RESULTS-BASED FINANCING AT THE WORLD BANK 54083 Democratic Republic of Congo PREPARED BY CARYN BREDENKAMP AND CLEARED BY PATRICK MULLEN PROJECT NAME: Health Sector Rehabilitation Support project (HSRSP) TIME PERIOD: 2006-2011 (Approved June 2005) LENDING INSTRUMENT: Specific Investment Loan (SIL) PROJECT ID: P088751 TTL: Patrick Mullen RBF COMPONENT OR PROJECT: Component UNIT: AFTH3 AMOUNT (USD): $150 million PILOT (Y/N): No Characteristic Description Health-related MDGs in Democratic Republic of Congo (DRC) are very poor. Under-five mortality (2002-06) was 148 per 1,000 live births, the prevalence of chronic malnutrition among children under five is 45% and maternal mortality in 2001 was 1,289 per 100,000 live births. Administrative capacity is low. Not all health workers are salaried, salaries are often paid irregularly and health workers rely on user fees for a significant proportion of their remuneration. In many poor and rural areas, there are shortages of skilled workers. International support for the development of RATIONALE the health system, building on government experience with partnerships with church groups and other non-governmental organizations, is often channeled through contracts with NGOs. The health sector component (USD 60 million) of a multi-sectoral emergency project (2002-09) contracted NGOs to provide support to government and confessional health services in target areas. Similarly, the HSRSP (2005-11) contracts NGOs to provide technical assistance, training, and inputs in order to improve delivery of the government's basic package of services which is designed to address the major causes of morbidity and mortality. The RBF component is in line with the overall Project Development Objective (PDO): to ensure that the target population of selected health zones OBJECTIVE OF THE RBF has access to, and utilizes, a well-defined package of quality essential health services. All workers at primary health care facilities, reference hospitals, reference health centers and health zone teams in 10 districts across 5 provinces BENEFICIARIES (with a population of around 9.4 million) of DRC. Other development partners (e.g. GAVI, CORDAID, EU) implement RBF schemes in other districts and provinces. INTERVENTION Cash bonus paid to the above-mentioned health workers for the attainment of targets related to output and process indicators. The bonus received by each worker at the health facility level has two parts: 70% is a "prime fixe" and 30% is performance-related. (a) The prime "fixe" is received monthly and equal to a defined percentage of a maximum monetary value which differs according to the rank of each worker. Originally envisaged as a performance-based payment for "professionalism", based on a set of indicators, this is now effectively TYPE AND AMOUNT a salary top-up that is paid regardless of performance. OF INCENTIVE PROVIDED (b) The performance prime is received every three months, based on facility performance, and allocated across workers based on their rank. The maximum possible payment for the facility is calculated on a trimester basis by taking the product of the number and type of workers in the facility, multiplied by 3 (because performance is measured over 3 months), then multiplied by 30% (in the case of HSRSP because the performance bonus for each worker is 30%). This figure is then adjusted based on the performance score (e.g. 80% performance) and dis- tributed according to each worker's share once every three months. (continued on next page) 1 COUNTRY SNAPSHOT DEMOCRATIC REPUBLIC OF CONGO Characteristic Description The share of total health worker remuneration to which this amounts has not yet been ascertained since government salary and incentive payments vary considerably between health workers of different administrative status, and most workers rely to varying degrees on user fees. Targets are set at the health facility level, the health zone team level, the reference health center level and at the hospital level. Indicators are related to both outputs (i.e. service utilization) and process (i.e. activities). Each indicator/target corresponds to a defined percentage of the total performance payment and is paid on an all-or-nothing basis. Although capturing broadly similar health services, different indicators are used in different provinces, depending on which NGO is contracted. As an example, the indicators used for payment in primary health care centers in the province of Katanga are: INDICATORS AND TARGETS OUTPUT INDICATORS FOR RECEIVING PAYMENT No. of new consultations for curative care ­ 10% of total maximum payment No. of facility-based deliveries ­ 10% No. of patients referred to the hospital or referral health centre ­ 10% No. of pregnant woman vaccinated against tetanus toxoid (2-5) ­ 10% No. of children correctly treated for fever, diarrhea and ARI ­ 10% Targets reached for all immunization objectives in the preceding month ­ 10% PROCESS INDICATORS Implementation of 80% or more of all activities planned in the previous community health management meeting ­ 5% Implementation of 80% or more of the recommendations made during the previous supervision visit ­ 5% Availability of the cash report of the previous month, in accordance with the financial management tools of the health centre ­ 10% Timeliness and completion of the health information system report ­ 10% Match between actual and planned drug stocks at the health centre's pharmacy ­ 10% MONITORING PROCESS Payment is made on the basis of a combination of (i) indicators contained in the HIS and (ii) qualitative indicators measured through supervision visits. The evaluation forms requires the signatures of the Head Nurse, Médecin Chef de Zone and community health management committee; health zone PROCESS FOR VERIFYING team evaluation requires signatures of Médecin Chef de Zone, Médecin de District, the implementing partner; hospital and reference health center ACHIEVEMENTS evaluation requires signatures of Médecin Directeur de l'HGR, Médecin de District, and the implementing partner. Verification of annual performance is contracted out to a monitoring and evaluation firm which conducts facility surveys to verify reported data against the HIS. NGOs (one per province) are contracted by the Ministry of Health to implement the incentive program. In collaboration with the health administration, the NGOs are responsible for measuring performance, calculating the bonus and paying the bonuses directly to each health worker in cash. Each INSTITUTIONAL NGO receives three types of funds from the Ministry of Health: (i) funds used to pay incentives, as well as funds that are to be used to support ARRANGEMENTS health service delivery (e.g. training, capacity-building, HIS strengthening, purchasing of pharmaceuticals, purchasing of certain equipment etc); (ii) a AND ROLES fee for implementing the performance-based financing mechanism; and (iii) a performance bonus equivalent to between 0% and 10% of the contract value, at mid-term and end. EVALUATION STRATEGY Overall project performance will be measured by baseline and follow-up household surveys. A baseline survey was conducted in 2007. AND RESULTS 2 COUNTRY SNAPSHOT DEMOCRATIC REPUBLIC OF CONGO