Annex 30. Once all the members of staff have been paid, the remaining amount from the total available for staff performance bonuses should be used for re‐investment. 20
4.2.3 Monthly Quantity Audit by the DMO The DMO is responsible for conducting a monthly quantity audit of the RBF incentivised indicators. The following are the steps required to prepare for a quantity audit:  A schedule of visits to health centres is developed on a monthly basis by the DMO.  A data verifier/evaluator is assigned by the DMO.  The evaluator works with the health centre in‐charge to prepare for the visit.  At the end of the assessment, data collected are compared with the self‐evaluation form. Data is then discussed and approved with names and signatures of the health facility in‐charge.  A copy of the results of the evaluation is given to the health centre for records.  The original copy of the evaluation is sent to the District Medical Officer who is the Secretary of the District RBF Steering Committee. 4.2.4 Quality Audit by the District or General Hospital The incentives provided under RBF can lead to increased coverage that is attained by compromising or without paying much attention to service quality. In order to ensure that RBF interventions support increases in both service coverage and quality, each health facility will be assessed on a quarterly basis by a designated district or general hospital using the health centre quality assessment tool. The DMO will make a decision on whether to use the District Hospital within its district or outside, but in no circumstance should the DMO conduct the quality assessment. The purpose of the Quarterly Quality audit is to obtain a quarterly summarised quality score for a Health Centre. The quality score will be used in the RBF performance framework in combination with the “quantity” performance indicators. The quality checklist applied in the audit incorporates national norms and values from 10 different areas deemed critical for assessing the quality of care. These are the following: 1. Curative Care 2. ANC 3. FP 4. EPI 5. Delivery Room 6. HIV 7. Supply Management 8. General Management 9. HMIS 10. Community Participation If for instance the quality score is 78%, then only 78% of the quarterly bonus fees will be paid to the health facility. This system is therefore designed to not only stimulate the quantity of certain services provided, but to also ensure a high level of quality. 21
4.2.5 Weights for the Quality Scores Weights have been attached to the ten (10) different service areas deemed critical for assessing the quality of care. This is shown in Table 8. Table 8: Weights attached to Quality Service Areas No. SERVICE WEIGHT 1 Curative Care 35
2 ANC 55
3 FP 45
4 EPI 38
5 Delivery Room 65
6 HIV 16
7 Supply Management 21
8 General Management 18
9 HMIS 18
10 Community Participation 9
TOTAL 320
Since weighting is indicative and meant to elicit change, adaptations will be made from time to time in line with preferred RBF quality outcomes. The checklist is a living document which will be modified regularly to incorporate lessons learned from the end‐users, changing protocols, and norms. For instance, set targets can be increased in instances where the majority of the health centres reach 90% or more. 4.2.6 Steps for conducting a Quality Assessment (i) The assessment is conducted unexpectedly without notifying the health centre team. (ii) The evaluators inform the health centre the same day the exercise commences. (iii) Evaluators work with the health centre In‐Charge and responsible facility staff when conducting their evaluation i.e. observation of clinical cases and gathering of documentation. (iv) At the end of the assessment, the evaluation forms should be signed by both the evaluators and service providers at the health centre. (v) At the end of the assessment, the team of evaluators should take time to talk to all the service providers at the health centre. Positive results should be acknowledged and encouraged. After discussions, the evaluators and the In‐Charge (and his/her staff) should draw up recommendations including those requiring technical supervisions. (vi) A copy of the results of the assessment is given to the health centre and hospital for analysis and documentation. (vii) The results of the quality assessment should also be given to the officer responsible for monitoring and evaluation of health centres at the DMO. (viii) The original copy of the completed assessment of the health centre is sent to the RBF focal point at the DMO after approval by the Medical Superintendent. (ix) The quarterly quality audit needs to be completed before the 10th day of the month after the end of the quarter. (x) Results are then presented and discussed during the quarterly District RBF Steering Committee meeting. 22
4.2.7 District RBF Steering Committee The District RBF Steering Committee (D‐RBFSC) is a sub‐committee of the District Development Coordinating Committee (DDCC). The Steering Committee plays an integral role in the RBF model as they are responsible for assessing the quantity and quality performance reports for the health facilities and approving the amount of the incentive payments (see the Guidelines for the D‐RBFSC in Annex 21). The D‐RBFSC shall constitute a minimum of 10 and a maximum of 12 members. Membership shall be gender balanced and consist of the following individuals: 1. Council Secretary (Chairperson) 2. District Medical Officer 3. Medical Superintendant of the District Hospital 4. District Health Planner 5. District Health Information Officer 6. District Pharmacist 7. Zonal Health Centre In‐Charge 8. A Representatives from government/local authority institutions 9. A Representative of Non‐governmental/Donor Organizations (maximum 3) 10. A Representative from the Community The DMO is responsible for organizing and calling for quarterly D‐RBFSC meeting. The minimum quorum for the D‐RBFSC shall consist of at least one representative from the 4 different categories: (i) DMO; (ii) District/General Hospital; (iii) NGO/Donor representative; and (iv) Community Representative. The meeting should not take place if a quorum is not reached. Scheduled meetings are held at least four times a year, but may be frequent depending on local arrangements. Each quarterly meeting (mandatory) must be held as follows: Before April 21 (Data for 1st quarter) Before July 21 (for the 2nd quarter data) Before October 21 (data for the 3rd quarter) and Before January 21 (data for the fourth quarter) Details of the procedures for convening meetings, the agenda and invitations for the meeting, data entry in the RBF data base, transmission of minutes of the previous meeting, duration of meeting and chairing of meetings are provided in Annex 21. 4.2.8 Determining Health Facility Payments The D‐RBFSC determines the award amount that the facility may earn in whole or in part at the end of the period of performance. This is decided upon based the facility’s performance against the monthly quantitative indicators specified in the performance payment plan on a quarterly basis. The actual amount of the performance payment to be paid to the facility shall be determined from a combination of the quantity and quality indicators based on the following formula as stated above: Amount to be paid = Total quantity amounts attained in 3 months multiplied by Quality Score The decision on incentive payments to health facilities made by the District RBF Steering Committee is final. The following are the deadlines for sending the approved invoices to the Provincial Medical Office: 23




For quarter 1 invoices: 22nd April For quarter 2 invoices: 22nd July For quarter 3 invoices: 22nd October For quarter 4 invoices 22nd January 4.2.9 Consolidating and Transmitting Data for Payment The DMOs will be the major beneficiaries and users of the Zambia RBF Web Application Management System elaborated in 4.4.6 below. The districts will be able to enter, via internet, the quantity indicators in the database on a monthly basis. The system has the capacity to produce facility‐specific performance reports linked to the calculation of the incentive payments. District quarterly consolidated invoices will be generated through the system and these will be printed and submitted to the D‐RBFSC for review and approval. The consolidated quarterly invoices for the district tabulated by each health centre in the district will be signed by the Chairperson of the D‐RBFSC and the District Medical Officer before transmission to the P‐RBFSC. 4.3
Provincial Level 4.3.1 Role of the Provincial Medical Office (PMO) At provincial level, the PMO is responsible for technical support to the districts as well as facilitating the implementation of the RBF project activities at district and community levels. Building on this function, the PMO will support RBF training and conduct RBF supervisory visits in the participating districts and communities. The specific RBF roles and responsibilities are as follows: (i) Provide office space and any other functional requirements for the Provincial RBF Technical Specialist; (ii)
Facilitating the implementation of the RBF project activities at district and community level; (iii) Calling the quarterly Provincial RBF Steering Committee meetings; (iv) Receiving, reviewing and forwarding to the PIU at MOH headquarters, progress reports and invoices submitted through the Provincial RBF Steering Committee; (v)
Ensuring that the indicators in RBF Districts are analyzed and bottlenecks identified and addressed; (vi) Conduct performance assessment in the RBF Districts and transmit the results to the PIU after approval by the Provincial RBF Steering Committee for payment on a bi‐annual basis; (vii) Conduct technical support supervision in the RBF districts, facilities, and communities where capacity building needs have been identified; (viii) Facilitate internal and external audits and verifications; and (ix) Settlement of all disputes arising during the implementation of the RBF project. 24
4.3.2 Provincial RBF Technical Specialist The Provincial RBF Technical Specialist plays a key role in coordinating RBF activities at the District and Provincial levels. He/she is responsible for the following key tasks: i.
Support RBF district health management team in the preparation and implementation of the RBF model (approximately 70%‐80% of time will be spent at district level); ii.
Pursuant to (i) above, the Provincial RBF Technical Specialist will be required to manage the RBF health information system by assist the districts in collecting and validating data on the key indicators that will be monitored for the RBF; iii.
Facilitate the performance of quality audits of the individual health facilities conducted by contracted entities; iv.
Actively participate in all relevant RBF training programmes and workshops; v.
Work closely with the Technical Assistance Agency at provincial level, the Technical Analyst and MIS Specialist at the PIU, and the External Verification Firm on all aspects of RBF implementation; vi.
Serve on the Provincial RBF Steering Committee and support the implementation of the District Steering Committees. He/she will be required to gather and maintain all the electronic copies of the minutes of the RBF Steering committees in the province; vii.
Monitoring of the District RBF performance frameworks, and coordinating partnerships related to RBF at district and provincial levels; viii.
Pursuant to (vii) above, the Provincial RBF Technical Specialist will be required to create and regularly update a database on all RBF projects in the province; ix.
Collate, analyze and identify performance gaps of the RBF district using the Health Management Information System (HMIS) and RBF reports and provide necessary technical support in order to build capacity for improvement; x.
Support the design and implementation of the Impact Evaluation component of the RBF Project; and xi.
Ensure the smooth transmission of invoices, minutes and other data required to trigger the payment of incentives to the MOH. 4.3.3 Provincial RBF Steering Committee The Provincial RBF Steering Committee (P‐RBFSC) is tasked with validating the district RBF performance frameworks and incentive payments. This committee is a replica of the district level steering committee. The P‐RBFSC will consist of a minimum of 9 members and a maximum of 11 members. The composition should be gender balanced and include the following persons: i.
Provincial Medical Officer (Chairperson) ii.
Provincial RBF Technical Specialist iii.
Provincial Health Planner iv.
Clinical Care Expert v.
Data Management Specialist vi.
Provincial Pharmacist vii.
Medical Superintendent of a General Hospital 25
viii.
ix.
Representative from a Government Department Donor/NGO representative (s) (maximum of 3) The minimum quorum of the P‐RBFSC meeting consists of at least one representative from the 4 different categories: (i) Provincial Medical Office; (ii) The General Hospital; (iii) Representative from a Government Department; (iv) A Donor/NGO Representative. The meeting should not take place when the quorum is not met. Scheduled meetings are held at least four times a year, but may be frequent depending on local arrangements. Each quarterly meeting (mandatory) must be held as follows: April 25 (Data for 1st quarter) July 25 (for the 2nd quarter data) October 25 (data for the 3rd quarter) January 25 (data for the fourth quarter) Details of the procedures for convening meetings, the agenda and invitations for the meeting, data entry in the RBF data base, transmission of minutes of the previous meeting, duration of meeting and chairing of meetings are provided in Annex 20. 4.3.4 Consolidating and Transmitting Data for Payment The PMO will be linked to the Zambia RBF Web Application management system. Each PMO, through the Provincial RBF Technical Specialist, will have a username and password. With these, the provinces will be able to enter, via internet, the district performance scores every quarter. It will therefore provide provinces with a “user friendly” option to assess how the districts are performing so that solutions can promptly be applied to support districts and facilities to achieve their targets. The system will produce district specific sheets to help teams assess their performance, which is linked to the calculation of the incentive payments. 4.4
National Level (Ministry of Health Headquarters) 4.4.1 Roles of the Ministry of Health Headquarters The MOH is the purchaser in the RBF model and has overall responsibility for project management. At the MOH Headquarters, the project will be implemented through the Directorate of Public Health and Research which will be responsible for all technical, administrative, and day‐to‐day running of the Project. The overall coordination aspects of the MOH include: (i) Continuous technical assistance in the overall design and implementation, training, M&E, financial management, linkages with other partners, contacting, and external validation (ii) Technical assistance in performance assessment, supervision, and support implementation and ensuring quality of care in health service delivery (iii) Procurement of reproductive health commodities (iv) Provide the bonus to the DMOs twice a year (every 6 months) (v) Support the design and implementation of the Impact Evaluation component of the RBF including the undertaking of operational research to understand what is working and what needs to be refined. 26
The overall coordination and implementation of the RBF project will be the responsibility of the RBF Project Implementation Unit at the MOH headquarters. 4.4.2 RBF Project Implementation Unit (PIU) The MOH will constitute a team at central level to manage the roll‐out the first phase of the RBF. The team will provide management support, technical oversight, coordination and implementation support. The PIU will consist of a Project Manager, a Health Systems Strengthening/Capacity Building Specialist, a Reproductive Health Specialist, a Financial Specialist, a Management Information System (MIS) Specialist, a Technical Assistant, a Programme Assistant, and a Driver. At Provincial level, eight (8) Provincial RBF Technical Specialists will also be recruited. The PIU will be supported by individuals or institutions contracted to undertake capacity building, technical assistance, external data verification, impact evaluation, and other forms of technical support. The specific terms of reference for the PIU are contained in Annex 25. The Project Manager will be responsible for the overall management of project activities under the PIU. The Project Manager will report to the Director of Public Health and Research for all technical, administrative, and day‐to‐day running of the Project. The Project Manager will also be required to maintain regular dialogue with the Director of Policy and Planning for all health care financing, resource mobilization, and Monitoring and Evaluation aspects of the Project. The Project Manager will be further required to maintain functional links to other Directorates and sub‐Programme Managers such as Technical Support, Human Resources, Health Planning and Budgeting, Reproductive Health, Accounts, Procurement, Internal Audit, and Cooperating Partners. Functional Linkages are depicted in Figure 3 below. Figure 3: Functional Linkages between the PIU and MOH Management Partners
Directorate of Technical Support
Directorate of Policy and Planning
Permanent Secretary
Directorate of Public Health and Research
M&E
Accounts
Unit
Directorate of Human Resources
Deputy D/ RH
Health Planning & Budgeting Directorate of Clinical Care
Procurement
Unit PBF‐ Project Management
RBF related decisions requiring the attention of the Permanent Secretary will therefore be prepared/initiated by the PIU, and then submitted to the Director of Public Health and Research who will, in turn submit the same to the Permanent Secretary. As an example, bonus payments submitted by the District RBF Steering Committees, through the PMOs, will be received and consolidated by the 27
PIU and then forward to the Director of Public Health and Research for onward submission to the Permanent Secretary. Once the Permanent Secretary has authorised payment, the documents will be sent back to the PIU through the Director of Public Health and Research to facilitate disbursements through the Account Unit of the MOH. 4.4.3 Purchaser Role of the MOH
As stated above, the MOH is the Purchaser in the RBF model. Through the PIU, the MOH will ensure that the incentive payments are made in a timely manner according to the guidelines. The MOH will be responsible for due diligence in ensuring that all of the paperwork is in order before the payments are made. Since health facilities and the DMO receive incentive payments based on the respective indicators, it could potentially create incentives to misreport on the achievement. To verify the accuracy of data reporting, an independent agent has to be contracted to conduct external validation reporting. Every quarter, two intervention districts will therefore be randomly selected for auditing. The audit at the district level will consist of a reconciliation of facility level reports with district aggregates over the last quarters of implementation of phase 2 (maximum 4 quarters). An acceptable amount of reporting errors will be determined. If reporting errors exceed the maximum, an agreed penalty will be enforced, consisting of repayment of the incentive and a 12 month period of exclusion from the scheme. All DMOs will be audited over the course of a year. During the first year of implementation of the pilot, a number of control districts will be audited to learn about typical unintentional errors in reporting. Every quarter, 25% of facilities (rounded up to the nearest whole number) will be randomly selected for auditing. The audit at facility level will have an exclusive focus on the last quarter reported. It will focus on 3 randomly selected indicators out of the 9 indicators. At the facility level, the audit will consist of (i) reconciliation of the tally sheet with the patient register; (ii) random selection of patients to contact and verify coverage of services. For the latter, a selection of all cases of the service will be audited to a total of 19 patients.4 If there are more than 19 patients that received the service, a group of 19 will be randomly selected for tracking and verification. Reporting on the audit will be to the MOH and the DMO, which will provide feedback to the audited health facilities. 4.4.4 Capacity Building and Training Programme This programme is geared towards building capacity and improving management and staff skills. This includes capacity building and training in data management and analysis; planning and budgeting; Monitoring and Evaluation; and financial and procurement management. Capacity building and training in the delivery of MCH services ‐ specifically Emergency Obstetric and Neonatal Care (EmONC) will also be provided. The overall strategy focuses on providing training and support through seminars, workshops, supervisory visits, and short courses. This will be based on individual needs as well as group requirements. MOH will prepare and submit to the Bank, for its prior review, an annual training program, as part of the project annual work plan, which shall, inter alia, identify: (a) the training and workshops 4
Sample size that maximizes precision following LQAS methodology
28
envisaged; (b) the justification for the training, how it will lead to effective performance and implementation of the project; (c) personnel to be trained; (d) the selection methods of institutions or individuals conducting such training; (e) the duration of proposed training; and (f) the cost estimate of the training. Reports by the trainee and trainers upon completion of training and/or supervisory visits will be mandatory. The Technical Agency firm, internal/external consultants, MOH and PIU staff, and other resource persons will be used in the Capacity Building and Training Programme. 4.4.5 The National RBF Steering Committee The National RBF Steering Committee (N‐RBFSC) is a sub‐committee of the Health Care Financing Technical Working Group and will meet every quarter to extensively discuss all matters pertaining to the implementation of RBF projects and other related initiatives in Zambia. The N‐RBFSC will be chaired by the Director of Public Health and Research. It will be composed of representations from the MOH, other Line Ministries, UNZA, Cooperating Partners (CPs), local and international NGOs, and community representatives. The unit of organization will be:  Director ‐ Public Health and Research ‐ Chairperson  Director ‐ Policy and Planning ‐ Member  Director ‐ Technical Support Services ‐ Member  Deputy Director ‐ Health Planning and Budgeting ‐ Member  Deputy Director ‐ Monitoring & Evaluation ‐ Member  Deputy Director ‐ Reproductive & Child Health ‐ Member  Programme Specialist ‐ Child Health ‐ Member  Chief Planner – Health Planning & Budgeting ‐ Member  Chief Planner – Development Cooperation ‐ Member  Chief Planner – Monitoring & Evaluation ‐ Member  Chief Accountant – Ministry of Health ‐ Member  Principle Accountant (Donor) – Ministry of Health ‐ Member  Representative – Medical Stores Limited ‐ Member  Representative ‐ Ministry of Finance & National Planning ‐ Member  Lead Cooperating Partners ‐ Member  Lead Civil Society/NGOs ‐ Member  NPO/RH focal person, WHO ‐ Member  RH Specialist, UNICEF ‐ Member  Senior Nutritionist, National Food and Nutrition Commission ‐ Member  Representative – University of Zambia ‐ Member  Representative ‐ Churches Health Association of Zambia ‐ Member  Representative – World Bank ‐ Member The N‐RBFSC will be responsible for ensuring timely implementation of the project by the various contracting agents. It will convene quarterly to: (i) Review the districts RBF performance frameworks, incentive payments, and other progress reports on the performance of the RBF project; (ii) Ensure that agreed performance targets and timelines for activities under the different RBF components are met; 29
(iii) Perform a trend analysis of the indicators (incentivized and non‐incentivised) in the RBF Districts and identify bottlenecks and address critical issues that could hinder project implementation; (iv) Ensuring that the Provincial and District RBF Steering Committee meetings are taking place in accordance with the set guidelines; (v) Settlement of disputes related to the implementation of the RBF project; (vi) Review the implementation of other RBF projects and related initiatives in Zambia aimed at harmonizing the entire RBF system. This includes making agreements on the incentive structure, indicators, supported interventions, performance monitoring, contracting, and community involvement in the implementation, and monitoring and evaluation; and (vii) Based on the RBF progress reports, make recommendations for presentation at the Health Sector Advisory Group (SAG) meeting and the Annual Consultative Meeting (ACM); 4.4.6 Zambia RBF Web Application Management System In order to facilitate accurate and reliable data consolidation and transmission from the health facility to the national level, the Zambia RBF Web Application Management System has been put in place. Programme managers at various levels will be able to enter, via internet, the quantity indicators in the database on a monthly basis. The database will show how the health facilities and districts are performing so that solutions can be promptly found to assist under‐achievers to meet their targets. The ‘Analysis’ menu on the database can generate analytical reports in table or chart form as shown in the Figure on the side. The system has the capacity to produce facility‐specific performance reports linked to the calculation of the incentive payments. Quarterly "consolidated invoices" will also be generated through the system. These will be printed and submitted to respective RBF Steering Committees for review and approval. There will be various users with specific roles on the Zambia RBF Web Application Management System. The PIU in collaboration with the IT department of the MOH will maintain the list of users on the system. The MOH retains the right to allow, or disallow access to the application, and to allocate user roles. The MOH will also manage the content, design and analytical outputs of the database. The Users on the system will include the following: 1. Super‐User: the highest level authority. The super‐users will have access to all functions, and can create new users, and change passwords. There will be typically very few super‐users on the system and this can include the IT or software consultant, the Permanent Secretary, the Director of Public health and Research, and the RBF Project Manager. 2. National Administrator: the second highest authority. The national administrator will be able to access most functions, bar functions related to adding or changing district specific fees, or the district tariffs. The national administrator can assist in changing passwords and creating users under his own level. 30
