Prioritizing Performance Problems and Choosing

Recipients

Benjamin Loevinsohn

Lead Public Health Specialist

The World Bank

June 2008

U5MR (per 1,000) in sub-Saharan Africa – MDG4 Target and Actual

0

20

40

60

80

100

120

140

160

180

200

1990 1995 2000 2005 2010 2015

Target

Actual

184

158

61

Source: Global Monitoring Report 2008

U5MR in Afghanistan Actual and MDG4 Target

0

50

100

150

200

250

300

1990 1995 2000 2005 2010 2015

Target

Actual

260

191

What do these graphs show?

Sub-Saharan Africa has a long way to go to achieve MDG4

Continuing current approaches is not likely to achieve sufficient progress to meet MDG4

There is no reason for pessimism, progress is possible

Bold actions are needed Need to try things, evaluate, and learn

A Few Messages to Start Don’t Panic:RBF has worked in difficult

situations, not everything has to be perfect, be creative!

Be Systematic: Write things down in a contract or manual or plan

The Limits of Planning: Endless planning and analysis can get in the way of action & learning

Humility: a) don’t be too sure of thingsb) knowledge must be larger than our experiencec) give people at local levels sufficient autonomy

d) keep learning, evaluating, adapting

An Iterative- Learning Model for RBF

Diagnose performance problems/issues Develop some options to test Implement the options on a reasonable scale Monitor and evaluate performance of the

different options Scale up successful options

Step 1: Identifying the Problems - Hard Work and Work Hard

There are many issues, there’s a need for looking at lots of data critically, some of the issues are «soft » – motivation, management

1. What are the leading causes of death?2. Are there particular interventions/programs

that are weak or is everything weak?3. Geographically, where are the problems?4. What are the institutional issues?

1. Leading Causes of Death – Understanding U5MR: In Pakistan Neonatal Mortality Rate is Stagnant and 58% of U5MR, not Cameroon

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20

40

60

80

100

120

140

160

Pakistan 1999 Pakistan 2006 Cameroon 2004

Child (1-5 years)

Post-Neonatal

Neonatal

source: PDHS 1990-91 & 2006-07, DHS 2004

2. Are there particular programs that are weak?

0

10

20

30

40

50

60

70

80

90

100

Skilled Birth Attendance ContraceptivePrevalence Rate

Antenatal Care DTP3 vaccinationcoverage

Afghanistan in 2003

65.4

83.4

61.8

1.3

13.5

0

10

20

30

40

50

60

70

80

90

100

DPT3 ANC SBA LLIN use (<5) CPR

Cameroon in 2004

3. Geographical Issues: 2003 Afghanistan – Rural vs. Urban

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20

40

60

80

100

ContraceptivePrevalence Rate

Antenatal Care DPT3 coverage

AFG. Rural

Afg. Urban

Differences between provinces – DPT3 Coverage in Cameroon

30

40

50

60

70

80

90

4. What are the institutional issues?

Management: Quality of management at provincial and district level?

Motivation of health workers? Absenteeism? Measurement: Are results measured? Is

there accountability for results? Milieu:What has been tried in the past? e.g.

What has been done with confessional NGOs? Any performance bonuses in MOH?

An Iterative- Learning Model for RBF

Diagnose performance problems/issues Develop some options to test Implement the options on a reasonable scale Monitor and evaluate performance of the

different options Scale up successful options

Step 2: Objectives and Recipients

Possible Objectives Possible Recipients

Increase institutional deliveries as means for reducing MMR

Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA,

Increase % of childen/mothers sleeping under LLINs last night, especially among the poor

Demand: Mothers, TBA

Increase Supply: TBA, Service provider

Supply: DHMT, NGOs, private providers, public sector providers

Service provider (NGO, public, private)

Example 1: CCT for Institutional Delivery

1. Objective: Increase institutional deliveries as means for reducing MMR

2. Recipient: Mother

3. Measurement: Mother actually in facility

4. Payment Terms: Mother receives cash

5. Use: Mother can spend cash as she likes

6. Manager: NGO or MOH or Social Welfare Ministry

Example 2: Contracting – In Management for Poorly Performing District

1. Objective: Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, index of quality of care, consultations by bottom income quintile

2. Recipient:NGO, firm, or individual that manages a health district

3. Measurement:Health Facility Survey (HFS), Household survey (HHS), HMIS,

4. Payment Terms: Bonuses for good performance, termination/embarrassment if it’s poor

5. Use: Bonuses can be used to increase pay to managers or staff, carry out other development activities, seperate from budget for service delivery

6. Manager: MOH, or Procurement/Management Firm

Example 3: Contracting for LLIN Distribution and Use

1. Objective: Increase % of childen/mothers sleeping under LLINs last night, especially among the poor

2. Recipient:NGO or firm or DHMT

3. Measurement:Household survey (HHS)

4. Payment terms: Bonuses for high LLIN use rates, or payment for each child user; termination or embarrassment if rates are low

5. Use: Bonuses can be used to pay managers or carry out other development activities

6. Manager: MOH or Procurement/Management Firm

Example 4: Internal Contracts

1. Objective: Improve 6-10 indicators of performance e.g. DPT3, ANC, CPR, SBA, index of quality of care, consultations by bottom income quintile

2. Recipient:District Health Management Team3. Measurement:Health Facility Survey (HFS),

Household survey (HHS), HMIS,4. Payment Terms: a) commendation; b) budget

increase; c) cash bonus to DHMT; d) cash bonuses to health workers

5. Uses: Also complicated6. Manager: PHD, MOH