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LesothoMinistry of Health

KINGDOM OF LESOTHO

MATERNAL AND NEWBORN HEALTH PERFORMANCE BASED FINANCING

PROJECT IMPLEMENTATION MANUAL

February 2013

Table of ContentsPREFACE............................................................................................................................................................ VI

ABBREVIATIONS AND ACRONYMS.................................................................................................................... VII

INTRODUCTION.................................................................................................................................................. 1

CHAPTER 1: PERFORMANCE BASED FINANCING AND THE LESOTHO HEALTH SYSTEM...........................................3

BACKGROUND..........................................................................................................................................................3Results Based Financing and Performance Based Financing defined................................................................3PBF Elements.....................................................................................................................................................3

LESOTHO HEALTH STATUS AND HEALTH SYSTEM................................................................................................................4Health Status......................................................................................................................................................4Health System.....................................................................................................................................................5

DECENTRALIZATION......................................................................................................................................................6

CHAPTER 2: LESOTHO PERFORMANCE BASED FINANCING PROJECT OBJECTIVES AND COMPONENTS...................7

HIGHER LEVEL PROJECT OBJECTIVES......................................................................................................................7PROJECT DEVELOPMENT OBJECTIVE.......................................................................................................................7PROJECT PHASES.....................................................................................................................................................7PROJECT FINANCING................................................................................................................................................7PROJECT BENEFICIARIES..........................................................................................................................................8PROJECT COMPONENTS............................................................................................................................................8PROJECT INDICATORS AND VALUES.......................................................................................................................12THE HEALTH SERVICE PACKAGES: MPA AND CPA..............................................................................................12FEE SETTING FOR THE SERVICES: DETERMINING THE SUBSIDIES...........................................................................18

Regular adjustment of the quantity unit fees.....................................................................................................18

CHAPTER 3: INSTITUTIONAL SET-UP, ORGANIZATION AND MANAGEMENT OF THE PROJECT..............................19

Ministry of Health (MOH)................................................................................................................................19The National Sexual and Reproductive Health Steering Committee (NSRHSC)...............................................19The Technical Working Group (TWG)..............................................................................................................20The PBF Unit.....................................................................................................................................................20The PPTA..........................................................................................................................................................20The Christian Health Association of Lesotho (CHAL).......................................................................................21

DISTRICT LEVEL.........................................................................................................................................................21The District Council..........................................................................................................................................21A District PBF Steering Committee..................................................................................................................21The District Health Management Team (DHMT).............................................................................................21

HEALTH CENTRE LEVEL...............................................................................................................................................22COMMUNITY LEVEL AND VILLAGE HEALTH WORKERS..............................................................................................24REQUIREMENTS FOR DISTRICTS TO PARTICIPATE IN PBF....................................................................................................30REQUIREMENTS FOR HEALTH CENTRES TO PARTICIPATE IN PBF:.........................................................................................30ANNUAL WORK PROGRAM AND BUDGET.......................................................................................................................31

CHAPTER 4: CONTRACTS, DETERMINATION OF PBF BENEFITS, AND BUSINESS PLANS.........................................43

CONTRACTING...........................................................................................................................................................43DETERMINATION OF PBF BENEFITS................................................................................................................................44

Remoteness bonus.............................................................................................................................................46PAYMENT FOR QUANTITY OF SERVICES...........................................................................................................................47

Payment to HCs based on quantity of services delivered..................................................................................47Quantity score for district/local hospitals.........................................................................................................47

PAYMENT FOR QUALITY OF SERVICES..............................................................................................................................47

Quality score for health centres........................................................................................................................47Quality score for District/local hospitals..........................................................................................................48Supervision quality score District Health Management Team (DHMT)...........................................................49Regular adjustment of the quality assessment methodology.............................................................................50

USAGE OF PBF BENEFITS.............................................................................................................................................50HEALTH FACILITY BUSINESS PLAN..................................................................................................................................53

Business Plan Management Cycle....................................................................................................................54

CHAPTER 5: FINANCIAL MANAGEMENT ARRANGEMENTS..................................................................................55

INTRODUCTION.....................................................................................................................................................55Background......................................................................................................................................................55About the manual..............................................................................................................................................55The PBF unit....................................................................................................................................................55Objectives of Accounting and Financial Management Operating Procedures.................................................56

COMMITMENT – CODE OF CONDUCT...................................................................................................................56RESPONSIBILITIES..................................................................................................................................................56

MOH Senior Management................................................................................................................................57Finance and accounts section PBF unit...........................................................................................................57Accountant District Hospital............................................................................................................................57Accountant DHMTs..........................................................................................................................................57CHAL finance Manager....................................................................................................................................57External Auditor...............................................................................................................................................57

CHART OF ACCOUNTS...........................................................................................................................................57Chart of accounts; components, activities........................................................................................................58Overview of chart of accounts (segments (digits) will be aligned to TOMPRO or the reverse)........................59

ACCOUNTING AND FINANCIAL MANAGEMENT PRINCIPLES/POLICIES......................................................................................59Fundamental accounting principles.................................................................................................................59

THE ACCOUNTING CYCLE..............................................................................................................................................59MONTHLY ROUTINES..................................................................................................................................................60THE ACCOUNTING AND FINANCIAL MANAGEMENT SYSTEM................................................................................61

The accounting system......................................................................................................................................61Financial management system..........................................................................................................................62Specific financial management systems............................................................................................................62

PETTY CASH IMPREST SYSTEM..............................................................................................................................62SYSTEM OF INTERNAL CONTROL...........................................................................................................................63AUTHORIZATION OF EXPENDITURE.......................................................................................................................64

Goods and/or services......................................................................................................................................64Authorization of expenditure for payment of PBF incentives............................................................................64

PAYMENT..............................................................................................................................................................65Payment of goods/services................................................................................................................................65Payment of PBF incentives...............................................................................................................................65No expenditure will be paid by the project if;...................................................................................................66

FINANCIAL REPORTING.........................................................................................................................................66Monthly reporting.............................................................................................................................................66Quarterly reporting..........................................................................................................................................67Annual reporting..............................................................................................................................................67

FUNDS FLOW.........................................................................................................................................................67BANKING...............................................................................................................................................................69

Bank signatories...............................................................................................................................................69Banking procedures..........................................................................................................................................69

ANNUAL AUDIT.....................................................................................................................................................69BUDGETING AND PLANNING.................................................................................................................................69TRAVEL POLICY......................................................................................................................................................70

Objectives of travel policy................................................................................................................................70Local Travel.....................................................................................................................................................70Travel outside of Lesotho.................................................................................................................................71Planned trip:....................................................................................................................................................71

WORKSHOPS.........................................................................................................................................................72Prerequisites.....................................................................................................................................................72WORKSHOP/TRAINING PROCEDURES........................................................................................................72

CHAPTER 6: PROCUREMENT ARRANGEMENTS...................................................................................................74

CHAPTER 7. ENVIRONMENTAL AND SOCIAL (INCLUDING SAFEGUARDS).............................................................75

CHAPTER 8: MONITORING & EVALUATION ARRANGEMENTS.............................................................................76

MONITORING OF THE PBF PROJECT IMPLEMENTATION......................................................................................................76PROJECT RESULTS FRAMEWORK.....................................................................................................................................85IMPACT EVALUATION..................................................................................................................................................95

ANNEXES.......................................................................................................................................................... 96

ANNEX 1. REFERRAL AND FEEDBACK FORM..............................................................................................96ANNEX 2. PBF PILOT DISTRICTS’ HEALTH CENTRES STAFFING PATTERN...........................................99ANNEX 3. CRITERIA FOR THE SELECTION OF DISTRICTS TO SCALE UP IN YEAR 2..........................101ANNEX 4. TOR FOR PBF NATIONAL STEERING AND NSRHSC....................................................................104ANNEX 5. TOR FOR TECHNICAL WORKING GROUP (TWG).......................................................................108ANNEX 6. TOR OF THE PBF UNIT AND JOB DESCRIPTIONS OF PBF UNIT STAFF........................................109ANNEX 7. TOR FOR PPTA (AS ISSUED FOR RFP)................................................................................................123ANNEX 8. TOR FOR PBF DISTRICT STEERING COMMITTEE......................................................................133ANNEX 9. CONTRACT FOR DHMT.................................................................................................................136ANNEX 10. TOR FOR HEALTH CENTRE COMMITTEE................................................................................141ANNEX 11. COMMUNITY MAPPING TOOL AND QUARTERLY VHW PERFORMANCE MONITORING TOOL..................................................................................................................................................................144ANNEX 12. MEMORANDUM OF UNDERSTANDING BETWEEN HEALTH CENTRE AND VHWS.......153ANNEX 13. CONTRACT FOR HEALTH CENTRES.........................................................................................155ANNEX 14. CONTRACT FOR DISTRICT/LOCAL HOSPITAL.......................................................................161ANNEX 15. MOTIVATION AGREEMENT HEALTH CENTRE STAFF..........................................................167ANNEX 16. MOTIVATION AGREEMENT DHMT STAFF..............................................................................170ANNEX 17. LERIBE AND QUTHING HEALTH FACILITIES CATEGORIZED FOR REMOTENESS.......173ANNEX 18. MONTHLY PBF INVOICE FOR HEALTH CENTRES.................................................................175ANNEX 19. MONTHLY PBF INVOICE FOR DISTRICT/LOCAL HOSPITALS..............................................178ANNEX 20. QUARTERLY QUALITY CHECKLIST FOR HEALTH CENTRES...........................................180ANNEX 21. QUARTERLY QUALITY CHECKLIST FOR DISTRICT/LOCAL HOSPITALS.......................201ANNEX 22. PERFORMANCE FRAMEWORK FOR DHMT AND INVOICE...................................................237ANNEX 23. INDIVIDUAL PERFORMANCE EVALUATION FOR HEALTH CENTRE STAFF....................246ANNEX 24. INDICES TOOL FOR ALLOCATION OF MOTIVATION BONUSES TO HC STAFF................250ANNEX 25. INDIVIDUAL PERFORMANCE EVALUATION DHMT STAFF.................................................254ANNEX 26. INDICES TOOLFOR ALLOCATION OF MOTIVATION BONUSSES DHMT STAFF...............258ANNEX 27. BUSINESS PLAN FOR HEALTH CENTRES................................................................................261ANNEX 28. BUSINESS PLAN FOR DISTRICT/LOCAL HOSPITALS.............................................................282ANNEX 29. CONTRACT FOR CBOS.................................................................................................................300ANNEX 30. CBO/NGO PATIENT TRACING AND SATISFACTION SURVEY FORMAT FOR HEALTH CENTRES...........................................................................................................................................................304ANNEX 31. CBO/NGO PATIENT TRACING AND SATISFACTION SURVEY FORMAT FOR HOSPITALS............................................................................................................................................................................307

ANNEX 32 CHAL HEALTH CENTRES MANUAL OF PROCEDURES…………………………... …….310

TABLES

TABLE 1. MINIMUM PACKAGE OF ACTIVITIES (MPA): SERVICES TO BE INCENTIVIZED AT THE HEALTH CENTRE LEVEL WITH RELATIVE WEIGHTS AND UNIT FEES..............................................................................................13

TABLE 2. COMPLEMENTARY PACKAGE OF ACTIVITIES (CPA): SERVICES TO BE INCENTIVIZED AT THE DISTRICT/LOCAL HOSPITAL LEVEL WITH RELATIVE WEIGHTS AND UNIT FEES....................................................15

TABLE 3. IMPLEMENTATION PLAN FOR THE PBF PROJECT (FEBRUARY 2013 TO JUNE 2014)....................................33TABLE 4. QUALITY BONUS CALCULATION..................................................................................................................44TABLE 5. CRITERIA FOR CATEGORIZING RELATIVE REMOTENESS OF HEALTH CENTRES.............................................45TABLE 6. QUALITY ASSESSMENT AND WEIGHT PER SERVICE FOR HEALTH CENTRE...................................................46TABLE 7. QUALITY ASSESSMENT AND WEIGHT PER SERVICE FOR HOSPITALS............................................................47TABLE 8. DHMT PERFORMANCE INDICATORS (FULL DETAILS ARE IN ANNEX 22):....................................................48TABLE 9. RECOMMENDED GOOD PRACTICE AND STANDARDS FOR A BUSINESS PLAN.................................................53TABLE 10. ACTIVITIES, SCHEDULE AND METHODS FOR PROCESS EVALUATION..........................................................75TABLE 11. STEPS FOR EX-ANTE VERIFICATION OF QUANTITY OF SERVICES AT HEALTH CENTRES AND HOSPITALS.....79TABLE 12. STEPS FOR EX-ANTE VERIFICATION OF QUALITY OF SERVICES AT HEALTH CENTRES AND HOSPITALS.......79TABLE 13. STEPS FOR EX-POST VERIFICATION OF QUANTITY AND QUALITY OF SERVICES AT HEALTH CENTRES AND

HOSPITALS BY CBOS/NGOS.............................................................................................................................80TABLE 14. STEPS FOR ANNUAL INDEPENDENT HEALTH FACILITY QUALITY OF CARE ASSESSMENTS BY QUALITY

ASSURANCE UNIT.............................................................................................................................................81TABLE 15. RESULTS FRAMEWORK AND MONITORING............................................................................................................87

FIGURES

FIGURE 1. PURCHASER-PROVIDER SPLIT IN THE LESOTHO MNH-PBF APPROACH.........................................................................4FIGURE 2. PBF INSTITUTIONAL ARRANGEMENTS.......................................................................................................27FIGURE 3. PHASES OF THE BUSINESS PLAN MANAGEMENT CYCLE............................................................................53FIGURE 4. FUNDS FLOW DIAGRAM..............................................................................................................................67

Preface

This PBF Project Implementation Manual (PIM) details the institutional arrangements for the Lesotho PBF system based on extensive interaction between the PBF Technical Working Group established by the Ministry of Health (MOH) and the World Bank (WB) task team. It provides an overview of the background and objectives of the introduction of PBF in the health services in Lesotho. But even more so, the main text and its many annexes provide an exhaustive overview of and explain the technicalities of the PBF project in Lesotho, i.e. its structures and processes.

This manual also contains a wider set of operational details, instructions and guidelines in line with MOH/WB procurement and project financial management rules and regulations.

The aim of this manual is that the users, whether at the national, district or facility level, have an adequate understanding of the PBF project and are able to use PBF to its full potential.

A document of this nature is never complete. Once PBF is piloted in two districts there will be a gradual expanding experience, which may warrant adaptations and additions to the PIM and its annexes. It will therefore be a “living document”, which is owned and maintained by the MOH PBF unit. Reflections from the users of the PIM will be more than welcome.

Ms ’Mamoruti TiheliPBF Unit Director

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Abbreviations and Acronyms

CBO : Community-Based OrganisationsCHAL : Christian Health Association of LesothoDC : District CouncilDHMT : District Health Management TeamsDPBFSC : District Performance Based Financing Steering CommitteeEmONC : Emergency Obstetric and Neonatal CareFH : Family HealthGOL : Government of LesothoHC : Health CentreHCC : Health Centre CommitteeHMIS : Health Management Information System HF : Health FacilityHPSD : Health Planning and Statistics DepartmentHRITF : Health Results Innovation Trust FundHSS : Health Systems StrengtheningICAP : International Centre for AIDS Care and Treatment Programs IDA : International Development AssociationIMCI : Integrated Management of Child IllnessesLSL : Lesotho LotiMCA : Millennium Challenge AccountMCH : Maternal and Child HealthMDG : Millennium Development GoalsMNH : Maternal and Neonatal (New-Born) HealthMODP : Ministry of Development PlanningMOF : Ministry of Finance MOH : Ministry of HealthMOLGCPA : Ministry of Local Government, Chieftainship & Parliamentary AffairsNGO : Non-Governmental OrganizationNSRHSC : National Sexual and Reproductive Health Steering CommitteePAD : Project Appraisal DocumentPBF : Performance Based FinancingPHC : Primary Health CarePIH : Partners in HealthPPTA : Performance Purchasing Technical AssistancePIM : Project Implementation ManualPUM : PBF Project User ManualTOR : Terms of ReferenceTWG : Technical Working GroupVHW : Village Health Worker WB : World Bank

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Introduction

The Lesotho Maternal and Newborn Health (MNH) Performance Based Financing (PBF) Project is a two phase operation that will be executed according to the provisions outlined in this Project Implementation Manual (PIM) which is supported by a detailed Project User Manual (PUM) and other Handbooks. Whereas the PIM provides a brief sector background, project objectives and components, and a roadmap of how the project phases will be implemented; what the institutional, organizational, implementation and management arrangements are; how the financial management and procurement arrangements will function; and the social and environmental aspects to keep in mind, the PUM (and handbooks) provides the individual details. The provisions of the PIM can only be changed by agreement between the Bank and the Government of Lesotho. The PIM provides a balance between wider guidance and a ‘set of operational details, instructions and guidelines in line with Ministry of Health/World Bank procurement and project financial management rules and regulations’.

The contents of this PIM are based on the project documents such the PAD, PUM, Health Policy and strategic plan, MOU between MOH and CHAL, MOU between MOH and Red Cross, including other research materials prepared by the Lesotho Project Team which is comprised of Government officials, donor partners’ technical staff, consultants and non-governmental actors. The health sector including its partners is all bound by the health policy and strategic plan and therefore the strategies outlined in this document will apply to all unless otherwise stated.

This document is comprised of eight chapters.

Chapter 1 provides a background to PBF and the Lesotho Health System thereby setting the stage for understanding why the PBF approach was adopted to address the challenges of maternal and newborn health among the Basotho. A simplistic model of the separation of functions and roles in the relationship between the purchaser, regulator and provider with the consumer in the middle is presented to demonstrate that the performance of all actors will be measured against the quality of services delivered and accessed by the mothers and newborns in selected districts in Lesotho. The decentralization process is also outlined.

Chapter 2 describes the project design, objectives, financing phases as well as the individual components.

Chapter 3 describes the institutional and implementation arrangement of the project. This is to ensure that the policy and authorizing environment, the management structure as well as the implementation mechanisms are in place and robust enough to deliver the project. The roles, functions and relationships of each level are articulated to ensure smooth delivery of services.

Chapter 4 details the contracts, determination of PBF benefits, performance payments, use of the PBF benefits, and business plans

Chapters 5, 6, 7 and 8 discuss the financial management arrangement, procurement arrangements, environment and social safeguards, and Monitoring and Evaluation arrangements

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respectively. Reference is made in Chapter 6 indicating that procurement arrangements are detailed in a separate procurement manual.

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Chapter 1: Performance Based Financing and the Lesotho Health System

Background

The Government of Lesotho’s Ministry of Health took a conscious decision to adopt Performance-Based Financing (PBF) as an approach to finance and bolster its efforts to meet the three health Millennium Development Goals, i.e. reduce child mortality (goal 4), improve maternal health (goal 5) and combat HIV/AIDS, malaria and other communicable diseases (goal 6). PBF approaches have been especially successful in improving access to curative services, and increasing the uptake of preventive services such as vaccination of children and pregnant mothers, voluntary counseling and testing for HIV, institutional deliveries and the use of modern family planning methods. Whilst increasing the volume of services, PBF also increased the quality of these services considerably.

The various linkages between the project components, sources of funds, implementation modalities and structures are well articulated in this Project Implementation manual (PIM).

Results Based Financing and Performance Based Financing definedResults-Based Financing (RBF) is any program that rewards the delivery of one or more health outputs or outcomes through financial incentives, upon verification that the agreed-upon result has actually been delivered. It encompasses the entire family of incentive approaches, both on the supply-side, and on the demand-side. PBF is a supply-side RBF providing incentives to only providers (facilities or individuals) and not to beneficiaries.1

PBF ElementsAlthough PBF approaches differ, they tend to have certain elements in common, they:

• link health financing to health care outputs and their quality;• promote managerial autonomy and decision making rights on resources utilization;• use non-governmental agencies for a purchaser role or management support; and• enhance HMIS (Health Management Information System), monitoring and evaluation.

In the PBF approach, regulation, planning and quality assurance are provided by the regulator, in this case the MOH also defines output, quality and equity targets with indicators. The regulator also establishes and oversees adherence to rules and regulations. The purchaser sets targets and buys results from health service providers. The provider in specific geographic catchment area is responsible for developing innovative strategies and implementing activities that will improve the volume and quality of services and achieve the agreed-upon health targets or goals efficiently. In the case of Lesotho, Performance Purchasing Technical Assistance firm (PPTA) will provide critical support to all functions and will build capacity for respective entities at national, district and community levels.

1 Musgrove, P. (2010). Financial and Other Rewards for Good Performance or Results: A Guided Tour of Concepts and Terms and a Short Glossary. Washington DC.