3. Report Manager: The Report Manager will have a specific set of controls. This role can be designated to the Provincial RBF Technical Specialists who can be allocated all the districts in his/her province. The Report Manager can manage and change existing reports in the districts in which he/she is permitted to do so. 4. District Administrator: This is the highest authority at the district level. Typically, there will be one District Administrator per district, ideally the District Medical Officer or somebody who has been delegated this task. 5. Report Author: an author is typically linked to one district only. It is characteristically one person who has been given the task of entering the RBF data (quantity and quality). The district report author works under the supervision of the district administrator. 6. Guest: the viewer account is created to allow interested parties or stakeholders to access RBF performance data. The guest or viewer can access all the data reports for the entire country through the analysis menu, and print them. For more details on the use of the Zambia RBF Web Application management system, a User Manual is available. 31
5. Fiduciary Arrangements 5.1 Financial Management The general guidelines on financial management for the RBF project are based on the Financial Procedures manual for the Zambia Malaria Booster Project. For the RBF Intervention districts, these guidelines have been simplified in the RBF Health Centre User Manual. The management staff at the health facilities shall be accountable to the community and the Government, as appropriate, for the proper use of the facilities’ resources. Specifically, management of the resources at the health facility shall be the responsibility of the Health Centre In‐Charge. In discharging this responsibility, the In‐
Charge may delegate to other staff in writing. The Health Centre Committee shall also lend their support to the In‐Charge of the health facility in respect of resource management but such support shall not constitute a change in the primary responsibility lines. Non‐compliance to the financial guidelines will constitute a breach of duty and those responsible shall be liable to disciplinary action under the provisions of the existing financial laws and regulations. The In‐Charge is required to maintain accounting records and to prepare financial statements, which show how the facility’s resources have been obtained, used and the financial position of the facility at specific dates. The MOH will conduct audit/inspection of facilities as part of internal control to provide assurances that the resources provided have been put to proper use. Furthermore, the Office of the Auditor General will audit the accounts in an annual basis as required by law. It is important that the financial arrangements are well‐understood by all implementing parties at the health facility, district and provincial levels. 5.1.1 Disbursement of Funds As earlier stated in Section 3.5 above, the health facilities in the RBF Intervention districts will receive EmONC equipment and RBF incentives while a selected number of remote facilities will receive a 25% higher incentive payment above the incentive payments due to the other health facilities. In the same realm, the health facilities in the Control I districts will receive EmONC equipment and the average amount of incentive payments in the RBF Intervention districts. A selected number of remote facilities in the Control I districts will also receive a 25% higher incentive payment above the incentive payments due to the other health facilities. The average amount for RBF incentive payments in the Intervention districts will be calculated at the end of each quarter. After the amount is determined, the money will then be paid out to Control I districts within a period of 45 days after the payment of incentives to RBF Intervention districts. The funds will flow to the health facilities in the Intervention and Control I districts in two ways. The intervention districts will receive funding directly into the individual health facilities bank accounts and through a special account for RBF at district level. The health facilities in the Control I districts will receive earmarked funding through a special account at district level for Maternal and Child Health which will be reported on through normal GRZ mechanisms. No funds will be disbursed to the Control II districts. The flow of funds to the health facilities in the RBF Implementing and Control I districts is described below. 32
5.1.1.1 RBF Intervention Districts All health facilities in each RBF Implementing district shall be required to open and maintain a separate commercial bank account as required by the project. This is because one of the conditions for a successful RBF project is financial and management autonomy. Opening individual health facilities’ bank accounts fulfills the condition for financial autonomy as prescribed by the project. This means that disbursements of funds to the respective health facilities in the RBF intervention districts will only commence once this requirement has been fulfilled. The signing arrangements and operation of the bank account will be as follows: a) The Health Centre In‐Charge and another officer from the Health Centre will operate the account on Panel A while the Health Centre Committee Chairperson and another Committee Member shall operate the account on Panel B. The mandate is that ALL payments and cheques will be signed by one person from each panel representing both the Health Centre and the community. b) All supporting documents relating to a payment must be attached to the payment voucher before the relevant signatories sign it. c) Health Centres should have a Safe where all accountable documents, Cheques and money are to be kept. A district level special account earmarked for MCH interventions will also be opened to cater for activities of the DMO. The maximum amount of money that the DMO can get as Performance Incentive is K30,000,000 (Thirty Million Kwacha) per quarter but this can be lower depending on the actual performance achieved. For example, a score equivalent to 80% will mean that the DMO can only receive 80% of K30,000,000 which is equivalent to K24,000,000. The actual amount earned should cater for staff incentive payments (75%); and re‐investments, monitoring, D‐RBFSC meetings, and other activities (25%). 5.1.1.2 Control I Districts MOH will open designated accounts for MCH interventions at district level in all the Control I districts specifically to cater for the management and disbursement of funds to the health facilities in these districts and use at the DMOs. The existing GRZ flow of resources for a typical district will be used in accordance with the legal and financial framework. The payments will be channeled from the national level to the respective accounts at the DMOs from which the health facilities will receive the earmarked funding. The resources disbursed for the RBF payments will be ring‐fenced and incremental to current funding levels. The funds will be distributed to the health facilities through an imprest while the district payments will stay in special account. The maximum amount of money that the DMO can get as Performance Incentive is K30,000,000 (Thirty Million Kwacha) per quarter but this can be lower depending on the actual performance achieved. For example, a score equivalent to 80% will mean that the DMO can only receive 80% of K30,000,000 which is equivalent to K24,000,000. The actual amount earned should cater for staff incentive payments (75%); and re‐investments, monitoring, D‐RBFSC meetings, and other activities (25%). The DMO should disburse the rest of the money (net of actual DMO Performance Incentive 33
earned) to the respective health facilities according to the schedule, ensuring that the selected higher incentive remote facilities get 25% more than the other facilities. Both the District Accountant and the Health Centre In‐Charge are required to maintain accounting records and to prepare financial statements, which show how the facility’s resources have been obtained, used and the financial position of the facility at specific dates. The MOH will conduct audit/inspection of facilities as part of internal control to provide assurances that the resources provided have been put to proper use. Furthermore, the Office of the Auditor General will audit the accounts in an annual basis as required by law. It is important that the financial arrangements are well‐understood by all implementing parties at the health facility, district and provincial levels. 5.1.2 Managing Cash and Bank Accounts Sound financial management should be adhered to at the DMOs and health facilities in the RBF Intervention and Control I districts. Funds received by a health facility must be properly documented and receipted. The funds shall be spent only on planned activities in the Business or Action Plans. All documents used in executing and recording receipts and payments shall constitute accounting records. The In‐Charge should co‐ordinate and control the implementation of the budget by:  Ensuring timely and optimal procurement decisions  Checking that various activities take place as scheduled and within approved financial limits  Organising regular meetings with the staff as well as with the Health Centre Committees to review actual performance against budget  Ensuring timely investigation of variances and determination of their implications 5.1.2.1 Records The records required for managing cash and operating the bank account is listed below.  Receipt Book  Cash Book  Cheque Book  Bank Pay‐in slip  Bank withdrawal forms  Bank Statement
In addition, the following records/documents are required to support/validate a transaction.  Payment Voucher  Suppliers’ Invoice/ Receipt  Suppliers’ Delivery Note  Minutes of the Health Centre Committee  Contract agreement (where appropriate)  Business Plan (RBF Districts) or Action Plan (Control I)  Claim Form or Incentives Pay Schedule
34
5.1.2.2 Mode of Payment Payment shall be made either by cheque or cash. The Health Centre In‐Charge shall maintain the cash book and ensure it is updated and balanced daily. The following procedures shall be observed when making payments: i.
All payments must be based on payment voucher supported by relevant documents and approvals. ii.
Individuals approving payments must satisfy themselves that the related goods or services were actually received by the health facility. iii.
Details on the cheque could also be recorded on the cheque counterfoil for reference. iv.
All payments must be correctly recorded in the Cash book on a daily basis. v.
Health facilities are encouraged to pay suppliers by cheque. 5.1.3 Initial Advances at Health Facilities, District and Provincial Levels Once the Contracts between the DMOs and the Health Facilities are signed and Business Plans are in place, MOH will disburse initial advances to kick‐start the running of the pilot phase of the project in the RBF Intervention districts. The advances will be equivalent to the average of the RBF services delivered in Quarter 1 of 2011 as informed through the HMIS. Money will be transferred directly to the individual health facilities bank accounts. An advance will also be disbursed to the district level special account earmarked for MCH interventions at the DMO. The advance at DMO will be equivalent to 50% of the total applicable amount. For the health facilities in the Control I districts, MOH will disburse initial advances equivalent to the average of the amounts disbursed in the RBF Intervention districts. In addition, for the DMO activities, MOH will disburse an equivalent of 50% of the total applicable amount at DMOs. The sums of the monies for the health facilities and DMOs will be transferred directly to the designated accounts for MCH interventions at district level. The DMOs will then distribute the appropriate portion of the funds to the health facilities through imprests while the remaining amount will be used for DMO activities. As will be discussed in 5.1.4 below, the In‐Charge and DMOs shall retire these funds by sending copies of relevant financial records to the PIU. In order to adequately execute their work, the Provincial RBF Technical Specialists will be receiving monthly allocations to fully support the implementation of RBF activities at District and Provincial levels as outlined in 4.3.2 above. This money will also include the cost of conducting quarterly audits of the DMO by a team from the PMO using the DMO RBF evaluation checklist. The allocations to the Provincial RBF Technical Specialists will be based on approved work plans and budgets in relation to the workload in the districts and provinces. Subsequent allocations will be triggered by achieving the agreed targets in the work plans. Transfers will be made directly to designated accounts for RBF activities which will be opened at Provincial level. The Provincial RBF Technical Specialists shall maintain accounting records including the preparation of financial statements which show how these resources have been used against the set targets, targets achieved, and the financial position at specific dates. At national level, the PIU will also make routine, random, or follow‐up supervisory visits to the RBF Intervention and Control 1 districts aimed at ensuring the smooth implementation of the RBF project 35
countrywide. These supervisory visits will be part of the broader Capacity Building and Training programme. 5.1.4 Financial Reporting and Replenishment of Accounts Sound financial management should be adhered to at the DMOs and health facilities in the RBF Intervention and Control I districts as outlined in 5.1.2. However, the reporting lines will be different. The health facilities in the RBF Intervention districts will report according to RBF project guidelines while the health facilities in the Control I districts will report according to regular GRZ/MOH reporting guidelines. The In‐Charges at the health facilities in the Control I districts shall submit periodic copies of relevant financial records to the DMOs to facilitate accountability and replenishment of funds. At District and national level the use of funds will be monitored through financial reports generated on the basis of the monthly expenditure returns as well as simple progress reports from facilities that will link funding to key health service indicators representing the main priorities outlined in the Annual Action Plans. 5.2 Procurement All procurement activities under the project will be governed by the guidelines detailed out in the Procurement Procedures Manual for the Zambia Malaria Booster Project (MBP), which has been put together in accordance with the World Bank procurement guidelines. The Procurement Procedures Manual details the standards and step‐by‐step procedures to be followed in the procurement of goods, works and services under the MBP. These standards and procedures are designed to: i.
ii.
iii.
iv.
v.
Guide the procurement processes; Provide uniform procedures for the procurement of goods, works and services; Ensure transparency and accountability in all operations; Improve the efficiency and effectiveness of operations; and Promote the consistent application of best international procurement practices. The Procurement Procedures Manual conforms to the principal hallmarks of proficient public procurement. These are Economy, Efficiency, Fairness, Reliability, Transparency, and Accountability and Ethical Standards. The Procurement Manual explains in more detail how specific aspects of procurement should be handled consistent with the principles referred to above. The Procurement Procedures Manual will be applicable during the procurement of all goods, works and services financed in whole or in part from funds allocated to the RBF project, whether the funds are drawn from GRZ’s own resources, the World Bank or any other CPs. A procurement plan for goods, works and consultancy service contracts should be prepared and used during the implementation of the project. The plan should include relevant information on goods, works and consulting services under the project, thresholds, as well as the timing of each milestone in the procurement process. The procurement plan may be updated once every six months and reviewed by the Bank. In the interest of efficiency, and where applicable, the scheduling of activities in the procurement plan for the works will be sequenced in such a manner that the inputs to be derived from the consultants are provided upfront and are used to carry out the procurement of the works. 36
5.3 Capacity Building and Training in Financial and Procurement Management It is important that financial and procurement arrangements are well‐understood by all implementing parties at the health facility, district and provincial levels. If is further appreciated that accounting and procurement skills should be imparted to staff at the health facilities and members of the Health Centre Committees. In this regard, members of staff from the PIU and MOH Accounts and Procurement Units will conduct tailored training in Financial and Procurement Management to health facility and community representatives, DMOs, and PMOs. This will enable them to fully understand the fiduciary arrangements. These trainings will be conducted immediately after the RBF cascade training. These trainings will be conducted as part of the broader Capacity Building and Training Programme which aims to build capacity and enhance management and staff skills. 37
6. The Technical Assistance Firm 6.1 Main tasks and specific deliverables The MOH will hire an independent firm which will provide technical assistance to the project. Its main tasks will be to ensure the effective implementation of the RBF project at district level, and effective integration of design issues arising during the pilot in the national level design of the scale‐up programme. The firm will work very closely with the PIU to provide hands‐on implementation support to the ten (10) full RBF intervention districts. This shall include the following activities: i. Conduct a minimum of four (4) comprehensive capacity building trainings in data verification aimed at strengthening the supervisory role of the DMO (DMO) on the RBF project as outlined in this PIM. ii.
Conduct monthly and quarterly routine, random or specially commissioned data audits aimed at ensuring the effective implementation of the RBF model at district level. iii.
Provide support to the DMO and a sub‐set of Health Facilities to effectively implement the district health management performance contracts; iv.
Support the process of establishing and sustaining effective operations of District and Provincial RBF Steering Committees (SCs); v.
Pursuant to the above, support the SCs in effectively reviewing and validating performance payments and consolidation of invoices; vi.
Support the Provincial SCs in validating the district RBF performance frameworks and incentive payments; vii.
Provide technical support to the District Hospital on the application of the quality tool and how feedback on the results of the quality audits can be effectively communicated and used by the DMOs, Health Facilities, and the SCs to improve health service delivery; viii.
Provide assistance to the DMOs to ensure that systems designed to engage community participation (such as Neighborhood Health Committees and Health Centre Committees) function in accordance with the RBF design and are sufficiently involved in the planning, implementation, and monitoring of service delivery in their respective health facilities and communities; ix.
Conduct at least three (3) comprehensive reviews of the overall performance of the RBF Project and provide suggestions for improvements to the PIU in a timely manner; x.
Facilitate regular professional and institutional development amongst implementers and health facilities, respectively, by identifying training needs and institutional inadequacies as informed through regular monitoring and supervisory visits; and xi.
Provide hands‐on training and capacity building to provincial RBF Coordinators, and district teams on RBF implementation. 38
The firm is also expected to provide technical assistance to the PIU on specific technical areas related to the effective implementation of the RBF pilot. This includes: xii. Service package and fees; xiii.
Training needs identification and institutional capacity building at district, provincial and national levels; xiv.
Provision of hand‐on technical advice and on the job training for the PIU on all issues relevant to the successful implementation of the RBF project; xv.
Provision of advice on the quantity and quality tools, and suggestions for revisions if any; and xvi.
Support the PIU in conducting three (3) national workshops to exchange lessons from the pilot district implementation and how the operational design and implementation of the pilot5 can be strengthened. 5
It is expected that these workshops will be organized by the PIU in collaboration with the TA firm. Participation will be drawn from the PMOs, DMOs, District Hospital, Health Facilities and Community organisations from the pilot districts. At national level, other government Line Ministries, academia, NGOs and Civil Society, and Bilateral and Multilateral Cooperating Partners are expected to attend. 39
7. ANNEXES 1­30 ANNEX 1: Pilot Districts with targeted Health Facilities ....................................................................................... 41 ANNEX 2: High Incentive Remote Facilities ............................................................................................................... 42 ANNEX 3: Varying Likelihood of Audit ......................................................................................................................... 44 ANNEX 4: RBF Training....................................................................................................................................................... 47 ANNEX 5: EmONC Sites and Assessments ................................................................................................................... 48 ANNEX 6: Contract between the Ministry of Health and the District Medical Office ................................ 49 ANNEX 7: Contract between the District Medical Office and the Health Facility ........................................ 55 ANNEX 8: Contract between the District Medical Office and the District/General Hospital ................. 60 ANNEX 9: Motivation Contract for Health Facility Staff ........................................................................................ 65 ANNEX 10: Motivation Contract for District Medical Office Staff ...................................................................... 68 ANNEX 11: Guidelines on Contract Management .................................................................................................... 71 ANNEX 12: Template of a Business Plan for a Health Facility Contract ......................................................... 74 ANNEX 13: Guide on Business Plan Development ................................................................................................... 83 ANNEX 14: Monthly RBF Invoice for Rural Health Centre ................................................................................... 89 ANNEX 15: Monthly RBF Invoice for High Incentive Remote Health Centre ................................................ 90 ANNEX 16: Definitions of Health Facility RBF Indicators ..................................................................................... 91 ANNEX 17: Critical Deadlines – From Receipt of RBF Invoice to Payment of Incentives ........................ 92 ANNEX 18: Flow Chart – From Receipt of RBF Invoices to Payment of Incentives ................................... 93 ANNEX 19: District Medical Office RBF Evaluation Checklist ............................................................................. 94 ANNEX 20: Guidelines for Provincial RBF Steering Committees ....................................................................... 99 ANNEX 21: Guidelines for the District RBF Steering Committee .................................................................... 106 ANNEX 22: Individual Evaluation Form for Health Facility Staff ................................................................... 113 ANNEX 23: Individual Evaluation Form for District Medical Office Staff .................................................... 115 ANNEX 24: District/General Hospital RBF Quotation Card .............................................................................. 117 ANNEX 25: Project Implementation Unit (PIU) ..................................................................................................... 118 ANNEX 26: Letter of Commitment between the District Commissioner and the Members of the District RBF Steering Committee ................................................................................................................................. 120 ANNEX 27: RBF Essential and Complementary Design Elements .................................................................. 121 ANNEX 28: Data Management under the RBF ........................................................................................................ 123 ANNEX 29: Quality Assurance under RBF ................................................................................................................ 125 ANNEX 30: Example of how to Calculate Individual Staff Performance Bonuses ................................... 127 40
ANNEX 1: Pilot Districts with targeted Health Facilities Group Intervention Control Group 1 Control Group 2 Name of District Mumbwa Lufwanyama
Lundazi
Mwense
Mporokoso
Isoka
Mufumbwe
Siavonga
Gwembe
Senanga
Total Kapiri Mposhi
Masaiti
Nyimba
Kawambwa
Chilubi
Nakonde
Mwinilunga
Namwala
Itezhi‐tezhi
Kalabo
Total Chibombo
Mpongwe
Chadiza
Milenge
Chinsali
Mpulungu
Chavuma
Mazabuka
Kazungula
Shangombo
Total Health Facilities 28 17 38 24 14 9 15 14 10 22 191 29 21 17 23 12 10 20 12 12 19 175 31 11 19 8 15 11 7 27 20 17 166 41
ANNEX 2: High Incentive Remote Facilities RBF Intervention Group Control I Group Health Facility Name District Health Facility Name District 1.
Chinemu Lufwanyama 1.
Matipa Chilubi 2.
Kapilamikwa Lufwanyama 2.
Chaba Chilubi 3.
Mibenge Lufwanyama 3.
Santa Maria Chilubi 4.
Mushingashi Lufwanyama 4.
Mofu Chilubi 5.
Shimukunami Lufwanyama 5.
Fube Chilubi 6.
