A new performance-based financing system will be implemented in the Democratic Republic of Congo, through a partnership involving the Global Fund, GAVI, Unicef and the World Bank. In 2016-2017, the Global Fund will allocate $20 million to finance health centers and their staff on the basis of the quantity and the quality of services provided.
“There are so many challenges in DRC, ranging from managing the supply chain to reporting and to the quality of treatment, that we need to try new methods,” said Nicolas Farcy, the fund portfolio manager for DRC. “It is a new business model which involves encouraging staff to work more and work better. The need to motivate staff is at the heart of the problems with health systems in DRC today.”
The goal of this PBF system is to improve the quality of treatment and to increase the number of patients. Instead of using the standard indicators associated with Global Fund grants, the results will be based on an evaluation of a minimum package of services that have been defined in agreement with the Ministry of Health. The operational manual, finalized in March 2015, identifies a minimum package of activities for the health centers (including new outpatient consultations, minor surgery, and pre- and post-natal consultations) and a “complementary” package of activities for hospitals (including major surgery).
Hadia Samaha, task team leader of the DRC Health Program, told GFO that health centers will receive an initial investment of funds when they sign a contract. “They will have to devise a business plan to identify the interventions they want to carry out to improve access to quality health services,” she said. An equity fund will be put in place for health centers that are the most remote. "They will receive a bigger amount than urban or semi-urban centers," she said. "Treatment in health centers that are only accessible by boat is more expensive than in a town because of the cost of transport of medication and other products."
The evaluation will be carried out at three different levels. First, independent public service institutions will audit the health centers every month to assess the volume of services provided. Second, the provincial directorates of health will visit the centers every quarter to determine whether the patients were well taken care of. Third, community associations will “cross-check” this information.
Under the PBF system, it is possible for a service provider to fake the information by, for example, inflating the results to get more money. To help prevent this, the operational manual includes guidelines on how to prevent fraud, such as by ensuring a “clear separation of roles to avoid conflict of interest and a credible system of sanctions (financial and administrative).”
The Global Fund sees this partnership as a way to harmonize donors’ interventions which are very fragmented in DRC. “What will be the donor's approach?” asks Nicolas Farcy. “Will they be conservative and only finance certain services in certain zones? Or will they take a more progressive approach and agree on a package of services financed by all? This is yet to be determined. I hope they go for the more progressive approach.”
Despite the good intentions, some observers fear that the PBF system might reinforce inequities. “Health centers can only achieve results if there is already a basic service in place,” the manager of an NGO told GFO. “But in the DRC, the centers lack everything. I am afraid that this system is going to leave behind the health centers that are performing poorly. How can a health center that lacks everything perform well? It could be a vicious circle.”
According to Nicolas Farcy, the problems are so profound in the DRC that donors don’t have a choice. They need to try a new approach. “There might be negative effects, but we need to remember where we are coming from. Right now, it is less urgent to fight inequities than to get as many centers as possible to start providing quality treatment.”
This article was altered on 25 September to correct some discrepancies between the French and English versions of the article.