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Figure 1. Purchaser-Provider Split in the Lesotho MNH-PBF Approach

Lesotho Health Status and Health System

Health StatusLesotho remains off track to meet the Millennium Development Goals (MDGs) 4 (reducing child mortality) and 5 (improving maternal health). The 2009 Demographic and Health Survey (DHS) reported Maternal Mortality Ratio (MMR) to be very high at 1,155 per 100,000 live births.2 Moreover, according to the 2012 WHO/UNICEF/UNFPA/World Bank report the average annual percentage decline in MMR between 1990 and 2010 was only 0.9 percent, far less than the 5.5 percent or more needed to be “on track” towards achieving MDG 5.3 The lack of progress towards MDG 5 is a particularly serious national concern, given that it is considered a proxy indicator for overall health system functioning.4 Similarly, under-five mortality rate was estimated to have only decreased slightly from 89 in 1990 to 86 deaths per 1,000 live births in 2011.5 Weak health service performance has contributed to Lesotho’s worsening health outcomes, which have been exacerbated by the HIV/AIDS epidemic. Lesotho has the third highest HIV adult prevalence rate in the world at 23 percent.6 Life expectancy at birth has declined from 60 years in 1992 to 49 years in 2012.7

Lesotho continues to have one of the highest levels of inequality with 57 percent of the population living below the national poverty line. Moreover, Lesotho is ranked 160 out of 187 in the 2011 United Nations Human Development Index (HDI). Government of Lesotho (GOL) has

2Lesotho Demographic and Health Survey (LDHS), 2009.3 WHO/UNICEF/UNFPA/The World Bank. 2012. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates.4 World Bank Reproductive Health Action Plan 2010-2015 (RHAP). www.worldbank.org/population5 WHO/UNICEF/UNFPA/The World Bank. 2012. Levels and Trends in Child Mortality: Report 2012. WHO, UNICEF, UNFPA and The World Bank estimates.6Lesotho Global AIDS Response Country Progress Report, January 2010-December 2011, March 26, 2012.7 WDI data

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identified ‘Improve health, combat HIV and AIDS and reduce vulnerability’ as one of the six key pillars of the 2012/13 to 2016/17 National Strategic Development Plan (NSDP). Against the backdrop of its health development goal, GOL has significantly increased its allocations to the health sector from US$147.80 million in fiscal year 2009/10 to US$186.70 in fiscal year 2011/12. Available expenditure data shows that Lesotho spent an average of US$33.20 per capita over the period 2004/5 to 2009/10.8 Given these circumstances, the Ministry of Finance (MOF), Ministry of Development Planning (MODP) and the Ministry of Health (MOH) have expressed renewed commitment to bringing efficiency and results to public spending in the health sector.

Health SystemLesotho’s health system is dominated by two main providers: the MOH and the Christian Health Association of Lesotho (CHAL). The health system consists of four-tiers: (i) tertiary and specialized hospitals; (ii) district hospitals; (iii) filter clinics and health centres; and (iv) village health workers (VHWs). There are 10 administrative districts in Lesotho. As of 2009, there were 216 health facilities across the country including 1 national referral hospital, 2 specialized hospitals, 19 hospitals, 190 health centres and 4 filter clinics. Of the 216 health facilities, 97 were operated by MOH, 81 were operated by CHAL, 34 were privately owned, and 4 were operated by the Lesotho Red Cross Society (LRCS).

Challenges

The challenges faced by the Lesotho health sector9 include the following; Widening disconnect between economic growth and development outcomes; Inverse relationship between health budgets and health outcomes; Inequitable resource allocation mechanisms that are not responsive to health needs of the

population; High levels of inequality in society with cost of health services being a major barrier to

access; Low utilization of existing health services and Lack of available inputs, particularly human resources, which is partly associated with

strong exogenous determinants, related to the geographical location of Lesotho.

System-wide problems in the health sector contribute to Lesotho’s worsening outcomes in maternal and newborn health. The first is low utilization of health facilities due to the poor (perceived and actual) quality of services. Service quality is not only undermined by the lack of equipment and a poor referral system between health centres and hospitals,10 but also by an inadequate number of healthcare workers. The country has one of the worst ratios of health workers to population in sub-Saharan Africa with just over one health professional per 1,000 people. On average, there are nine primary facilities and just one hospital per 100,000 people, with Quthing and Mohale’s Hoek districts having the lowest ratio of primary facilities to the population.

Financial and geographic barriers to access also remain a challenge. The healthcare delivery challenge in Lesotho is compounded by the fact that about 40 percent of the population lives in

8 Expenditure data from published budget book, MOF and Directorate of Finance, MOH, 2012.9 Lesotho Health Expenditure Review: World Bank, September 2009.10WHO, UNICEF and UNFPA, “Reduction of Maternal and Newborn Morbidity and Mortality,” 2010

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remote rural villages, often several hours walk through rough mountain paths to the nearest facility. Despite the GOL’s effort to improve access to health care by eliminating user fees from all public health centres including facilities affiliated with CHAL and LRCS in 2008, access to health services remains a serious challenge. Seventy three percent of women cited at least one problem in accessing health care respondents cited unavailability of drugs (59 percent), treatment costs (33 percent), transportation cost (32 percent) and long distance to facility (31 percent) as problems for accessing health services (2009 LDHS).

Decentralization

The DHMTs are currently responsible for all health services delivered in the district including the health centres. It should also be noted that the DHMTs are delinked from the district hospitals with separate cost centres.

To date, decentralization has not yet been fully implemented. Partly due to the complexity of such a process, it is fair to state that it may take many months if not years before decentralization would be fully implemented. This includes arrangements between the MOH and the Ministry of Local Government, Chieftainship and Parliamentary Affairs (MOLGCPA) regarding their respective roles and responsibilities as far as the delivery of health services to the district is concerned.

The introduction of PBF therefore comes at this critical stage and thus its design rests on the on the following assumptions.

The DHMTs with the support of the District Council will be the contracting party of HCs at the district level, under the guidance/oversight of a District PBF Steering Committee

The DHMTs are delinked from the hospitals and will be established as part of the District Council when the decentralization is complete; the latter will also be responsible for its performance however the MOH will remain the regulator.

The District Councils have the authority to provide day to day administration of the health care workers, ultimate responsibility remains with the MOH. However the DHMTs will have its own establishment list to ensure that health centres are fully staffed and rotation is minimized.

The HCC will provide an oversight and support to the health centre. In PBF the committee will also counter sign and support implementation of health centre PBF contracts, business plans, quality of care reviews and, where applicable, the health centre’s bank account.

The District Council or community councils will also facilitate transfer of PBF benefits to the health centres.

It is apparent that the PBF project will be launched before decentralization is fully implemented therefore design of the PBF project have been (temporarily) adjusted to the prevailing situation. Therefore the PBF project training and sensitization programs will take the prevailing situation into account.

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Chapter 2: Lesotho Performance Based Financing Project Objectives and Components

Higher level Project Objectives

The PBF project is closely aligned with the second area of engagement of the Country Assistance Strategy (CAS) 2010-2014, human development and service delivery, which aims to reverse negative trends in health and improve access to services. The proposed operation is consistent with the priorities and goals identified by the CAS: to protect and better serve the needs of the poor and the vulnerable; increase access to services; strengthen institutional capacity; upgrade quality and effectiveness of services delivery; enhance the role of the private sector in achieving important public health goals; and decentralize through enhanced participation of local government bodies and communities. The project will contributes to these objectives by improving quality and uptake of MNH services. Further, the project supports the National Strategic Development Plan (NSDP) 2012/13 to 2016/17. The NSDP aims to: “improve the quality of health; reduce maternal and child mortality; combat and prevent the spread and new infections of HIV and AIDS; and, reduce social vulnerability, especially for children and old people.” Additionally, the PBF mechanism will contribute to the government’s decentralization agenda in Lesotho.

Project Development Objective

The overall project development objective is to improve the utilization and quality of maternal and newborn health (MNH) services in selected districts in Lesotho.

Project Phases

The project will be implemented in three phases. In Phase I (July 2013-June 2014), the project will be piloted in Leribe11 and Quthing districts. In Phase II (July 2014-June 2015) and Phase III (July 2015-June 2017), the project will gradually scale-up to all selected districts excluding Maseru district.12 This three-phased approach will allow for adjustments in design based on lessons learned during the pilot phase. Districts enrolled in the PBF implementation in phases I and II will continue implementation through phase III, incorporating lessons learned in each phase.

Project Financing

The Project is jointly funded by International Development Association (IDA) ($12 million) and the Health Results Innovation Trust Fund (HRITF) ($4 million). The Lesotho counterpart contribution, as parallel financing to the IDA and HRITF financing, is US$4 million. This will

11In Leribe district, Mamohau Hospital is being excluded because PIH is currently supporting a small PBF project there, which would be a confounding factor.12 Phase I districts are Leribe and Quthing; Phase II districts are Mafeteng, Mohale’s Hoek, Mokhotlong, and Thaba Tseka; Phase III districts are Berea, Botha-Bothe, and Qacha's Nek. During the pilot phase, the districts for Phases II and III will be reviewed to determine which ones are ready for scaling up at each phase. Maseru district will not be included because the district’s health outcomes are better than other districts.

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consist of the operating costs for the MOH PBF Unit in years 1 and 2, which is estimated to be a total of US$500,000. In years 3 and 4, the total counterpart funding of US$3,500,000 will consist of the operating expenses as well as the cost of Phase III scaling up, in parallel to the 6 districts initiated in years 1 and 2, the three remaining districts not covered by IDA and HRITF funds (Berea, Botha-Bothe, and Qacha's Nek).

The preparatory phase and project implementation readiness activities were financed through an HRITF preparation grant13 (US$400,000) and a Project Preparation Advance14 (PPA) (US$635,048).

Project Beneficiaries

In addition to specific maternal and newborn health services, selected services such as HIV and AIDS, tuberculosis and nutrition in the Lesotho essential services package will also be covered. It is expected that these services will contribute to reducing maternal and newborn deaths in Lesotho given the high maternal mortality and HIV prevalence. Therefore, direct beneficiaries are women of childbearing age, newborns and children below 5 years of age, as well as tuberculosis and HIV patients. The indirect beneficiaries initially include the 417,417 inhabitants in the 2 districts (Leribe and Quthing) participating in phase I of the project and will eventually include three-quarters of the population, excluding Maseru district, during the phase II and phase III scale up.15 The project will specifically target beneficiaries in hard-to-reach areas within the selected 9 districts (through a remoteness bonus) and will aims to improve utilization by the poor. From an institutional perspective, health personnel, notably doctors, nurses and midwives at hospitals and health centres as well as VHWs will benefit from training in MNH care and from having more conducive work environments due to changes made at the health facilities using the incentive funds. Finally, the knowledge and experience on PBF in the health sector could potentially benefit other sectors.

Project Components

The project has two components: Component 1 is MNH service delivery at community, primary and secondary levels through PBF while Component 2 entails training of health professionals, and VHWs as well as improving M&E capacity.

13 The preparation grant supported a consultancy firm which worked closely with the MOH PBF Technical Working Group (April-October 2012) to: i) build PBF competence and capacity at the various levels for both MOH and CHAL through workshops, training sessions, sensitization activities and study tours (Rwanda and Zimbabwe) ; ii) develop the list of services to determining services to be incentivized as well as quality checklists for health centres and hospitals; (iii) determine the use of incentives; iii) compile a PBF User Manual; iv) prepare a roadmap, including phasing of the pilot PBF project; and v) develop terms of references for various entities.14 A Project Preparation Advance (PPA) of was approved for the following preparatory activities: i) HMIS consultancy; ii) PBF training course in Mombasa, Kenya for PBF Unit staff; iii) study tour for senior Government officials from MOH and other Ministries to March 2013; iv) development of a web-enabled application for PBF invoicing; v) pretesting of the quality checklist for health centres and hospitals; and vi) training of VHWs.15Population estimates for Leribe (293,369) and Quthing (124,048) are taken from the Lesotho Statistical Yearbook 2010. The potential districts for Phase II are Mafeteng (192,621), Mohale’s Hoek (176,928), Mokhotlong (97,713), and Thaba Tseka (129,881) while the Phase III districts are Berea (250,006), Botha-Bothe (110,320), and Qacha's Nek (69 749).

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Component 1: Improving Maternal and Newborn Health (MNH) Service Delivery at Community, Primary and Secondary levels through PBF (US$17.7 million).This component will be jointly financed by IDA (US$9.7 million), the Health Results Innovation Trust Fund (US$4 million) and, in parallel by GOL (US $4 million).16 The objective of this component is to improve MNH service delivery at health facility and community level through two sub-components, as detailed below. The sub-components will dovetail the almost complete support provided by the Millennium Challenge Account (MCA) to renovate, refurbish17 and equip health centres, including reinstating adequate provisions for waiting shelters for expecting mothers. Building on infrastructure improvement supported by MCA, the project will contribute to the supply-side improvements which are fundamental to strengthen the quality and utilization of health services.

Sub-component 1A: Delivery of MNH Services through PBF will support the provision of quality MNH services as well as selected services in the Essential Services Package in communities, health centres and hospitals by providing performance-based payments to VHWs, health centres, and hospitals. Health centres and VHWs will be considered as one unit for payments in their respective catchment areas in order to strengthen their collaboration. Furthermore, performance payments for VHWs will be linked to the overall performance of the health centres to which they are mapped. The incentivized services to be delivered by health centres (Minimum Package of Activities [MPA]) and hospitals (Complementary Package of Activities [CPA]) are in Annex 2 (Tables 3 and 4).

Additionally, performance-based payments will be made to DHMTs (which will become part of the District Councils with the decentralization of health services) based on supervision of health facilities using a quality checklist, providing feedback to health facility staff, submission of quarterly overall reports to the District Council Secretary with lessons learned, identified constraints and suggested solutions, and other information related to service delivery within the district. The performance-based payments linked to achievement of predefined quantity and quality indicators at the health facilities are expected to stimulate health worker motivation and productivity and provide additional cash to overcome obstacles affecting the quality or continuum of care of patients. Performance-based payments will be adjusted based on comparative isolation of a facility to provide additional payments to hospitals and health centres in remote areas and influence retention of health personnel in remote areas.

Sub-component 1B: PBF Implementation and Supervision Support will provide critical support for: (i) PBF implementation and supervision; (ii) capacity building of the MOH and CHAL at central and district levels, district and community councils; and, (iii) best practice documentation and sharing. The PBF Unit handles the day-to-day management of the MNH PBF Project. The PBF unit consists of five full time MOH staff. Given that MOH and CHAL have had limited experience with PBF, both strategic and operational capacity will be built at respective levels. The project will competitively recruit a performance purchasing technical assistance (PPTA) firm to provide technical assistance and build in-country capacity. The PPTA’s key functions are 16 If at Midterm review, the project has progressed satisfactorily and there is need for additional financing, the Government could use its own resources, seek funding from DPs, or seek additional financing from IDA and HRITF. 17 This MCA-Lesotho support was expected to be completed in August 2012 but has experienced some delays. Thus, works under this support does not trigger any World Bank-related environmental safeguards.

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to: (i) provide technical and implementation support to the MOH PBF unit and other PBF implementing entities on managing performance-based contracts for the delivery of incentivized services; and (ii) verify delivery of the quantity and quality of services, prepare the invoices for performance-based payments, and assist health facilities with preparing PBF business plans. The role of the PPTA will gradually reduce as the implementing entities and facilities gain greater experience with PBF implementation.

Component 2: Training of health professionals and VHWs and improving Monitoring and Evaluation (M&E) capacity (US$2.3 million)This component will be solely financed through IDA financing and have two sub-components.

Sub-component 2A: Training health professionals and Village Health Workers will support an ongoing MOH program for training doctors, nurse anesthetists and midwives to achieve an acceptable standard of competency in the delivery of MNH services including EmONC. In August 2012, the Bank engaged a consultant to review the turnaround time in the working capital management of the National Drug Service Organization (NDSO) and related processes at NDSO, MOH, GOL and CHAL health facilities.18 Based on the report’s findings, the project will support a 5-day training of health centre nurses on the MOH adopted drug supply management manual. This would allow the health centres to improve their forecasting and order preparation for NDSO, which will potentially reduce the delays in turning around and delivering orders and curtail stock-outs of drugs and medical supplies at the health centre level. Additionally, 18 hospital and DHMT pharmacists, one NDSO staff, and one MOH Pharmacy Directorate staff will participate in Eastern and Southern African Management Institute (ESAMI) training courses on (i) overview of supply chain management and (ii) quantification of health commodities. Refresher training will also be provided to MOH financial management19 and procurement20

staff.

Currently, health centres do not provide the full complement of Basic EmONC services since midwives are not allowed to perform three basic EmONC procedures: manual removal of retained placenta; removal of retained products of conception; and assisted vaginal delivery.21

The Nursing and Midwifery Act is being revised to allow advanced midwives to perform these procedures.

Advanced midwives are needed at hospitals to train nurse midwives and also for the mentorship and preceptorship of newly trained nurse midwives. The Directorate of Nursing indicated that 36 advanced midwives are required (two for each of the 18 hospitals), but there are currently only 18NDSO Working Capital Management Report. November 2012, prepared by Thiagarajah Veluppillai, FCCA19The MOH PBF Unit Financial Management Officer and Accountant will participate in a two-week course for the ICT Based Financial Management and Disbursements Course for Project Accountants for World Bank funded Projects in Kenya. They will also receive hands-on training on TOMPRO accounting software.20ESAMI training on procurement management programmes for MOH Procurement Unit staff on: i) Works Procurement and Selection of Consultants; ii) Advanced Works Procurement and Selection of Consultants; iii) Goods and Equipment Procurement; and iv) Advanced Goods and Equipment Procurement Programme. Additionally, a consultant will provide hands-on training of key MOH Procurement Unit staff, District Councils, DHMTs, District Hospitals and CHAL Secretariat on public procurement and strengthening of procurement systems. 21The remaining four Basic EmONC services that all midwives are allowed to perform are: administration of parenteral antibiotics, oxytocic drugs, and anticonvulsants (magnesium sulphate) for pre-eclampsia/eclampsia, and basic neonatal resuscitation (bag and mask).

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http://www.esami-africa.org/index.php?option=com_content&view=article&id=636&Itemid=636

http://www.esami-africa.org/index.php?option=com_content&view=article&id=636&Itemid=636

three advanced midwives nationwide. The project will support part-time training for 15-20 nurse midwives at a university in South Africa for Advanced University Diploma in Advanced Midwifery and Neonatology.22 Given the shortage of nurse anesthetists, the project will also support the ongoing MOH effort to provide pre-service training of nurse anesthetists in African training institutions. Twelve nurse anesthetists are expected to be trained.23

MOH together with UNFPA, UNICEF and WHO plan to conduct an EmONC assessment which will inform the need for on-the-job training for nurse midwives and medical doctors providing obstetric services in districts. This is planned to be conducted in 2013 and the project will provide support for this assessment.

In terms of VHWs, the MOH, with support from development partners, has established a VHW training manual and curriculum and is conducting ongoing training for VHWs.24 This sub-component will support the ongoing VHW training on basic services such as family planning and referrals as well as taking care of mothers and children in the postnatal period and promotion of exclusive breastfeeding. VHWs will also be supported to conduct community head count and periodically update the village health registers for more accurate health facility catchment area data.

Sub-component 2B: Improving M&E capacity will support the strengthening of the Health Management Information System (HMIS) in all districts and build the capacity of M&E personnel at the central and district levels. Specific activities under this sub-component include: (i) improving the quality of health data by reviewing, updating and harmonizing data collection tools for strengthening the HMIS; (ii) printing, training, dissemination, and utilization of the updated data collection tools, HMIS registers, forms and reports at all health facilities over the project duration; (iii) enrolling District Health Information Officers (DHIO) and central MOH staff in a short course on M&E of health programs (for 2 central and 10 district personnel) as well as a two-year part-time Master of Public Health (MPH) degree program with an M&E or Biostatistics concentration (for 2 central personnel);25 and (iv) conducting health facility quality of care assessments26 and baseline household survey.27

22As per the 2008 Training and Development Policy in the Public Service of Lesotho, Regulation 97, each trainee will enter into a bonding agreement to work in Lesotho for a number of years.23As per the 2008 Training and Development Policy in the Public Service of Lesotho, Regulation 97, each trainee will enter into a bonding agreement to work in Lesotho for a number of years.24 The project will support a total of 1,811 VHWs to be trained: 1,044 and 383 in Leribe and Quthing respectively. The Government plans to train VHWs in all the other districts. 25As per the 2008 Training and Development Policy in the Public Service of Lesotho, Regulation 97, each trainee for the MPH degree program will enter into a bonding agreement to work in Lesotho for a number of years.26 Annual health facility quality of care assessments will be conducted by the MOH Quality Assurance Unit under this sub-component.27Impact evaluation of the project, which will entail baseline and endline household surveys, will be carried out with a Bank-executed HRITF. The Impact Evaluation study will carry out baseline survey in districts covered under Phase II and III just before scale-up in those districts. It will also support an endline survey in those districts.

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Project Indicators and Values

Performance-Based Financing uses a mix of quantity and quality indicators to define the level of performance of a health institution. Performance frameworks are also applied to the health administration but in general are more of the process indicator type. In the PBF facilities the quantity performance is measured monthly and the quality performance is measured quarterly. Each defined service has a unit fee/subsidy and the quality carries a bonus up to 25% of the earnings.

The Health Service Packages: MPA and CPAThe PBF health service packages are carefully designed to respond to health problems facing the Basotho population. They are also based on 12 years of incremental experience gained on purchasing indicators/services through PBF. The services chosen have the highest potential to contribute to meeting the health-related Millennium Development Goals, particularly relating to maternal and infant mortality. There are two types of health service packages:

1. Minimum Package of Activities (MPA): for the health center and community level,2. Complementary Package of Activities (CPA): for the district hospital.

The MPA and CPA are listed below in Tables 1 and 2. Each defined service carries a variable unit fee/subsidy.

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Table 1. Minimum Package of Activities (MPA): Services to be incentivized at the health centre level with relative weights and unit fees

No

Incentivized indicator Definitions Data source/register

Index PBF Credit USD

PBF Credit LSL

Total Unit Cost USD

PBF subsidization level %

1 Number of new outpatient consultations for curative care consultations

Patients attending OPD for a new complaint or disease. If a patient has multiple complaints, s/he is counted only once

OPD Register 1 $0.50 4 15.14 3.3%

2 Number of pregnant women having their first antenatal care visit in the first trimester

Pregnant women attending antenatal care for the first time during first 12 weeks of their pregnancy

ANC Register 28 $14.00 115 30.46 46%

3 Number of pregnant women with four antenatal care visits

Pregnant women with four (4) antenatal care visits completed

ANC Register 20 $10.00 82 25.54 39.2%

4 Number of women delivering in health facilities

Women delivering in a health facility assisted by skilled/trained health staff

Delivery Register

50 $25.00 206 53.15 47%

5 Number of women with 2 postnatal care visits within 1 week

Women who have delivered, receiving at least two postnatal care visits within one week according to protocol. It is assumed that women who deliver in health facilities receive post natal care prior to discharge.