St Marys Lufwanyama 6.
Kaluwe Kalabo 7.
Chikomeni Lundazi 7.
Mambolomoka Kalabo 8.
Chisera Lundazi 8.
Tuuwa RHC Kalabo 9.
Chitungulu Lundazi 9.
Lueti Kalabo 10. Lunzi Lundazi 10. Kuuli Kalabo 11. Mkasanga Lundazi 11. Tapo Kalabo 12. Ndaiwala* Lundazi 12. Libonda Kalabo 13. Chitoshi Mporokoso 13. Lukena Kalabo 14. Chiwala Mporokoso 14. Mukubwe Kapiri Mposhi 15. Kalabwe Mporokoso 15. Chilumba Kapiri Mposhi 16. Kapatu Mporokoso 16. Chipepo Kapiri Mposhi 17. Mukolwe Mporokoso 17. Lunsemfwa Kapiri Mposhi 18. Mukupa Kaoma Mporokoso 18. Chapusha Kapiri Mposhi 19. Kabanda Mufumbe 19. Chishinka Kapiri Mposhi 20. Kalengwa Mufumbe 20. Chilwa Kapiri Mposhi 21. Kashima Mufumbe 21. St Pauls Kapiri Mposhi 22. Matushi Mufumbe 22. Mambwe Kawambwa 23. Miluji Mufumbe 23. Musungu Kawambwa 24. Nyansonso Mufumbe 24. Chibote Kawambwa 25. Kayanga Mumbwa 25. Mutaba Masaiti 26. Keezwa Mumbwa 26. Chinondo Masaiti 27. Mukulaikwa Mumbwa 27. Miengwe Masaiti 28. Mwembezhi Mumbwa 28. Michinka Masaiti 29. Nampundwe Mumbwa 29. Kashitu Masaiti 30. Shachele Mumbwa 30. Fiwale Masaiti 31. Chibondo Mwense 31. Mishikishi Masaiti 32. Chisheta Mwense 32. Mupapa Masaiti 33. Kalundu Mwense 33. Kafulafuta GRZ Masaiti 34. Kaoma Makasa Mwense 34. Kazozu RHC Mwinilunga 35. Kapamba Mwense 35. Tom‐Ilunga Mwinilunga 36. Katuta Mwense 36. Chiwoma Mwinilunga 37. Kawama Mwense 37. Chisengisengi Mwinilunga 38. Lukwesa Mwense 38. Kamapanda Mwinilunga 42
39. Luminu Mwense 39. Mukalizi Nakonde 40. Mambilima Mwense 40. Muchila Namwala 41. Mata Senanga 41. Kantengwa Namwala 42. Mwanamwalye Senanga 42. Moobola Namwala 43. Nalolo Senanga 43. Kasenga Namwala 44. Sibukali Senanga 44. Luembe FDS E16 Nyimba 45. Sikumbi Senanga 45. Chalubilo Nyimba 46. Sinungu Senanga 46. Msima Nyimba 47. Kapululira Siavonga 47. Mtilizi Nyimba 48. Manchanvwa Siavonga 48. Chimphanje Nyimba 49. Munyama Siavonga 49. Kalingindi Nyimba 50. Sianyolo Siavonga 50. Chinambi Nyimba 51. Bbondo Gwembe 51. Banamwaze Itezhi‐tezhi 52. Chisanga Gwembe 52. Nansenga Itezhi‐tezhi 53. Luumbo Gwembe 54. Nyanga/Chaamwe Gwembe 43
ANNEX 3: Varying Likelihood of Audit 100 Percent Likelihood of Audit 30 Percent Likelihood of Audit 10 Percent Likelihood of Audit Facility Name District Facility Name District Facility Name District Lukonde Gwembe Luumbo
Gwembe
Sinafala
Gwembe
Chisanga Gwembe Bbondo
Gwembe
Chabbobboma Gwembe
Gwembe HAHC Gwembe Chipepo
Gwembe
Munyumbwe Gwembe
Nzoche Isoka Nyanga/Chaamwe
Gwembe
Lualizi
Isoka
Kapililonga Isoka Kantenshya
Isoka
Sansamwenje Isoka
Kasoka Isoka Kapumbu
Isoka
Kalungu
Isoka
Matipa Lufwanyama Kafwimbi
Isoka
Nkana
Lufwanyama
Lumpuma Lufwanyama Bulaya
Lufwanyama
Mushingashi Lufwanyama
Fungulwe Lufwanyama Kapilamikwa
Lufwanyama
Shimukunami Lufwanyama
Chantete Lufwanyama Chinemu
Lufwanyama
Mukutuma Lufwanyama
Chasefu Lundazi Mibenge
Lufwanyama
Chikabuke Lufwanyama
Chisera Lundazi St Joseph
Lufwanyama
St Marys Lufwanyama
Chikomeni Lundazi Mukumbo
Lufwanyama
Lundazi Urban Lundazi
Mankhaka Lundazi Mibila
Lufwanyama
Hoya*
Lundazi
Mukolwe Mporokoso Munyukwa
Lundazi
Lundazi
Township Clinic Mporokoso Lumezi
Lundazi
MwaseMphangwe Schemes Lunzi
Chishamwamba Mporokoso Egichikeni*
Lundazi
Umi*
Lundazi
Kalabwe Mporokoso ZASP
Lundazi
Lundazi
Munyambala Mufumbe Zokwe*
Lundazi
MwaseMphangwe Zonal Nkhanga Mufumbwe HAHC Matushi Mufumbe Phikamalanza
Lundazi
Chitungulu Lundazi
Mufumbe Ndaiwala*
Lundazi
Kazembe Lundazi
Lubilo Mufumbe Kamsaro
Lundazi
Nyangwe Lundazi
Chunga Mumbwa Mwimba
Lundazi
Mukupa Kaoma Mporokoso
Nalubanda Mumbwa Mwase Lundazi
Lundazi
Mporokoso
Chiwena Mumbwa Nkhanyu*
Lundazi
Mwange Refugee Clinic Vincent Bulaya Shabasonje Mumbwa Mukomba*
Lundazi
Chitoshi
Mporokoso
Lubunda Mwense Mkasanga
Lundazi
Moseni
Mporokoso
Mambilima Mwense Mwanya
Lundazi
Kalengwa Mufumbe
Kashiba Mwense Mchereka
Lundazi
Kaminzekenzeke Mufumbe
Mwenda Mwense Ng'onga
Lundazi
Kikonge
Mufumbe
Nasilimwe Senanga Kanyanga
Lundazi
Kashima Mufumbe
Litoya Senanga Chijemu
Lundazi
Jivundu
Mufumbe
Mata Senanga Kapichila
Lundazi
Nakanjoli Mumbwa
Nanjuca Senanga Zumwanda
Lundazi
Muchabi Mumbwa
Ibbwemunyama Siavonga Malandula
Lundazi
Maimwene Mumbwa
Kariba Lukwizizi*
Lundazi
Mukulaikwa Mumbwa
Siavonga Lundazi
Lundazi
Mporokoso
44
Manchanvwa Siavonga Mtwalo
Lundazi
Sichobo
Mumbwa
Matua Siavonga Lusuntha
Lundazi
Mpusu
Mumbwa
Total health facilities 100% likelihood of audit = 38 Chiwala
Mporokoso
Kapyanga Mumbwa
Kapatu
Mporokoso
Kamilambo Mumbwa
Sunkutu
Mporokoso
Kaindu
Mumbwa
Shibwalya Kapila
Mporokoso
Lungobe Mumbwa
Njalamimba
Mporokoso
Musalango Mwense
Mushima
Mufumbe
Kawama Mwense
Kabipupu
Mufumbe
Lupososhi Mwense
Miluji
Mufumbe
Lukwesa Mwense
Nyansonso
Mufumbe
Mupeta
Mwense
Boma Clinic
Mufumbe
KaungaLueti Senanga
Kabanda
Mufumbe
Kataba
Senanga
Shachele
Mumbwa
Sibukali
Senanga
Kayanga
Mumbwa
Mapungu Senanga
Prisons
Mumbwa
Liangati
Senanga
Urban Clinic
Mumbwa
Lui River Senanga
Nambala
Mumbwa
Liliachi
Senanga
Naluvwi
Mumbwa
Ngundi
Senanga
Myooye
Mumbwa
Litambya Senanga
Nampundwe
Mumbwa
Sianyolo Siavonga
Keezwa
Mumbwa
Jamba
Siavonga
Mwembezhi
Mumbwa
Chikanzaya Siavonga
Kapepe
Mumbwa
Siavonga HAHC Siavonga
Lutale
Mumbwa
Total health facilities 10% likelihood of audit = 60 Kaoma Makasa
Mwense
Mutipula
Mwense
Kapamba
Mwense
Katuta
Mwense
Mukonshi
Mwense
Kalundu
Mwense
Luminu
Mwense
Mwense Stage II
Mwense
Chipili
Mwense
Mukanga
Mwense
Mununshi
Mwense
Mubende
Mwense
Chibondo
Mwense
Chisheta
Mwense
Musangu
Mwense
45
Senanga HAHC*
Senanga
Lui‐Namabunga
Senanga
Sinungu
Senanga
Muoyo
Senanga
Sikumbi
Senanga
Nalolo
Senanga
Mwanamwalye
Senanga
Itufa
Senanga
Lui‐Wanyau
Senanga
Chaanga
Siavonga
Munyama
Siavonga
Chipepo
Siavonga
Lusitu
Siavonga
Kapululira
Siavonga
Mtendere Mission HAHC Siavonga
Total health facilities 30% likelihood of audit = 91 46
ANNEX 4: RBF Training A critical component of the World Bank supported RBF pilot is support to management and capacity building. This is aimed at strengthening the relevant aspects of the health system for effective implementation of the RBF initiative. This includes training, strengthening of data quality and reporting, financial management and introduction of quality of care protocols for reproductive health. A Curriculum has been developed for all levels which includes Health Centres, Districts, and Hospitals. The three (3) types of curricula will be delivered to Health Centre staff, chairpersons of the Health Centre Committees, DMO staff and partners, District RBF Steering Committee members, PMO staff and national level stakeholders during the implementation of RBF in Zambia. Training on other aspects of the health systems including the strengthening of the HMIS data quality, indicators and target setting, financial management and reporting, quality assurance, and EmONC will also be conducted. Case‐studies which explore the use of demand‐side incentives to increase the demand for maternal and child health services in health facilities will also be used. The Ministry of Health will provide oversight on the roll‐out of the training while implementation will be executed by a core group of internal and external experts on health care financing, financial management, Monitoring and Evaluation, health systems governance, and reproductive health. To support the initial roll‐out of the RBF, several consultants will be hired to support the Ministry of Health specifically the implementing provinces, districts, hospitals, and health centres. 47
ANNEX 5: EmONC Sites and Assessments The Ministry of Health has identified Emergency Obstetric and Neonatal Care (EmONC) as one of the key interventions that can have tremendous effect on the maternal and neonatal morbidity and mortality. However according to the EmONC needs assessment survey done in 2005/2006, some facilities do not have delivery space while others did not have water and electricity. There were stock outs of essential drugs, supplies, and equipment necessary for the care of complications of pregnancy and the newborn. The health facilities need to have basic equipment to manage these complications. The referral of patients to the health facilities and later to the hospitals for the much needed emergency caesarean section is hampered by the lack of transport and poor road and telephone networks. One of the outcomes of this RBF pilot is to demonstrate an improvement in the indicators of maternal and neonatal health. This will only be achieved if there is adequate equipment and skilled birth attendants in the health facilities. An equipment needs assessment was therefore conducted in all the participating districts. Thereafter, equipment was procured for the pilot and control group I districts and the requisite EmONC training conducted in 16 districts that were hitherto not offering a comprehensive EmONC package. The equipment included the following; delivery beds, delivery kits, resuscitaires, suction machines, sterilizers, vacuum extractors, MVA kits, spotlights, suction machines, incubators and anaesthetic machines.. In addition, MOH will conduct training of health workers in EmONC in the RBF districts that are not yet providing a comprehensive EmONC package services. Each district will have four Basic EmONC sites that have trained health workers with skills in management of postpartum haemorrhage by giving parenteral oxytocics, removal of retained placenta, removal of retained products of conception, management of eclampsia by giving parental anticonvulsants, management of assisted deliveries and management of sepsis by giving parenteral antibiotics. The districts will further have one comprehensive EmONC site at the district hospital, i.e. that will be providing basic EmONC services and in addition caesarean sections and blood transfusion. 48
ANNEX 6: Contract between the Ministry of Health and the District Medical Office Republic of Zambia Ministry of Health RESULTS BASED FINANCING (RBF) CONTRACT BETWEEN THE MINISTRY OF HEALTH AND THE DISTRICT MEDICAL OFFICE Purchaser Province: ……………………………….…………………………………. Acting on behalf of the Ministry of Health And Provider: …………………………………………………………………..District Medical Office 49
Article 1: Results Based Financing (RBF) Results Based Financing (RBF) strategies lie within the scope of Zambia’s National Health Policy and the Sixth National Development Plan (2011‐2015) which seek to improve health and reduce poverty. RBF refers to a range of mechanisms designed to improve the performance of the health sector through focus on accountability for results, intensive use of evidence‐based decision making for service delivery, systematic data verification and provision of incentives to facilities and staff. This ultimately leads to the provision of quality health care delivered in compliance with national guidelines and standards. RBF does not replace other strategies on Health Systems Strengthening but seeks to harmonize and augment the effectiveness of all strategies in a health system. Article 2: Decentralized governorship of the RBF The RBF lies within the decentralized general scope of the government and the public health delivery system of Zambia. Therefore, to ensure the coordination of the RBF at district level, it is agreed that the District Medical Office is the principal actor at district level. Article 3: Objective of this Contract This Contract establishes the organs and rules of governing the RBF scheme in Zambia. The general governorship of the RBF in Zambia is the mandate of the Ministry of Health with the day‐to‐day administrative and technical management the responsibility of the Project Implementation Unit (PIU). All district level contracts shall be subject to the existence of this Contract. Article 4: Obligation of the Ministry of Health 4.1 Within the framework of its relations with the other components of the Government of Zambia 4.1.1 To lay down the general and specific goals pursued by the RBF by taking care that those goals are integrated in the general policy of the government. 4.1.2 To submit to the Ministry of Finance on an annual basis, the budget specifying the amounts planned for the RBF scheme. 4.2 Within the framework of its relations with the External Partners 4.2.1 To harmonize and align RBF activities with other Partner initiatives in the health sector in Zambia. 4.2.2 To direct the partners and their resources towards the priorities identified by the Ministry of Health. 4.3 In the framework of its relationships with Health Facilities and Decentralized Levels 4.3.1 To draw up the various Contracts and regulations for the implementation of the RBF scheme. 4.3.2
To draw up the list of the resources, procedures and characteristic of the services and indicators to purchase. 4.3.3
To establish the purchase prices of the various indicators. 50
4.3.4
To impose the respect of the Contracts and rules, including the administration of the sanctions envisaged in the Contracts. 4.3.5
To approve or reject requests of payment from the decentralized entities. 4.3.6
To facilitate the withdrawal of funds from the Partners and the Ministry of Finance. Article 5: Obligation of the District Medical Office 5.1 The District Medical Office will have the principle responsibility of making operational mechanisms for collecting and verifying data, facilitating the payment of incentive payments, and implementing control measures, and decisions capable of supporting the success of the RBF scheme. The District Medical Office will also implement measures to improve quality of health care at the health facilities. 5.2
To impose the respect of the Contracts and rules, including if necessary the administration of the sanctions envisaged in the Contract. 5.3
Collect all RBF records and provisional invoices and submit these to the District RBF Steering Committee for consideration. 5.4
To help health facilities and decentralized levels to be able to implement the RBF strategy by: 5.4.1
Managing the various resources (material, financial and human) in a transparent manner. 5.4.2
Providing information and sensitizing the population on the importance of participating in the various public health strategies. 5.4.3
Epidemiologic monitoring. 5.5
Quantity Audit: By the 10th day of the following month, members of the District Medical Office will review the entries in the designated registers and compare them to the numbers recorded during their self assessment; prepare monthly provisional invoices and submit them to the District Health Information Officer for reconciliation. 5.6
To ensure the availability (display) of a schedule of RBF Health Facilities quantity audit containing: The Date, names of the Health Facilities, names of the Evaluators; and signatures of the District Health Planner and the District Medical Officer. 5.7
To circulate the performance audit schedule to the Health Facilities at least five days before the quantity audit. The data should be captured, aggregated and made available to members of the District RBF Steering Committee at least 5 days before the planned meeting. 5.8
Provide the RBF quality assessment tools to the District/General Hospital. 5.9
To avail the District/General Hospital with schedules of Health Facilities activities and share information on any change on these schedules. 5.10 Coordinate regular quality assessment of the Health Facilities by the District/General Hospital. 5.11 Ensure timely flow of funding to the Health Facilities based on the performance achieved. 5.12 Act on recommendations made by the District/General hospital on the quality assessment. 5.13 Support the Health Facilities in realizing good pharmaceutical management. 5.14 Data audits and entry in the RBF database: 51
5.14.1
During the first two months of the quarter, Provisional Invoices from Health Facilities will be verified monthly and received by the District Medical Office. 5.14.2
By the 7th day of first month after the end of the quarter: The third Provisional Invoices from the Health Facilities received by the District Medical Office. 5.14.3
By the 10th day of the first month after the end of the quarter: Data audits conducted by the DMO. Monthly quantity audits will be done by the 10th day after the end of each month. Immediately after the quarterly quantity audit, the DMO will prepare a consolidated provisional invoice for all the Health Facilities in the district. 5.14.4
Inform Health Facilities about the incentives they will receive after the decision of the District RBF Steering Committee meeting. Article 6: Obligation of the Provincial Medical Office (PMO) At provincial level, the PMO is responsible for overall technical support to the districts as well as facilitating the implementation of the RBF project activities at district and community levels. Building on this function, the PMO will support RBF training and conduct RBF supervisory visits in the participating districts and communities. The specific RBF roles and responsibilities at the PMO are as follows: 6.1 Providing office space and any other functional requirements for the Provincial RBF Technical Specialist. 6.2
Facilitating the implementation of the RBF project activities at district and community level. 6.3
Calling the quarterly Provincial RBF Steering Committee meeting. 6.4
Receiving, reviewing and forwarding to MOH/PIU the reports and invoices submitted through the District RBF Steering Committee. 6.5
Ensuring that the indicators in RBF Districts are analyzed and bottlenecks identified and addressed. 6.6
Conducting the District RBF Performance Assessment and transmitting the results to the PIU for payment on a bi‐annual basis. 6.7
Conducting RBF Performance Assessment and technical support supervision in the districts and identify capacity building needs at District, Health Facilities and Community Levels. 6.8
Facilitating the internal and external audits and verifications. 6.9
Settlement of disputes including contractual disputes. Article 7: Responsibilities of Health Facilities The responsibilities of Health Facilities are contained in the Contract between the respective District Medical Offices, and the respective Health Facilities in the RBF districts. Article 8: Evaluation of the District Medical Office 8.1 The MOH represented by the Provincial Medical Office will evaluate the District Medical Office at least once per quarter to ascertain the extent to which it has performed its mandate as outlined in Article 5 above. 52
8.2 The MOH, reserves the right to communicate to the citizens of Zambia, via the national media, the variations of performance observed in districts where the RBF scheme is being implemented. 8.3 The MOH, reserves the right to modify the composition of the District Medical Office if serious dysfunctions are observed on a countrywide scale. Article 9: Determination of the amount to be paid to the DMO as Performance Incentive The Provincial RBF Steering Committee (P‐RBFSC) shall validate the DMO’s performance against the indicators specified in the District Medical Office RBF Evaluation Checklist on a quarterly basis. The maximum amount of money that the DMO can get as Performance Incentive is K30,000,000 (Thirty Million Kwacha) per quarter but this can be lower depending on the actual performance achieved. For example, a score equivalent to 80% will mean that the DMO can only receive 80% of K30,000,000 which is equivalent to K24,000,000. Article 10: Expenditure Ceilings and Determination of the amount to be paid to individual staff at DMO as Staff Incentives From the total amount earned as Performance Incentive, 75% should cater for staff incentives while the remaining 25% shall be used for re‐investments, monitoring, D‐RBFSC meetings, and other activities at the DMO. Furthermore, the DMO will be required to determine an amount for staff incentives for each employee on a monthly basis. The incentive to be paid to the employee is the total amount available for staff incentives compared to the results of the monthly individual evaluation and the index corresponding to his/her professional category. The indices for apportioning the staff incentives at the DMO are shown below. DMO Staff Categories with Indices for staff incentives Categories 1 District Medical Officer 2 Accountant 3 Assistant Accountant 4 District Planner 5 Human Resources Officer 6 Pharmacist 7 Information Officer 8 Clinical Officer (MCH) 9 Clinical Care Officer 10 Environment Health Officer 11 Nutritionist 12 TB/Leprosy Officer 13 Secretary/Typist 14 Driver Total Indices for Staff Incentives 0.18
0.06
0.04
0.06
0.06
0.12
0.06
0.11
0.11
0.04
0.04
0.05
0.04
0.03
1.00
53
Article 11: Payment for Services Rendered Payment of the DMO’s Performance Incentives should be done within 45 days after receipt of the performance evaluation report from the P‐RBFSC. The payment shall be a fixed amount with adjustments made on the verifiable performance of the DMO. The DMO will be paid 100% of the applicable amount if it executes its duty satisfactorily as required. Article 12: Entry into Force This Contract constitutes the entire agreement between the Ministry of Health and the District Medical Office. There shall be no variation of it, except in writing and signed by duly appointed representatives from the Ministry of Health and the District Medical Office. This Contract shall enter into force on the date of signature by duly appointed representatives from the Ministry of Health and the District Medical Office. IN WITNESS WHEREOF the undersigned, being duly authorized by their respective representatives, have caused their hands and seals to be hereby affixed the day and year first before written. For the Ministry of Health For the District Medical Office Signature:……………………………….……..…… Signature:…….………........................…………………. Name: …….........………….……………...........……… Name: ...............................................…………………….… Provincial Medical Officer District Medical Officer Date:………………………………………..………………….. In the Presence of Witness: Signature:…….………........................…………………. Date:………………………………….……..…………. In the Presence of Witness: Signature:……………………………….……..…… Name: …….........………….……………...........……… Name: ...............................................…………………….… Provincial Planner Council Secretary Date:………………………………………..………………….. Date:………………………………….……..…………. 54
ANNEX 7: Contract between the District Medical Office and the Health Facility Republic of Zambia Ministry of Health RESULTS BASED FINANCING (RBF) CONTRACT BETWEEN THE DISTRICT MEDICAL OFFICE AND THE HEALTH FACILITY Purchaser: Name of the District: …………………………………………………………. And Provider .…………………………………………………………….…………. Health Centre 55
Article 1: Principles of Results Based Financing Results Based Financing (RBF) strategies lie within the scope of Zambia’s National Health Policy and the Sixth National Development Plan (2011‐2015) which seek to improve health and reduce poverty. RBF refers to a range of mechanisms designed to improve the performance of the health sector through focus on accountability for results, intensive use of evidence‐based decision making for service delivery, systematic data verification and provision of incentives to facilities and staff. This ultimately leads to the provision of quality health care delivered in compliance with national guidelines and standards. RBF does not replace other strategies on Health Systems Strengthening but seeks to harmonize and augment the effectiveness of all strategies in a health system. Article 2: Nature of this Contract This Contract between the District Medical Office and the Health Centre aims at increasing the use of and provision of quality basic health care services to the population through the RBF strategy. This will be achieved by reinforcing the financial incentives for Health Centres and by increasing decisional rights on the organization of operations at the Health Centres. This Contract establishes the mutual obligations of the District Medical Office and the Health Centre for the effective implementation of the Results Based Financing (RBF) pilot project at the Health Centre. Article 3: Contract type and Payment Schedule This is a fee‐for‐service Contract with performance payments based on the achievement of 9 key health facility indicators found in the HMIS and deemed as critical in improving maternal and child health services. Attainment of these indicators is based on both quantity and quality. These indicators are: i.
