2013年-世界发展银行全球_Verification_of_Performance_in_Result-Based_Financing___The_Case_of_Burundi_154页_3mb

Summary of "Verification of Performance in Result-Based Financing (RBF): The Case of Burundi"

Core Content

This document presents an analysis of the verification system used in Burundi's Performance-Based Financing (PBF) program, which is a form of Results-Based Financing (RBF). The study is conducted by Adrien Renaud, a freelance health economist, and is part of a broader World Bank initiative to explore verification practices in RBF schemes across multiple countries. The PBF program in Burundi, one of the first in Africa, aims to improve health system performance by linking financial incentives to service delivery and quality of care.

Main Objectives

• To describe the methods used for performance verification in the Burundian PBF program.
• To present the results of these verification efforts.
• To identify obstacles, solutions, and future challenges in the implementation of the verification system.

Key Components of the Verification System

The verification system includes four main mechanisms:

1. Quantity Verification

   • Performed monthly by provincial committees (CPVV) for all contracted health facilities.
   • Involves recounting cases from providers' registers.
   • Health centers: 22 indicators; Hospitals: 24 indicators.
   • Verification data is used to determine monthly fee-for-service subsidies.

2. Technical Quality Assessment

   • Conducted quarterly by district health offices for health centers and by peers for hospitals.
   • Uses predefined checklists to evaluate adherence to clinical guidelines.
   • Results determine quarterly quality top-up or sanction payments.

3. Household Surveys

   • Performed semiannually by local NGOs.
   • Involves interviewing 80 patients per facility.
   • Aims to assess whether patients received services and their satisfaction level.
   • Results are used in conjunction with technical quality assessments to determine quality payments.

4. Counter-Verification

   • Conducted quarterly by an independent organization (Health, Development, and Performance – HDP).
   • Uses the same tools as the previous mechanisms to verify the accuracy of data.
   • Focuses on validating the data collected by the CPVV and local offices of the Ministry of Health (MoH).

Key Findings

• Quantity Verification

  • In health centers, 69% of quantity performance was accurately assessed, 22% overestimated (average 19%), and 9% underestimated (average 4%).
  • In hospitals, 62% of quantity performance was accurately assessed, 26% overestimated (average 13%), and 12% underestimated (average 7%).

• Technical Quality Assessment

  • Average scores for health centers: 70%; for district hospitals: 77%; for national hospitals: 74%.
  • Scores can vary significantly depending on the quality assessment checklists.

• Household Surveys

  • Proportion of patients not found in the community ranged from 8.6% to 6.9% in health centers.
  • In hospitals, the range was from 9.8% to 15.4%.

• Counter-Verification

  • For health centers, no significant differences were found between CPVV and HDP data.
  • For hospitals, there were large and systematic differences, with an average absolute discrepancy of 31%.
  • MoH assessments of technical quality in health centers were overestimated in 79% of cases (average 20%).
  • Peer assessments of technical quality in hospitals were overestimated in 84% of cases (average 24%).

Use of Findings

• Verification results are used to:
  • Pay monthly quantity subsidies.
  • Determine quarterly quality top-up or sanction payments.
  • Assess the correctness of the work done by CPVV and local MoH offices.

Verification Costs

• Verification costs represent about 16% of total PBF expenses.
• The system is seen as both a control and an educational tool.

Challenges and Obstacles

• Systemic discrepancies between verification and counter-verification data.
• Overestimation is more common than underestimation.
• Need for stronger sanctions and continuous training of verification actors.
• Potential complacency in technical quality assessment due to close ties between CPVV and MoH.

Institutional Setup

• The PBF program is led by the Ministry of Health (MoH).
• The CT-FBP (Technical Unit for PBF) coordinates the program at the central level.
• Provincial committees (CPVV) implement the program at the provincial level.
• The CPVV is a joint institution, with representation from both government and civil society.
• The verification unit and validation unit are separate to avoid conflicts and improve performance incentives.

Conclusion

• The verification system in Burundi is effective in detecting fraud and ensuring data reliability.
• It is considered a vital component of the PBF program, which has shown promising initial results.
• Continuous improvements in verification methods and stronger enforcement mechanisms are needed to address discrepancies and enhance program effectiveness.

Key Information

• Country: Burundi
• Region: African Great Lakes
• Population: ~8.6 million
• GDP per capita (2011): ~$270
• Poverty rate (2011): 67%
• Total health expenditure per capita (2011): ~$21
• Life expectancy at birth: 50 years
• Under-five mortality rate: ~142 per 1,000 live births
• Maternal mortality ratio: ~800 per 100,000 live births
• Exchange rate (November 2012): 1 USD = 1464 BIF

Lessons Learned

• A well-integrated verification system with independent counter-verification is essential for trust and reliability.
• Training and capacity building for verification actors are critical.
• The system should be adapted to reduce discrepancies and improve accuracy.
• The verification process is not only a control mechanism but also an educational one, promoting better performance among health providers.