Postnatal Register

30 $15.00 123 3.59 417.8%

6 Number of patients referred who arrive at the District/local hospital

Patients referred who arrived at District/Local hospital with referral letter from their health centre.

Referral Register

10 $5.00 41 N/A

7 Number of new and repeat users of short-term modern contraceptive methods

Women receiving 3 monthly cycles of oral contraceptives (Pills) or quarterly contraceptive injections for the first time. Women receiving a refill after 3 months will be counted as repeat visits.

Family Planning Register

3 $1.50 12 N/A

8 Number of new and repeat users of long-term modern

Women receiving intrauterine device and Implants for the first time or are

Family Planning

15 $7.50 62 14.97 50.1%

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No

Incentivized indicator Definitions Data source/register


PBF Credit LSL

Total Unit Cost USD

PBF subsidization level %

contraceptive methods repeat users. Each of the method provides an estimated protection for 3 or more years.

Register

9 Number of children under 1 year fully immunized

Children who have completed their primary course of immunization before the age of one year. A primary course includes BCG, Polio 3, Pentavalent 3 and measles before one year of age.

Under 5 Register

15 $7.50 103 17.75 42.3%

10 Number of children under 5 years whose weight and height are monitored regularly according to protocol

Children under 5 years whose weight and height are monitored regularly according to the following protocol(six times in the first year, four times in the second year, and thereafter three times yearly from 2 to 5 years)

Under 5 Register

1 $0.50 4 5.02 10%

11 Number of notified HIV-positive tuberculosis patients completed treatment and/or cured

Notified tuberculosis patients tested HIV-positive and completed their treatment or cured. TB patients are confirmed to be cured (Category I- by sputum negative smears at end of treatment month 6 and at least one previous occasion, Category II sputum negative smears at 5 and 8 months) and completed treatment (not classified as cured and not as failure e.g for sputum negative declared tuberculosis patients)

TB Register 90 $45.00 370 123.45 36.4%

12 Number of children born to HIV-positive women who receive a confirmatory HIV test at 18 months after birth

All children of known HIV-positive mothers have a HIV test between 18 and 24 months. This test should be done before the child is 2 years old.

Under 5 Register

25 $12.50 103 N/A

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Table 2. Complementary Package of Activities (CPA): Services to be incentivized at the district/local hospital level with relative weights and unit fees

No

Incentivized indicatora Definitions Data source/register


PBF Credit LSL

Total Unit Cost USD

PBF subsidization

level %

1 Number of referred indigent patients from Health Centre to the OPD of a District/local hospital

Indigent referred patients by health centres needing hospital OPD services

OPD Register/referral register

1.0 $8.00 66 N/A

2 Number of counter referral forms returned to health centresb

Hospital returns counter referrals letter with feedback on the referred patient to the referring health centre

Referral Register /Counter Referral forms File

0.5 $4.00 33 N/A

3 Number of indigent inpatient admissions

Indigent patients admitted as inpatient to the district/local hospital

Inpatient Register 7.5 $60.00 493 N/A


Pregnant women attending antenatal care for the first time during first 12 weeks of their pregnancy

ANC Register 1.0 $8.00 66 30.46 26.3%

5 Number of major obstetric complications treated

The list of major obstetric complications treated include Severe pre-eclampsia or eclampsia, ectopic pregnancy, haemorrhage (antepartum or postpartum) prolonged or obstructed labor (dystocia, abnormal labor), postpartum sepsis and complications of abortion

Delivery Register 3.3 $26.40 217 51.12 51.6%

6 Number of assisted vaginal deliveries

Number of assisted vaginal deliveries (vacuum extraction or forceps)


7 Number of Caesarean deliveries

Number of pregnant women who undergo Caesarean delivery with


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No



PBF Credit LSL

Total Unit Cost USD

PBF subsidization

level %

an appropriate indication (absolute or relative) for the procedure as per protocol.

8 Number of referred newborn children for emergency neonatal care

Referred new born children who require emergency care due to perinatal complications, low birth weight, etc.

Neonatal/postnatal registerReferral Register /Counter Referral forms File

3.0 $24.00 197 38.5 62.3%


Women who have delivered, receiving at least two postnatal care visits within one week according to protocol. It is assumed that women who deliver in health facilities receive post natal care prior to discharge.

Postnatal Register 1.0 $8.00 66 3.59 222.8%

10 Number of new and repeat users of long-term modern contraceptive methods

Women receiving intrauterine device and Implants for the first time or are repeat users. Each of the method provides an estimated protection for 3 or more years.

Family Planning Register

0.8 $6.00 49 14.97 40.1%

11 Number of HIV-positive tuberculosis treatment-resistant patient referred to the hospital

HIV-positive tuberculosis treatment resistant patients referred by health centre to the hospital for appropriate treatment advice

TB Register 5.0 $40.00 329 N/A


Notified tuberculosis patients tested HIV-positive and completed their treatment or cured. TB patients are confirmed to be cured (Category I- by sputum negative smears at end of treatment month 6 and at least one previous occasion, Category II

TB Register 4.5 $36.00 296 123.45 26.2%

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No



PBF Credit LSL

Total Unit Cost USD

PBF subsidization

level %

sputum negative smears at 5 and 8 months) and completed treatment (not classified as cured and not as failure e.g for sputum negative declared tuberculosis patients)


All children of known HIV-positive mothers have a HIV test between 18 and 24 months. This test should be done before the child is 2 years old.

Under 5 Register 0.8 $6.00 49 N/A

aIndicators 4, 9, 10, 12, and 13 are selected MPA indicators which will only be incentivized for patients in the catchment population of the hospital and not the whole district. Hospitals are expected to provide primary health care services for those who live in the vicinity or catchment area. bThe Health Centre has to register referrals and give a referral letter (Annex 1) to the patient, if referred to the District/Local Hospital. The hospital returns the letter with feedback to the Health Centre and keeps a copy of this letter in their administration. Only if the feedback letter is received and filed in the Health Centre will there be a payment for that indicator to the hospital.

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Fee setting for the services: Determining the SubsidiesThe fees were modeled using a financial risk forecasting method commonly used in PBF projects.28 Baseline data were drawn from the 2009 Demographic and Health Survey, Annual Joint Review 2011-12 and existing HMIS data. It is important to note the difference between a PBF fee, and a traditional fee-for-service provider payment mechanism. In PBF systems it is assumed that the costs for the services are already met (human resources; building; equipment and various recurrent expenses for vertical programs). However, these services do ‘not move’; there is low output and a general lack of coverage for important public health services. Therefore in PBF we talk about ‘subsidies’. As part of the preparation process for the PBF project pilot, a consultant was recruited to provide estimates of the actual cost per service for the MPA and CPA services selected. These actual costs were determined by calculating the estimated time required for different types of personnel, the equipment, drugs, medical supplies, utilities and facilities required for that service to be provided to one patient. These are the costs that are already being met by the MOH and CHAL to provide the services.

The PBF ‘fee’ for a ‘new outpatient consultation’ is not meant to pay for the cost of delivering this consultation. It is a subsidy for this service and constitutes a proportion of the actual cost without reaching 100% of the actual cost. The level of these PBF subsidies can change, depending on certain equity adjustments, local priorities and available budget. These variables are discussed below.

The combined subsidies for all services are modeled at $2.30 per capita per year for the MPA and $0.45 per capita per year for the CPA. Within a given district, the purchaser can allocate an ‘equity weighting’ for relative destituteness of a facility (‘remoteness’). Contracted facilities can be categorized in four categories 1 – 4; with a maximum difference in subsidy levels for individual services of 20%.

Regular adjustment of the quantity unit feesPBF fees/subsidies can be negotiated quarterly, if need be, depending on the level of achievement/performance, and locally perceived needs and targets; this requires a process of negotiation between the health facility and the purchaser. Changing the fees/subsidies will require that the purchaser again reviews that the proposed fees/subsidies are compared against the estimated actual cost of the service to ensure that the project is not reimbursing for the service but is subsidizing a portion of the actual cost. A similar process would need to be followed to include new services in the MPA and CPA than those that are currently included.

28 SOETERS, R. (2011) PBF in Action: Theory and Instruments, course guide Performance-Based Financing. The Hague.

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Chapter 3: Institutional Set-up, Organization and Management of the Project

This section describes institutional and implementation arrangements for Lesotho PBF project, outlining reporting structures and their relationships; management and implementation arrangements; the actors that influence the way the project operates, the rules, regulations, policies and procedures (see Figure 2 and Schedule 1). National level

Ministry of Health (MOH)

At the National level, the MOH will be the main implementing agency as the Regulator, Fund holder and Purchaser. However, this PBF institutional design is an interim arrangement while the MOH is piloting the project in the two districts. The MOH will therefore use the lessons learnt and the capacity building efforts through PPTA, to gradually adopt a PBF institutional design with clear separation of functions in order to avoid conflict of interest and ensure transparency.

As a Fund Holder, MOH (PBF Unit) will receive and manage PBF funds from the World Bank. It will also ensure that the PBF funds are used for the intended purposes based on payment advices that have been processed.

The regulatory function of the MOH entails determination and monitoring of health care standards in the country, and more specific in respect to PBF:

Setting PBF design and priorities for health care Planning, administration and coordination of PBF interventions Monitoring and evaluation Defining the quality standards for health care

At the facility level, the MOH will purchase services by contracting health facilities from public sector (MOH) and Christian Health Association of Lesotho (CHAL) health facilities.

The National Sexual and Reproductive Health Steering Committee (NSRHSC)In the MOH, the overseer of the project is the existing National Sexual and Reproductive Health Steering Committee (NSRHSC) which assumes the responsibility of being PBF Steering Committee. The NSRHC is a multi-sectoral committee (Annex 4) on which key sector Ministries e.g. Ministry of Finance, Ministry of Local Government, Chieftainship and Parliamentary Affairs , etc. and NGOs (see Schedule for details) and representatives of key MOH departments sit to ensure full coordination of service providers and coverage of all facets of MNH at all levels of the health system.

The NSRHSC will meet quarterly and be responsible for endorsing the ultimate design of the PBF scheme, setting standards, providing project policy guidance and implementation oversight to the PBF Unit, and approving the annual work programs and budget.

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The Technical Working Group (TWG)The existing Technical Working Group (TWG) will provide operational and administrative support for the preparation and implementation of the PBF scheme. For instance, the TWG will prepare meeting agenda, reference documents and meeting minutes for the Steering Committee’s endorsement. The TWG is comprised of technical, working-level staff from MOH, MOF, MODP, CHAL, and LRCS (Annex 5).

The PBF UnitA PBF Unit has been established in the MOH Health Planning and Statistics Department (HPSD) to manage the day-to-day implementation, monitoring and management of the project, in coordination with relevant technical units, NSRHSC, the Performance Purchasing Technical Assistance (PPTA) firm and the TWG. The PBF Unit will endorse and process PBF payments to contracted service providers, i.e. district hospitals, health centres, and DHMTs, based on the invoices prepared according to the predetermined formula (i.e. PBF outputs adjusted for quality and remoteness). Detailed TORs for the PBF Unit and for the specific positions are in Annex 6. It was agreed that the PBF Unit should be fully staffed with personnel under established posts in the MOH rather than recruiting external consultants for sustainability. The following staff has been appointed to the PBF unit from existing MOH personnel: (i) PBF Unit Director, (ii) Financial Management Officer, (iii) Accountant, (iv) M&E officer, and (v) Operations Officer.The PPTAThe PPTA firm will provide technical and operational support to the PBF Unit while simultaneously building PBF capacity at national and district levels. In addition, it will provide capacity building on PBF implementation to health workers at facility level; at community level to health centre committees and VHWs; at district level to DHMTs and the District PBF Steering Committee; and at national level to the PBF Unit and the NSRHSC. The PPTA will also verify delivery of the services, prepare the performance payment invoices for delivery of incentivized services (in quantity and quality terms), and assist health facilities and the district and community councils with preparing PBF business plans. The goal would be to build sufficient capacity in the MOH to ultimately facilitate the transfer of the purchaser function to the PBF Unit. The detailed functions and roles of the PPTA are in Annex 7.

The PPTA will have a diverse staff composition, which minimally includes the following positions: Performance-based Contract Manager, Technical Advisor, PBF Monitoring and Data Verification Specialists, Verification officers and Administrative support staff. The exact composition of PPTA staff, temporary and permanent staff will be agreed during the contracting phase. PPTA responsibilities and tasks which include: provision of technical and implementing assistance to the PBF Unit and other PBF entities at national and district levels on managing performance-based contracts with health facilities for the delivery of incentivized services; verifying delivery of the services through initially monthly data verification, conducting quarterly client tracing & satisfaction surveys and annual health facility surveys; preparation of the invoices for performance payments, assist health facilities and the district with preparing their PBF business plans; and provision of capacity building support to MOH administrative and technical departments, the national level PBF unit, the PBF Steering Committees at national and district level and the Districts (district councils and DHMTs) on PBF implementation.

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The PPTA firm will be preferably placed within the MOH and will maintain a close working relationship with the PBF Unit, to strengthen the PBF Unit to take independent charge of the PBF project within an agreed time frame of not more than three years.The Christian Health Association of Lesotho (CHAL)For Christian Health Association of Lesotho (CHAL), the MOH signs a PBF Addendum to the existing MOU that specifies responsibilities, which provides a grant29 to CHAL which CHAL will allocate to its member institutions. However, the method of allocation of PBF incentives to its members will be defined in the PBF Addendum and further in the CHAL facilities PBF contracts with explicit clauses for responsibilities of CHAL facilities. CHAL members have multiple ownership, autonomy and funding arrangements.

District LevelThe District CouncilThe District Council, as the overall authority at the district level will, under the terms of decentralization per the Ministry of Local Government, Chieftainship and Parliamentary Affairs, has policy oversight over the project through the District Project Steering Committee (DPSC). Management responsibility for the project will be vested in the District Health Management Team (DHMT). A District PBF Steering CommitteeThe DPSC comprised of the District Administrator (Chairperson), District Council Secretary (Alternate chair), Representation of the District Council, District Director of Health Services, Matron/Hospital Manager, Public Health Nurse, Ministry of Social development, Ministry of Finance (Sub-Accountancy), Pharmacist, District Health Information Officer, Representation of the Area Chiefs, Security Representation i.e Police, and a representative local NGOs. The composition may vary depending on the district needs. District PBF Steering Committee will review and endorse the business plans of all the health centres within their district, and validate invoices for payment once the quantity and quality have been verified at the district level. At the community level, the Health Centre Committees will play a role in working with health centre personnel to develop business plans and review VHWs performance in line with the business plans. This will apply to both GoL and CHAL facilities. The detailed TORs for the District PBF Steering Committee and the Health Centre Committees are also outlined in Annexes 8 and 10 respectively. The District Health Management Team (DHMT)DHMTs enter into a performance-based contract to ensure that they provide effective supervision of health centres, build capacity and support provision of quality health services at the community level i.e health campaigns and outreaches (Annex 9). The PPTA (national level) through the PHC department will review the performance of the DHMT against their performance contract.

Capacity BuildingThe project will provide support and training to participating District Councils/DHMTs, District/local Hospitals, and health centres to help them improve their planning, implementation, coordination and supervision capacities.

29 This refers to any funds disbursed by the MOH to CHAL as per MOU

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The project will strengthen the capacity of the MOH PBF Unit, District Councils, its DHMT and participating health facilities in the target districts. The focus will be on a pre‐agreed essential services package of 12 facility based output quantity indicators, to rapidly expand the maternal and child health interventions at health facility and community level. It will also include support to the next referral level, the District/local hospitals with a pre-agreed complementary services package of 13 hospital based quantity output indicators. Performance based benefits will be based on measured quantity and quality output indicators.

Performance-contracts are introduced throughout the system. Performance frameworks exist for health facilities, i.e. district and local hospitals and health centres, and for the community client verifiers who will be sub-contracted for patient tracing and service verification as well as assessing client satisfaction. The District Councils-DHMTs will receive a performance contract with mixed quality and quantity output indicators.

Health Centre LevelThe Health Centre The health centre is the lowest level facility in the Lesotho health system that is closest to the community. The health centre is therefore the key actor in the PBF model, as it is the level where primary health services are provided. Health centres, and the community (through representation in Health Centre Committees) and VHW constitute this level. The TOR for the Health Centre Committees (HCC) together with the inventory for Leribe and Quthing districts as of December 2012 is presented in Annex 10.

The health centre is managed by a nurse-in charge, supported by a HCC and clinically supervised by the DHMTs including, medical officer based at the district.

The responsibilities of the health centre include a range of outpatient, clinical, preventive and health promotion services. Health centres also provide support and supervision to the health activities provided at the community level by the VHWs.

PBF places more emphasis on a number of (operational management) activities and introduces additional activities. The following activities are considered relevant:

Developing an annual business plan that will be updated quarterly. The business plan outlines the strategies and resources required to reach the targets set for the selected PBF indicators

Mobilizing and managing of resources for service delivery Provision of the relevant health services to clients Undertaking any other (at the facility level and at the community level through intensive

collaboration with and provision of supervision and support to VHWs) interventions that enhance access to and utilization of health service of good quality.

Timely submitting HMIS/PBF data for invoicing the delivered services Facilitating access to information for audits and verification exercises Decision making on use of PBF incentives in accordance with the agreed business plan. Ensuring complete compliance to PBF procedures and full accountability for all received

PBF resources.

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A quarterly performance contract will be signed between each participating health centre (provider) and the purchaser. The contract specifies the terms and conditions for PBF involvement. The health centre nurse in‐charge and the chairperson of the Health Centre Committee are co‐signatories to the contract with the purchaser. However, in the case of CHAL, the Proprietor is the Chairperson of the Health Centre Committee and therefore the second signatory of the quarterly performance contract. The CHAL Health Centre Committee will elect one of its members to be a third signatory.

The two co‐signatories have the following specific roles to play in overall contract management for the health facility:

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 PBF interactions (including settlement of disputes)

with the DHMT.

Copies of the contract document, together with other PBF support documents and templates should be filed and safely stored in an office or location that allows smooth retrieval and referencing.

Role of the Health Centre CommitteeThe Health Centre Committee (HCC) provides oversight to the HC and sees to it that the HC accommodates the health care needs of the community that depends on the HC. The HCC is therefore an important link between the HC and the community. The HCC consists of representatives of the community groups, including a representative of the VHWs. The TOR for the Health Centre Committees together with the inventory for Leribe and Quthing districts as of December 2012 is presented in Annex 10.

The roles played by HCCs include the following facilitate people in the area to identify their priority health problems, identify what they

think can be done about them, using participatory approaches and information from technical personnel;

plan how to raise their own resources, organize and manage community contributions, and tap available resources for community health activities;

use information from the health information system and from communities in planning and evaluating their work and should be trained to do this;

assess whether the health interventions in the area are making a difference to people’s health using health information system and community information;

are a channel for information flow from the health centre to the community and district councils/DHMT and back to the community;

are informed about the activities of different health providers in the area raise and discuss aspects of patient care and represent communities on issues they raise

on services offered, to see how these can be addressed;

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obtain information from the community/district councils and DHMT on budget allocations for health, on village level allocations, give input and feedback to the CC/DC and DHMT on budget planning and keep communities informed on health budget issues, particularly where this relates to local resource mobilization; and

work with the community/district council to motivate and implement public health standards, such as water supply and sanitation

HCC PBF responsibilities include the following: to serve as the board of the health centre, which implies provision of leadership to the HC

staff and representing the health centre to the community and the local government to contribute to the development of the business plan for the HC in close collaboration

with the in-charge of the health centre and eventually endorse the business plan to be co-signatory (chair) to the HC in charge in respect to signing PBF contracts with the

District Council to be present at health centres quality assessments and other actions that are part of the

PBF control systems to authorize accountable documents including where applicable health centre bank

accounts through the chair, health centre nurse in charge and in the case of CHAL the proprietor and or other nominated person. and will also oversee accountability for use of PBF funds for the purposes stated in the business plans

Community Level and Village Health WorkersCommunity LevelThe Health Centre Committees represents the community in the process of development and implementation of the health centre business plans and also in the review of the VHWs performance in line with the business plans.

Community participation will be promoted to strengthen project ownership and accountability. The PPTA will engage local NGOs or Community Based Organizations (CBOs) for tracing patients, randomly selected from health facility records, and verifying the services received and determining their satisfaction with these services. The outcomes of patient verification and patient satisfaction surveys will partly determine the quantity and quality of care scores and influence quarterly PBF payments. A financial audit of the health facilities, DHMTs and MOH PBF Unit will be conducted annually by an external auditor.

Village Health WorkersVHWs are an essential part of the continuum of care model and can play a crucial role in improving the health of the Basotho people given Lesotho’s challenges in providing access to quality health services given the geographical (mountainous) nature which hinders access and referral, the social, economic and cultural situation. There is solid evidence for under-utilisation of vital health services. At the same time there is notion that the health services do not adequately meet the needs of the communities. These compounded factors, to a large extent, explain low health outcomes.

VHWs, whose role is to link communities and the first line of care at health centres are however currently under-utilized and ill equipped. Moreover, their activities are not well captured in the

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current Health Management Information System (HMIS). They receive a fixed compensation (LSL 300 per month, approximately $35).

All these factors negatively impact primary health care outreach and referral, including provision of maternal and newborn health care information, education and client motivation at the community level.

The VHWs will be trained, supervised and provided basic commodities as per MOH guidelines. VHWs will conduct community mapping and sensitization in an effort to achieve inclusive maternal and child care (See annex 11). Community mapping will provide more comprehensive information about the population served by the VHWs who are linked to a particular health centre, with age and gender breakdowns, reproductive health histories, the actual number of pregnancies, newborn children and provides information about chronic diseases such as TB and HIV/AIDS. At the same time community mapping will require the support from community leaders to receive cooperation from the community and will re-emphasize the relevance of VHWs and therefore contribute to their self-esteem.