Curative consultations ii.
Institutional deliveries by skilled birth attendant iii.
ANC prenatal and follow up visits iv.
Postnatal visit v.
Full immunization of children under 1 vi.
Pregnant women receiving 3 doses of malaria IPT FP users of modern methods at the end of the month vii.
viii.
Pregnant women counselled and tested for HIV ix.
Number of HIV pregnant women given Niverapine and AZT A health centre fee schedule outlining the respective fees per indicator is available. However, a few selected remote health facilities will receive 25% more than the regular price per indicator. The District RBF Steering Committee shall validate the facility’s performance against the indicators at the end of each quarter. The achievement of the indicators will be a combination of the scores attained in both the quantity audit and quality assessment. Article 4: Obligation of the Health Centre The Health Centre Committee must take care that the funds generated through the RBF are managed in the general interest of the Health Centre. These incomes must be used to implement initiatives likely to improve public health and quality service delivery. Under the present Contract, 56
the Health Centre is represented by the Health Centre Committee Chairperson and the Health Centre In‐Charge. The Health Centre Committee Chairperson and the Health Centre In‐Charge undertake to: 1. Develop strategies to be implemented by the Health Centre Committee to achieve the project goals; 2. Ensure that all actions undertaken are not in contradiction with the national policy of health and the medical ethics; 3. Inform the District Medical Office of any changes in the status of equipment and the technical skills of the health centre which could compromise its technical capability to produce the activities remunerated through the project; 4. Ensure availability of registers on the implementation of activities and various management tools; 5. Make sure that all necessary documents are accessible to interested parties for the execution of the Contract and the project as a whole; 6. Report any fraud committed at the Health Centre to the District RBF Steering committee (in writing); 7. Be completely transparent regarding the sharing and use of funds generated by the RBF and in accordance with the Motivation Contract; 8. Implement sanctions against individuals responsible for professional misconduct; 9. Not to pay bonuses which are higher than the rightful entitlements to any individual; 10. Allocate a minimum of 25% of the total revenues from the RBF to investment and/or operational costs except remuneration and trainings; 11. Support Community actors to carry out their own strategies under the RBF project; and 12. Lodge a complaint to the District RBF Steering committee through their representative in an event of a dispute during the execution of this Contract. Article 5: Representation of the Health Centre in the District RBF Steering committee The Health Centres of the district will be represented at the District Steering Committee by Zonal Health Centre In‐Charges. Article 6: Reporting Requirements Invoices must be prepared by the health centre and received by the DMO with HMIS data by the 7th day of first month after the end of the quarter. The Health Centre In‐Charge and the Chairperson of the Health Centre Committee will append their signatures on the invoice and submit it to the DMO. Article 7: Mode of Payment Bonuses will be paid to the Health Centre no later than 45 days after the quarter in which they were earned. Performance payments will be paid out as team bonuses in the form of a cheque to the health centre. The earned amount will be deposited directly into the Health Centre Bank Account. 57
Article 8: Payment Calculations The quarterly payment is determined by two factors: Quantity Audit: The DMO will conduct quarterly data audits on the health facility by the 10th day of the first month after the end of the quarter. Monthly audits will be done by the 10th day after the end of each month. During the data audit, members of the District Medical Office will review the entries in the designated registers and compare them to the numbers recorded during the self assessment. Quality Assessment: Each indicator will be assessed once a quarter by the Hospital contracted by the District Medical Office to conduct quality assessment and this shall be factored into the payment. This is to ensure that the services delivered meet the agreed upon quality standards. The payment will therefore be calculated as follows: Quantity Earned X Quality Score = Quarterly Incentive Payment. The Ministry of Health reserves the right to amend the formula of its support to the Health Facilities during the tenure of this Contract. Article 9: Health Centre Committee Autonomy over the use of RBF Funds The use of the funds earned from the RBF will be decided by the Health Centre Committee within the limits stated in Article 4 of this Contract. Against this background the Health Centre in charge, should ensure that all documents are well secured. All payments made to staff and other beneficiaries should be clearly signed or thumb printed. Article 10: External Validation A third party will be contracted to verify quality of reporting, quantity and quality of HMIS data being collected at District Medical Office and Health Facilities level. Random spot checks will also be carried out down at household level on a periodic basis aimed at verifying the results. The District Medical Office and Health Centre will grant full access to relevant records as requested. Article 11: Irregularities If any irregularities are discovered in subsequent periods, bonuses must be repaid and all missing money must be returned. Irregularities include items such as stealing, falsification of records, or misreporting. Subsequently, the health facility will be barred from the RBF incentive scheme for a period of 12 months. Article 12: Business Plan The Health Centre Business Plan approved by the District Medical Office is an integral part of this Contract. The absence or the non‐observance of the Business Plan will result in the cancellation of this Contract. The health centre will submit the Business Plan for twelve months (see attached format) within three months after signing this Contract. The Business plan specifies the strategies to be implemented to increase the quantity and the quality of the services. This plan will indicate 58
the essential resources (human, material and financial) required to achieve the business plan objectives. Article 13: Non­incentivized indicators In order to avoid a situation where the incentivized indicators become the centre of attention and improve at the detriment of all other health indicators, efforts to improve the non‐incentivized indicators should also be made. Thus, during the implementation of the RBF, the Health Centre agrees to ensure that both the incentivized and non‐incentivized indicators are improved. If the non‐incentivized indicators fall below 80 percent of the expected trend (based on historical data) at any time during the Contract period, the Health Centre should meet with the District Medical Office to discuss the situation and define corrective measures. If the downward trend continues, the District Medical Office reserves the right to nullify this Contract. The Health Centre agrees to participate in all organized RBF technical assistance and capacity building activities. Article 14: Entry into Force This Contract constitutes the entire agreement between the District Medical Office and the Health Centre. There shall be no variation of it, except in writing and signed by duly appointed representatives from the District Medical Office and the Health Centre. This Contract shall enter into force on the date of signature by duly appointed representatives from the District Medical Office and the Health Centre. IN WITNESS WHEREOF the undersigned, being duly authorized by their respective representatives, have caused their hands and seals to be hereby affixed the day and year first before written. For the District Medical Office For the Health Centre Signature:……………………………….……..…… Signature:…….………........................…………………. Name: …….........………….……………...........……… Name: ...............................................…………………….… District Medical Officer Health Centre In‐Charge Date:………………………………………..………………….. In the Presence of Witness: Signature:…….………........................…………………. Date:………………………………….……..…………. In the Presence of Witness: Signature:……………………………….……..…… Name: …….........………….……………...........……… Name: ...............................................…………………….… Council Secretary Health Centre Committee Chairperson Date:………………………………………..………………….. Date:………………………………….……..…………. 59
ANNEX 8: Contract between the District Medical Office and the District/General Hospital Republic of Zambia Ministry of Health RESULTS BASED FINANCING (RBF) CONTRACT BETWEEN THE DISTRICT MEDICAL OFFICE AND THE DISTRICT/GENERAL HOSPITAL Name of the District: …………………………………………………………. And .…………………………………………………………….…………. District/General Hospital 60
Article 1: Results­Based Funding Results Based Financing (RBF) strategies lie within the scope of Zambia’s National Health Policy and the Sixth National Development Plan (2011‐2015) which seek to improve health and reduce poverty. RBF refers to a range of mechanisms designed to improve the performance of the health sector through focus on accountability for results, intensive use of evidence‐based decision making for service delivery, systematic data verification and provision of incentives to facilities and staff. This ultimately leads to the provision of quality health care delivered in compliance with national guidelines and standards. RBF does not replace other strategies on Health Systems Strengthening but seeks to harmonize and augment the effectiveness of all strategies in a health system. Article 2: Purpose of the Contract This Contract between the District Medical Office and the District/General Hospital aims at improving the provision of quality basic health care services to the population at Health Centre level. The District Medical Office engages the District/General Hospital to conduct quarterly quality assessment of the Health Facilities in the District using the RBF quality assessment tool/checklist. Article 3: Responsibilities of District Medical Office The District Medical Office undertakes to: i.
Coordinate the process of conducting quality assessment of the Health Facilities by the District/General Hospitals. This includes ensuring that the Health Facilities are ready for the quality assessment; ii.
Provide the RBF quality assessment tool/checklist to the District/General Hospital; iii.
Avail the hospital with schedules of Health Facilities’ activities and share information on any change on those schedules; iv.
Ensure timely payment of evaluation costs to the District/General hospital and flow of funding to the Health Facilities based on the performance achieved; and v.
Act on the recommendations made by the District/General Hospital on the quality performance assessment. This includes conducting follow‐up technical support supervision. Article 4: Responsibilities of District/General Hospital The District/General Hospital undertakes to: i.
Conduct quarterly quality6 assessments at Health Facilities in the districts in compliance with the standard guidelines and protocols by using the RBF quality assessment tool/checklist; ii.
Make available clinical protocols and guidelines for the Health Facilities and provide technical support supervision when necessary; iii.
Submit a monthly schedule of Health Facilities to be assessed to the District Medical Office before the 5th of the current month; iv.
Ensure regular quality assessment of the Health Facilities and transmit the results each quarter to the District Medical Office for data entry and analysis by the 7th day of the month after the end of the quarter; v.
Participate in quarterly District RBF Steering Committee meetings; and vi.
Make a presentation on the findings from the quality assessments during the District RBF Steering Committee meeting. 6
Health Center quality assessment tool to be used 61
Article 5: Hospital Assessment Team The District/General Hospital shall establish a permanent and well identified Hospital Assessment Team which will be responsible for undertaking the quality assessments. The Medical Superintendent of the District/General Hospital will be responsible for the choice of the assessors among his/her staff and he/she will be expected to communicate this to the District Medical Office. The choice of the assessors must be in conformity with the following:  Minimum qualification of a Diploma in a health discipline or other equivalent;  At 2 years experience in the field of health; and  Training or experience in the supervision of Health Facilities and quality assessment. Article 6: Periodicity and Organization of the of Assessment Assessment will be done once per quarter. When conducting the assessment, the following should be adhered to:  A schedule for the assessments for the next quarter should be submitted to the District Medical Office at least one week before assessment;  The assessors should consolidate the allocated points and make recommendations at the end of the assessment; and  The results of the quality assessment should be sent to the District Medical Office by the 7th day after the end of the quarter. Article 7: Payment for Services Rendered The payment shall be a fixed amount per health centre assessed with adjustments made on the actual performance of the District/General Hospital during the quality assessment. The DMO and the District/General Hospital should hold discussions and agree on the amount to be charged per health facility. This amount should take into account all the costs required to undertake the quality assessment including administrative costs, institutional and individual evaluation/consultancy fees. Once the amount per health facility is established, this figure should then be multiplied by the total number of health facilities participating in the RBF in the district to come up with the maximum applicable amount. The contracted District/General Hospital will only be paid 100% of the agreed fees if it executes its duty satisfactorily in accordance with this Contact, compliance to the Health Centre Quality Assessment Tool, and if all the health facilities in the district have been assessed. If this is not the case, sanctions against non‐performance will be instigated against the contracted District/General Hospital as outlined in Article 9 below. Payment for the quality assessment will be made within 45 days after receipt of the quality assessment performance report. Article 8: Amendment of this Contract This is a standard Contract for all the District/General Hospitals which will be used to conduct quality assessment of Health Facilities during the RBF scheme implementation in Zambia. It can be changed, amended or extended provided there is written correspondence from duly appointed representatives from the District Medical Office and the District/General Hospitals. In the event of 62
any change in policy, however, the Zambian Government reserves the right to discontinue this Contract. Article 9: Sanctions against non­performance The District RBF Steering Committee reserves the right to take disciplinary action in terms of penalties against any District/General Hospital that violates the rules established under the RBF scheme. Penalties will be considered for any one of the following reasons: i. Creating fictitious reports - If it is discovered that all/some data reported are invented, the contracted District/General Hospital will not be paid and may appeal to the Provincial RBF Steering Committee ii. Quality assessment not conducted - If one of the Health Facilities in the District has not been completely assessed, the contracted District/General Hospital will lose 25% of the budgeted evaluation payments/fees for that quarter. -
If two to five Health Facilities have not been completely assessed, the contracted District/General Hospital will lose 50% of the budgeted evaluation payments/fees for that quarter. -
If five or more Health Facilities have not been completely assessed, the contracted District/General Hospital will lose the entire budgeted evaluation payments/fees for that quarter. Conflicts with assessments - If the conflict is caused by one of the assessors from the District/General Hospital, the District/General Hospital will have to give an explanation at the District RBF Steering Committee meeting. The penalty will be a 10% loss of the budgeted evaluation payments/fees for that quarter. Article 10: Settlements of disputes In the case of any misunderstandings or disputes during the interpretation and execution of this Contract, the differences should be solved amicably. If this fails, the Provincial RBF Steering Committee and or the National RBF Steering Committee shall be called upon for arbitration. Article 11: Entry into Force This Contract constitutes the entire agreement between the District Medical Office and the District/General Hospital. There shall be no variation of it, except in writing and signed by duly appointed representatives from the District Medical Office and the District/General Hospital. This Contract shall enter into force on the date of signature by duly appointed representatives from the District Medical Office and the District/General Hospital and shall be valid for a period of 12 months. iii.
63
IN WITNESS WHEREOF the undersigned, being duly authorized by their respective representatives, have caused their hands and seals to be hereby affixed the day and year first before written. For the District Medical Office For the District/General Hospital Signature:……………………………….………..…… Signature:…….…………........................…………………. Name: …….........………….……………...........……… Name: ...............................................…………………….… District Medical Officer Medical Superintendent Date:…………………………………..……..…………. Date:………………………………………..………………….. In the Presence of Witness: Signature:…….………............................…………………. In the Presence of Witness: Signature:………………………………….……..…… Name: …….........………….……………...........……… Name: ...............................................…………………….… Council Secretary Hospital Administrator Date:………………………………….……..…………... Date:………………………………………..………………….. 64
ANNEX 9: Motivation Contract for Health Facility Staff This is a Motivation Contract which has been entered into between ………………………..........................................Health Centre represented by the Health Centre In‐Charge and ................................................................................ occupying the position of ......................................................................................, and hereafter called the “Employee” and the two collectively known as “Parties”. The Parties declare to have entered into an agreement on the payment of performance incentives according to the following modalities: Article 1: General Information This Contract lies within the scope of the Results Based Financing (RBF) set up in the health system in Zambia, and more specifically within the framework of the Contract stating the remuneration of health workers on the basis of their performance between ……………………………………………………….. Health Centre and ………………………………………………………District Medical Office. It is understood that the payment of incentives in the Contract between ……………………………………………………….. Health Centre and ……………………………………………………… District Medical Office constitutes a commitment but not a right. In the event of change in policy or force majeure, the Government of the Republic of Zambia or the external partners could decide to cease the payment of the incentives before the closing date of the Contract. The Motivation Contract institutes a mode of conditional remuneration to the Employee, by variable bonuses according to personal work performance and in respect of his/her engagement. Article 2: Limits of the Contract The Employee acknowledges that this Contract includes the conditions of services of the Employee, his/her job description, and profile of his/her duty station. Nonetheless, this Motivation Contract is different from the normal work Contract. The Motivation Contract may end automatically and without royalty when the Employee’s employment is terminated or when the Motivation Contract itself is terminated by either Party. Article 3: Validity The validity of this Contract is strictly subordinated to the existence and the duration of the Contract stating the remuneration of Employees on the basis of their performance. If the Contract between the Health Centre Committee and District Medical Office suddenly ends in accordance with its clauses, this Motivation Contract will have to be regarded as null and void. Article 4: Obligation of Both Parties The Employee commits him/herself to respect the various obligations which are assigned to him/her by this Contract and its appendices7. He/she particularly commits him/herself to delivery of quality health care, working in harmony and in a team spirit with his colleagues at the Health Centre and/or others from outside the Health Centre. He/she personally commits to transparency and authenticity of information that will be transmitted to his/her supervisor and/or to the District 7
Individual Evaluation Form 65
Medical Office. He/she will be held responsible for the errors or frauds made individually or severally on the information or data transmitted. The Health Centre Committee represented by its Chairperson commits to evaluating the performance of the Employee on a monthly basis, in an objective and transparent manner, on the tasks assigned to him/her. The Health Centre Committee Chairperson further commits to the payment of monthly motivation bonuses as defined in Articles 5, 6 and 7 of this Contract. Moreover, the District Medical Office commits within the limits of its mandate, to place at the disposal of the Employee ‐ the essential resources to the achievement of his/her tasks. Article 5: Individual performance evaluation The Health Centre Committee will evaluate the performance of each Employee in accordance with the tasks which are assigned to him/her by using the Individual Evaluation Form on a monthly basis. The result of the evaluation will be valid and applicable for the motivation of the Employee during the evaluated month. The evaluation of the Health Centre In‐Charge will be based on the quality score attained by the health facility in the previous quarter. This implies that he/she will get the same score for three consecutive months. Article 6: Determination of the amount to be allocated as Motivation bonus Before the end of each month, the management at the Health Facility will determine an amount intended for the Motivation bonuses of the personnel. At the same time they will approve the payment of those bonuses. To maintain equity between the Employees, it is agreed that the individual monthly Motivation fees will be defined by the remunerations schedule in use. The staff bonus will be calculated based on the Employees’ individual staff index (which is derived from his/her basic salary), total amount available for staff performance incentives, and the percentage score from the individual performance evaluation (Article 5). The formula is: Individual Motivation Fees = (Staff Index) X (Total Amount Available for Staff Performance Incentives) X (Percentage Score from Individual Evaluation) Please refer to the example on Bonus Calculation in the Project Implementation Manual (Annex 30) for more details on how to calculate the individual staff indices. Article 7: Payment of Motivation Fees Motivational fees will be paid to the Employees on a quarterly basis. Article 8: Temporary suspension of the Motivation Bonuses In the event of fraud, record falsification, or any other serious irregularity, the District Medical Office can decide to suspend the bonuses of an Employee for a maximum period of 3 months. This decision will have to be subject to approval by the District RBF Steering Committee. 66
Article 9: Resolution of Disputes In the event of disputes in the application of this Contract, either party shall lodge a complaint to the District RBF Steering Committee in writing. Article 10: Duration of the Contract This Contract will be valid for a period of 12 months from the date of signature by both Parties. The Contract will be automatically renewed as long as the Remuneration Contract between the Health Centre and District Medical Office exists. For the Health Centre For the Employee Signature:……………………………….……..…… Signature:…….………........................…………………. Name: …….........………….……………...........……… Name: ...............................................…………………….… Health Centre In‐Charge Position:....................................………………………….… Date:………………………………………..………………….. In the Presence of Witness: Signature:…….………........................……………………. Date:………………………………….……..…………. In the Presence of Witness: Signature:……………………………….……..……… Name: …….........………….……………...........……… Name: ...............................................…………………….… Health Centre Committee Chairperson Date: ..........................................………………………….… Date:………………………………….……..…………. 67
ANNEX 10: Motivation Contract for District Medical Office Staff This is a Motivation Contract which has been entered into between ………………………..........................................District represented by the District Medical Officer and ................................................................................ occupying the position of ......................................................................................, and hereafter called the “Employee” and the two collectively known as “Parties”. The Parties declare to have entered into an agreement on the payment of performance incentives according to the following modalities: Article 1: General Information This Contract lies within the scope of the Results Based Financing (RBF) set up in the health system in Zambia, and more specifically within the framework of the Contract stating the remuneration of health workers on the basis of their performance between ………………………………………………………..District and ………………………………………………………Provincial Medical Office (PMO). It is understood that the payment of incentives in the Contract between the Ministry of Health (through the PMO) and the District Medical Offices constitutes a commitment but not a right. In the event of change in policy or force majeure, the Government of the Republic of Zambia or the external partners could decide to cease the payment of the incentives before the closing date of the Contract. The Motivation Contract institutes a mode of conditional remuneration to the Employee, by variable bonuses according to personal work performance and in respect of his/her engagement. Article 2: Limits of the Contract The Employee acknowledges that this Contract includes the conditions of services of the Employee, his/her job description, and profile of his/her duty station. Nonetheless, this Motivation Contract is different from the normal work Contract. The Motivation Contract may end automatically and without royalty when the Employee’s employment is terminated or when the Motivation Contract itself is terminated by either Party. Article 3: Validity The validity of this Contract is strictly subordinated to the existence and the duration of the Contract stating the remuneration of Employees on the basis of their performance. If the Contract between the District Medical Office and the Ministry of Health (through the PMO) suddenly ends in accordance with its clauses, this Motivation Contract will have to be regarded as null and void. 68
Article 4: Obligation of Both Parties The Employee commits him/herself to respect the various obligations which are assigned to him/her by this Contract and its appendices8. He/she particularly commits him/herself to delivery of quality health care, working in harmony and in a team spirit with his colleagues at the District Medical Office and/or others from outside the District Medical Office. He/she personally commits to transparency and authenticity of information that will be transmitted to his/her supervisor and/or to the PMO. He/she will be held responsible for the errors or frauds made individually or severally on the information or data transmitted. The District Medical Officer and the Human Resource Officer commits themselves to evaluating the performance of the Employee on a monthly basis, in an objective and transparent manner, on the tasks assigned to him/her. The District Medical Officer and the Human Resource Officer further commits to the payment of monthly motivation bonuses as defined in Articles 5, 6 and 7 of this Contract. Moreover, the District Medical Office commits within the limits of its mandate, to place at the disposal of the Employee ‐ the essential resources to the achievement of his/her tasks. Article 5: Individual performance evaluation The District Medical Officer and the Human Resource Officer will evaluate the performance of each Employee in accordance with the tasks which are assigned to him/her by using the Individual Evaluation Form on a monthly basis. The result of the evaluation will be valid and applicable for the motivation of the Employee during the evaluated month. The score for the District Medical Officer will be based on the performance score attained by the District Medical Office during the previous quarter’s RBF evaluation of the District Medical Office by the Provincial Medical Office. This implies that he/she will get the same score for three consecutive months. Article 6: Determination of the amount to be allocated as Motivation bonus Before the end of each month, the District Medical Office will determine an amount intended for the Motivation bonuses of the personnel. At the same time they will approve the payment of those bonuses. To maintain equity between the Employees, it is agreed that the individual monthly Motivation fees will be defined by the remunerations schedule in use. The staff bonus will be calculated based on the Employees’ individual staff index (which is derived from his/her basic salary), total amount available for staff performance incentives, and the percentage score from the individual performance evaluation (Article 5). The formula is: Individual Motivation Fees = (Staff Index) X (Total Amount Available for Staff Performance Incentives) X (Percentage Score from Individual Evaluation) Please refer to the example on Bonus Calculation in the Project Implementation Manual (Annex 30) for more details on how to calculate the individual staff indices. Article 7: Payment of the Motivation Fees Motivational fees will be pain on a quarterly basis. 8
Individual Evaluation Form 69
Article 8: Temporary suspension of the Motivation bonuses In the event of fraud, record falsification, or any other serious irregularity, the District Medical Office can decide to suspend the bonuses of an Employee for a maximum period of 3 months. This decision will have to be subject to approval by the Provincial RBF Steering committee. Article 9: Resolution of Disputes In the event of disputes in the application of this Contract, either party shall lodge a complaint to the Provincial RBF Steering committee in writing. Article 10: Duration of the Contract This Contract will be valid for a period of 12 months from the date of signature by both Parties. The Contract will be automatically renewed as long as the Remuneration Contract between the District Medical Office and the Ministry of Health (through the PMO) exists. For the District Medical Office For the Employee Signature:…….………........................…………………. Signature:……………………………….……..…… Name: …….........………….……………...........……… Name: ...............................................…………………….… District Medical Officer Position:....................................………………………….… Date:………………………………………..………………….. In the Presence of Witness: Signature:…….………........................……………………. Date:………………………………….……..…………. In the Presence of Witness: Signature:……………………………….……..……… Name: …….........………….……………...........……… Name: ...............................................…………………….… Human Resources Officer Date: ..........................................………………………….… Date:………………………………….……..…………. 70
ANNEX 11: Guidelines on Contract Management This paper attempts to list the basic requirements to set up and maintain a reliable, simple and cost efficient management system for a large number of national Results Based Financing (RBF) Contracts. It takes into account the decentralized administrative district authorities, and the respective roles and responsibilities of actors at various levels on RBF Scheme. The Contracts to be managed are: a. Contract between the Ministry of Health (MOH) and the District Medical Office b. Contract between the District Medical Office and the Health Facilities c. Contract between the District Medical Office and District/General Hospitals d. Motivation Contract between the District Medical Office and individual health workers e. Motivation Contract between the Health Facilities and the individual health workers All the five (5) different types of Contract indicated above will require close follow‐up as they are tied to payments and business plans. Close follow‐up is aimed at ensuring maximum delivery of the outputs/outcomes of the RBF project, and transparent performance‐based distribution of RBF related bonuses. The following are proposals aimed at putting in place a comprehensive Contract management within the health system, both at central and decentralized level: Section I: Contract Management at Central Level 1. The aim is to create an efficient and reliable filing system in order to keep track and be accountable for all the contracts. This requires: (a) A uniform reference number and/or file naming convention. (b)
The original signed copies of all Contracts between the MOH and District Medical Offices should be kept at MOH, ideally by the Project Implementation Unit (PIU). (c)
The original signed copies of all Health Facilities Contracts each in a separate folder attached with the respective Business Plans. (d)
The original signed copies of all Contracts between the District Medical Offices and District/General Hospitals should be kept at MOH, ideally by the PIU. (e)
One folder with one hard copy sample of (i) MOH and District Medical Office Contract, (ii) District Medical Office and Health Facilities Contract, (iii) District Medical Office and District/General Hospital Contract, (iv) Motivation contract between the District Medical Office and individual health workers, (v) Motivation contract between the Health Facilities and individual health workers, (vi) Samples of old contracts (one each), (vii) Business Plan template, (viii) District RBF Steering Committee guidelines, (ix) Provincial RBF Steering Committee guidelines, (x) Quotation cards 2. Preferably a dedicated and access‐controlled Contracts Office should be set‐up. At the very least, dedicated filing and storage facilities should be arranged. 3. A specific folder with the Minutes of the District, Provincial and National RBF Steering Committee meetings each in separate folders. 71
4. Contract Management Meetings should be held quarterly or when need arises. During the meetings, ‘due diligence’ should be done on procedures (District RBF Steering committee minutes; timeliness and accuracy of reporting etc), and quarterly district consolidated invoices. Eventual additional actions should be reflected in the minutes (e.g. follow‐up on certain data; counter‐evaluations etc). All relevant partners and other main donor representatives need to be invited to this meeting to enhance transparency. Section 2: Contract Management at District Level 1. The filing system in place at central level should be duplicated in order to keep track and be accountable for all the contracts at District level. This includes: a) A uniform reference number and/or file naming convention b) The original signed copy of MOH and District Medical Office Contract c) The original signed copies of all Health Facilities Contracts in separate folders including the respective Health Centre Business Plans d) Original signed copies of District Medical Office and District/General Hospital Contracts e) One folder with one hard copy sample of (i) MOH and District Medical Office Contract, (ii) District Medical Office and Health Facilities Contract, (iii) District Medical Office and District/General Hospital Contract, (iv) Motivation contract between the District Medical Office and individual health workers, (v) Motivation contract between the Health Facilities and individual health workers, (vi) Samples of old contracts (one each), (vii) Business Plan template, (viii) District RBF Steering Committee guidelines, (ix) Provincial RBF Steering Committee guidelines, (x) Quotation cards 2. Ideally there should be a dedicated Contracts Management Office with restricted access or at the very least, dedicated filing/storage cabinets. One person needs to be made formally responsible for Contract Management. This can be done by formally assigning (in writing) an existing member of the District Medical Office to manage the Contracts. 3. Districts should ensure that every participating Health Facility acknowledges receipt of quarterly funds. Special folders with receipts (per quarter) should be kept. 4. A specific folder with Minutes of the District RBF Steering Committee meetings. 5. A specific folder with reports on community surveys (quantity and patient satisfaction). 6. Original signed copies of each Motivation contract with the employees in separate folders. 7. One specific folder with approved invoices for quantity 8. One specific folder with quarterly quality assessment results well arranged and signed by the quality assessment team and health centres 9. One specific folder with documentation related to the distribution of bonuses to staff and additional documentation related to incentives/bonuses, if any. 72
Section 3: Contract Management at Health Facility Level 1. Due to work overload, health facilities will only be requested to perform minimal contract management functions. This include: filing the original copies of their own contracts with the District Medical Office, complete with their own Business Plan. 2. Original signed copies of each Motivation contract with the employees in separate folders 3. One specific folder or file with monthly provisional invoices for quantity signed by evaluators and the Health Facilities 4. One specific folder or file with quarterly quality assessment results well arranged and signed by the quality assessment team and health centre 5. One specific folder with documentation related to the results of individual evaluation of health facility staff 6. One specific folder with documentation related to the distribution of bonuses to staff and additional documentation related to incentives/bonuses, if any. 7. One folder with one hard copy sample of (i) MOH‐DHMT Contract, (ii) DHMT‐Health Centre Contract, (iii) DHMT‐D/General Hospital contract, (iv) Motivation contract, (v) Samples of old contracts (one each), (vi) a business plan template, (vii) PBF District Steering committee guide line, (vii) Sample of individual evaluation form of health center staff, (ix) Health center assessment tools (Quality tool, quantity tools and definitions of quantity indicators) 73
ANNEX 12: Template of a Business Plan for a Health Facility Contract District: .................................................................................................................. Name of the Health Centre: .............................................................................. A: Population 2010 : ……………..………………………….. B: Population 2011 : .................................................... (Population 2010 (A)*…………………….………) C: Number of the Expected Pregnancies (B * .........… %) : ........................................................ D: Number of Children from 0 to 11 months (B * …........... %): ................................................ E: Number of Women in Child Bearing Age 15­49 years (B * …...........%): ............................................ 1. PMTCT: Number of pregnant women counseled and tested for HIV Coverage Jan. 2011 (Total No. of Pregnant women counselled and tested for HIV in PMTCT/(A*…....…%) * 100%) Coverage Jan. 2012 (Total No. of Pregnant women counselled and tested for HIV in PMTCT 2011/C*100%) Problems (Continue on the back if needed) Plan (Continue on the back if needed) 1
Strategies & Resources
2
Strategies & Resources
3
Strategies & Resources
74
2. PMTCT: Number of HIV pregnant women given Niverapine and AZT Coverage Jan. 2011 (Total No. of HIV+ pregnant women given Niverapine and AZT 2010/ Total No of HIV+ women in PMTCT 2010) *100% Coverage Jan. 2012 (Total No. Of HIV pregnant women given Niverapine and AZT 2011/Total No. of HIV+ women in PMTCT 2011) *100% Problems (Continue on the back if needed) Plan (Continue on the back if needed) 1 Strategies & Resources
2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
75
3. Outpatients Attendance Coverage Jan. 2011 (Total No. of Out patients attendance new cases 2010/A) Coverage Jan. 2012 (Total No. of Outpatients attendance new cases 2011/B) Problems (to continue with the back if needed) Plan (to continue with the back if needed) 1 Strategies & Resources
2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
5 Strategies & Resources
76
4. Institutional deliveries Coverage Jan. 2011 (Total No. of Institutional deliveries 2010/A*…..%*100%) Coverage Jan. 2012 (Total No. of Institutional deliveries 2011/C*100%) Problems (Continue on the back if needed) Plan (Continue on the back if needed) 1 Strategies & Resources
2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
5 Strategies & Resources
6 Strategies & Resources
77
5. ANC prenatal and follow up visits Coverage Jan. 2011 (Total No. of ANC prenatal and follow up visits 2010/A*…..%*100%) Coverage Jan. 2012 (Total No. of ANC prenatal and follow up visits 2011/C*100%) Problems (Continue on the back if needed) Plan (Continue on the back if needed) 1 Strategies & Resources
2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
5 Strategies & Resources
78
6. Postnatal Visit Coverage Jan. 2011 (Total No. of Postnatal visit 2010/ Total No of deliveries in 2010)*100% Coverage Jan. 2012 (Total No. of Postnatal visit 2011/ Total No of deliveries in 2011)*100% Problems (Continue on the back if needed) Plan (Continue on the back if needed) 1 Strategies & Resources
2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
5 Strategies & Resources
79
7. Third dose of Fansidar/IPT Coverage Jan. 2011 (Total No. of pregnant women given third dose of Fansidar/IPT in 2010/Total No of pregnant women eligible to 3rd dose IPT 2010)*100% Coverage Jan. 2012 (Total No. of pregnant women given third dose of Fansidar/IPT in 2011/Total No of pregnant women eligible to 3rd dose IPT 2011)*100% Problems (Continue on the back if needed) Plan (Continue on the back if needed) 2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
5 Strategies & Resources
80
8. Fully Vaccinated Children Coverage Jan. 2011 (Total No. of fully vaccinated children (0­11 months) 2010/A*……%*100%) Coverage Jan. 2012 (Total No. of fully vaccinated children (0­11 months) 2011/D*100%) Problems (Continue on the back if needed) Plan (Continue on the back if needed) 1 Strategies & Resources
2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
5 Strategies & Resources
81
9. New Family Planning acceptors Coverage Jan. 2011 (Total No. of New family Planning acceptors at the end of every month for 2010/12/( A*…..%)*100% Coverage Jan. 2012 (Total No. of New family Planning acceptors at the end of every month for 2011/12/E*100%) Problems (Continue on the back if needed) Plan (Continue on the back if needed) 1 Strategies & Resources
2 Strategies & Resources
3 Strategies & Resources
4 Strategies & Resources
5 Strategies & Resources
82
ANNEX 13: Guide on Business Plan Development STAGES FOR DEVELOPING A BUSINESPLAN 1. Obtain and analyze data on incentivized indicators for the previous year. 2. Identify current strengths and weaknesses 3. Analyze the causes of identified weaknesses: a. Structure (Infrastructure and equipment, personnel, organization) b. Population (financial, geographical, and cultural accessibility) c. Community and political‐administrative authorities 6. Identify the appropriate strategies for attaining set targets 7. Priorities amongst the strategies. 8. Set targets for the current year. 9. Work out a detailed Business Plan; which includes: a. Targets b. Strategies c. Dates and times d. Essential resources (human, material, and financial) 10. Transfer a summary from the detailed plan in the official Business Plan included in the contract. 11. Discuss the Business Plan with the District Health Planner and the District Medical Officer before approval 12. Take the plan to be approved by the District Health Planner and the District Medical Officer. 83
CARD­INDEX SYSTEMATIC REFLECTING THE DEVELOPMENT OF BUSINESS PLAN 1. To obtain and analyze the data on RBF indicators for the previous year CURRENT SITUATION No INDICATORS MCH/HIV 1 HIV PMTCT: Pregnant women counselled and tested for HIV 2 PMTCT: Number of HIV pregnant women given Niverapine and AZT
Out patients attendance Antenatal follow ups Institutional deliveries Post natal visit Third dose of Fansidar/IPT Full immunization (0‐11months)
New family Planning acceptors 3 4 5 6 7 8 9 DATA SUMMARY HIV MCH MCH MCH MCH MCH MCH MCH 2. To enumerate the strengths and weaknesses 84
3. To analyze the causes of these weaknesses: a. Structure (Infrastructure and equipment, staff, organization) b. Population (financial, geographical, and cultural accessibility) c. Community and political‐administrative authorities ANALYZES STRENGHTS AND WEAKNESSES NO Indicators Strengths
Weaknesses