The main duties of VHWs are: Community mapping (collecting vital statistics). See Annex 11 for the format for

community mapping Continued tracing of community members who are in need of reproductive health

services as well as TB, HIV/AIDS services (quarterly follow-up format, also in Annex 11)

Basic health promotion and provision of basic curative health services in line with the policies

Timely referral to health centre/hospital Reporting to health centre and attending or being represented (by other VHWs serving

the same village) during monthly meetings at the HC

To facilitate the cooperation, monitoring and payments of the VHWs attached to one health centre (ideally VHWs serve 20 households), the VHWs should preferably select one or more persons who could interact with the health centre on their behalf and could become a member in the HCC.

At the health centre one of the health workers, for example Nursing Assistant will be assigned to be the focal point for the VHWs. Village Health Workers also associate with village health committees, who may play a relevant role at the village level.

The VHW performance will be monitored quarterly by the health centre’s Focal Point (a health worker assigned by the nurse in charge to work with the VHWs). Depending on their performance in increasing the uptake of MNH/TB/HIV/AIDS services at the health centre the VHWs will be entitled to receive part of the PBF benefits earned by the health centre on a quarterly basis. The method for sharing the PBF benefits will be decided upon by the VHWs. (Memorandum of Understanding between health centre and VHW is in Annex 12).

Figure 2 below reflects the institutional arrangements as described above.

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Figure 2. PBF Institutional Arrangements

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Schedule 1: Institutional Set-up

Level Institution Roles and Functions Composition CommentsNational National Sexual and

Reproductive Health Steering Committee

Endorse the PBF design; Provide policy guidance to the

PBF Unit; Oversee implementation by:

defining maximum payments to districts and facilities; deciding on incentivized services (indicators) as well as eligibility criteria on which districts and facilities are enrolled in the PBF scheme; defining quality of care standards and mechanism for calculating PBF credits (unit costs, weights and adjustments for quality and remoteness) and conditions for their use; setting standards for health facility business plans.

Approve the annual work programs and budget;

(Annex 4)

Director General for Health Services, MOH directorates*, representatives from MODP, MOLGCPA, Ministry of Public Service, Ministry of Education and Training, Ministry of Gender, Youth, Sports and Recreation, Ministry of Justice, Human Rights and Rehabilitation and Law and Constitutional Affairs, CHAL, LRCS, Lesotho Planned Parenthood Association, Lesotho Medical, Dental and Pharmacy Council, Lesotho Nursing Council, National University of Lesotho Dean of the Faculty of Health Sciences. The heads of UN agencies and the heads of delegation of Irish Aid, the European Union, PEPFAR, other international NGOs, a parliamentarian/community member and the private sector are also included.

PBF Technical Working Group

Provide operational and administrative support: prepare meeting agenda, reference documents and meeting minutes for the Steering Committee’s endorsement;

(Annex 5)

Technical, working-level staff from MOH, MOF, MODP, CHAL, and LRCS;

PBF Unit in which the PPTA sits

Coordinates, manages and implements the project

(PBF Unit in Annex 6 and PPTA in Annex 7)

District District PBF Steering Committee,

Purchase health services provided by: MOH (public

DDHS, other members identified in PUM for DPBFSC

Potential tension between the DMOH and the District

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managed provider), CHAL -managed health facilities.

Monitor project at district level;

(Annex 8)

Council Secretary heading the Council

District Health Management Team

Technical coordination of PBF at district level;

Supervision of health facilities at district;

process contract of HCs; quarterly supervision and reporting of HCs.

(Annex 9)

DDHS and staff

Health Centre Level

Health Centre Committee

Oversee operations of the HC; Develop, implement and

monitor annual plans; Co-signatory to PBF contracts

with District.

Health promotion and basic curative services;

tracing community members; timely referral to HC/Hospital;

(Annex 10)

Nurse-in charge, members are provided in HCC TORs in PUM?Elected community members, VHWs

Potential for conflict with the HCC Chairman and local administration staff.

*Directorates include: primary health care, nursing services, health planning, clinical services, human resources, social welfare, finance, pharmacy, laboratory services, family health, health education, and quality assurance; MODP: Ministry of Development Planning; MOLGCPA – Ministry of Local Government, Chieftainship and Parliamentary Affairs; CHAL: Christian Health Association of Lesotho; LRCS: Lesotho Red Cross Society; LPPA: Lesotho Planned Parenthood Association; LMDPC: Lesotho Medical, Dental and Pharmacy Council; LNC: Lesotho Nursing Council; NUL: National University of Lesotho Dean of the Faculty of Health Sciences; EU: European Union; PEPFAR: President’s Emergency Plan for AIDS Relief;

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Requirements for Districts to participate in PBF Whereas it has been decided that all rural districts in Lesotho will in due time be enrolled in the PBF project, it remains essential that criteria are identified which are critical for the future success of the PBF project. These are:

DHMT core positions, e.g. District Director of Health Services, Public Health Nurse, Accountant, Human Resource Officer, District Health Information Officer, Pharmacist should all be filled

DHMT have the means to carry out operational and supervision functions, in particular adequate means to cover operational expenses, adequate (functional) means of transport for facility supervision, adequate means of communication

Health facilities should meet minimum staffing criteria as per MOH standards for health centres (capable of providing essential package of services) and district/local hospitals (capable of providing complementary package of services. The staffing pattern of the health centres in the two pilot districts as of June 2013is shown in Annex 2.

Health facilities should have sufficient numbers of (trained) VHWs so that facility catchment areas are adequately covered: minimum of 1 (trained) VHW for every 20 households

All health centres should be up to standards as regards their infrastructure, equipment, staff accommodation and utilities

Baseline data of Health facilities and VHWs are available to set applicable standards For district or local hospitals, the hospital’s management and proprietor should be willing

to sign a PBF contract DHMT, District Council and facility staff and their boards or committees should have

received PBF training

Requirements for Health Centres to participate in PBF:Health centre need to fulfill the following criteria to be enabled to participate successfully in PBF:

Staffing: Key positions for the facility are filled, based on MOH staffing guidelines, with a minimum of 3 qualified staff for a health centre: one nursing officer (nurse clinician or nurse with advanced midwifery), one nursing sister (registered nurse with midwifery), and one nursing assistant. The staffing pattern of the health centres in the two pilot districts as of December 2012 is shown in Annex 2. Trained nurse midwives are required to perform safe obstetric and newborn care; where applicable, refresher training has to be organized for them. Posting of staff to health centres should be for minimum of one year to reduce rotation of staff

Building/Equipment: The Health centre should have buildings and equipment according to minimum MOH standards which includes availability of water and electricity (or solar power). The above are the prerequisite for the conducting deliveries at the health centre. Consideration will be given to the Health facilities that have not yet achieved the above minimum standard at the launch of the project due to the delays experienced by the MCA project. An environmental waste management plan should also be in place.

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Administrative issues: Critical administrative activities necessary for the implementation of PBF;

Health facility staff trained on PBF Health Centre Committee (HCC) in place and actively providing oversight. At least one

member of the HCC has received a PBF training Health facility staff trained and able to develop business plans according to the format

provided by the PBF unit/PPTA, which is approved by the DHMT and in line with the District Operational Plans

Health facility and the PBF/PPTA negotiated a contract with clear targets including benefits per target.

The facility is enabled to be entrepreneurial and is allowed to spend PBF funds according to the agreed business plan

Community mapping conducted and together with the health needs. The following information should be included in the business plan

VHWs committee should be in place. The VHWs should be known to be active and each VHW is responsible for a minimum of 20 Households (HH). If necessary and at least temporarily until the MOH has trained more VHWs responsibilities can be extended to a higher number of households. It is important that all households in the catchment area are covered by VHWs.

The health centre cooperates with the VHWs according to agreed plan.

The facilities will be supported by the MOH/DHMTs, with technical assistance from the PPTA to meet above mentioned criteria. For facilities that do not meet the mentioned criteria but are promising to do so in near future, an exception can be made. Exceptions will always be decided by the PPTA firm and MOH/District Council together. It will be included and explained in the business plan and contract. The necessary steps and actions (roadmap to fulfillment of the minimal requirements) need to be concrete and realistic and are captured in the business plan. The maximum timeline, in which the minimal requirements will be met, is 60 days from the start of the PBF contract.Requirements for Hospitals to participate in PBF There will be no eligibility criteria for District/local hospitals, considering the fact that these institutions are providing crucial secondary care in the district and are the prime referral option for health centres.

However, it is essential that they offer quality services, which will be assessed during the quarterly quality audits and have a business plan prepared. If the hospital does not meet the minimum quality standards, e.g. the quality score is below 50%, there will be no bonus for quality of care provided and the MOH is advised to take appropriate measures.

Annual Work Program and Budget

Each Fiscal Year, the MOH PBF Unit will prepare an Annual Work Program of activities (including Training and Operating Costs) proposed for inclusion in the Project during the following Fiscal Year (April-March), including: (a) a detailed timetable for the sequencing and implementation of PBF implementation, training and other relevant activities; and (b) a proposed budget and financing plan for such activities, which will also include the estimated quarterly budget that the different districts and health facilities expect to earn over the fiscal year (these

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annual budgets have to be reviewed to ensure that no health facility or district exceeds the maximum allowable annual allocation stated in the Financing Agreement). It will be submitted for the World Bank’s No Objection no later than February 28 of each year. A draft 2013/14 implementation plan is shown in Table 3 below.

The MOH PBF Unit will ensure that in preparing any training or workshops proposed for inclusion in the Project under an Annual Work Program shall include; (a) the objective and content of the training or workshop envisaged; (b) the selection method of the institutions or individuals conducting such training or workshop, and said institutions if already known; (c) the expected duration and an estimate of the cost of said training or workshops; and (d) the selection method of the personnel who will attend the training or the workshop, and said personnel if already known.

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Table 3. Implementation Plan for the PBF Project (February 2013 to June 2014)

Activity Responsible Entity

Timeline Costs (USD

Costs (LSL) (Exchange rate 9.2)

Comments

Recruit PBF consultant to provide technical support in the evaluation of the PPTA proposals.

MOH Procurement and MOH PBF Unit

February 2013 7100 65320

Two staff members from IT Unit went for web enabled application study tour in Burundi from the 4th to the 7th June 2013

MOH IT UNIT and MOH PBF UNIT

June 2013 12292 113085.4

Three PBF staff members and one from Procurement Unit to participate in the Joint Workshop for Fiduciary, Governance, Fraud and Anti-Corruption in South Africa.

MOH PBF and Procurement Units

May 7-9 2013

Prepare TOR for consultancy for Lesotho PBF web-enabled application

MOH IT Unit and MOH PBF Unit

June 2013

National Sexual and Reproductive Health Steering Committee (NSRHSC) meeting to approve Project Implementation Manual and PBF annual workplan and budget

MOH PBF Unit July 3, 2013 PIM and PBF 2013/2014 annual work plan and budget endorsed

Enrollment in one year training of nurse anesthetists in Zimbabwe and Tanzania (2 enrolled in Tanzania in May 2013, 3 will enroll in Zimbabwe in July 2013, and up to 6 in Tanzania in August 2013)

Director of Nursing July 2013 156000 1435200 Two nurses left for training in Tanzania in May two left for Zimbabwe

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Timeline Costs (USD


Comments

on the 30th June.

Recruit the HMIS consultant to strengthen the HMIS – submit No Objection request with minutes of negotiation and draft contract to WB

MOH PBF Unit July 2013 50000 460000 Consultant selected awaiting financial proposal

Office of the Auditor General to include the project in the external audit calendar

FMO and Accountant, MOH PBF Unit

July 2013 Process initiated

Liaise with the Office of the Auditor General to recruit an External Auditor


July 2013 10000 92000 FMO in discussions with the office

Participate in PBF training course for PBF Unit staff Mombasa, Kenya (3 trained in February 2013 and 2 more in July 2013)

MOH PBF Unit July 2013 20000 184000 One member from the PBF Unit and CHAL left for a two week course beginning from the 1st of July.

Submit No Objection request for list of participants and costs for study tour for MOH Senior Management and Senior officials from other Government Agencies

MOH PBF Unit July 2013 TORs and tentative list developed still to be endorsed

Initiate recruitment of consultant for the development of Lesotho PBF web-enabled


July 2013 50000 460000 Work in progress

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Timeline Costs (USD


Comments

application for PBF invoicing

PPTA starts activities at national and district level

PPTA August 2013 Current negotiations failed, to initiate the process of re-advertising immediately. This will however push back timelines for all PPTA related activities.

MOH Senior Management and Senior officials from other Relevant Sectors to undertake study tour to countries that have successfully implemented PBF.

MOH PBF Unit August 2013 60000 552000 Dependent on the finalization and endorsement of the TORs and the list of participants and availability thereof.

MOH Pharmacists to conduct 5-day training of 315 health centre nurses on the MOH adopted drug supply management manual (this training will be over several months)

MOH Pharmaceutical Directorate, MOH PBF Unit

August 2013 168750 1552500

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Timeline Costs (USD


Comments

Recruitment of District Director of Health Services for Leribe and Quthing DMHTs

MOH Management August 2013 400 3680 Consultations on-going

Training of Village Health Workers in Leribe and Quthing

Family Health Division

August 2013 10000 92000 FHD in the process of requesting for proposals from the two pilot districts

Prepare initial six-month cash flow forecast based on annual work plan and budget


August 2013

Purchase additional licenses for TOMPRO FMO and Accountant, MOH PBF Unit

August 2013 33000 303600

Training on TOMPRO for FMO and Accountant FMO and Accountant, MOH PBF Unit

August 2013 15000 138000

Quality Assurance Unit to collect baseline quality checklist assessment data in all health centres and hospitals in the 9 districts

Quality Assurance Unit

September 2013 5740 52808 The PBF unit is in discussions with the QA unit on the approach and timing

M&E Unit to collect HMIS baseline data on incentivized service indicators in all districts

PBF Unit September 2013 11005 101246 This will be dependent on the completion

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Timeline Costs (USD


Comments

of the HMIS consultancy

M&E Unit to collect the Results Framework HMIS baseline data for the period October 2012 to September 2013

M&E Unit September/October 2013

25000 230000 Needs further internal consultations

Draft TORs for CBOs/NGOs for ex-post verification

PPTA, PBF Unit September 2013 Dependent on the completion of the process of engagement of the PPTA

ESAMI training on Works Procurement and Selection of Consultants (http://www.esami-africa.org)2 Procurement Officers

MOH Procurement Unit, MOH PBF Unit

Next available course date

16294 149904.8 Procurement unit in the process of identifying the course and matching them with the prospective trainees

ESAMI training on Advanced Works Procurement and Selection of Consultants2 Procurement Officers



16294 149904.8 Same as above

ESAMI training onGoods and Equipment Procurement2 Procurement Officers



16294 149904.8 Same as above

ESAMI training on Advanced Goods and MOH Procurement Next available 16294 149904.8 Same as above

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http://www.esami-africa.org/



Timeline Costs (USD


Comments

Equipment Procurement Programme for MOH PU staff2 Procurement Officers

Unit, MOH PBF Unit

course date

Recruit consultant for hands-on training and mentorship of key MOH Procurement Unit staff, District Councils, DHMTs, District Hospitals and CHAL Secretariat on public procurement and strengthening of procurement system – this will be done 2 weeks every quarter for 18 months


October 2013 16500 151800 Preparations will start as soon as the above trainings are in progress.

Enrollment of District Health Information officers and central M&E staff in short term M&E course in University of Pretoria, South Africa

M&E Unit October 2013 71345 656374 Have already negotiated with the University of Pretoria for the 8 Information Officers to be admitted for the course.

Establishment and training of the District PBF Steering Committee

MOH PBF Unit October 2013 16000 147200

PPTA to update the annual work plan PPTA October 2013

PPTA to develop PBF training manual PPTA October 2013

PPTA to organize trainings on PBF PPTA October 2013

PPTA to assist health centres and hospitals to PPTA October 2013

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Timeline Costs (USD


Comments

prepare business plans

Sign PBF contracts including business plans (health centre with District Councils Secretary; GOL/CHAL hospitals with MOH Dir. of Clinical Services; DHMT with MOH Dir of Primary Health)

MOH PBF Unit October 2013

NSRHSC meeting to review plans for the initiation of pilots in Leribe and Quthing districts

MOH PBF Unit October 2013

ESAMI training on overview of supply chain management for Hospital and DHMT pharmacists (5), 1 NDSO procurement, 1 MOH Pharmaceutical directorate (http://www.esami-africa.org)



75607 695584.4

ESAMI training on Quantification of health commodities) for Hospital and DHMT pharmacists (5), 1 NDSO procurement, 1 MOH Pharmaceutical directorate



75607 695584.4

Two-week course for the ICT Based Financial Management and Disbursements Course for Project Accountants for World Bank funded Projects to be held in Kenya



12000 110400

Commencement of PBF pilot in Leribe and Quthing

MOH PBF Unit November 2013

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Timeline Costs (USD


Comments

CBOs/NGOs for ex-post verification recruited and contracted

PPTA/PBF Unit December 2013 200000 184000

Training of CBOs/NGOs for ex-post verification PPTA December 2013

Lesotho PBF web-enabled application ready for use


December 2013

Submission of previous month’s invoices – health centres, hospitals, DHMT

MOH PBF Unit, PPTA

December 2013

District PBF Steering Committees to endorse the previous month’s invoices

District PBF Steering Committees

December 2013

Enrollment of 10 nurse midwives into Advanced University Diploma in Advanced Midwifery and Neonatology University of Orange Free State, South Africa

Director Nursing Services Family Health Division

January 2014 150000 138000 Preparations at an advance stage for the launch of the Advance Midwifery distant learning course with the University of Free State.


MOH PBF Unit, PPTA

January 2014

District PBF Steering Committees to endorse the District PBF January 2014

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Timeline Costs (USD


Comments

previous month’s invoices Steering Committees

Enrollment of 2 central MOH M&E Staff in two-year part time M&E Masters course

M&E Unit January 2014 40820 375544 Identified two officers who are awaiting letters of admission

Process evaluation/assessment of pilot program initiated

MOH PBF Unit, PPTA

January 2014

To fund data collectors and supervisors for the 2014 Demographic and Health Survey up to $300,000. The DHS will be a source of baseline data for selected indicators in the results framework

M&E Unit January 2014 300000 2760000


MOH PBF Unit, PPTA

February 2014

District PBF Steering Committees to endorse the previous month’s invoices

District PBF Steering Committees

February 2014

NSRHSC meeting to review the first quarter of implementation and the April 2014 to March 2015 Annual plan and budget

MOH PBF Unit February 2014

First ex-post verification Ex-post CBOs/NGOs/PPTA

February 2014

First performance-based payments will be made MOH PBF Unit, March 2014 65180 599656

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Timeline Costs (USD


Comments

to contracted health facilities and DHMTs PPTA

MOH Ethics committee approval of impact evaluation design

WB March 2014

Start preparations in scale-up districts MOH PBF Unit, PPTA

April 2014 42000 386400

Review PPTA performance for contract extension for another year

MOH PBF Unit April 2014

Total 4, 264, 522 39, 233, 602

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Chapter 4: Contracts, Determination of PBF Benefits, and Business plans

The principles which underpin the PBF in Lesotho are: Autonomy in management and planning of service providers (health facilities) Involvement of the population/community in managing the services Use of instruments: business plans, contracts, external data verification and quality

assessments Strengthening the institutional configuration by separating functions of policy

formulation/regulation, service provision and purchasing.

In order to effectively manage the elaborate institutional framework described in Chapter 3, and to 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.

Contracting The pilot phase will inform the MOH and build capacity to gradually institute a clear separation of functions in line with PBF principles. It should be noted however, that during the pilot phase, the MOH will use the existing structures.

The following will therefore constitute the contracting PBF model during the pilot phase: Performance Contracts of Health Centres will be signed between the DHMTs and

Health Centre, The Director of DHMT under the auspices of the PBF District Steering Committee, will be responsible for its monitoring whilst at the HC a nurse in charge will be supported by the Health Centre Committee to ensure its implementation. (see Annex 13)

Performance Contracts of the District/Local Hospitals will be signed between the MOH-Director Clinical Services and Chairperson of the hospital board (CHAL) or the District Hospital Management Committee (MOH) and countersigned by the PBF Unit Director under the auspices of the NSRHSC. The PBF Unit will also be responsible for its monitoring through the support of the PPTA. (see Annex 14)

Performance Contract of the DHMT will be signed between the MOH-Director Primary Health Care and countersigned by the PBF Unit Director under the auspices of the NSRHSC. The latter will also be responsible for its monitoring through the support of PPTA. The District Steering Committee will support the DHMTs to ensure implementation. (see Annex 9)

So-called “motivation contracts” will be signed with staff that may receive performance bonuses based on individual performance, which is assessed on a quarterly basis, using standard performance review forms. These bonuses will be part of PBF benefits generated through an institutional/collective effort of the health centre. Motivation agreements aim to formalize the arrangement and further imply regular performance reviews.

There will be the following motivation agreements:1. Motivation Agreement of Health Centre Staff will be signed with HC in-charge (under

the auspices of the HCC) (See Annex 15)2. Motivation Agreement of DHMT staff will be signed with MOH-PHC (See Annex 16)

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In addition, there will be a Memorandum of Understanding (MoU) between the HC in-charge (under auspices of HCC) and VHWs on sharing PBF benefits earned by the HC, partly through VHW efforts. (See Annex 12).

Determination of PBF benefits

The overall benefits to be offered to health facilities, VHWs and DHMTs are currently budgeted at US$3.00 per capita per year. The amount is consistent with PBF benefit payments utilised in other African countries. The amount is considered sufficient to make a difference in the efficiency and quality of health services while still being low enough to be absorbed by the regular MOH budget when the PBF project funding expires.

At the time of writing the US$ 3 per capita per year has been designated as follows: $ 2.30 indicative benefit per capita per year for health centres $ 0.45 indicative benefit per capita per year for hospitals $ 0.25 indicative benefit per capita per year for DHMT

These amounts are exclusive of the PPTA costs, since the PPTA costs have been removed off-the-top from the available budget for the project.