1. 2. 3. 4. 5. 6. 7. 8. 9. Causes of the weaknesses 85
4. To identify the strategies which you can adopt to address weaknesses and to reach your targets Causes of the weaknesses Possible strategies 5. To choose the priority strategies to implement Possible Strategies Selection criteria of the strategies Impact Economic (less expensive) Realizable Availability of the Resources Total Selected strategies (X) 1 = Weak 2 = Middle 3 = Extremely 6. To determine the targets for the current year. 86
7. To develop detailed Business Plan this includes: (i) Targets, (ii) Strategies, (iii) Dates/times, (iv) Essential resources (human, material, financial) DETAILED BUSINESS PLAN District _____________________________________________ Health Centre________________________________________ Target 1. 2. 3. 4. 5. 6. 7. 8. 9. Strategies Times/Dates Human
Essential Resources
Material
Financial
87
8. To transfer a summary from the detailed business plan into the Official Business Plan to be attached in the contract a. Weaknesses (Problems) with the column “Problems” b. Strategies and essential resources with the column “Plan” 9. To discuss the Business Plan with the District Health Planner and the District Medical Officer before approval 10. To get the Business Plan approved by the District Medical Officer 88
ANNEX 14: Monthly RBF Invoice for Rural Health Centre District: ……………………….………………………… Health Centre: ………………………..…………………..……. Month: ………………………….…… Year: 20…… INCENTIVISED INDICATORS Date:…………………………………………………………………. UNIT FEE (KWACHA) TOTAL AMOUNT FOR THE MONTH (KWACHA) 1. Curative Consultation K1,000.00 2. Institutional Deliveries K32,000.00 K8,000.00 4. Postnatal visit K16,500.00 5. Fully vaccinated child K11,500.00 6. Third dose of Fansidar/IPT K8,000.00 7. FP users of modern methods at the end of the month K3,000.00 8. PMTCT: Number of pregnant women counseled and tested for HIV K9,000.00 9. PMTCT: Number of HIV pregnant women given Niverapine and AZT K10,000.00 QUANTITY PRODUCED FOR THE MONTH 3. ANC prenatal and follow up visits TOTAL AMOUNT Total Amount in words [………………………………………………………………………………………………..] Kwacha Health Centre Committee Chair person: …………………………………….……………………… Health Centre In­Charge: …………………………………………………..……………………………….. Verifier 1: …………………………………………………………….. Verifier 2: …………………………………………………………….. Official Health Centre Stamp 89
ANNEX 15: Monthly RBF Invoice for High Incentive Remote Health Centre District: ……………………….………………………… Health Centre: ………………………..…………………..……. Month: ………………………….…… Year: 20…… INCENTIVISED INDICATORS Date:…………………………………………………………………. UNIT FEE (KWACHA) TOTAL AMOUNT FOR THE MONTH (KWACHA) 1. Curative Consultation K1,250.00 2. Institutional Deliveries K40,000.00 3. ANC prenatal and follow up visits K10,000.00 4. Postnatal visit K20,625.00 5. Fully vaccinated child K14,375.00 6. Third dose of Fansidar/IPT K10,000.00 QUANTITY PRODUCED FOR THE MONTH 7. FP users of modern methods at the end of the month K3,750.00 8. PMTCT: Number of pregnant women counseled and tested for HIV K11,250.00 9. PMTCT: Number of HIV pregnant women given Niverapine and AZT K12,500.00 TOTAL AMOUNT Total Amount in words [………………………………………………………………………………………………..] Kwacha Health Centre Committee Chair person: …………………………………….……………………… Health Centre In­Charge: …………………………………………………..………………………………. Verifier 1: …………………………………………………………….. Verifier 2: …………………………………………………………….. Official Health Centre Stamp 90
ANNEX 16: Definitions of Health Facility RBF Indicators Indicators Definitions Source of data MATERNAL AND CHILD HEALTH 1. Curative Consultation Sum of all outpatients attendance in curative consultation during the evaluated month Principle source of data: OPD‐Registers Secondary source of data: HIA2 OPD‐Attendance Activity Sheet 2. Institutional Deliveries All institutional deliveries during the evaluated month conducted by skilled personnel (midwives, Clinical officer, nurses, doctors) Principle source of data: Delivery Register Secondary source of data: HIA2 RH: Obstetric Care Activity Sheet 3. ANC prenatal and follow up visits Number of pregnant women who have completed the ANC visits during the evaluated month NB: Only pregnant women who come at 34 weeks & before delivery who have had three previous visits according to guidelines Principle source of data: SMH Register Secondary source of data: HIA2 RH‐SMH Activity Sheet‐
Antenatal/Postnatal Services 4. Postnatal visit The number of female clients that visit a facility for postnatal care after delivery (at home or in facility) during the evaluated month. NB: Only clients that visit health facility between 6 days and 6 weeks after delivery but who have had the 1st previous visit within 6 days after delivery Principle source of data: SMH Register˂˃Delivery Register Secondary source of data: HIA2 RH‐SMH Activity Sheet‐
Antenatal/Postnatal Services 5. Fully vaccinated child under one year of age All children who have completed their primary course of immunization before the age of one year. A primary course includes BCG, OPV 0,1,2 & 3,4, DTP‐Hib+Hep and 1st measles dose before one year of age during the evaluated month. Principle Source of data: Child Health Register Secondary source of data: Child Health (˂5) Activity Sheet HIA2 6.Third dose of Fansidar/IPT All pregnant women who received the 3rd dose of Fansidar/IPT during the evaluated month NB: Only pregnant women who took 3rd dose of Fansidar who have had two previous doses according to guidelines Principle source of data: SMH Register Secondary source of data: HIA2 RH‐SMH Activity Sheet‐
Antenatal/Postnatal Services 7. FP users of modern methods at the end of the month All contraceptives users at the end of evaluated month (Pills, Injectables, Implants) including old and new users Principle source of data: Family Planning Register Secondary source of data: HIA2 RH: Family Planning Activity Sheet 1. PMTCT: Number of pregnant women counseled and tested for HIV All pregnant women tested for HIV with results at ANC visits during the evaluated month including HIV‐ and HIV+ results Principle source of data: Integrated PMTCT Register Secondary source of data: HIA2 PMTCT‐ANC: Activity Sheet 2.PMTCT: Number of HIV pregnant women given Niverapine and AZT All pregnant woman dispensed with Niverapine and AZT during labour according to the national guidelines All HIV Positive Women already on ART Treatment during labour Principle source of data: PMTCT Labour Ward Register Secondary source of data: Baby‐Mother Follow‐up Register HIA2 HIV 91
ANNEX 17: Critical Deadlines – From Receipt of RBF Invoice to Payment of Incentives It is imperative that dates proposed for the submission of reports should be strictly adhered to so that the RBF project can operate smoothly and so that payments can be made promptly. Prompt payment of the incentives for the RBF is dependent on the timely submission of data. A delay in submitting reports may result in delayed payments of incentives and loss of confidence in the system and low output by the health staff. The Table below shows the critical deadlines for submitting reports and making payments. Date 1 By 7th day of first month after the end of the quarter 2 10th day of first month after the end of the quarter 3 14th day of first month after the end of the quarter 21st day of first month after the end of the quarter 22nd day of first month after the end of the quarter 22nd day of first month after the end of the quarter 25th day of first month after the end of the quarter 26th day of first month after the end of the quarter 30th day of first month after the end of the quarter 1st day of second month after the end of the quarter 4 5 6 7 8 9 10 11 12 4th day of second month after the end of the quarter 15th day of second month after the end of the quarter Activity Responsible Person Monthly Provisional Invoice prepared by DMO staff District Medical Office during quantity data audit at the Health Facility. Staff Provisional Invoice and HMIS data are received by Information officer at DMO DMO conducts Data Audit on the Health Facility District Health (monthly audits will be done by the 10th day after Information Officer and the end of each month) Planner at DMO Submission of results for the quality assessment at Medical Superintendent at contracted Hospital Health Centre by the District/General Hospital District RBF Steering Committee Meeting held Invoices sent to PMO
District Medical Officer at DMO District Medical Officer at DMO PMO conduct a performance audit at the DMO
Provincial RBF Technical Specialist Provincial RBF Steering Committee Meeting held
Provincial RBF Technical Specialist Invoices sent to the Project Implementation Unit (PIU) by courier Provincial RBF Technical Specialist PIU receives all invoices from all PMOs and begins processing them Project Manager at MOH PIU processes and submits invoices for approval to the Permanent Secretary, Ministry of Health through the Director of Public Health and Research. PIU receives approved aggregated Invoices and submits to the accounts department Project Manager at MOH Payments done by direct transfer to the accounts PMO, DMO and health facilities. Financial Specialist at the PIU at MOH Project Manager at MOH 92
ANNEX 18: Flow Chart – From Receipt of RBF Invoices to Payment of Incentives District Medical Office First Month after the end of the quarter By 7th Day Day 14 Day 10 Monthly Provisional Invoice prepared by DMO staff during quantity data audit at Health Facility. Provisional Invoice and HMIS data are received by Information officer at DMO District Medical Office conducts RBF Data Audit on Health Facility Submission of results for the quality assessment at Health Centre by the District/General Hospital Day 21 District RBF Steering Committee Meeting held Day 22 Invoices sent to PMO PMO First Month after the end of the quarter Day 26 Day 25 Day 22 Invoices cent to PIU by courier Provincial RBF Steering Committee Meeting held PMO conduct a performance audit at the PMO MOH Second Month after the end of the quarter Day 1 for PIU processes and submits invoices approval to the Permanent Secretary, Ministry of Health through the Director of Public Health and Research Day 4 PIU receives approved aggregated Invoices and submits to the accounts department Day 15 Payments done by direct transfer to the accounts at DMO and Health Facilities 93
ANNEX 19: District Medical Office RBF Evaluation Checklist SYNTHESIS OF DISTRICT MEDICAL OFFICE QUARTERLY RBF ASSESSMENT BY PROVINCIAL MEDICAL OFFICE EVALUATION OF THE DISTRICT MEDICAL OFFICE ________QUARTER 20_________ DISTRICT:______________________________________________ N 1 2 3 4 5 6 7 8 9 10 11 ASSESSED ACTIVITIES Available Points 100% of Health Centres have been supervised at least once 20 per quarter based on the recommendations from the RBF Quantity and Quality audits, and Performance Assessment
Health Centres with 100% of qualified clinical health 10 workers according to Health Centre establishment At least one Meeting with Health Centres Staff held during 10 the past quarter At least one half hour training on one specific topic, during the quarterly HC staff meetings 10 Organize quarterly Health Centre RBF Quantity audits 15 Attributed Points % Observations Quarterly quality assessment of the Health Facilities in the district conducted by the District/General Hospital Monthly HC RBF and HMIS data entered in the RBF and HMIS databases and printed before the 7th day after the end of the month Participation in the Quarterly District RBF Steering Committee Meetings Management of the District Pharmacy 10 20 15 25 Quarterly Performance Assessment of the Health Centres done Communication equipments with health facilities 20 5 TOTAL 160 94
No 1 Indicator/Performance Measure 100% of Health Centres have been supervised at least once per quarter based on the recommendations from the RBF Quantity and Quality audits, and Performance Assessment 2 Health Centres with 100% of qualified clinical health workers according to Health Centre establishment 3 At least one Meeting with Health Centres Staff held during the past quarter 4 At least one half hour training on one specific topic, during the quarterly HC staff meetings Composite Criteria/Validation Criteria Availability of:  Supervision Reports  Justification of the visits  Payment Voucher  Vehicle Logbook (or other transport justified) If all 4 criteria met = 20 Points Even one criterion not met = 0 points Total number of health centres with 100% staffing level for clinical health workers (i.e. Clinical officers, midwives, nurses) in relation to the approved MOH establishment for health centres 
Documented in HR office 
Confirmed by evaluators by phone calls or actual visit of at least 3 HCs All HCs with 100% staffing =10 75% of HCs with 100% staffing =7.5 50% of HCs with 100% staffing =5 Less than 50% of HCs with 100% staffing =0
Meeting held and availability of : 1)Meeting Minutes with the following criteria:  Date and time indicated  Agenda available  Signed participants list available  Discussion on the contents of the past month’s HC monthly reports using the Printed Monthly HC reports (from the HMIS database  Follow up of recommendations and tasks from previous meeting  Action points listed with tasks attributed 2)Payment Voucher Minutes with all criteria and Payment voucher available = 10 Points One or both criteria are lacking or not fulfilling criteria = 0 points Meeting minutes with the description of the topic as follows:

Objective of the training 
Short Description of the session, referring to the available national protocol 
Participants List 
Payment Voucher All 4 criteria met: 10 Points Even one criterion not met: 0 points Weight Attributed Score 20 Justification of score 10 10 10 95
No 5 Indicator/Performance Measure Organize quarterly Health Centre RBF Quantity audits 6 Quarterly quality assessment of the Health Facilities in the district conducted by the District/General Hospital 7 Monthly HC RBF and HMIS data entered in the RBF and HMIS databases and printed before the 7th day after the end of the month 8 Participation in the Quarterly District RBF Steering Committee Meetings Composite Criteria/Validation Criteria 100% of all HC have had their three monthly RBF audit during the past quarter with availability of: 
Monthly Activity Calendars approved by DMO 
RBF Monthly Provisional Invoices available and well filled in and signed/Stamped by HC and signed by evaluators 
Travel Request Forms Signed All 3 criteria met = 15 Points Even one criterion not met = 0 points Existence of a contractual obligation with a District/General Hospital and evidence of process and results of the quality assessment. Availability of: 
Signed Contract between DMO and Hospital 
Quality assessment schedule 
Quality assessment report All 3 criteria met = 10 Points Even one criterion not met = 0 points Availability of: 
Printed Monthly HC RBF and HMIS Report Available and Filed in a Specific Files 
Original Monthly HC RBF and HMIS Reports Available and Filed in the Specific HC Files 
All HC RBF and HMIS Reports for all HCs in the district available 
Monthly Cumulative Report For each of the 4 criteria fulfilled = 5 Points For each of the 4 criteria not fulfilled = 0 Points
Availability of: 
Minutes of the District RBF Steering Committee Meeting according to RBF guidelines 
Printed quarterly RBF Invoice and original provisional invoices have been presented and discussed and or validated in the District RBF Steering Committee meeting. 
Eventual changes suggested to the RBF Final Invoice (missing data, data entry errors etc) are documented in the meeting minutes. 
PowerPoint presentation on RBF quantity data analysis with trends of the indicators 
Meeting was held subject to the legal quorum defined in the District RBF Steering Committee guidelines All criteria met = 15 Points Even one not met = 0 Points Weight Attributed Score 15 Justification of score 10 20 15 96
9 Management of the District Pharmacy 10 Quarterly Performance Assessment of the Health Centres done 11 Communication with health facilities Availability of: 
Stock control cards not used in reserve 
100% stock control cards filled in all entries 
List of expired drugs present and reporting done and removed from shelf timely 
Ordering of drugs according to schedule For each of the 4 criteria fulfilled = 6.25 Points For each of the 4 criteria not fulfilled = 0 Points Availability of: 
HC Quality Performance reports 
100% of HC assessed for the past quarter evaluated before the end of the fourth month, using the designated Quality Checklists 
Correct use of the HC Quality Performance Evaluation Form (all items filled) including the recommendation section 
All HC performance evaluation forms correctly filed in a specific folder. 
Travel Request Forms Signed For each of the 5 criteria fulfilled = 4 Points For each of the 5 criteria not fulfilled = 0 Points Availability of: 
Radio and/or mobile accessible and functional (Tested in presence of the evaluators) 
Phone number of DHMT known by three health facilities randomly chosen All the 2 criteria met = 5 Even one criterion not met = 0 25 20 5
Weight
= 160 Obtained Score= 97
QUARTERLY SYNTHESIS OF THE OBSERVATIONS AND RECOMMENDATIONS District: _______________________________________ Quarter_____________ Year: 20_________ Date:__________________________________ 1. Non achieved tasks and justifications
2. Identified strong points during this assessment 3. Identified weak points to improve during this assessment 4. Recommendations __________________________________ _____________________________ _________________________________________ _____________________________________ Evaluators Team Leader/Name & Signature Name, Signature & Stamp of Council Secretary 98
ANNEX 20: Guidelines for Provincial RBF Steering Committees Republic of Zambia Ministry of Health Guidelines for the Provincial Results Based Financing Steering Committee (P­RBFSC) in Zambia 99
1. MAIN ROLES AND RESPONSABILITIES OF P­RBFSC The P‐RBFSC is tasked with validating the district RBF performance frameworks and incentive payments. This committee is a replica of the District RBF Steering Committee (D‐RBFSC). i.
Validating the districts RBF performance frameworks and incentive payments ii.
Providing office space and any other functional requirements for the Provincial RBF Technical Specialist iii.
Facilitating the implementation of the RBF project activities at districts and community levels iv.
Ensuring that the D‐RBFSC meetings are taking place according to the guidelines v.
Receiving, reviewing and forwarding reports and invoices submitted through the D‐
RBFSC to the Project Implementation Unit (PIU) at the Ministry of Health Headquarters vi.
Ensuring that the Health Facilities get paid their RBF incentives at the rightful time as indicated in their contracts with the District Medical Office. i.e. Not later than 45 days after the end of the quarter in which they were earned vii.
Ensuring that the District/General Hospitals get paid their RBF evaluation fees for the quality assessments in a timely manner. i.e. Not later than 45 days after the end of the quarter in which they did the quality assessment viii.
Ensuring that there is a trend analysis of the indicators in the RBF Districts and bottlenecks identified and addressed ix.
Conduct performance assessments of the RBF Districts and transmit the results to the PIU for payment on a bi‐annual basis x.
Conduct RBF performance assessment and technical support supervision in the districts and identify capacity building needs at district, facility and community levels xi.
Facilitates the internal and external audits and verifications xii.
Settlement of all disputes arising during the implementation of the RBF project. 2. MEMBERSHIP The P‐RBFSC will consist of a minimum of 9 members and a maximum of 11 members. The composition should be gender balanced and include the following persons: x.
Provincial Medical Officer (Chairperson) xi.
Provincial RBF Technical Specialist xii.
Provincial Health Planner xiii.
Clinical Care Expert xiv.
Data Management Specialist xv.
Provincial Pharmacist xvi.
Medical Superintendent of a General Hospital xvii.
Representative from a Government Department xviii.
Donor/NGO representative (s) (maximum of 3) 100
3. MAIN ROLES AND RESPONSIBILITIES OF THE MEMBERS OF THE P­RBFSC 3.1 Provincial Medical Officer  Chairperson for the P‐RBFSC  Calls for meeting  Provides leadership and ensures that all the members play their roles in the committee  Ensures that quality and quantity assessments are conducted before the meeting  Spearhead the process of validating the districts RBF performance frameworks and incentive payments  Facilitates the validation of invoices through the P‐RBFSC  Ensures that final/validated RBF invoices are signed  Reports proceedings of P‐RBFSC to other relevant bodies (stakeholders) in the district i.e. the Provincial Development Coordinating Committee 3.2 Provincial RBF Technical Specialist (Secretariat)  Generates schedule of meetings and calls for P‐RBFSC meetings  Provides overall technical coordination and oversees RBF activities in the district.  Circulates Minutes of the P‐RBFSC to all members of the P‐RBFSC, the National RBF Steering Committee, the PIU at the Ministry of Health HQ and other stakeholders  Ensures that consolidated invoices from all the D‐RBFSCs in the provinces are circulated to members of the P‐RBFSC in time before the P‐RBFSC meeting  Reports on quantity assessments at the P‐RBFSC meetings  Ensures that final reports and invoices approved by the P‐RBFSC are sent to the PIU at the Ministry of Health headquarters and the National RBF Steering Committee according to the agreed timelines  Reports on technical support visits conducted or action taken following the findings/recommendations of quantity and quality data audits  Work with the Provincial Medical Officer in validating the districts RBF performance frameworks and incentive payments  Facilitates internal and external data audits and verifications 3.3 Medical Superintendant of a General Hospital  Act as independent verifier on quality for the RBF at district level  Reports on quality assessments at the P‐RBFSC meetings  Ensures that the schedule for quality assessment as submitted by the D‐RBFSC to the P‐RBFSC is strictly adhered to  Ensures that the skills for quality assessment and the composition of the quality assessment teams at District/General Hospitals are adequate  Ensures that quality assessment tools/checklists are adequate and generating the required data in line with the principles of the RBF and national guidelines/protocols on quality assurance 3.4 Provincial Health Planner  Makes timelines/schedules of various committees/entries for reports/final invoices  Facilitate the process of preparing and circulating minutes of the P‐RBFSC meetings/graphic reports/trend analysis  Identifies shortfalls in equipment, human resource, data collection tools and capacity building 101
3.5 Clinical Care Expert  Conduct performance assessments of the RBF Districts and transmit the results to the P‐RBFSC for consideration and triggering of payment  Conduct routine RBF performance assessment and technical support supervision in the districts and identify capacity building needs at district, facility and community levels  Facilitate the process of conducting follow‐up technical support visits in the districts and Health Facilities based on findings/recommendations from quantity and quality data audits 3.6 Data Management Specialist  Works with the Provincial RBF Technical Specialist in planning and coordinating quantity and quality data audits  Ensures that all consolidated district invoices are entered into the database  Facilitate the process of submitting all the consolidated RBF invoices and RBF data on indicators in the province to the P‐RBFSC for consideration 3.7 Provincial Pharmacist  Reports on the management of drugs at the Health Facilities and District Pharmacies in the province. This includes providing updates on: o
o
o
o
o
o
Shortage of drugs at any Health Centre and District within the last quarter Ordering of drugs according to schedule Use of GRZ and RBF funds to procure emergency drugs Usage of stock control cards and appropriateness of entries Expired drugs and management of expired drugs Submission of reports on expired drugs 3.8 Government Representative  Representative of other Government ministries and departments in the province  Plays a role in lobbying and mobilizing services not available  Identify gaps and show how they could be filled  Play a role of ensuring social equity  Evaluates the RBF indicators and how they affect the broader social and economic aspects of the economy 3.9 Donor/Non­Governmental Organization (NGO)  Representative of the NGOs in the province  Plays a role in lobbying for and mobilizing services not available  Identify gaps and show how they could be filled  Ensuring social equity by acting as a voice for the unprivileged in the province  Evaluates the RBF indicators 102
4. MINIMUM QUORUM The minimum quorum of the P‐RBFSC meeting consists of the Chairperson and at least one representative from the 4 different categories: (i) Provincial Medical Office (ii) The General Hospital (iii) Representative from a Government Department (iv) A donor/NGO representative The meeting should not take place when the quorum is not met. 5. FREQUENCY OF MEETINGS Scheduled meetings are held at least four times a year, but may be frequent depending on local arrangements. Each quarterly meeting (mandatory) must be held as follows: a) Not later than 25th April of current year (1st quarter) b) Not later than 25th July of current year (2nd quarter) c) Not later than 25th October of current year (3rd quarter) d) Not later than 25th January of following year (4th quarter) NB: Minutes of the meeting and final invoices from the districts should be submitted to the PIU at the Ministry of Health Headquarters by the 28th day of the month after the end of the quarter. 6. PROCEDURES Notices of meetings will be issued by the Provincial Medical Officer. The agenda and invitations for the meeting should be made at least 5 days before the planned day of the meeting through a letter or by e‐mail. Minutes of the previous meeting and all the relevant documentation related to the Agenda of the meeting should also be attached. 7. THE MEETING Duration: 1hour and 30 minutes maximum Chairperson: Provincial Medical Officer (In his/her absence, Medical Superintendent) Secretary: Provincial RBF Technical Specialist Timekeeper: To be appointed for each meeting The minutes of the previous meeting will be discussed and approved at each meeting. The draft Minutes of the current meeting should be sent by regular mail or e‐mail to all members at least two days after the meeting. 103
7.1
Agenda and Allocated Time Agenda Item a. Opening b. Correction and Adoption of the Minutes of the Previous meeting
c. Follow‐up on Action Taken after the last meeting d. Report or presentation on the activities of RBF in the province (Quantity and Quality Assessments) e. Presentation and discussion on the Quarterly Consolidated Invoices
f. Discussion on other activities for the next Quarter including follow‐
ups on Technical Support activities conducted to improve Quantity and Quality Assurance g. Any Other Business and Closing Time Allocated (2 minutes)
(15 minutes)
(15 minutes)
(30 minutes)
(15 minutes)
(8 minutes)
(5 minutes)
7.2
Template and Format for Minutes of P­RBFSC Meeting Minutes are primarily produced to provide an accurate written record of the business conducted or decisions made or issues resolved by a meeting. They can therefore be said to be a summarized true record of the deliberations of the P‐RBFSC meeting. The Minutes should have the main heading showing: (i) the name of the P‐RBFSC which met; (ii) the venue at which the meeting was held; and (iii) the date and time when the meeting was held. The Minutes should also have the list of members present and absent at the meeting, with their titles; apologies; and items discussed. Draft Minutes should be in Word while the Final Approved Minutes should be in PDF and signed by both the Chairperson and Secretary. The font type should be Times New Roman throughout the document with the main heading in font size 14 and the other parts of the document in font size 12, single spacing. 7.2.1 List of Participants No. Name of Member 1. 2. Etc 7.2.2
Name organization of Email/mobile Layout/Main Headings The layout or main headings of the P‐RBFSC should follow the main agenda items of the meeting. This should be: i.
ii.
iii.
iv.