The Calculation of PBF benefit payments for Health Centres and Hospitals is based on a formula with three elements:

(i) quantity of services provided; (ii) quality of services provided; (iii) a top up of the incentives related to the relative remoteness of the HC.

The three elements are defined as follows: 1. Amount based on quantity of incentivized services delivered calculated against the

price per unit of service

2. A quality bonus, which is an additional payment on top of the quantity incentive payment, is based on the quality score obtained by the health facility on the quality assessment check list. The quality score defines standard for quality of care for District/Local hospitals and Health Centres and the patient/client satisfaction score. Table 4 presents a sliding scale of the scores on quality checklist (%) and the corresponding quality bonus (%). A maximal quality bonus of 25% (weighing factor) of the PBF benefits related to the quantity of services provided, i.e. if the quality score would be 100%, will be applied for each health facility.A minimum quality score, threshold, will be used, i.e. 50%. If this threshold is not met there will be no quality bonus. For facilities scoring below the minimum quality threshold, the DHMT will take adequate measures to improve the quality of services provided. The proportion for the additional payment and the target quality score will be adjusted during implementation to reflect ongoing improvements in the service quality and ensure that the objective of continually improving quality is maintained.

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Table 4. Quality bonus calculation

Score on quality checklist (%)

Quality bonus (%)

100 2590-99 2080-89 1570-79 1060-69 550-59 250 or below 0

3. A remoteness bonus based on comparative isolation of a facility to provide additional incentives to health centres in remote areas and influence adequate distribution of health personnel and support GOL’s pro-poor approach. The % remoteness bonus will be based on a scoring matrix (See Table 5 for details). District and Local hospitals are not considered for a remoteness bonus.

Total PBF incentive payments are calculated as follows: In words

PBF benefits are based on the account calculated for quantity services, to be increased by the percentage score for quality of services (maximum of 25%) and on top of it a further additional bonus for remoteness.

In a formula:- Amount for Quantity => A- Quality Bonus (%) => B - Remoteness Bonus (%) =>C

The formula to be used is: PBF benefit = A x (1+B) x (1+C)

The following examples illustrate how the formula works:

Example 1: The assessment of 12 output indicators of a HC led to a benefit for quantity services

of Lesotho Loti (LSL) 5,000 The quality of care has been assessed at 90% which corresponds to a quality bonus of

20% (as per Table 4). The HC is located in the district, but needs between 1 and 2 hours travel to the centre

of the district by vehicle, indicating remoteness category 2 and a corresponding remoteness bonus of 10% (as per Table 5).

The PBF incentive calculation for this scenario is as follows: LSL 5,000 x 1.20 x 1.10 = LSL 6,600.

Example 2:

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Suppose the same HC would have had a quality score of 45%, it would not receive a bonus for quality performance (quality bonus is zero when the quality of care score is below 50%). Its benefit will equal to LSL 5,000 x (1 + 0) x 1.10 = LSL 5,500.

Example 3:Suppose another HC that is entitled to LSL 3,000 for quantity of service, had a quality of care score of 80% (corresponding to a quality bonus of 15%) and a 20% remoteness bonus, the PBF incentive calculation would be: LSL 3,000 x 1.15 x 1.20 = LSL 4,140.

Remoteness bonusHealth facilities located in remote areas face inequities, such as difficulties to maintain their staff in place, higher transport and communication cost and limited access to other services. To overcome the aforementioned inequities and to make it more attractive for health personnel to work in remote areas, a so-called remoteness bonus is provided which is proportionate to the relative isolation of the health centre. Ten percent of the budget for the payment of PBF incentives for HCs has been set aside for remoteness bonuses.

Relative remoteness for each health centre will be determined using the criteria in Table 5. Annex 17 illustrates the use of the criteria for categorizing remoteness of health Centres in Leribe and Quthing districts. Each DHMT will be tasked to categorise the HCs. District and Local Hospitals will not be considered for remoteness bonuses

Table 5. Criteria for categorizing relative remoteness of health Centres

Category Remoteness bonus percentage

1 HCs where health professionals prefer to work, mostly centrally located in towns, or within one hour travelling by vehicle

0%

2 HCs located in the district, but needs between 1 and 2 hours travel to the centre of the district by vehicle

10%

3 HCs located in the district, but needs 2 hours and more to reach the centre of the district by vehicle

20%

4 Geographically hard to access.HCs located in areas where health providers do not want to work, far from the main roads, irregular transport, bad roads, difficulty to reach in rainy season, where sometimes there is no water, electricity in HC and village, schools and so on

30%

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Payment for quantity of services

Payment to HCs based on quantity of services deliveredTable 1 in Chapter 2 presents the Minimum Package of Activities (MPA), that is, the services to be incentivized at the health centre level together with relative weights and unit fees. For each service “weighting” was done, i.e. a weight has been determined based on relative priority given to that particular service and the estimated relative effort required to produce one more unit of services. Subsequently the weight is translated into a price, expressed in LSL.

The health centres will fill out the PBF invoice with the quantity for each PBF indicator after every month. Annex 18 presents a sample of the monthly PBF invoice for health centres. After submission to the DHMT with a copy to the PPTA, the PPTA will schedule and conduct a verification session at the HC. The DHMT will be present during most of these visits, at least on a quarterly basis for the quarterly quality supervision.

In case of a discrepancy of more than 5% between the indicator quantity forwarded by the HC and the verified number, this indicator will not be “bought” for that particular month, meaning there will be no PBF benefit to that HC for this indicator.

Quantity score for district/local hospitalsTable 2 in Chapter 2 presents the Complementary Package of Activities (CPA) that is the services to be incentivized at the district/mission hospital level together with relative weights and unit fees. The methodology is similar to the methodology for HCs payment for quantity scores. Annex 19 presents a sample of the monthly PBF invoice for hospitals.

Payment for quality of services

Quality score for health centresThe quality score is a composite score based on both the quarterly quality assessment by the DHMT and the client satisfaction survey with a weight of 80% of the score assigned to the DHMT’s quality assessment and 20% to the client satisfaction survey.

A quality assessment checklist for health centres has been designed (see Annex 20), which assigns scores to a range of areas, each with many sub-components and a relative weight according to a rated contribution to overall quality of service provision (Table 6).

Table 6. Quality assessment and weight per service for Health Centre

No Service Max Points %1 General Management 24 92 Child Survival 43 163 Environmental Health 26 104 General Consultations 22 85 Reproductive Health 15 6

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6 Essential drugs Management 17 67 Tracer Drugs 25 98 Maternal Health 56 219 STI, HIV and TB 21 810 Community based services 21 8

Total 270 100%The purpose of the quality checklist is to guide and ensure that the health facility is delivering services according to prevailing norms, standards and protocols. The focus of these checklists is predominantly on pre-conditions for quality services (staffing, availability of drugs, appropriateness of buildings and equipment, management, collaboration with VHWs, etc.). In addition, emphasis is placed on clinical processes (e.g rational drug prescribing patterns and adherence to defined treatment protocols).

These checklists attempt to be as objectively verifiable as possible, i.e. assuring consistency in scoring even when done by different persons. The District Health Management Team (DHMT) will conduct one quality assessment to each contracted facility per quarter, making use of the quality list. This activity is included in the performance assessment that is used to appraise DHMT performance. Failure by the DHMT to conduct this assessment will lead to non-payment on quality bonus for the quarter. This therefore encourages the DHMT to visit each facility during the quarter.

There will be a third-party Ex-Post-verification mechanism (described in Chapter 2 and the steps for carrying out is outlined in Chapter 8) set up for this quality checklist: through a defined protocol, the scores provided by the DHMT will be counter-verified intermittently by the PPTA, initially by regularly joining DHMT quality assessment visits to assist in instilling the quality checklist protocols. In due time, this responsibility could be given to another (independent) agency.

Quality score for District/local hospitals The District/Local hospital will likewise be subjected to a quality assessment, also on a quarterly basis. A transparent evaluation mechanism will be set up, whereby key technical and administrative staff from other hospitals, with representatives from the MOH, CHAL, and civil society, will form an assessment committee which will evaluate the hospital performance in terms of quality of care delivered. There will be three parts to the quality checklist for hospitals:

a quality score for general hospital services; a quality score for primary care functions; a quality score for secondary clinical, diagnostic and institutional care.

In addition, a transparent counter-verification mechanism (ex-post verification) will be set-up (PPTA initially). The District/local hospital quality checklist can be found in (Annex 21).

Table 7. Quality assessment and weight per service for Hospitals

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Service Max Scores %

Part A - General Hospital Services 144 36

1 General Management 36 9

2 Hygiene & Medical Waste Disposal 27 7

3 Essential Medicine Management 17 4

4 Tracer Drugs and supplies 50 13

5 Emergency services 14 4

Part B - Primary Care Services 128 326 Child survival 43 117 General consultation 22 68 Reproductive Health 15 49 ANC and PNC 27 710 STI/HIV/TB 21 5

Part C - Secondary Care Services 128 32

11 In-patients wards 32 812 Delivery room 29 7

13 In-patient ward gynaecology/obstetrics 7

2

14 Surgery 26 7

15 Laboratory 20 5

16 Radiological Services 14 4

TOTAL 400 100%

Supervision quality score District Health Management Team (DHMT)The DHMT will not have a service contract like the health facilities but will receive a performance based contract. This contract combines both quantity and quality indicators, whereby the main emphasis will be on quality of supportive supervision. The DHMT will not develop a (quarterly) business plan, but will use its current operational planning system which will have an additional emphasis on the PBF project related responsibilities that the DHMT will have. Reference is made to Chapter 3, which further describes the role of the DHMT.

Table 8. DHMT performance indicators (full details are in Annex 22):

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ASSESSED ACTIVITIES Maximum score possible

%

1 100% of Health Centres have received at least one comprehensive quality assessment applying the appropriate checklist and protocol, and providing adequate feedback per quarter

35 17.5

2 100% of all health centres have a quarterly renewable contract with a business plan attached

20 10

3 100% of health centres have received one quarterly visit for data verification jointly with PPTA

15 7.5

4 DHMT prepares quarterly progress report 15 7.55 At least one Meeting at district headquarters with

Health Centres’ staff during the past quarter20 10

6 At least one hour training on a specific topic, offered immediately following the quarterly HC staff meetings

10 5

7 Monthly HC HMIS report entered in the HMIS database; report has a separate page with PBF indicators

20 10

8 DHMT activity planning well organized 5 2.59 Participation in the quarterly district PBF Steering

Committee Meetings15 7.5

10 HCs have 100% of qualified staff as per minimum criteria based on HC establishment list and assessed by actual presence

20 10

11 Management of the District Pharmacy 20 1012 Maintain regular communication with health facilities 5 2.5

Total points 200 100

Regular adjustment of the quality assessment methodologyQuality has various dimensions, and the PBF checklists can only measure some dimensions. Lessons learned from other PBF projects point at the importance of regular – typically once per year - review of the quality checklists. New norms and guidelines can thus be incorporated as they become available. Feedback from the end users can inform the design. Over time the quality bar will be put progressively higher to motivate health staff to continue improving the quality of the services. Adjusting the quality bar can be done in various ways: by adjusting the points value of certain items; by revising the items; by increasing the requirements where a numerical value is used and by lifting the threshold bar before a quality bonus is offered (at present set at 50%). Lastly, it is possible to increase the weight factor for quality scores, which currently stands at 25%.

Usage of PBF benefits

A PBF principle is that PBF benefits (or incentives) should be monetary awards. This feature is based on the conviction that the beneficiary will use the benefits as a “social entrepreneur” and

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will strive to maximise future benefits earned and thereby will contribute to realising the aims of the PBF project.

One of the key features/principles of PBF projects is that the recipient of benefits has autonomy on the use of these incentives. The PBF pilot in Lesotho will offer autonomy in usage of benefits too, but not unrestrictedly. It is felt essential – particularly during the pilot phase – to offer guidance to contracted parties on the usage of the PBF benefits. It is essential to safeguard the realisation of the aims and to avoid negative (side) effects, such as short-term gain over long-term win, decisions that may have an adverse impact on public health or staff collaboration, etc.

In the PBF pilot in Lesotho the following parties are considered for PBF contracts: Health Centres District/local Hospitals DHMTs

It is important to note that contracts will solely be issued to institutions, and not to individuals. This is based on the understanding that PBF requires a collective performance i.e. of a group of individuals who jointly implement an action that generates the services that may lead to the PBF benefits.

Nevertheless, individual staff will benefit, either indirectly (improvement in their working and living environment, access to resources that contribute to their performance, etc.) and/or directly by receiving motivation (performance) bonuses.

The method for allocation of motivation bonuses to individuals is guided by a tool, which links the bonus to the individual salary, to seniority and to the individual performance, which is assessed quarterly. Staff who want to be entitled to a motivation bonus have to sign a so-called “motivation agreement”. .

Health Centres /VHWsIn Lesotho health centres (MOH/CHAL) will be contracted under the assumption that the health centres will actively engage with the communities they serve. This refers to collaboration with the community leadership and with the village health workers that provide elementary health services at village level. Health Centres and VHWs will be considered as one institution, although the contract will be with the health centre only. The PBF benefits earned in a particular quarter will be divided between three main purposes, which are:

a. Resources for improvement of service delivery minimum 25% of totalb. Incentives (motivation bonuses) to HC staff range 20-45% of totalc. Incentives to Village Health Workers range 20-45% of total

(a) Refers to (re)investments in facilities in improvement of quality of care, accessibility to care and improvement of staff welfare. For example, this part could be used for improvement in facilities, staff accommodation, medical and non-medical equipment, social marketing, items for service delivery, contributions towards transport cost for referrals, engaging an additional staff, etc.

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The quarterly, renewable and updated health centre business plan is to provide guidance to the actual division of PBF benefits between these three purposes, as well as accountability afterwards for the actual use.

In order to determine individual motivation bonuses to health centre staff, use is made of the following documents and tools:

A health centre staff motivation agreement (see Annex 15) An individual health centre staff quarterly performance assessment (see Annex 23) A so-called Indices Tool for health centre to allocate available financial resources for

motivation bonuses to individual staff (see Annex 24)

District/Local HospitalsDistrict/Local hospitals will be contracted for (i) limited range of primary care services offered to their catchment area, and (ii) for a limited set of (second line) referral health services to the whole district (or part of the district in case the district has more than one hospital).

The PBF benefits to be earned by a District/local hospital based on its performance is to be used for investment in the hospitals functioning, more in particular in efforts to improve the quality of care. There will be no provision for individual motivation bonuses. The quarterly renewable and updated hospital business plan will provide guidance to the actual use of PBF benefits and for accountability afterwards.

District Health Management TeamThe DHMT will be contracted for a range of supervisory and supportive functions for the delivery of health care services in the district and for providing essential support to the PBF project. The DHMT performance will be measured quarterly in quality and quantity terms.

The PBF benefits may be used by the DHMT in accordance with a quarterly, renewable business plan that is endorsed by the Director PHC, after having received a recommendation from the PPTA. Accountability afterwards for the actual use of the PBF benefits needs to be assured.DHMT PBF benefits may be used for two purposes:

Resources for improvement of DHMT functioning range 80-100% of total Incentives (motivation bonuses) to DHMT staff: range 0-20% of total

It is up to the DHMT and the Chairperson of the District Steering Committee to decide on the actual % of the benefits received (an amount expressed in LSL that will be allocated to motivation bonuses for DHMT staff).In order to determine individual motivation bonuses to DHMT staff, use is made of the following documents and tools:

A DHMT staff motivation agreement (see Annex 16) A quarterly individual performance evaluation for DHMT staff (see Annex 25) A so-called Indices Tool for DHMT to allocate available financial resources for

motivation bonuses to individual staff (see Annex 26) A quarterly performance framework and invoice for DHMT (see Annex 22)

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Health Facility Business Plan See Annex 27 for the format for an annual business plan for health centres See Annex 28 for the format for an annual business plan for district/local hospitals

The health facility business plan is one of the most important tools for promoting health facility performance in a targeted manner. Once well designed it provides a solid reference document that underpins health facility autonomy.

Each health facility will develop an annual business plan as an integral part of the PBF contract. The plan will be in the annex of the performance contract and should be updated quarterly. The plan must be completed, discussed and approved by the purchaser (DHMTs in case of health centres and MOH Directorate of Clinical Services in case of hospitals) and should be in line with the district annual health action plan.

For health centres the business plan must be signed by the in‐charge of the health facility together with the chairperson of the Health Centre Committee. For district and local hospitals, it must be signed by the superintendent/DMO of the hospital and countersigned by the board (CHAL) or MOH (in case the District Hospital has no board).

The absence or failure to develop such a business plan may result in the termination of the performance contract or not qualifying for a contract renewal.

The first business plan sets the strategies to achieve certain targets to be achieved for a full year, while listing the targets for the initial quarter. Subsequent business plans build on this and presented updated targets for the following quarter. Business Plans have the following content:

(a) The targets for the quarter as per PBF incentivized Essential Service Package; (b) Problem analysis and health (care) needs; (c) Strategies proposed to solve the problems;(d) Infrastructure and equipment requirements and (e) Human resources required and how to motivate staff; (f) Financial planning. (g) For subsequent business plans: an analysis whether output and quality targets are

achieved,

Through the business plan, the health facility therefore specifies strategies and targets to increase the quantity and quality of the health services. A business plan, though initially developed for a year, is then modified per quarter so that it actually serves as a quarterly work plan. Updating a plan every three months allows more flexibility, will accelerate improvements and timely flag serious problems in a health facility. Table 9 shows the recommended good practice and standards for a business plan.

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Table 9. Recommended good practice and standards for a business plan

1 The Business Plan should be updated quarterly and the latest copy made accessibleThe DHMT verifies the current/updated Business Plan

2 The Business Plan should be prepared with key stakeholdersThis includes key health centre/hospital staff, health centre committee/hospital board members/Hospital management team, Village Health Workers (VHWs), NGOs and Community Based Organizations (CBOs) providing health services in the catchment area

3 Business Plan should contain a comprehensive plan covering the whole catchment populationClear strategies for various zones, outreach activities and VHWs cooperation and demand generating initiatives(including social marketing where applicable)

4 Business Plan should analyse the Human Resource (HR) situationHealth Facility addresses this subject in the Business Plan including a strategy foroptimising the availability of staff in accordance with the facility staffing pattern.

5 Business Plan should project revenues and expenditureBusiness Plan outlines expenditure for delivering the incentivized indicators as well as the relevant revenues

Business Plan Management Cycle

The business plan management will undergo a cycle involving four stages (Figure 3). During the first stage of the contracting process, the DMHT invites the health facility to develop a business plan. The DHMT and PPTA will provide technical support as health facilities will not be familiar with such plans. District PBF training courses will have business plans as one of the focus areas.The second stage concerns the implementation of the business plan by the health care providers. During the third stage, the DHMT, and the external verifier the PPTA monitor 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, utilization of the feedback to renew and improve the business plan, followed by renegotiation and renewal of contracts.

Figure 3. Phases of the Business Plan Management Cycle

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Chapter 5: FINANCIAL MANAGEMENT ARRANGEMENTS

INTRODUCTION

Background The government of the Kingdom of Lesotho has established a Performance Based Financing (PBF) project whose main objective is to improve utilization and quality of maternal and newborn health services at all levels of care. The PBF project which is expected to start in 2013 shall be financed jointly by the government of the Kingdom of Lesotho, the World Bank and the Health Results Innovation Trust Fund (HRITF). The project shall be implemented by the Ministry of Health (MOH) together with Christian Health Association of Lesotho (CHAL) and shall be composed of the following components and sub-components;

Component 1: Improving Maternal and Newborn Health (MNH) Service Delivery at Community, Primary and Secondary levels through PBF

Sub-component 1A: Delivery of MNH Services through PBFSub-component 1B: PBF Implementation and Supervision Support

Component 2: Training of health professionals and VHWs and improving Monitoring and Evaluation (M&E) capacity

Sub-component 2A: Training health professionals and Village Health WorkersSub-component 2B: Improving M&E capacity

The PBF Project shall be implemented in phases starting July 2013. The first phase shall be a pilot which will cover two districts namely Leribe and Quthing. The second and third phases shall run between July 2014 and June 2017 and shall cover the remaining districts except Maseru.

About the manual

This guide, the accounting and financial management procedures manual has been developed to improve credibility of all financial information and reports that shall be produced by the project. It is intended to cover accounting and financial management procedures that shall apply throughout the project’s life. This manual shall be a living document and shall therefore be updated as and when there are changes in accounting and financial management operating procedures. Any changes to this manual shall be made only through the prior written approval of the financiers as stipulated in the financing agreement. The FMO shall be the custodian of this manual and shall therefore ensure proper procures are followed before any amendments (additions and deletions) can be done. The manual shall be adopted as an official document when approved by all stakeholders. It should however be noted that operating procedures for CHAL are hereon appended.

The PBF unit

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The MOH shall establish a unit which will be responsible for day to day administration of the project. The unit shall be called the PBF unit and shall be staffed with five officers as shown in the chart below and elaborated in Chapter 3 and Annex 6. The PBF unit shall work together with an independent (international) performance-purchasing technical assistance (PPTA) firm which will have experience in PBF implementation in the health sector in Africa to support the implementation of PBF in accordance with the MOH/World Bank endorsed design. The PPTA shall also provide capacity building and implementation support to the PBF Unit.

Objectives of Accounting and Financial Management Operating Procedures

The objectives of this accounting and financial management operating procedures manual are; To ensure effective procedures for use of all assets and resources towards meeting the project

objectives, in an accountable and transparent manner. To ensure consistency in the application of accounting principles to all transactions under the

project To safeguard the assets and resources of the project

COMMITMENT – CODE OF CONDUCT

The PBF unit of the Ministry of Health (MOH) commits itself to always; Safeguard the assets and resources of the project Ensure the most effective use of all assets and resources towards meeting the project’s goals Spend funds received according to the purpose for which they have been given Conduct accounting and financial management in an accountable and transparent manner and

in accordance with Generally Accepted Accounting Principles (GAAP)

RESPONSIBILITIES

The section is intended to give an overview of different roles and responsibilities of different officers as far as financial management is consent under the PBF project.