Opening Correction and Adoption of the Minutes of the Previous meeting Follow‐up on Action Taken after the last meeting Report or presentation on the activities of RBF in the province (Quantity and Quality Assessments) 104
v. Presentation and discussion on the Quarterly Consolidated Invoices vi. Discussion on other activities for the next Quarter including follow‐ups on Technical Support activities conducted to improve Quantity and Quality Assurance vii. Any Other Business and Closing 7.2.3 Signing of the Minutes At the end of the Minutes, there should be a space for names and signatures of Chairperson and Secretary for signing the approved Minutes. The signing should be done after the next meeting when the Minutes have been confirmed as a true record of the proceedings by the P‐RBFSC. Chairperson: .............................................. Date: .............................................................. Secretary: .................................................... Date: .............................................................. ACTION POINT SHEET An Action Point Sheet is a list of tasks emanating from the resolutions and decisions made at the P‐
RBFSC. It indicates the list of identified actions, responsibility for each identified action, and deadlines or completion dates. It is relatively easy to prepare and can be circulated even before the minutes are completed. It serves as a reminder to members who have been assigned tasks based on the resolutions and decisions made at the P‐RBFSC. The Action Point Sheet is not only a summary of the required actions but it is also a monitoring tool for the Chairperson to follow up on the implementation of agreed tasks. The following is an example of an Action Point Sheet: Action Point Sheet Responsibility Deadline Identified Action 1. 2. 3. 4. 105
ANNEX 21: Guidelines for the District RBF Steering Committee Republic of Zambia Ministry of Health Guidelines for the District Results Based Financing Steering Committee (D­RBFSC) in Zambia 106
1. MAIN ROLES AND RESPONSABILITIES OF THE D­RBFSC 1.1 Facilitates the internal and external audits and verifications 1.2
To ensure that quantity control is carried out; 1.3
To ensure that the District/General Hospital carries out quality assessments at the implementing Health Centres in a timely and professional manner; 1.4
To ensure timely data entry; 1.5
To compare and certify the quantity and quality data that have been entered in the RBF district database; 1.6
To organize, respecting the timelines, quarterly D‐RBFSC meetings; 1.7
To submit, without undue delay, the minutes of the D‐RBFSC meetings to the Provincial RBF Steering Committee and the Provincial RBF Technical Specialist; 1.8
To consolidate quarterly district invoices and submit these to the Provincial RBF Steering Committee for consideration and approval. 1.9
Conduct RBF performance assessment and technical support supervision at the health centre and community levels and identify capacity building needs 1.10 Settlement of all disputes arising during the implementation of the RBF project in the district. 2. MEMBERSHIP The D‐RBFSC shall constitute a minimum of 10 and a maximum of 12 members. Membership shall be gender balanced and consist of the following individuals: i. Council Secretary (Chairperson) ii. District Medical Officer iii. Medical Superintendant of the District/General Hospital iv. District Health Planner v. District Health Information Officer vi. District Pharmacist vii. Zonal Health Centre In‐Charge viii. A Representative from a government/local authority institution ix. Representatives from Non‐governmental/Donor Organizations (Maximum 3) x. A representative from the Community 3. MAIN ROLES AND RESPONSIBILITIES OF THE MEMBERS OF THE D­RBFSC 3.1 Council Secretary  Chairperson for the D‐RBFSC  Calls for meeting  Provides leadership and ensures that all the members play their roles in the committee  Ensures that quality and quantity assessments are conducted before the meeting 107



Facilitates the validation of invoices through the D‐RBFSC Ensures that final/validated RBF invoices are signed Reports proceedings of D‐RBFSC to other relevant bodies (stakeholders) in the district i.e. the District Development Coordinating Committee 3.2 District Medical Officer (Secretariat)  Generates schedule of meetings and calls for D‐RBFSC meetings  Provides overall technical coordination and oversees RBF activities in the district  Circulates consolidated minutes to the members of the D‐RBFSC, the Provincial RBF Steering Committee, the Provincial RBF Technical Specialist and other stakeholders  Ensures that consolidated invoices from all the Health Centres in the district are circulated to members of the D‐RBFSC in time before the D‐RBFSC meeting  Ensures that final reports and final invoices approved by the D‐RBFSC are sent to the Provincial RBF Steering Committee and the Provincial RBF Technical Specialist in accordance with the agreed timelines  Presents Health Centre Business Plans and quantity assessments to the D‐RBFSC  Reports on technical support visits conducted or action taken following the findings/recommendations of quantity and quality data audits 3.3 Medical Superintendant  Act as independent verifier on quality for the RBF at district level  Submits schedule for quality assessment to DMO  Identifies skills for quality assessment and organizes the team for quality assessment  Ensures that quality reports are submitted to the DMO before the D‐RBFSC meeting  Provides information on the technical support required to be provided to Health Centres  Identifies shortfalls e.g. relevant equipment, human resource, data collection tools and capacity building  Reports on quality assessments at the D‐RBFSC meetings 3.4 District Health Planner  Facilitates the process of preparing Health Centre Business Plans  Makes timelines or schedules of various committees/entries for reports/final invoices  Makes schedules for quality data assessments in consultation with the District/General Hospital  Facilitate the process of preparing and circulating minutes of the D‐RBFSC meetings  Facilitates the process of conducting technical support following the findings/recommendations from quantity and quality data audits  Facilitate the process of conducting follow‐up technical support visits in the districts and Health Facilities based on findings/recommendations from quantity and quality data audits 3.5 District Health Information Officer  Coordinate the process of conducting routine and random quantity data audits and technical support supervision on data quality at health facility and community levels  Enter RBF health facility data in the RBF database at district level 108




Coordinate the process of undertaking quality data assessments by the District/General Hospital Facilitate the process of preparing graphic reports and trend analysis on the RBF indicators for presentation at the D‐RBFSC meetings Ensures that all invoices from the Health Centres in the district are entered into the RBF district database Facilitate the process of submitting all the consolidated RBF invoices and RBF data on indicators in the district to the Provincial RBF Technical Specialist and the D‐
RBFSC for consideration 3.6 District Pharmacist  Reports on the management of drugs at the Health Facilities and District Pharmacy in the District. This includes providing updates on: o
o
o
o
o
o
Shortage of drugs at Health Centres, if any, during the last quarter Ordering of drugs according to schedule Use of GRZ and RBF funds to procure emergency drugs Usage of stock control cards and appropriateness of entries Expired drugs and management of expired drugs Submission of reports on expired drugs 3.7 Zonal Health Centre In­Charge  Link between the other Health Centres in the zone and the D‐RBFSC  Stakeholder interest  Ensures that all the Health Centres in the zone are adequately represented on all matters pertaining to the implementation of the RBF  Provide salient explanations on health seeking behaviour, client‐health worker contacts, changes in indicators, etc. 3.8 Non­Governmental Organization (NGO)  Representative of the NGOs in the district  Plays a role in lobbying for and mobilizing services not available  Identify gaps and show how they could be filled  Ensuring social equity by acting as a voice for the unprivileged in the district  Evaluates the RBF indicators 3.9 Government/Local Authority Institution  Representative of other Government ministries and departments in the district  Act as the Chairperson of the D‐RBFSC in situations when the Council Secretary is unavailable or is entirely not able to serve as Chairperson  Plays a role in lobbying and mobilizing services not available  Identify gaps and show how they could be filled  Play a role of ensuring social equity  Evaluates the RBF indicators and how they affect the broader social and economic aspects of the economy 109
3.10 Community Representative  Link between the Community, Health Centre, and the D‐RBFSC  Stakeholder interest  Act as independent verifier 4. MINIMUM QUORUM The minimum quorum for the D‐RBFSC shall consist of at least one representative from the 4 different categories: (i)
District Medical Office (ii)
District/General Hospital (iii) NGO/Donor representative (iv)
Community Representative 5. FREQUENCY OF MEETINGS Scheduled meetings MUST be held at least four times a year (quarterly), but may be frequent depending on local arrangements. Each quarterly meeting must be held before the 21st of the 4th Month. Meetings should ideally be held as follows: For the first Quarter: before 21st April of the current year For the second Quarter: before 21st July of the current year For the third Quarter: before the 21st October of the current year For the fourth Quarter: before the 21st January of the following year NB: Minutes of the meetings and consolidated invoices approved by the D‐RBFSC should be sent to the Provincial Medical Office by the 22nd day of the month after the end of the quarter. 6. PROCEDURES Notices of meetings will be issued by the District Medical Officer. The agenda and invitations for the meeting should be made at least 5 days before the planned day of the meeting through a letter or by e‐mail. Minutes of the previous meeting and all the relevant documentation related to the Agenda of the meeting should also be attached. 7. THE MEETING Duration: 2 hours maximum Chairperson: Council Secretary (in his/her absence, a Government Representative) Secretary: District Medical Officer Timekeeper: To be appointed for each meeting The minutes of the previous meeting will be discussed and approved at each meeting. The draft Minutes of the current meeting should be sent by regular mail or e‐mail to all members at least two days after the meeting. 110
7.1
Agenda and Allocated Time TIME ALLOCATED Opening (2 minutes) Correction and Adoption of the Minutes of the Previous meeting
(10 minutes) Follow‐up on Action Taken after the last meeting (10 minutes) Presentation of the Quantity Audit Report
(15 minutes) Presentation of the Quality Assessment Report (15 minutes) Presentation and discussion on the Quarterly Consolidated (30 minutes) Invoices Discussion on trends in indicators (15 minutes) Discussion on the Health Centre Business Plans and other (8 minutes) activities for the next Quarter Discussion on follow‐up Technical Support activities conducted to (10 minutes) improve Quantity and Quality Assurance Any Other Business and Closing (5 minutes)
AGENDA ITEM i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
7.2
Template and Format for Minutes of D­RBFSC Meeting Minutes are primarily produced to provide an accurate written record of the business conducted or decisions made or issues resolved by a meeting. They can therefore be said to be a summarized true record of the deliberations of the D‐RBFSC meeting. The Minutes should have the main heading showing: (i) the name of the D‐RBFSC which met; (ii) the venue at which the meeting was held; and (iii) the date and time when the meeting was held. The Minutes should also have the list of members present and absent at the meeting, with their titles; apologies; and items discussed. Draft Minutes should be in Word while the Final Approved Minutes should be in PDF and signed by both the Chairperson and Secretary. The font type should be Times New Roman throughout the document with the main heading in font size 14 and the other parts of the document in font size 12, single spacing. 7.2.1 List of Participants No. Name of Member 1. 2. Etc Name organization of Email/mobile 111
7.2.2
Layout/Main Headings The layout or main headings of the D‐RBFSC should follow the main agenda items of the meeting. This should be: i. Opening ii. Correction and Adoption of the Minutes of the Previous meeting iii. Follow‐up on Action Taken after the last meeting iv. Presentation of the Quantity Audit Report v. Presentation of the Quality Assessment Report vi. Presentation and discussion on the Quarterly Consolidated Invoices vii. Discussion on trends in indicators viii. Discussion on the Health Centre Business Plans and other activities for the next Quarter ix. Discussion on follow‐up Technical Support activities conducted to improve Quantity and Quality Assurance x. Any Other Business and Closing 7.2.3
Signing of the Minutes At the end of the Minutes, there should be a space for names and signatures of Chairperson and Secretary for signing the approved Minutes. The signing should be done after the next meeting when the Minutes have been confirmed as a true record of the proceedings by the D‐RBFSC. Chairperson: .............................................. Date: .............................................................. Secretary: .................................................... Date: .............................................................. 8. ACTION POINT SHEET An Action Point Sheet is a list of tasks emanating from the resolutions and decisions made at the D‐
RBFSC. It indicates the list of identified actions, responsibility for each identified action, and deadlines or completion dates. It is relatively easy to prepare and can be circulated even before the minutes are completed. It serves as a reminder to members who have been assigned tasks based on the resolutions and decisions made at the D‐RBFSC. The Action Point Sheet is not only a summary of the required actions but it is also a monitoring tool for the Chairperson to follow up on the implementation of agreed tasks. The following is an example of an Action Point Sheet: Action Point Sheet Responsibility Deadline Identified Action 1. 2. 3. 4. 112
ANNEX 22: Individual Evaluation Form for Health Facility Staff Quotation 2= 60% of the points on Quotation 1= 30% of the points on the criteria the criteria 1 Conscientiousness including the concepts of: (20 points) Punctuality Often arrived late (at least 4 times Sometimes arrived late (1 to 3 times per month) per month) Availability Was often absent at its station Was sometimes absent at its station without known reason (at least 4 without known reason times per month) Working uniform Not wearing at the work station Neglected uniform (dirty or torn or not (Even 1 time per month) ironed) 2 Team spirit including concept of: (30 points) Interpersonal Was often in conflict with the Was sometimes in conflict with the relationships colleagues (reported more than 1 colleagues (Reported 1 time to the time at the supervisor) supervisor) Sense of co‐
Often refused to give assistance Sometimes refused to give assistance operation and and/or expertise to the colleagues and/or expertise to the colleagues (even collaboration (more than 1 time per month) 1 time) Devotion Has often abandoned work (not Has sometimes abandoned work (not finished) without changing under finished) without changing under pretext that hours of service are pretext that the hours of service are finished (more than 3 times per finished (1 to 3 times per month) month) Initiative Has never accomplished an Always awaited the orders of the additional work hierarchy to achieve at least an additional work 3 Technical skills and adaptability in work: (40 points) Organization Never lay out daily plan of activities Always do not lay out daily plan of (report during each internal activities (lack at least 1 time during the supervision) internal supervision) Quality of work Never respect the specific standards Always do not respect the specific to his/her tasks (according to the standards to his/her tasks (report at least report of the internal supervision) 1 time during the internal supervision) Quantity of work Never finish the tasks defined in Always do not finish the tasks defined in his/her daily plan of activities his/her daily plan of activities (report in (report at each internal month 1 time at internal supervisions) supervision) CRITERIA Quotation 3= 100% of the points on the criteria Max Never arrived late
8
Never absent at its station without known reason 7
Uniform always worn (washed, ironed and not torn) 5
Has never been in conflict with the colleagues 8
Has never refused to give assistance and/or expertise to the colleagues 8
Has never abandoned work (not finished) under pretext that the hours of service are finished 8
Achieved at least an additional work without awaiting the orders of the hierarchy 6
Always lay out daily plan of activities 10
Always respect the specific standards to his/her tasks 15
Always finish the tasks defined in his/her daily plan of activities 15
Quotation 113
4 Personal Development Will: (10 points) To consider the Never consider the Always do not consider the Always take consider the recommendations recommendations received during recommendations received during the last recommendations received during of the last the last internal and external internal and external supervisions (report the last internal and external internal and supervisions (report during each even 1 time during the internal and supervisions external internal and external supervision) external supervisions); supervisions TOTAL
5 Participation in the results and the performance of the quarter Participation in the results and the performance of the quarter by the presence with the service Business days (N) = 22 Worked during the business days during the three (3) evaluated months. days (n) = 18 NB: Consider the business days actually worked without considering the reasons of absence with the Percentage of worked days (P) = service (leave, disease, disciplinary suspension…), except the days of recovery which, by (n/N) * 100 compensation, are regarded as worked days. Result of quarterly individual evaluation = (Total of the column quotation from 1 to 4) *P 10 100
100%
P=
Evaluation Team: Name ………………………………………..… Function …………………………………………. Signature ………………………………… Date ……………………………… Name ………………………………………..… Function …………………………………………. Signature ………………………………… Date ……………………………… Employee: Name ………………………………………..… Function …………………………………………. Signature ………………………………… Date ……………………………… 114
ANNEX 23: Individual Evaluation Form for District Medical Office Staff CRITERIA Quotation 1= 30% of the points on the criteria Quotation 2= 60% of the points on the criteria 1 Conscientiousness including the concepts of : (18 points) Punctuality Often arrived late (at least 4 times Sometimes arrived late (1 to 3 per month) times per month) Availability Was often absent at its station Was sometimes absent at its without known reason (at least 4 station without known reason times per month) 2 Team spirit including concept of : (32 points) Interpersonal Was often in conflict with the Was sometimes in conflict with relationships colleagues (reported more than 1 the colleagues (Reported 1 time time at the supervisor) to the supervisor) Sense of co‐
Often refused to give assistance Sometimes refused to give operation and and/or expertise to the colleagues assistance and/or expertise to collaboration (more than 1 time per month) the colleagues (even 1 time) Devotion Has often abandoned work (not Has sometimes abandoned work finished) without changing under (not finished) without changing pretext that hours of service are under pretext that the hours of finished (more than 3 times per service are finished (1 to 3 times month) per month) Initiative Has never accomplished an Always awaited the orders of the additional work hierarchy to achieve at least an additional work 3 Technical skills and adaptability in work : (40 points) Organization Never lay out daily plan of Always do not lay out daily plan activities (report during each of activities (lack at least 1 time internal supervision) during the internal supervision) Quality of work Never respect the specific Always do not respect the standards to his/her tasks specific standards to his/her (according to the report of the tasks (report at least 1 time internal supervision) during the internal supervision) Quantity of work Never finish the tasks defined in Always do not finish the tasks his/her daily plan of activities defined in his/her daily plan of (report at each internal activities (report in month 1 supervision) time at internal supervisions) Quotation 3= 100% of the points on the criteria Max Never arrived late
8
Never absent at its station without known reason 10
Has never been in conflict with the colleagues 8
Has never refused to give assistance and/or expertise to the colleagues Has never abandoned work (not finished) under pretext that the hours of service are finished 8
Achieved at least an additional work without awaiting the orders of the hierarchy 8
Always lay out daily plan of activities 10
Always respect the specific standards to his/her tasks 15
Always finish the tasks defined in his/her daily plan of activities 15
Quotation 8
115
4 Personal Development Will: (10 points) To consider the Never consider the Always do not consider the Always take consider the recommendations recommendations received during recommendations received recommendations received of the last the last internal and external during the last internal and during the last internal and internal and supervisions (report during each external supervisions (report external supervisions external internal and external supervision) even 1 time during the internal supervisions and external supervisions); TOTAL
5 Participation in the results and the performance of the quarter Participation in the results and the performance of the quarter by the presence with the Business days (N) = 22 Worked service during the business days during the three (3) evaluated months. days (n) = 18 NB: Consider the business days actually worked without considering the reasons of Percentage of worked days (P) = absence with the service (leave, disease, disciplinary suspension…), except the days of (n/N) *100 recovery which, by compensation, are regarded as worked days. Result of quarterly individual evaluation = (Total of the column quotation from 1 to 4 which is [….%] ) *P 10 100
[….%]
100%
P= Evaluation Team: Name ………………………………………..… Function …………………………………………. Signature ………………………………… Date ……………………………… Name ………………………………………..… Function …………………………………………. Signature ………………………………… Date ……………………………… Employee: Name ………………………………………..… Function …………………………………………. Signature ………………………………… Date ……………………………… 116
ANNEX 24: District/General Hospital RBF Quotation Card DISTRICT: ………………………………….… HOSPITAL: ……….………………………..…… No. OF HCs: ….……. QUARTER ………..… YEAR: ……….…. HEALTH CENTER QUALITY ASSESSMENT BY DISTRICT/GENERAL HOSPITAL No Subject Indicator Validation criteria 1 HEALTH CENTER QUALITY ASSESSMENT 1) Acknowledgement of delivery of the transmission letter addressed to the district, of the quality scores of the previous Prompt quarter (seal for reception) within the first transmission of 7 days of the 1st month of the following the assessment results quarter 2) To annex to the transmission letter the summary table of quarterly result of quality of each health center, signed by the District/General hospital Director Quality 2 Evaluation Plan Quality assessment monthly plan of the quarterly health centers transmitted to the district assessment (with acknowledgement of delivery, seal for reception of the district) before the 5th day of the month in progress The proper assessment of health centers: 3 The following criteria must be filled: (Put % in the box beside Number of 1)Availability of the copy of the quality Health Centres quarterly tool per health center assessed 2)Completely and correctly filled for the activities available among 10 (Put % in the box beside) 4 Participation in To Prepare and present the report or the RBF steering presentation on the activities of Quality committee audit by the District/General hospital meeting during the RBF steering committee meeting TOTAL DISTRICT/GENERAL HOSPITAL ASSESSMENT Month M1 M2 Indication for quotation M3 100 Max Letter transmitted with all criteria=10 One criterion not filled = 0 %