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PBF Director

M & E Manager

Operations Manager

Financial Management officer (FMO)

Accountant

MOH Senior ManagementIt is the responsibility of MOH senior management to ensure that all sections of the PBF project including the finance and accounts section put in place appropriate and adequate internal controls to safeguard all the assets of the project and ensure achievement of project’s goals.

Finance and accounts section PBF unit It is the responsibility of the finance and accounts section to ensure that this accounting and financial management operating procedures are complied with. Specific responsibilities for accounts staff are as follows;

Financial Management Officer (FMO)The FMO is responsible for managing the financial and accounting functions of the PBF unit as well as the PBF project in line with sound financial accountability practice. This shall include among others annual financial work plans, budgets, monitoring of income and expenditure and reporting.

Accountant PBFThe accountant shall be responsible for the execution of routine financial and accounting functions of the PBF unit as well as the PBF project in line with sound financial accountability practice. This will include among others supporting the production of annual financial work plans, budgets, financial reports, monitoring of income and expenditure.

Accountant District HospitalIt is the responsibility of the hospital accountant to record all accounting transactions of the participating hospital relating to the PBF project and submit monthly reports to the FMO.

Accountant DHMTsThe Accountant at DHMTs shall be responsible to record accounting transactions relating to the PBF project for all health facilities at the specified district and shall submit monthly reports to the FMO. This shall include management of the imprest system for all participating government health centres in the district.

CHAL finance ManagerCHAL finance manager shall be responsible for financial management of the PBF project component implemented by CHAL facilities and will be supported by the accountants at the facilities.

External AuditorThe external Auditor shall be responsible to express his/her opinion on the annual financial statements.

CHART OF ACCOUNTS

The chart of accounts to be developed will be compatible with the financial structure and be in agreement with the amount of detail required in the financial statements. It shall provide a logical structure according to which all accounting transactions will be classified and hence determines

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the limits for reporting financial information. The chart of accounts shall be designed to capture the following; sources of funds (income), uses of funds (expenditure), assets and liabilities.

Chart of accounts; components, activitiesUses of funds shall cover overall project expenditures and shall be further broken down into useful categories like project component, location and categories as illustrated below.

Component 1: Improving Maternal and Newborn Health (MNH) Service Delivery at Community, Primary and Secondary levels through PBF

Sub-component 1A: Delivery of MNH Services through PBFCategories

i. Goods, small works, non-consulting services and POC required for each Heath Service Package provided under a Heath Service Project and to be financed out of a PB Grant under Part A.1 of the Project and paid at the Unit Price for said Heath Service Package

ii. Consultants servicesiii. Trainingiv. Operating costs

Sub-component 1B: PBF Implementation and Supervision SupportCategories



Component 2: Training of health professionals and VHWs and improving Monitoring and Evaluation (M&E) capacity

Sub-component 2A: Training health professionals and Village Health WorkersCategories



Sub-component 2B: Improving M&E capacityCategories



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Overview of chart of accounts (segments (digits) will be aligned to TOMPRO or the reverse)

The chart of accounts shall have a total of seven (7) digits as show below.

Segment 1 Segment 2 Segment 3 Segment 4 Segment 5 Segment 6 Segment 7Project ref #

Source of funds

Use of funds

Location/ district

Project component

Project sub component

Categories

One digit One digit One digit One digit One digit One digit One/digit

Accounting and financial management principles/policies

Financial and accounting policies shall be applied to ensure uniformity in policies and procedures applicable to all PBF project transactions within accounting periods and from one period to the other.

Fundamental accounting principlesThe following fundamental accounting principles shall be applied;

i. Cash basis accounting – this accounting principle assumes that receipts and expenditures shall be recognized in the books when money/cash is received or paid.

ii. Going concern – this accounting principle dictates that the financial statements be prepare as if the project shall exist into the foreseeable future.

iii. Consistency concept – as much as possible like transactions shall be treated similar in order to facilitate comparison from one period to the other.

iv. Financing agreement – the PBF unit shall comply with all the principles and policies of the financiers as stipulated in the financing agreement and also comply with the reporting requirements as agreed between the parties.

v. The financial accounting year shall be a period of twelve months beginning in 1st April and ending 31st March.

The accounting cycle

The accounting cycle shows the flow of documents from the time a transaction is initiated, documents produced and the information on them entered into the system, the system will process the data and finally produces the useful reports. The chart below shows the flow;

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Monthly routines

The following is a monthly accounting checklist that must be followed to ensure the accuracy and completeness of financial information. (Will be aligned to TOMPRO):

TASK RESPONSIBLE OFFICER

Date

Enter all receipts and payments for the month using check/payment requisitions, deposit books, receipts etc

Accountant PBF unit, hospital accountant, Accountant DHMTs

Every day

Raise and process invoices for services provided or costs to be recharged


As requiredFixed costs once a month

Process petty cash and expense claims and ensure all supporting documentation is received (such as log books, petrol slips, etc.)


Month end and whenever a replenishment is required

Ensure bank balances are updated Accountant PBF unit, hospital accountant, Accountant

Weekly and whenever there has been a major transaction

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Transcation

Document

Input into the System

The accounting

system

Final reports

DHMTsPut through other journal entries (examples, photocopy charges, cost allocation, petrol charges) using a journal notification form


End of 3rd week of month

Complete the bank reconciliation(s) Accountant PBF unit, hospital accountant, Accountant DHMTs

End of 1st week of month

Review the detailed ledger and reports for all possible mispostings or misallocations in the income and expenditure accounts.

FMO End of 3rd week of month

Review the balance sheet accounts to ensure all control accounts are analyzed and/or cleared and all other balances can be explained

FMO 4th week before management meeting

Enter final journals arising from the review End of 4th week

Print the following final reports:(reports to be aligned to World Bank requirements/TOMPRO)

1. Detailed ledger for the month2. Trial balance to date3. Final bank reconciliation4. Income and expenditure statement/sources and uses of

funds5. Balance sheet6. Cash movement report

FMO Beginning of 4th week of the month

THE ACCOUNTING AND FINANCIAL MANAGEMENT SYSTEM

The PBF unit (finance and accounts section) will establish a sound financial management system in order to ensure reliable, accurate and timely financial information for decision making and control. The system shall comply with International Accounting Standards IAS) and Generally Accepted Accounting Principles (GAAP).

The accounting systemAll transactions shall be processed through a double entry accounting system. There shall be the general ledger which will include control accounts for all assets, liabilities, receipts and expenditures. The following primary and subsidiary books will be maintained;

i. Cash books – they will form part of the double entry systemii. Journal book -

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iii. fixed assets register - iv. check issued register - v. Trip advances management register -

Financial management systemFunction of the financial management systemFunctions of the financial management system will include the following;

i. To provide MOH with timely, accurate and reliable financial informationii. To provide MOH with information for control and decision making

iii. To provide MOH with information for financial planningiv. Facilitate timely preparation of monthly, quarterly and annual accounting statements and

reports

Specific financial management systemsTOMPROThe PBF unit (finance and accounts section) will therefore use TOMPRO to record transactions and produce the required monthly, quarterly and annual reports.

GOLFIS District hospital accountants and Accountant DHMTs will use GOLFIS to record financial transactions and report to the FMO on a monthly basis.

PASTEL Accounting CHAL will use its existing ‘Pastel’ accounting system. CHAL Finance manager will submit reports to the PBF FMO on (specify date) for consolidation. Both managers will agree on the best possible way of reconciling the two systems to enable timely production of consolidated monthly, quarterly and annual reports.

PETTY CASH IMPREST SYSTEM

Petty cash is only used to pay for incidental costs where a cheque or EFT is not appropriate. Amounts reimbursed from petty cash are subject to the authorisation limits by the PBF unit Director. The petty cash float will be reimbursed using the imprest system.

The following procedures shall be observed; Staff must request the amounts required together with a reason for needing the amount,

before making the purchase. Under no circumstances can staff purchase an item and then claim from petty cash. In such cases claims for payment must be made using an expense claim form.

For every payment of petty cash, an internal petty cash voucher must be prepared, describing the nature and purpose of the expense and the amount issued.

This voucher must be signed by the person receiving the money and authorized in terms by the designated authorizer.

Wherever possible, external supporting vouchers should be attached to the internal petty cash voucher, such as till slips, invoices, receipts, etc.

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The petty cash voucher must be numbered and the supporting vouchers stapled to the voucher.

Requests for reimbursement of petty cash must be made using the imprest system. No additional amounts must be issued until the full float amount has been fully accounted for. At all times the cash plus the total internal petty cash vouchers (i.e. that which has been spent) must equal the float amount.

The actual expenditure from petty cash should be presented for reimbursement at least once a month.

The actual expenditure must be analysed by expenditure type on a petty cash sheet or in a petty cash analysis book using relevant columns, entering each petty cash voucher in number sequence.

Petty cash should be kept in a separate locked cash box. This should not be mixed with any other cash. Any shortfall must be recovered.

Only one person should have control over the petty cash and the box so that one person is held fully responsible for the petty cash float. It should not be passed from one person to another but, if this cannot be avoided, the cash and vouchers must be checked by both parties and signed for to ensure responsibility is passed officially.

The Financial management Officer must carry out regular “surprise checks” to ensure that the full amount of the petty cash float can be accounted (in cash plus vouchers). The check must be evidenced by a full signature on the petty cash sheet/book.

SYSTEM OF INTERNAL CONTROLIt is the responsibility of MOH senior management to ensure that there is a strong system of internal controls in place. Management should ensure that there are sufficient internal controls in place to enable them to effectively manage the operations of the project and therefore enforce adherence to the system of internal controls. The following controls shall be put in place; No one officer can execute a single transaction from the beginning to the end.

Responsibilities entailed within a single transaction should be shared among a chain of personnel to ensure checks and balances. But in the unusual circumstances where one person is required to carry out multiple responsibilities, independent check and accountability will be enforced.

Transactions can only be executed after they have been approved and authorized by the authorised personnel.

There should be adequate supervision at all levels to ensure that controls are adhered to at all times.

The PBF Unit should have formal, documented organizational structure with clear lines of responsibility

The PBF Unit should ensure that there are adequate controls in place to ensure the completeness and accuracy of the financial records.

There should be adequate physical control to ensure the security and safekeeping of all the assets.

AUTHORIZATION OF EXPENDITURE All activities under this project including financial transactions such as requisitions for goods/services purchase orders, payment vouchers, checks and bank instructions letters must be approved by relevant officers.

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Goods and/or servicesAuthorization of expenditure MOHPrincipal Secretary for Health, Director General for health services, Director primary health care, Director Planning and Statistics, Director PBF Unit and Director Finance and Accounts.

In cases where signatories are going to be direct beneficiaries to the payments, they should not authorise such expenditures. Authorization shall also be guided by the provisions of the financing agreement and the current rules and regulations governing MOH expenditure authorization.

Authorization of expenditure CHALExpenditure for CHAL shall be dealt with as per the organization’s policy and procedures.

Authorization of expenditure district hospitals Government hospitals expenditure shall be approved by the DMO and the Nursing Manager.

Authorization of expenditure DHMTsThe DHMT approval shall be done by Director DHMT, the Public Health Nurse and one member from the DC’s office.

Authorization of expenditure Health centresSince health centres do not currently have capacity to manage the financial transactions they shall be assisted by the Accountant DHMTs who shall submit monthly reports to the FMO at the PBF unit. The Director DHMT, the Public Health Nurse and one member from the DC’s office shall authorize all payments on behalf of the Health centres.

Authorization of expenditure for payment of PBF incentivesAll invoices for quarterly/monthly payments to health facilities must be verified and approved by the PPTA before the finance and accounts section of the PBF unit can prepare them for payment. The PPTA and the PBF unit shall decide on administrative procedures for the flow of invoices.

Responsibility of authorizing officersAuthorizing officers must always ensure that;

i. All the relevant supporting documents are attached and that payments are only made for transaction in favour of the Project.

ii. Amounts in the payment vouchers match with amount on the cheque and invoices.iii. Payments are charged to the correct donor account.iv. All transactions are made for the benefit of the projectv. All transactions are made in accordance with business plans and/or PBF operational plans

PAYMENT

Payment of goods/servicesAll payments for goods/services received shall be made against properly authorised documentation (requisition, order, invoice, budget) and approved by any two of the authorised signatories mentioned above.

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The following must be observed before a payment is made;i. An original invoice must be obtained from the supplier and matched to the order as

evidence of receiving the goods or services (delivery note). Payment must not be made against a statement. If an original invoice is lost, a copy invoice can be processed only if a reason is

added to the copy being processed and full checks have been carried out to ensure that a payment has not been made previously against the original invoice.

No payment can be approved against a manually altered invoice. If checking reveals that an error has arisen on the invoice, the invoice cannot be amended and the supplier must be asked to provide either a credit note and replacement invoice or an adjusting credit note.

ii. A cheque/payment vorcher is prepared for the payment, showing a detailed description of the purpose of the payment, details of the supplier to whom payment is due, the goods/services being paid for, the invoice value (and any VAT amount included) and the account(s) to be charged.

iii. The following supporting documents shall be attached to the cheque/payment voucher: Original unaltered invoices Authorised order form Proof of delivery (where appropriate) or a signature on the invoice as evidence of

a service being delivered. Any other document that may be found necessary depending on the type of

transaction

Payment made through bank transfers should also be signed by any two officers authorized to approve transaction under the project.

Payment of PBF incentivesAll payments for PBF incentives shall be made against properly authorised documentation (invoice, business plan) and approved by any two of the authorised signatories mentioned above.The following must be observed before a payment is made;

i. An original invoice must be obtained from PPTA and must have been verified and approved for payment.

ii. A cheque/payment voucher is prepared for the payment, showing a detailed description of the purpose of the payment, details of the health facilities to whom payment is being made, the type of PBF incentive (quantity, quality, remoteness), the total invoice value, and the account(s) to be charged.

iii. The following supporting documents must be attached to the cheque/payment voucher whenever applicable:

Original unaltered invoices from PPTA Copy of the quarterly business plan period to which payment is made Report on quality assessment by DHMT Any other attachments as agreed between the PBF unit and the PPTA

Payment made through bank transfers shall also be signed by any two officers authorized to approve transaction under the project.

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Payment of VHWs incentiveVHWs incentives shall be transferred directly into individual personal accounts by the PBF unit (finance and accounts section) after receipt of the instructions from the concerned health facilities.

No expenditure will be paid by the project if;i. The expenditure does not fall within the objectives of the project or within the relevant

budget lineii. The expenditure is unnecessary in completing those objectives effectively or in

otherwise supporting the projectiii. There is no funding specified or available for the type of expense or purpose.iv. There is no money available in the bank to cover the cost.v. Such expenditure is not covered by the financing agreement

FINANCIAL REPORTING

It is the responsibility of the MOH senior management to ensure that there is financial accountability and that financial statements are prepared and submitted for audit within three months of the financial year. The project shall be expected to produce monthly reports, quarterly reports and annual reports as shown below.

Monthly reportingThe project is expected to produce monthly reports which shall be discussed at the PBF monthly meetings and can also be presented to MOH senior management as and when required to do so. These reports will also be shared with the PPTA. On a monthly basis CHAL shall be expected to submit monthly reports in a format that will be agreed upon between the FMO and the CHAL finance manager. The DC’s finance managers and hospital accountants shall also be expected to submit monthly reports to the FMO. CHAL finance manager or any other CHAL officer can also be invited to attend the monthly meetings where these reports are discussed. The monthly reports shall be composed of the following;

i. Cash and bank reportThis statement is intended to show the summary of the project’s liquidity position and the report is prepared every month.

ii. Bank reconciliation statementThe main purpose of the statement is to identify the discrepancy between the Bank statement balance and Cash Book balance by checking all transactions relating to Bank and Cash Book are properly recorded to arrive at the correct balance.

iii. Receipts and expenditure statementThis statement shows how much revenue has been received and how much has been paid in a particular month. Both receipts and payments can also be compared to the budget and the reasons for any under/over be established.

iv. Sources and uses of funds statement

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This statement is a summary of the opening balance of Funds and incoming funds from different sources during the project. Deductions of Funds are made for Funds used to meet expenses in order to arrive at the closing cash and bank balances.

Quarterly reportingThe finance and accounts section of the PBF project shall prepare and submit quarterly Interim unaudited Financial Reports (IFRs) to the World Bank/IDA and they will be composed of the following;

i. Sources and uses of funds Statementii. An updated six month forecast

iii. Designated account activity statementiv. Uses of funds by componentv. Uses of funds by activities

vi. Statement of eligible expenditure under contracts subject to and not subject to prior review

The quarterly IFRs shall be furnished to the Bank no later than forty-five days after the end of each calendar quarter. The reports are intended for reporting purpose and must include information from CHAL, DCs and district hospitals.

Annual reportingThe FMO and the accountant of the PBF unit shall prepare the annual financial statements in accordance with the Generally Accepted Accounting Practice. The annual financial statements shall be composed of the annual Sources and uses of funds Statement, annual Designated Account activity statement, Uses of funds by component, Uses of funds by activities and Statement of eligible expenditure under contracts subject to and not subject to prior review. There shall also be notes to the accounts accompanying the financial statements. These reports shall be made available to the external Auditor for auditing purposes not later than three months after the year end.

FUNDS FLOW

It has been mentioned that the project shall be financed by the World Bank and HRITF. The MOH shall open two accounts, one denominated in US$ and the other in Maloti. The US$ account is called Designated Account (DA) and the funds from the financiers will be deposited into it. The amount to be deposited will be based on approved six month cash forecast. The MOH shall open another operational account with a commercial bank. The operational bank account shall be a Maloti account. The two accounts shall be maintained by the PBF unit. On a quarterly basis the PBF unit shall transfer funds to CHAL (the secretariat) on behalf of health facilities participating in the PBF project. This will be a lump sum transfer for all facilities under CHAL for a particular quarter. The funds transferred will be based on approved business plans and verified invoices by the PPTA. It will be the responsibility of CHAL finance manager to transfer funds to individual facilities account. The time taken to transfer funds is expected to be as short as possible and the PPTA is expected to monitor the turnaround time for the transfer of funds to facilities.

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The PBF unit shall also transfer funds to hospitals and DCs accounts based on business plans and invoices approved and verified by PPTA. The diagram below shows how funds will flow from the PBF unit to CHAL, DCs and hospitals.

Figure 4. Funds flow diagram

BANKINGThis section is intended to give guidance to PBF unit for proper management of all bank accounts and transactions relating thereto and therefore maintain good relations with banks.

Bank signatoriesThe following officials shall be signatories to the project bank accounts and all financial instruments; Director General for health services, Director primary health care, Director

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GOL

MOH Operational Account in Maloti

Transfers to implementing entities for performance-

based payments

Suppliers/Service providers for all

components

HRITFIDA

MOH Designated Account (DA) in USD

Planning and Statistics, Director PBF Unit and Director Finance and Accounts. Each transaction shall be signed jointly by two signatories.

Banking procedures A request for new check books shall always be signed by at least two of the signatories All unused booklets shall be kept in a safe box in custody of the FMO A Check-Issued Register shall be maintained to record cheques to suppliers Cash books/financial records shall be reconciled monthly with the bank statements and the

FMO shall make an independent checking and approved accordingly. All differences will be investigated and resolved within the relevant financial period;

Checks that are not presented for payment to the bank within six months of the date they are written will be added back into the project’s books of accounts one month after their negotiable period has elapsed;

Official receipts must be issued serially for all cash or check collected and recorded serially in the cash book, and all cancelled receipts shall have the originals attached to the duplicates;

Money collected shall be deposited into the bank within 24 hours. Where this is not feasible, money not yet banked shall be kept in the safe box. Under no circumstances shall personal money be kept in the safe

All check shall be written out in the name of the beneficiary that appears on the supporting documents or the proxy thereof.

ANNUAL AUDIT

The project shall conduct an annual audit as required by the financiers. The project shall prepare accurate and properly supported draft financial statements with notes prior to the commencement of the annual audit. The project shall also have to ensure that an engagement letter has been signed and a pre-audit meeting is held with the auditors to ensure that requirements and expectations are clear. This is the meeting that shall highlight the audit terms or scope of the work requirements of the financiers. The FMO must ensure that not only copies of funding agreements or contracts are made available to the auditors but must also ensure that the Auditors have access to all documents of the project needed to perform the task. The project shall be expected to furnish to the Bank audited financial statements for each period not later than six months after the end of such period.

BUDGETING AND PLANNING

All facilities shall prepare annual business plans with the assistance of the PBF unit and PPTA agency. Health facilities staff, proprietor, the community representatives and other stakeholders will be expected to take part in the development of this tool. The business plan shall be used as a guiding and monitoring tool to help facilities achieve their objectives. All plans shall be approve by the relevant authorities before submission and implementation. The PBF unit and PPAD Shall also assist facilities to constantly monitor their plans and hence ensure improved quality of services.

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In addition the PBF unit shall develop an annual operational plan which will ensure proper implementation of the overall project. This shall be done in consultation with the PPTA. As the national overseer of the PBF project the PBF unit shall ensure that all parties taking part in the project use the budgeting and planning tool to achieve the project’s objectives. See sample business plan in PIM/PUM.

TRAVEL POLICY

This section is intended to give guidance to the PBF unit (finance and accounts section) on how to pay allowances where officers are on official trips both inside and outside of Lesotho. By all means possible, the section shall be in line with the rules and regulations governing the civil service as issued by the Ministry of Public Service.

Objectives of travel policyThe objective is to standardise the basis at which allowances shall be payable to officials travelling on PBF business based on the financial support available, the nature of the travel, whether sponsored or not, and other administrative issues as may be stipulated by the financiers in the project agreement documents.

Local TravelOfficials shall be entitled to M50/night for overnight stay. Meal allowance shall be payable at the rate of M100.00 per meal for all official field trips provided; The trip is approved by the relevant authorities It is budgeted for under PBF project (Donors or GOL funding) and funds are available Meals are not covered by any PBF project or GOL purchase order Meals are not provided by another party

In cases where a purchase order has been issued and covers only bed and breakfast, meal allowance for lunch and supper shall be paid using one of the following options ;

i. Be given M100.00 per meal and shall only be accounted for using the filled expenditure form

ii. Allowance for lunch and supper shall be payable at the prevailing booked hotel rates for meals and the officer shall be expected to account for the money by producing authentic invoices from the supplier and return the change to the PBF unit (finance and accounts section).

Travel outside of LesothoThis section covers all international trips sponsored under the project. It is intended to cover all the incidental costs i.e. meal allowances, accommodations costs and other emergency costs while on official international trips.

Fully Sponsored trip by organisers:For all travels where the officers have been officially invited to attend and the organiser is fully sponsoring the essential costs (airfare, accommodation, meals, per diem) , the PBF project shall not provide the delegate with any per diems since they will be payable by the organisers.

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Partly Sponsored trip by organisers:In the case where the organiser is one of the Project’s partners and the PBF unit is required to pay per diem to the delegate, such will only be payable to the extent that it is budgeted for and that funds are still available within the particular budget line. Per Diem shall be payable on the rates determined by the organiser (donor) or the GOL travel policy. Such a per diem shall not be accountable.

Depending on various issues pertaining to the travel, there may be situations where the delegate will be given a certain amount as accountable per diem that will cover incidental costs that may arise from time to time based on GOL travel policy.

Where the organiser is not covering for payment of per diems, the PBF project can only pay for such if funds are available within the respective budget line from the delegates program or there is funding from GOL.

For all travels where the PBF unit delegation has been officially invited to attend the event and the organiser is partly sponsoring the essential costs (airfare, accommodation and meals), the PBF unit shall only provide the delegate with per diems at the rate applicable under GOL travel policy provided it is budgeted for and funds are available.

Planned trip:Where the trip is an internal initiative and form part of the operational plan or it is believed to be an investment to the attainment of the project’s objectives, the employee shall be expected to submit the following to facilitate prior approval:

Formal invitation /acceptance letter The concept paper A brief highlighting how the trip, workshop or training will benefit the Project and contribute

to the attainment of projects objectives. A detailed breakdown of all costs related to the trip

On the basis of availability of funds and whether it was a planned activity covered in the annual work plan, the employee can then be authorised to attend the workshop, training, etc. In cases where funds are in-sufficient, the costs shall be prioritised to ensure that direct costs are covered first.

For all travels, the delegates will be expected to submit their “boarding pass cards” to the PBF unit (finance and accounts) and any other accountable documents.

For all travels, delegates are expected to submit a narrative report to the immediate supervisors within five working days after the activity. A 10% per diem per day to a maximum of fourteen days shall be payable to an officer who attends training outside Lesotho.

WORKSHOPS

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Since the project shall provide a number of trainings through workshops and also that the financing agreement so require, it is desirable that this manual should provide guidance on handling finances relating to workshops.

PrerequisitesWhen the project conducts workshops, trainings or other similar activities, the activities shall be accurately recorded, both in terms of results and costs. Any proposal to conduct training and/or workshop shall include the following;

i. Objectives and content of the training/workshop ii. How institutions or individuals conducting the training/workshop will be selected and

if known their namesiii. A mini- budget of the training/workshop and expected durationiv. How the personnel who shall attend the training/workshop will be selected and if

known their names/designations

WORKSHOP/TRAINING PROCEDURES The following procedures shall apply to all trainings and workshops conducted under the PBF project; Events must be planned and approved in principal and scheduled well in advance of the event Workshop costs should be incurred on the basis of the original project budget and in

conformance with the donor’s requirements. A mini-budget shall be used to help monitor project spending. Any procurement that shall be done as part of this activity will be done in a competitive manner

The officer responsible for the workshop shall sign the mini-budget form to confirm the request for funds and other resources that need to be made available

The PBF director or the PPTA must finally check the proposed mini-budget against the overall activity/programme budget and sign so that the cash advance (if necessary) or purchase order can be issued to the responsible officer

The person who receives any advances provided to prepare for the workshop shall be responsible for the funds, for preparation and submission of expenses reports, to account for the advance and depositing the full amount of any unused funds into a designated/operational bank account. She/he will also be responsible for submitting bank deposit slips to the Accountant. Such advances shall be retired within two weeks of the end of the event

Failure to return the slips and remaining funds shall result in further advances not being granted to such officer. In such instances, an acknowledgement of debt will be signed and the unaccounted amount deducted from the officers next salary as per government treasury regulations

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Chapter 6: Procurement Arrangements

The procurement arrangements are detailed in a separate procurement manual.

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Chapter 7. Environmental and Social (including safeguards)

No major works will be directly financed by the project. However, health centers and hospitals may use the performance-based payments under sub-component 1A for small repairs of existing health structures. Such minor works shall exclude any new building and will be undertaken according to national and local laws and regulations. Accordingly, no specific environmental safeguard instrument is required here.

The project will increase the utilization of health services which will increase health care waste production. Accordingly, the health center and hospital quality checklists, which will be filled out once per quarter for each PBF facility, will enable the monitoring and incentivizing adherence to GOL health care waste management regulations and guidelines.

Consequently, the proposed project has been classified as a Category B for environmental assessment given the risks associated with the handling and disposal of health care risk waste (HCRW) and health care general waste (HCGW). The project is not expected to generate any major adverse environmental impacts. Possible environmental risks include the inappropriate handling and disposal of hazardous medical waste, including sharps, and especially the inadequate management of disposal sites in rural areas, where domestic and health care waste, in particular HCRW, could be mixed.

To address the potential negative impact consistent with the requirements of the triggered Environmental Assessment safeguard policy, OP/BP 4.01, the MOH will implement the Consolidated Lesotho National Health Care Waste Management Plan (CLNHCWMP) which was prepared and adopted in 2010, and consolidated and updated in August 2012 for the purposes of the proposed project. The consolidated HCWMP provides adequate recommendations regarding appropriate waste management and disposal procedures pertaining to both HCRW and HCGW, a detailed account of the current policy framework, baseline situation and capacity building needs, and a detailed implementation and monitoring plan going forward, in order to ensure its proper and effective execution. Under the CLNHCWMP, a phased approach – 4 phases - to the implementation of an improved HCWM system was developed. MOH is currently implementing Phase II (2012-2014) first through a Pilot Project testing improved HCW management options for containerization, collection, and disposal of HCRW. The pilot is being implemented in Berea, Leribe, and Maseru districts and will run November 2012 to November 2013. National roll-out is anticipated to be launched for all other districts starting in May 2013. IFC is supporting the Pilot Project through the Health Care Waste Management PPP which has helped the MOH with the procurement of a private operator to undertake health care waste management services. As part of the IFC’s PPP pilot, collection and disposal of HCRW has been outsourced to a service provider. The pilot will help the MOH: (i) build capacity in HCRW collection and disposal, (ii) complete a cost-benefit analysis of different methods for HCRW collection and disposal, and (iii) decide whether to continue to outsource HCRW collection and disposal or to keep these functions in-house.

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Chapter 8: Monitoring & Evaluation Arrangements

The Project Development Objective (PDO) is to improve the utilization and quality of maternal and newborn health (MNH) services in 9 districts in Lesotho. Selected services in the Lesotho essential services package such as HIV and AIDS, tuberculosis and nutrition will also be covered.

The M&E arrangement for the project has three sections: (i) monitoring of the PBF implementation (or process evaluation); (ii) results monitoring of the project using the results framework; and iii) impact evaluation of the project. The documentation or reporting of the M&E of the PBF project is critical to regularly keep the Government, Civil Society Organizations, Development partners and other stakeholders informed of progress towards the achievement of the PDO.

Monitoring of the PBF project implementation

The monitoring of the PBF project implementation (or process evaluation) entails “The systematic collection of information on a program’s inputs, activities, and outputs, as well as the program’s context and other key characteristics” (Center for Disease Control and Prevention, 2008). Process evaluation is essential for the following reasons: (i) allows early identification of implementation challenges and for timely appropriate corrective actions to be taken; (ii) provides records on what actually happened during project implementation and for the dissemination of lessons learned with local, national and international audiences; and (iii) helps explain the findings of the impact evaluation by providing contextual information on how and why (or not) the PBF project was successful.

Several activities as outlined in other chapters of the PIM will be undertaken and monitored. Table 10 provides a list of some of the activities to be monitored, the data sources, frequency of reporting, and the responsible entities.

Table 10. Activities, schedule and methods for process evaluation

Description of activity Method/data source Frequency/timing ResponsibilityDevelopment of health facility Business plans:timeliness, target setting, challenges, recommendations etc

Business plans, DHMT supervision reports, interviews of health facility staff, District PBF steering committee and DHMT

Quarterly PPTA, DHMT, PBF Unit

Contract for health centres - timelines in preparing and signing, challenges in implementing it, sanctions for non-compliance or fraudulent data etc

Health centre contracts, DHMT supervision reports, interviews of health facility staff, District PBF steering committee and DHMT

Quarterly PPTA, DHMT, PBF Unit

Motivation agreement for health Motivation agreements, Quarterly Health centre

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Description of activity Method/data source Frequency/timing Responsibilitycentre staff interviews of health

personnel and administrators

committees, DHMT

MOU between health centres and VHWs;performance of VHWs, is supervision adequate, do VHWs submit their reports timely, relationships between VHWs and health centre staff, are there issue with the proportion of incentive payments to the VHWs, community participation etc

MOU, interviews of VHWs, and health centre staff

Quarterly Health Centre, DHMT

Contract for district/local hospitaltimelines in preparing and signing, challenges in implementing it, sanctions for non-compliance or fraudulent data etc

Hospital contracts, MOH Clinical services Directorate supervision reports, interviews of health facility staff and DHMT

Quarterly MOH Clinical services Directorate, PPTA

Contract for DHMTtimelines in preparing and signing, challenges in implementing it, sanctions for non-compliance or fraudulent data etc

DHMT contracts, MOH Primary Health Care Directorate supervision reports, interviews of health facility staff and DHMT

Quarterly MOH Primary Health Care Directorate, PPTA

Motivation agreement for DHMT staff

Motivation agreements, interviews of DHMT staff, District PBF Steering committee members

Quarterly MOH Primary Health Care Directorate, PPTA

Ex-ante verification – quantity of services at health centres: comments on the quality of data, timeliness of submission of report, over reporting or fraudulent data, Which services are (or not) performing well and why etc

Health centre monthly report, ; interviews of health centre personnel

Monthly PPTA verification officers and DHMT

Ex-ante verification – quantity of services at hospitalscomments on the quality of data, timeliness of submission of report, over reporting or fraudulent data Which services are (or not) performing well and why etc

Hospital monthly report, interviews of hospital personnel

Monthly PPTA verification officers, MOH Clinical Services Directorate

Ex-ante verification – quality of services at health centres:Challenges noted in supportive supervision visits, have recommendations been addressed – why or why not;

DHMT health centres supervision reports/quality checklist; interviews of health centre personnel who were present

Quarterly DHMT and PPTA verification officers

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Description of activity Method/data source Frequency/timing Responsibilityappropriateness of the checklist during supervision

visitsEx-ante verification – quality of services at hospitalsChallenges noted in supportive supervision visits, have recommendations been addressed – why or why not; use of the checklist

Peer review mechanism/quality checklist, supervision reports; interviews of hospital personnel who were present during supervision visits

Quarterly Personnel from other hospitals, MOH Clinical Services Directorate, DHMT, PPTA verification officers

Ex-post verification – quantity and quality of services at health centres and hospitals:Challenges, areas for improvement, success stories,

Randomly selected clients from the health facility registers for client satisfaction surveys by phone interviews or home visits

Quarterly CBOs/NGOs contracted by PPTA

Independent health facility quality of care assessments

Health centre and hospital quality checklists

In May each year MOH Quality Assurance Unit, PPTA

Review and validation of invoices submitted by health centresVariation in quantity and quality of services among health centres within and across districts and why

Heath centre invoice; interviews of health centre personnel, district PBG Steering committee, DHMT

Monthly District PBF Steering Committee

Review and validation of invoices submitted by hospitalsVariation in quantity and quality of services across hospitals and why

Hospital invoice, interviews of hospital personnel

Monthly MOH Clinical Services Directorate

Review and validation of invoices submitted by DHMT

DHMT invoice Monthly District PBF Steering Committee

Use of incentive payments at health centres and hospitals

Health centre and hospital quarterly report, field visits, interviews/group discussions

Quarterly DHMT, PPTA, PBF Unit

Performance of National Sexual and Reproductive Health Steering Committee

Minutes and observation of meetings; interview of committee members, TWG, MOH PBF Unit

Quarterly PPTA, PBF Unit

Performance of the District PBF Steering committees

Minutes and observation of meetings; interview of committee members, DHMT, health centres

Quarterly PPTA, PBF Unit

Performance of the health centre committees

Minutes and observation of meetings; interview of committee members, DHMT, health centres

Quarterly DHMT, PBF Steering committee

Working relationships between district PBF steering committees

Interviews of members of both committees

Quarterly PPTA

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Description of activity Method/data source Frequency/timing Responsibilityand health centre committeesPerformance of CBOs/NGOs on ex-post verificationtimeliness of the reports

Review of ex-post verification reports, interviews of CBOs/NGOs

Quarterly PPTA

HMIS – quality of data, challenges, timeliness, areas for improvements; did the PBF help improve HMIS data?

Health facility monthly reports on quantity of services, PPTA reports on data summited in invoices, PBF web-enabled application

Quarterly PBF M&E officer, PPTA

PBF web-enabled application – usefulness, challenges and success stories, areas for improvement, is data in the paper monthly invoices the same as that in the website

Review of the functioning of the PBF web-enabled application

Quarterly MOH IT Unit, PPTA

Performance of PPTA-Key performance indicators in the PPTA contract

Interviews of various entities in the PBF institutional arrangements described in chapter 3

Quarterly PPTA, MOH PBF Unit

Performance of PBF Unit:overall management of the project; adequacy of staffing (time allocation), office equipment, transport etc;

Interviews of various entities in the PBF institutional arrangements described in chapter 3

Quarterly PPTA, MOH PBF Unit

Verification of data provided by health facilities To ensure accurate reporting and payments, several mechanisms have been put in place for ex-ante and ex-post verification of data reported by health facilities.

(a) Ex-Ante Verification: The quantity of services delivered by the health centres and hospitals will be verified prior to making the incentive payment. Each PBF facility will report monthly on delivery of agreed outputs. The quantities reported will be systematically verified by the PPTA verification officers and DHMT. Additionally, a PPTA verification officer will participate in quarterly DHMT supervision visits to health centres to verify the quality of service delivery using a health centre quality checklist. For the hospitals, a peer review mechanism will be employed to perform quality verification to provide immediate feedback to the hospital staff regarding their performance on the quality checklist. Peer reviews will comprise personnel from other hospitals and the MOH Clinical Services Directorate with a representative from the DHMT. Based on performance data (both quantity and quality), the District PBF Steering Committee and PBF Unit will review and validate the quarterly amounts to be paid to each health centre and hospital, respectively. A PBF web application,30 that will be developed by an independent consultant working closely with MOH ICT staff, will facilitate invoicing and reduce delays in the payment of incentives.

30 These are currently being used in Rwanda, Burundi, Zambia, Nigeria, Chad and Benin.78

Table 11. Steps for ex-ante verification of quantity of services at health centres and hospitals

HC Level/Facility level Hospital/District/LocalA schedule of visits to health centres is developed on a monthly basis by the DHMT/PPTA

A schedule of visits to district/local hospital is developed on a quarterly basis by the MOH M&E Unit/PPTA.

A data verifier/evaluator is assigned by the DHMT/PPTA A data verifier/evaluator is assigned by the M&E/PPTA.

The evaluator liaises with the health centre in‐charge and the District Health Information Officer to prepare for the visit and ensures that the HC registers are ready for verification.

The evaluator liaises with the hospital in‐charge (DMO or Superintendent) to prepare for the visit ensures that the hospital registers are ready for verification.

At the end of the assessment, the data verified in the registration/referral books are compared with the monthly HMIS/PBF submitted data.

At the end of the assessment, the data verified in the registration books are compared with the monthly HMIS/PBF submitted data.

In case of any deviation between submitted and verified data recommendations for improvement in recording are given; in case of major discrepancies found (more than 5%) this will have consequences for PBF benefits.

In case of any deviation between submitted and verified data recommendations for improvement in recording are given; in case of major discrepancies found (more than 5%) this will have consequences for PBF benefits.

The DHMT/PPTA prepares the final monthly invoice31

(Annex 30) based on the verified data in the health facility. The invoice is then discussed and approved with names and signatures of the nurse in‐charge. A copy of the invoice is given to the health centre for records. The original copy of the invoice is sent to the PBF District Steering Committee (DSC). Once per quarter the PBF DSC will review the monthly invoices for quantity of care delivered and the quarterly report on the quality of care delivered. These will be subsequently forwarded to the PBF Unit.

The MOH M&E/PPTA prepares the final quarterly (initially monthly) invoice32 (Annex 31) based on the verified data in the health facility. The invoice is discussed and approved with names and signatures of the DMO/superintendent. A copy of the invoice is given to the hospital for records.

The original copy of the Invoice is kept by the PBF Unit

The PBF unit will prepare a payment advice per facility based on the invoices/reports received, which will be forwarded to HPSD Director for authorisation after which the MOH fund holder will effectuate payments.

The PBF unit will prepare a payment advice per facility based on the invoices/reports received, which will be forwarded to HPSD for authorisation after which the MOH fund holder will effectuate payments

Table 12. Steps for ex-ante verification of quality of services at health centres and hospitals

HC Level/Facility level Hospital/District/LocalA schedule of visits to health centres is developed on a quarterly basis by the DHMT/PPTA

A schedule of visits to district/local hospital is developed on a quarterly basis by the MOH/Directorate of Clinical Services.

The DHMT/PPTA liaise with the health centre in charge to prepare for the visit

The MOH/Directorate of Clinical Services liaise with DDHS/Superintendent to prepare for the visit

The assessors together with the health centre in charge The assessors including peer reviewers from other

31 The invoices will be submitted online after the PBF web-based application is fully functional32 The invoices will be submitted online after the PBF web-based application is fully functional

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conduct the assessment hospitals together with hospital staff conduct the assessment

The team of assessors will discuss the findings with the health centre staff. Positive results should be acknowledged and encouraged. After the discussions, the assessors, together with the facility in-charge, should draw up recommendations including those requiring technical supervisions.

The team of assessors will discuss the findings with the health centre staff. Positive results should be acknowledged and encouraged. After the discussions, the assessors, together with the facility in-charge, should draw up recommendations including those requiring technical supervisions.

At the end of the assessment, data are approved with names and signatures of the health centre in charge or his/her substitute.

At the end of the assessment, data are approved with names and signatures of the DDHS and Hospital Superintendent.

A copy of the results of the assessment is given to the health centre and DHMT

A copy of the results of the assessment is given to the hospital for records

A copy of the scored checklist and a summary of the quarterly assessment of the health centre is shared with the health centre in charge or his/her substitute.

A copy of the scored checklist and a summary of the quarterly assessment of the hospital is shared with the DDHS and Hospital Superintendent.

Results are then presented and discussed together with data on quantity of services during the quarterly PBF District Steering Committee meetings.

Another copy is given to the PBF Unit that will compile it with quantity results to produce a final invoice for payment processing

(b) Ex-post verification: This will be carried out in two ways. The PPTA will contract local community-based organizations or non-governmental organizations to visit homes (or by telephone) of randomly chosen clients from the registers in facilities to determine whether they exist, whether they received the services that have been paid for, and their satisfaction with these services (client satisfaction survey). Each quarter, a random selection of health facilities and services will be assessed. Each defined service will be recorded with a client address and a mobile phone number through which a client can be reached (for efficiency purposes patients will be interviewed through their cell phones, where possible). The contract for CBO/NGO contract is in Annex 29 while the CBO patients tracing and satisfaction survey format for health centres and District/Local hospitals are shown in Annexes 30 and 31 respectively. Additionally, health facility quality of care assessments will be carried out to independently by the Quality Assurance Unit to verify the Health Facility Quality of Care Score.

Table 13. Steps for ex-post verification of quantity and quality of services at health centres and hospitals by CBOs/NGOs

Health centre or hospitalEvery month, PPTA to select a random sample of users of the health services of the contracted health centres and hospitals

PPTA to provide to CBO, the full names, name of health facility, name of district, name of village, date of received service, address, telephone number of patient or family member etc

CBO to make phone calls to each selected participant and administer the patient tracing and satisfaction survey 80

questionnaire

For clients without telephone numbers, CBO to visit at home and administer the survey questionnaire. If the client cannot be traced, then the PPTA will replace with another client

CBO to ensure questionnaires are complete before submitting to the PPTA.

PPTA the data and share reports with the District PBF Steering Committee and the PBF Unit

Table 14. Steps for annual independent health facility quality of care assessments by Quality Assurance Unit

Facility level (Health Centre/Hospital)The Quality Assurance Unit is mandated by the PBF Unit to organize this third party evaluation according to a protocol

The QA Unit should assure that the quality checklist has been field-tested rigorously to ascertain that indicators are objectively verifiable and reproducible by a second person

A method of random selection of facilities to be audited will be developed

The QA Unit to meet with the Chair of the PBF District Steering Committee to prepare for the visit in the respective district

The meeting ends with choosing a date for carrying out the evaluation

The QA Unit will carry out the evaluation according to the agreed schedule

The QA will write a short report on the results, after comparison with the results that have been submitted and utilized during the preceding assessments

The report should be submitted to the PBF District Steering Committee and to the PBF Unit

The PBF Unit will provide guidelines on how to interpret results

Health centre monthly reports Each month the health facility will be required to fill out a monthly HMIS/PBF report that summarises the number of services delivered under each incentivised indicator as recorded in each of the corresponding facility registers and/or other registers created for the purpose.