10 Transmission within the time and additional summary table = 20 One criterion not filled = 0 20 By plan filling criteria = 10 One criterion missing = 0 10 100% of services = 50
One HC missing or not completely filled f=25 Two or more HC missing or not fully assessed = 0 Participation and presentation on the HC quality activities= 10 One of participation and presentation or both missing = 0 50 Attributed Points Justification of quotation if not max 10 100 Stamp & Signature of District Medical Officer: ……………………………………………… Stamp & Signature of contracted Hospital: …………………………………………… 117
ANNEX 25: Project Implementation Unit (PIU) The Ministry of Health will constitute a team at central level to manage the roll‐out the first phase of the RBF. The team will provide management support, technical oversight, coordination and implementation support. The PIU will consist of a Project Manager, a Health Systems Strengthening/ Capacity Building Specialist, a Reproductive Health Specialist, a Financial Specialist, a Management Information System (MIS) Specialist, a Technical Assistant, a Programme Assistant, and a Driver. At Provincial level, eight (8) Provincial RBF Technical Specialists will also be recruited. The Project Manager will be responsible for the overall management of project activities under the PIU. The PIU will be supported by individuals or institutions contracted to undertake capacity building, technical assistance, external data verification, impact evaluation, and other forms of technical support. The specific terms of reference for the PIU are as follows: 1. Provide leadership on the management and implementation of the RBF grant on behalf of the Ministry of Health. This includes liaising with the various Directorates and units involved in the RBF project regarding service delivery, quality assurance, procurements, and the release of incentive payments to districts and health facilities; 2. Support various administrative activities under the RBF project including the creation of effective communication between the MOH, Provincial Medical Offices, districts, and health facilities on all aspects of the RBF project; 3. Provide secretariat to the National RBF Steering Committee; 4. Support the process of establishing and sustaining effective operations of District and Provincial RBF Steering Committees; 5. Coordinating and establishing effective links with all partners and donor organizations in the health sector including those implementing other RBF initiatives in Zambia. This will require collaboration with partners on technical aspects of the RBF as well as co‐financing of this RBF project; 6. Manage the RBF health information system by regularly updating the RBF Database at national and sub‐national levels in collaboration with the ICT Unit of the MOH; 7. Conduct random or specially commissioned data audits aimed at ensuring the effective implementation of the RBF model at district level; 8. Ensuring that all financial and accounting requirements are met. This requires that that the system for due diligence, financial management and reporting are adhered to in accordance with the project operating procedures; 9. Preparing annual work plans and budgets on RBF in consultation with MOH; 10. Prepare requests for the payment of incentives based on quantity and quality data audits, and invoices approved through the Provincial RBF Steering Committees; 11. Verification of the district RBF performance framework and quality assessments of the individual health facilities conducted by contracted entities; 12. Provide technical support on all consultancies on the project including the External Validation Firm, the Technical Assistance Firm, and the IT Firm; 118
13. Coordinate the RBF research agenda, including the implementation of the Impact Evaluation component of the RBF Project, and carrying out comprehensive reviews of the overall performance of the RBF Project; 14. Translate operational aspects of the RBF into the policy dialogue of the broader health sector agenda. This includes integration of the RBF into the broader health sector agenda at the MOH; 15. Assist the MOH in the scale up of EmONC services and leverage resources with other stakeholders; 16. Facilitate the procurement of medical equipment through the RBF and their delivery to the health facilities. 17. Strengthen the capacity of the provincial and RBF district medical offices to ensure improved management skills of the district teams to effectively plan, manage and supervise Maternal and Child Health services. This includes the delivery of EmONC training workshops; 18. Support the hospitals to provide regular quality assessments to the RBF health facilities and ensure that on‐site mentorship is provided for any gaps identified; 19. Provide assistance to the DMOs to ensure that the communities function in accordance with the RBF design and are sufficiently involved in the planning, implementation, and monitoring of service delivery; 20. Facilitate regular professional and institutional development amongst implementers and health facilities, respectively, by identifying training needs and institutional inadequacies as informed through regular monitoring and supervisory visits; 21. Ensure that RBF capacity building activities are designed, implemented and monitored in accordance with the project plans, budgets and expected outcomes at all levels of implementation; 22. Initiate re‐investments and other resource mobilization activities aimed at sustaining the implementation of the RBF Project beyond the timeline of the project; and 23. Dissemination of best practices and lessons learned on the RBF in Zambia to other stakeholders within the country and other part of the World. 119
ANNEX 26: Letter of Commitment between the District Commissioner and the Members of the District RBF Steering Committee This letter of commitment is an agreement between the District Commissioner of …………………………………………………..……… District and ……………………….…………………………………….a member of the District Results Based Financing Steering Committee. This letter defines the Terms of Reference of the member that sits on the steering committee whose main role is to participate in the evaluation of the health facility’s performance against the indicators specified in the performance payment plan on a quarterly basis. The Committee bases the amount the facility may earn on the scores attained in both the quantity and quality audits. The members of the District RBF Steering Committee undertake to: 1. Actively participate in quarterly meetings of the Steering Committee; 2. Execute any responsibilities related to the RBF steering committee when called upon; 3. Actively participate in the evaluation of the Health Facilities performance against specified indicators and determine the performance payment. 4. Support the district in developing recommendations derived from the findings of the health facility performance audits. This commitment is valid for a period of one year commencing on the ……................ day of ……………………………………….. 20…………. and it may be renewed for a further period of one year. Signed and agreed by: District Commissioner:……………………………………………... Date: ……………………………………….. Committee Member:……………..………………………………….. Date: ……………………………………….. Institution:……………………………………………………………..... Position:………………………..……………………………………..….. 120
ANNEX 27: RBF Essential and Complementary Design Elements Level of the Health System National Level Design Issues District Level Design Issues Essential Design Elements Complementary Design Elements RBF included in national policy and strategy documents
Demand side interventions: conditional cash or in‐kind transfer programs Dedicated Project Implementation Unit at MOH
Significant financial incentives through performance frameworks for central MOH departments Dedicated additional Technical Assistance for the Issues of Equity and rural programme; coordination of technical assistance; hardship compensation communication; Management Information System (MIS); frameworks (analysis of training and IT support financial inflows per capita per province/district/health facility, and build compensatory mechanisms through RBF payments) Leveraging Technical Assistance with in‐country available resources Strong national technical coordination platform dedicated to RBF (degrees of freedom; secretariat) Strong technical coordination platform dedicated to providing TA on RBF to districts (‘bridging the gap between policy and implementation’) Ministry of Finance line‐item for ‘RBF payments’
MOF: ensure RBF budget is available/protected to pay performance Sufficient budget for RBF: estimated ‘output‐only budget’ at about $3/capita/year under ideal conditions (70% HC and 30% DH) Sustainability for RBF funding: donor coordination
Decision on ‘kick starting’ the payment cycle (4‐5 months lag of first payment as it is output‐based) MIS system able to capture and feedback data efficiently and effectively (web‐based solution) Drugs and medical supplies: ensure access to sufficient supply at a reasonable quality and price Rigorous evaluations (formal third party and formative multi‐donor mission type) National and Provincial level RBF Steering Committees
Civil Society/NGOs participation in the National and Provincial level RBF Steering Committees Significant financial incentives through performance framework for District Health Management Teams and District Hospitals. Purpose: Performance frameworks targeting the support tasks of these institutions Intense dedicated TA during introduction and subsequently making operational and refining RBF system Decentralized management of RBF budgets 121
Level of the Health System Health Facility Level Design Issues Essential Design Elements District level RBF Steering Committee. Formalized through a contract/agreement with higher level authorities. Purpose: overall governance of RBF in all its aspects of performance improvements at the district level, including approval of performance invoices (i.e. governing board for RBF at the district level). Civil Society/NGOs: (i) participation in data verification and (ii) participation in District RBF Steering Committee (NGO is part of a quorum) Performance Framework Targeting Health Facilities and individual health workers Significant financial incentives reaching frontline health workers (transparent rules/process). Health Centre Bank account
Regular bonus payments for health workers, preferably monthly, but at least once per quarter Autonomy (management and administrative/financial autonomy) to manage resources and to make decisions) Health Centre Management Committee (includes community representatives) Purpose: transparent use of performance funds and other decision­making Contract/agreement (between the providers and purchaser, e.g. decentralized government) Purpose: this defines the rules of the game/responsibilities/RBF system Services that are purchased need to be ‘RBF‐SMART’
Conduct Routine and random Data Quantity Audits.
Purpose: to ensure the consistency and accuracy of reporting of services delivered –monthly Conduct Routine Household Visits Purpose: to validate that services were actually delivered and get feedback on services delivered (community client surveys) Conduct Routine Quality Assessments through an independent verifier Purpose: objectively verify conditions to provide quality care and or quality of care actually provided, with strong impact on performance payments. Regular update of the Quality Assessment Tool/Checklist
Complementary Design Elements Performance framework for decentralized governance of RBF Try to diversify sources of revenue for the health centre (don’t only depend on RBF). E.g. for introducing risk pooling mechanisms such as CBHI, one needs a price signal. Decentralized Funding for Government Staff paid into health facility bank accounts. Once per quarter facility performance payment (can be converted in monthly bonus instalments) Transparent rules can be emphasized through so‐called ‘motivation contracts/agreement’ (contracts/agreements between health facilities and the individual health workers) ‘Business plan approach’
Using grassroots organizations in carrying out these community client surveys 122
ANNEX 28: Data Management under the RBF In order to strengthen the RBF planning and monitoring activities, the various actors at all levels must acquire sufficient knowledge of the RBF data management. This involves process control, collection of information, transmission, analysis and interpretation of data. The first step would be for stakeholders to gather information by using the available routine information through the Health Management Information System (HMIS). The raw data are in records and data sheets and requires identification, collection, and summarization in line with the RBF indicators. To limit errors, only competent and trained staff should be entrusted to perform this task. How to collect data in general 
Teams at health centres and evaluators should ensure that the data collected are comprehensive, complying with the requirements of HMIS, and relevant to the RBF. RBF relevant indicators should be fully completed. 
The basic rules of filling must be met: o Cleanliness and writing: Use legible writing and avoid using correction ink especially on the indicators. o

Failure in reporting: Avoid leaving an empty box in the tools for data collection. Maintaining logical links and data consistency. Transmission and archiving of data The health centre must keep a copy of each assessment. These reports must be stored in a workbook to facilitate data access and be placed where it is easily accessible to the In‐charge. Evaluators and providers must ensure that records are complete and that they do not include any errors. Remember that some errors can be a huge problem at the time of evaluating the reports. The original RBF statements should be sent to the respective RBF Steering Committees by the evaluators within two days preceding the data collection. Analysis and interpretation of the information Analysis of information must be methodical and go through a certain logical steps: 
Organization of information is the first step, i.e. to organize the information presented in tables or in graphics so that the comparison can be made according to geographic characteristics, groups, and other attributes. 
Identification of the problem. The problem is defined as a gap between what is and what is desired. 
Selection of comments Check the pattern of comments from health centres on a monthly basis or quarterly from the RBF Steering Committee. All types of comments – whether positive or negative – need to be addressed. The positive observations, such as an increase in coverage, ought to be highlighted to encourage health centre staff. 123

The problems identified will not all have the same importance. All problems will therefore not deserve equal reflection and analysis. Trying to solve too many problems at a time is unrealistic and leads to a dispersion of energy. Addressing one or two problems during a given period of time is more realistic. 
Formulation and checking of assumptions is important for developing hypotheses that may explain the differences or variations. The following steps are recommended in this regard: 
o
Scrutinize for interpretation errors related to data collection by checking the quality and/or completeness of the data o
Search the factors influencing the problem. This helps in coming up with assumptions about the possible causes of the problem. Evaluating the solutions. This is critical once the causes of the problem have been identified. The choice of solutions to implement must be done systematically. Through a participatory approach, an exhaustive list of possible solutions can be developed that will assist in deciding on the most effective/efficient solution. 124
ANNEX 29: Quality Assurance under RBF 1. Introduction Quality is a complex and multidimensional concept. The MOH has identified the following quality dimensions in its strategic plans:  Professional competence  Technical performance  Efficiency  Effectiveness  Safety  Accessibility  Interpersonal relations  Continuity of care  Coverage/usage  Choice of services These are the standards that define clearly and precisely what ought to be achieved for each quality dimension. For the health care provider, what is produced has to be compatible with the desired quality dimension. The improvement of quality is based on four principles of quality assurance which are: (i) focus on the satisfaction of customers, (ii) process analysis and systems, (iii) teamwork, and (iv) use of data for decision‐making decision. 1.1 Emphasis on the client The customer is the centre for all quality improvement efforts, more especially under RBF. The objective is to respond to the needs and expectations of the client. Once clients access the provided services, he/she makes judgments about the quality of the health services. The client perception of quality greatly determines future health seeking behaviour. Health providers participating in RBF are encouraged to work with the community health workers and structures to routinely assess client perceptions on the quality of services provided. 1.2 Focus on the processes and systems Within the RBF context, a quality assurance approach focuses on the processes and systems that are critical in producing positive health outcomes. A systemic analysis of the problems identified through feedback helps in improving performance. The following steps are recommended in this regard:  Identify the process elements which are neglected  Show explicit links between the inputs, processes and results  Analyse the causes of poor performance  Suggest process options for improvement 125
1.3 Teamwork A third principle of the quality assurance approach is the involvement of staff teams in the process of improving quality. "Teamwork" means the involvement of all members of staff at the health facility in the various activities in order to constantly ensure availability of good quality services to all customers. Regular quality meetings, transparent communication, resolution of conflicts, and the creation of a positive atmosphere for team participation are therefore critical. 1.4 Data for decision making In the context of quality assurance, data are used to:  Identifying and assessing problems  Reviewing the possible causes of problems  Making evidence‐based decisions  Tracking progress overtime to see if proposed positive changes are made and maintained Having the appropriate data at hand helps to ascertain if the main activities have been executed as planned (according to the set standards) and whether intended effects have reached the target population. The objective of quality monitoring is, therefore, to detect, measure, and express the difference between the current attained level of quality and the expected level of quality. 2. Link between RBF and Quality Assurance Quality assurance and RBF aim at the same objective, i.e. the improvement of performance. RBF leads to quality improvements through the identification of gaps between current performance and the desired performance. The quality assurance approach applies different solutions and tools. By following the quality assurance model of quality improvement, the health centre staff would raise the following questions: How can we change in order to lead to sustainable improvements? What type of changes can we make which will have measurable improvements? The process of studying changes would help to commit the health centre to prepare for the next assessment. The staff will compare changes implemented with the initial plan, check the validity of the data, compare performance with baseline indicators, and compare performance indicators with the expected results. By acting on the changes, the health centre can refer to lessons previously learnt and decide whether to adopt the change as standard, abandon it, or change it. Each health facility will be assessed on a quarterly basis by a designated district or general hospital using the health centre quarterly quality assessment tool. 126
ANNEX 30: Example of how to Calculate Individual Staff Performance Bonuses Before the end of each month, the management at the institution will determine an amount intended for the motivation bonuses of the personnel. At the same time they will approve the payment of those bonuses. To maintain equity between the employees, the individual staff motivation bonuses will be defined by the remunerations schedule in use. The staff bonus will be calculated based on the employees’ individual staff index (which is derived from his/her basic salary), total amount available for staff performance incentives, and the percentage score from the individual performance evaluation. The formula is: Individual Staff Motivation Bonus = (Staff Index) X (Total Amount Available for Staff Performance Incentives) X (Percentage Score from Individual Evaluation) The following steps should be made when calculating the individual staff indices. (i) Count the total number of Staff at the institution (Health Centre or District Medical Office) including support staff such as Secretaries, Office Orderlies, Security Guards, Data Clerks, Cleaners, etc. (ii) List down the monthly salaries of all the members of staff from the highest paid to the lowest (iii) Add the monthly salaries for all the members of staff to come up with a total amount (iv) Divide the salary of each member of staff by the total amount to come up with individual staff indices (v) Use the individual staff indices in the formula above to get the performance bonus for each member of staff For example, as shown in Column 1 in the Table below, Theo Health Centre has 7 members of staff each of them holding different positions. The salaries of each of these members of staff are listed in Column 2 and then added up in the last row to come up with a total. The index for each member of staff (Column 3) is then obtained by dividing his/her salary by the total amount for salaries for all the member of staff. The Clinical Officer will have an index of 0.22, Registered Nurse an index of 0.22, and so forth. Column 4 simply shows the results from the Individual Evaluation. Staff Positions with Basic Salaries and Indices for Performance Bonuses at THEO Health Centre 1 2 3 4 5 6 7 1 Staff Position Clinical Officer Registered Nurse Enrolled Nurse EHT Data Entry Clerk Cleaner Security Guard Total 2 Official GRZ Fixed Basic Monthly Salary (Kwacha) 2,332,115
2,332,115
2,166,966
2,166,966
650,000
500,000
450,000
10,598,162 4 3 Indices for Results from the performance bonus Individual Evaluation 0.22
95%
0.22
85%
0.20
90%
0.20
95%
0.06
95%
0.05
85%
0.04
95%
1.00 127
Lets now assume that THEO Health Centre earns a total of K15,000,000 for Performance Incentives. The Health Centre should first deduct 25% of this money (K3,750,000) and use it for re‐
investment. The remaining 75% which is K11,250,000 is the total amount that can be used for staff motivation bonuses. Using the Formula above, the individual staff bonuses will then be calculated as follows: For the Clinical Officer = (0.22 X 11,250,000 X 95%) = K 2,351,250 For the Registered Nurse = (0.22 X 11,250,000 X 85%) = K 2,103,750 For the Enrolled Nurse = (0.20 X 11,250,000 X 90%) = K 2,025,000 For the EHT = (0.20 X 11,250,000 X 95%) = K 2,137,500 For the Data Entry Clerk = (0.06 X 11,250,000 X 95%) = K 641,250 For the Cleaner = (0.05 X 11,250,000 X 85%) = K 478,125 For the Security Guard = (0.04 X 11,250,000 X 95%) = K 427,500 TOTAL K10,164,375 AMOUNT REMAINING K 1,085,625 Once all the members of staff have been paid, the remaining money (K1,085,625) should be used for re‐investment. In conclusion, the key thing to calculating the individual staff bonuses is the total number of staff available at the institution and the employees’ individual staff index (which is derived from individual staff salaries). The other factors are the total amount available for staff performance bonuses and the percentage score from the individual performance evaluation. 128