OPD register ANC register Delivery register Referral book/letters PNC register FP register Under 5 register TB register

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An essential activity at the health facility is ensuring that the services that have been reported have actually been delivered. Accurate reporting therefore becomes an essential part of this model. The monthly HMIS/PBF report is sent to the DHMT (by the 7th of the following month), respecting the agreed deadlines for submission.

District/Local Hospital monthly reportsAs is the case with health centres, each month the district/local hospital will fill out a monthly HMIS/PBF report that summarizes the number of services delivered under each incentivized indicator as recorded in each of the corresponding facility registers and/or other registered created for the purpose:

OPD register ANC register Delivery register Operations records Inpatient register Referral records/counter referral letters

The HMIS data with additional information required for the PBF output indicators are sent monthly to the PBF Unit/PPTA and the District Health Information Officer. The MOH-M8E Unit, supported by the PPTA, is responsible for conducting quarterly quantity audit of the PBF incentivized indicators, which coincides with the quarterly quality assessment carried out by the MOH/peer review.

District/local hospitals have a large number of indicators for both primary and secondary care services whereby some of these indicators are not readily produced in the HMIS in place. Hence it is essential that initially the audits will be performed on a monthly basis until the minimum standards are met, i.e. no or limited (less than 5%) discrepancies between what the facility submitted and what has been verified.

Trustworthiness/completeness of data reporting

In case of any fraud discovered by either the PPTA, the DHMT or the NGO/CBO contracted for counter verification, a report will be filed and forwarded to the PBF District Steering Committee. Fraud includes the intentional falsification of institutional registers, such as entering non-existent patients in the registers or services that have not been provided to the patient, for the sole purpose to receive additional PBF benefits.

Any suspected fraud will be reported to the PBF Districting Steering Committee, the MOH PBF Unit and to the Human Resources Directorate of the MOH. Disciplinary action may follow if the complainant report is considered serious and after the accused person, if indeed the fraud can be related to one or more persons, has been heard. The chair of the “disciplinary hearing” will advise the MOH PS who will decide on a suitable penalty for the individual or the facility where fraud is determined.

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Apart from any disciplinary actions against individuals, there may be penalties for the HC and district/local hospital. These penalties could consist of a financial penalty in case of first time intentional abnormalities in the records, or in more serious cases could consist of a suspension for PBF benefits for a minimum of one month.

In order to promote data accuracy, a penalty clause will also be applied if case data forwarded to the DHMT during the monthly HMIS reporting differs, due to mainly administrative flaws on the side of the HC, by more than 5% to the numbers found during the monthly data verification visit by the PPTA/DHMT. However, in case of intentional misreporting the fraud clause will apply.

Required Quarterly reports

The PPTA in close cooperation with the PBF unit will compile quarterly reports which consolidate all the review of activities and reports noted in Table 10 above. The reports will be submitted to the NSRHSC for review and endorsement. The MOH PBF Unit will share copies of the final quarterly reports with relevant Government agencies and stakeholders, including the World Bank. Such reports will be furnished within one month of the end of the quarter

The quarterly report will include the following sections: (i) progress in implementation of the PBF project; (ii) problems encountered and solutions undertaken; recommendations in the preceding

reports that have (or not) been addressed(iii) relations and collaborations with stakeholders such as the district (health) authorities,

the community, and other NGOs operating in the assigned areas; (iv) progress in transfer of knowledge activities from PPTA to PBF Unit staff and

decentralized implementing entities; and (v) a summary of MOH HMIS forms with analysis. (vi) a financial report (vii) case studies and/or best practice examples identified, documented and adapted into

Lesotho PBF implementation and disseminated locally, regionally and internationally(viii) key performance indicators including:

Number and percentage of health facilities that submitted quarterly report on time (progress, financial and HMIS data)

Number and percent of health facilities that received quarterly performance payment on time

Number and percent of health facilities that received payment of performance incentives in line with the fees for services and quality incentive formula set for the selected geographic area

Number and percent of health facilities where third party verification was carried out on both quantity of services reported and the quality of care index

Number and percent of health facilities able to independently complete adequate business plans per quarter

Number and percentage of district steering committee meetings held with PPTA support

Number and percentage of health centres supervised by DHMT with PPTA support

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Project results framework

A comprehensive description of the project’s results framework is shown in Table 15. It has the list of indicators for overall project monitoring, description of each indicator, unit of measure, baseline and target values, frequency of data collection, and responsibility for data collection. The results framework will be tracked and a mid-term review will provide the opportunity to assess progress and make appropriate mid-course corrections.

The M&E implementation arrangements described below include sources of data and data collection mechanisms, frequency of the data collection, capacity on monitoring and evaluation, and investments in the M&E system.

1. Sources of data, frequency and data collection mechanisms: Data for the indicators in the results framework as well as the quantity and quality indicators to be incentivized come primarily from government sources and the impact evaluation study: (i) the MOH’s routine Health Management Information System (HMIS), (ii) annual health facility quality of care assessments, (iii) household surveys (impact evaluation study and Demographic and Health Survey [DHS]), and (iv) PBF Unit administrative records. HMIS data collection will be done monthly, consistent with current practice. In addition, monthly supervisory visits are essential, especially in the pilot phase and initial scale up phase. Health facility quality of care assessments will be conducted annually while population-based surveys will be collected at baseline (impact evaluation or 2014 DHS), and endline (impact evaluation).33 Institute for Health Measurement (IHM) with financial support from PEPFAR has hired a consultant to demarcate the catchment areas to determine health services coverage at the community council levels to provide population denominators for annual measurement of outcome indicators in the results framework.

Health Management Information System: The HMIS, which is managed by the MOH’s HPSD, provides routine data for the monitoring of the indicators on health service provision and utilization. The districts hold two quarterly meetings (first and third) but the second and fourth quarterly reviews are coordinated by the HPSD. At the national level, a meeting is held with all DHMTs at the end of the second quarter of the financial year during which the district reports are discussed. Awards such as computer are given to the best improved district. A review conducted by the MOH and the Health Metrics Network (HMN) in 2006 indicated that the HMIS covers all MOH and CHAL health facilities, there is a complete list of health facilities (public and private) that are annually updated, and that clearly defined set of essential indicators are tracked quarterly.34 The weaknesses noted by the review include shortage of appropriate District Health Information Officers (DHIO), paper-based reporting system that adversely affects the timeliness of the submission of reports, and the lack of feedback to the health facilities. Following the 2006 33 An impact evaluation of the project, which will entail baseline and endline household surveys, will be carried out with a Bank-executed HRITF. The Impact Evaluation study will carry out a baseline survey in the 4 Phase II districts (Mafeteng, Mohale’s Hoek, Mokhotlong, and Thaba Tseka.) just before scale-up in those districts. It will also support endline survey in all project districts. The baseline household survey data to be reported in the results framework will be from either the impact evaluation study or the 2014 DHS depending on which one is administered earlier34 GOL Ministry of Health and Social Welfare, and Health Metric Network. Lesotho Health Information System: Review and Assessment. January 2007.

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review, a HMIS Strategic Plan (2008-2012) was developed which aimed at: (i) Functional District Health Management Information System by 2012 in all 10 districts; (ii) Integrated and harmonized data collection, management analysis, sharing and use at all levels by 2012; (iii) Health data quality meeting the HMN/WHO/GOL Standards by 2012; and evidence-based information is used to achieve desired results at all levels by 2012. Nevertheless, a 2011 Health Facility Survey revealed that the HMIS needs further strengthening.35,36 For instance, health facilities continue to submit paper summary reports to the DHMTs and only 24 percent of health facilities receive feedback from the district or national levels.

Based on discussions with Central MOH M&E staff, selected DHIOs, and Development Partners, the challenges in M&E of health programs include: (i) critical shortage of key personnel--some health centres lack data entry clerks, DHMT’s lack ICT personnel, and the central level lack key adequately trained staff for regular supervision of the DHIO; (ii) inadequate data quality assessment and verification, and supervision of the DHIOs from the central MOH remains patchy; (iii) inadequate skilled trainers to conduct trainings for the districts councils, community councils, and health personnel; (iv) a MOH Monitoring and Evaluation Plan/framework is yet to be developed in line with the recently developed National Health Policy,37 (v) some registers such as Outpatient Department, postnatal, referral, and family planning registers are yet to be developed; (vi) HMIS data for some programs such as tuberculosis, HIV/AIDS, immunization, and nutrition are kept by the respective programs instead of by the HPSD M&E Unit; and (vii) low utilization of HMIS data to inform decision-making at health facility level.

Health facility quality of care assessments: The MOH Quality Assurance Unit has developed health facility quality of care checklist for health centres and hospitals which cover domains of staff attendance, record keeping and timeliness of reports, adherence to protocols and guidelines for child survival, environmental health, general consultations, reproductive health, essential drugs management, tracer drugs, maternal health, STI, HIV, tuberculosis, and community based services. Quality of care of health facilities will be assessed as part of project supervision using the checklist on a quarterly basis for performance-based payments. The value for this indicator in the results framework will be verified by independent health facility quality of care assessments conducted by the MOH Quality Assurance Unit.

Health facility surveys are periodically conducted to provide data for the monitoring of indicators that are not available from the routine HMIS. A 2011 national health facility survey jointly funded by the Government and the Millennium Challenge Account Lesotho (MCA-Lesotho) covered 138 health centres, and 14 hospital Outpatient Departments, collected data on physical infrastructure, human resources, equipment and supplies, HMIS, service provision, and quality of care.38 However, the 2011 HFS did not collect information on the provision of EmONC; this would have updated information on the 2005 EmONC assessment conducted by 35 ICON-INSTITUT Public Sector GmbH, NUL-CONSULS of the University of Lesotho, and Millennium Challenge Account Lesotho (MCA-Lesotho). Health Facility Survey – Round 1. November 21, 2011.36 Ministry of Health and Social Welfare. HMIS Strategic Plan (2008 – 2012). Prepared by Health Planning and Statistics Department, September 2007.37 The National Health Policy is yet to be translated into Strategic and Operational Plans38 In Lesotho, there are 216 health facilities across the country including 1 referral hospital, 2 special hospitals, 19 hospitals, 190 health centres and 4 filter clinics

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MOH and UNICEF.39 The MOH plans to conduct EmONC assessment in all 10 districts (both intervention and control districts) in 2013 to provide baseline data on EmONC.

Demographic and Health Survey: The Bureau of Statistics is the main Government institution that provides support to line ministries in the execution of national surveys. It supported the MOH in the execution of the 2004 and 2009 DHS.40 The DHS is the main source of population-based data for the monitoring of health outcomes in all 10 districts. The next round of DHS is scheduled to be conducted in 2014. This project will support similar population-based surveys in selected districts in 2014 and 2017 to provide baseline and endline data respectively.

Capacity and investments in Monitoring and Evaluation: It is imperative to have an adequate HMIS to effectively monitor the provision of incentivized services at the health centres and hospitals. Development Partners continue to provide support for the strengthening of the HMIS. Through the support of MCA, the MOH has engaged a Health Systems Strengthening firm to develop this integrated software solution. There is a need to ensure that data collections tools at facility level are user friendly, that there is no duplication and the registers, tally sheets or other summary forms are effectively used to collect good quality data for capturing in the newly developed integrated HMIS software solution. As part of the preparation for the implementation of the PBF project, the MOH engaged a consultant to assist the MOH to improve the quality of health data through the review and update of data collection tools in order to strengthen and harmonize data collection at health centres and hospitals. The project will also support central MOH M&E and DHIOs to undertake formal courses on M&E as described in Chapter 2.

Required semi-annual reports

The MOH PBF Unit is responsible for semi-annual progress reports (including a section on the status of the indicators in the results framework) to the World Bank (April-September and October –March). Financial reports as indicated in chapter 5 will also be submitted to the World Bank.

39 GOL Ministry of Health and Social Welfare and UNICEF. Lesotho Emergency Obstetric Care Assessment. June 200540 Ministry of Health and Social Welfare (MOHSW) [Lesotho] and ICF Macro. 2010. Lesotho Demographic andHealth Survey 2009. Maseru, Lesotho: MOHSW and ICF Macro.

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Table 15. Results Framework and Monitoring

Project Development Objective (PDO): To improve the utilization and quality of maternal and newborn health (MNH) services in selected districts in Lesotho.

PDO Level Results Indicators*

Cor

e Unit of Measure Baseline41’42 Cumulative Target Values** Frequency43 Data Source/

Methodology

Responsibility for Data

Collection

Description (indicator definition etc.)

YR 1 YR 2 YR3 YR 444

PDO1: Pregnant women delivering in health facilities

Percent Aggregate – 56.2Leribe – 61.2Quthing – 53.0Mafeteng – 55.8Mohale’s Hoek –50.6Mokhotlong – 47.6Thaba Tseka – 41.7Berea – 65.7Botha-Bothe – 63.9Qacha's Nek – 63.5

58635558524943686565

64696163585749727070

2014

2017

Impact evaluation baseline or 2014 DHS

Impact evaluation endline survey

MOH HPSD/BOS

Number of births in health facilities /Number of births in the same area and period *100

41 Baseline values: i) for the indicators with household survey as data sources, values shown here are from the 2009 LDHS. These will be updated in the first Implementation Support and Results report with the baseline data from either the impact evaluation study or the 2014 DHS, whichever comes earlier; ii) for PDO4, the value reported here is the composite score for Leribe and Quthing from an assessment conducted in January 2013. Similarly, this will be updated with the May 2013 baseline data from health facility quality of care assessment in all 9 project districts; iii) for indicators with data from the HMIS, the values reported are for the period January-December 2012 but will be updated with data to be collected for the year preceding project implementation (ie June 2012-May 2013). Further, the cumulative values are based on the fact that the baseline values are zero since the project had no beneficiaries at the beginning of the project. Thus, the baseline values provided are only to give indication of the number of beneficiaries prior to the project’s implementation.

42 The aggregate values for indicators with percentages were computed using a weighted average taking into account the indicator value and the value of the denominator of the indicator in the survey sample for each of the nine districts. The formula for computing a weighted average for all nine districts, eg for PDO1, is computed as (% of pregnant women delivering in health facilities * number of live births in the survey sample for Leribe) + (% of pregnant women delivering in health facilities * number of live births in sample for Quthing) + (% of pregnant women delivering in health facilities * number of live births in sample for Mafeteng) + (% of pregnant women delivering in health facilities * number of live births in sample for Mohale’s Hoek) + (% of pregnant women delivering in health facilities * number of live births in sample for Mokhotlong) + (% of pregnant women delivering in health facilities * number of live births in sample for Thaba Tseka) + (% of pregnant women delivering in health facilities * number of live births in sample for Berea) + (% of pregnant women delivering in health facilities * number of live births in sample for Botha-Bothe) + (% of pregnant women delivering in health facilities * number of live births in sample for Qacha's Nek) divided by (number of live births in sample survey for Leribe + number of live births for Quthing + number of live births for Mafeteng + number of live births for Mohale’s Hoek + number of live births for Mokhotlong + number of live births for Thaba Tseka + number of live births for Berea + number of live births for Botha-Bothe + number of live births for Qacha's Nek)

43 The MOH is currently delineating the catchment areas for each health facility to provide population denominators for annual measurement of outcome indicators. If well done, it might complement or obviate the need for expensive household surveys. 44 The target values for the outcome indicators took cognizance of the change in indicator values from the 2004 to 2009 DHS.

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PDO2: Children 1 year-old who received all basic vaccinations45

Percent Aggregate – 62.1Leribe – 54.9Quthing – 58.5Mafeteng – 66.4Mohale’s Hoek–59.5Mokhotlong - 74.7Thaba Tseka – 52.7Berea – 71.2Botha-Bothe – 53.7Qacha's Nek – 79.0

64566068617654735581

67616471647957755884

2014

2017



MOH HPSD/BOS

Number of children age 12-23 months who received all basic vaccinations at any time before the survey/number of children age 12-23 months in the same area and period

PDO3: Currently married women using modern contraceptive method

Percent Aggregate – 42.6Leribe – 44.2Quthing – 32.3Mafeteng – 49.6Mohale’s Hoek-40.7Mokhotlong – 29.5Thaba Tseka – 32.0Berea – 48.5Botha-Bothe – 53.7Qacha's Nek – 34.3

44453451413133495435

48483853433335515637

2014

2017



MOH HPSD/BOS

Number of currently married women using modern contraceptive method /Number of currently married women ages 15-49 in the same area and period (per 100 women)

PDO4: Average Health Facility Quality of Care Score46

Percent Aggregate – 43.8Leribe – 47.3Quthing - 36.7Mafeteng –Mohale’s Hoek- Mokhotlong –Thaba Tseka –Berea -Botha-Bothe -Qacha's Nek -

44 45 46 50 Yearly Health facility quality of care assessment


A composite Health Facility Quality Index on scale of0-100 will be computed for all health facilities in a given district and the average score reported

INTERMEDIATE RESULTS

45 BCG, measles, three doses of pentavalent vaccine (diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenza type b) and three doses of polio vaccine (excluding polio vaccine given at birth)46Quality of care will be assessed as part of project supervision using a health facility quality checklist on a quarterly basis for incentive payments. The score will be based on a composite Health Facility Quality Index covering domains of staff attendance, recordkeeping and timeliness of reports, adherence to protocols and guidelines for child survival, environmental health, general consultations, reproductive health, essential drugs management, tracer drugs, maternal health, STI, HIV, tuberculosis, and community based services. The value for this indicator in the results framework will be verified by independent health facility quality of care assessments conducted by the MOH Quality Assurance Unit. The baseline data reported here were collected in the two pilot districts in January 2013. This will be updated with baseline data to be collected in May 2013 in all 9 project districts.

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Intermediate Result (Component One): Improving Maternal and Newborn Health (MNH) Service Delivery at Community, Primary and Secondary levels through PBF (US$17.7 million)

Intermediate Result indicator One:; Pregnant women in a lowest wealth quintile delivering in health facilities47

Percent 32.2 33 35 2014

2017



MOH HPSD/BOS

Number of births in health facilities in project districts by women from households in the lowest wealth quintile/Number of births in project districts in the same area and period *100

Intermediate Result indicator Two: Women with at least four antenatal care visits during pregnancy48

Percent Aggregate – 70.4Leribe –Quthing –Mafeteng –Mohale’s Hoek-Mokhotlong –Thaba Tseka –Berea -Botha-Bothe -Qacha's Nek -

71 74 2014

2017



MOH HPSD/BOS

Number of pregnant women attended by skilled health personnel/ Number of births in the same area and period * 100

Intermediate Result indicator Three: Births attended by skilled health personnel

X

Number Aggregate – 17,453Leribe – 3499Quthing – 1058Mafeteng – 1746Mohale’s Hoek-1432Mokhotlong – 1242Thaba Tseka – 1614Berea - 3957Botha-Bothe - 1894Qacha's Nek - 1011

18,000 37,000 57,000 77,000 Yearly HMIS MOH HPSD Number of births attended by skilled health personnel

Intermediate Result indicator Four: Mothers who received postnatal care within two days of

Percent Aggregate – 42.1Leribe – 40.7Quthing - 34.0

434235

474639

2014 Impact evaluation baseline or 2014 DHS

MOH HPSD/BOS

Number of mothers who received postnatal care visit

47 This is to ascertain whether the project has contributed to improvement among the poor. In future household surveys, this indicator will be computed for the 9 project districts. 48 Data not available in the 2009 DHS report by district. The baseline household survey will provide the data by district.

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childbirth Mafeteng – 40.0Mohale’s Hoek-49.9 Mokhotlong – 37.7Thaba Tseka – 33.5Berea – 46.2Botha-Bothe – 48.7Qacha's Nek – 39.9

41513835474941

44544138505243

2017 Impact evaluation endline survey

within two days of childbirth / Number of women age 15-49 giving birth in the same area and period * 100

Intermediate Result indicator Five: Pregnant women receiving antenatal care from a health provider

X

Number Aggregate – 24,324Leribe - 5693Quthing - 1668Mafeteng – 2806Mohale’s Hoek- 2756Mokhotlong – 1977Thaba Tseka – 2333Berea - 3605Botha-Bothe - 1849Qacha's Nek - 1637

25,000 50,500 76,000 100,000 Yearly HMIS MOH HPSD Number of pregnant women receiving first antenatal care visit to a health provider

Intermediate Result indicator Six: Children receiving pentavalent vaccine (diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenza type b)

X

Number Aggregate – 26,474Leribe - 5611Quthing - 1432Mafeteng – 3187Mohale’s Hoek- 2465Mokhotlong – 2205Thaba Tseka – 2951Berea - 4520Botha-Bothe - 2512Qacha's Nek - 1591

26,500 53,000 70,000 98,000 Yearly HMIS MOH HPSD Number of children who received pentavalent vaccine (diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenza type b)

Intermediate Result indicator Seven: Tuberculosis treatment success rate

Percent Aggregate –69Leribe - 65Quthing – 65Mafeteng – 57Mohale’s Hoek- 78Mokhotlong – 70Thaba Tseka – 70Berea - 65Botha-Bothe - 76Qacha's Nek - 59

70666658797171667760

71676759807272677861

72686860817373687962

73696961827474698063

Yearly Annual Joint Review

MOH HPSD Number of tuberculosis cases treated/ Number of registered cases

Intermediate Result indicator Eight: People receiving tuberculosis treatment in

X Number Aggregate – 8,553Leribe - 1724Quthing - 361

8,600 17,600 26,600 35,600 Yearly HMIS MOH HPSD Number of people receiving tuberculosis

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accordance to the WHO-recommended “Directly Observed Treatment Short course” (DOTS)

Mafeteng – 1003Mohale’s Hoek- 1222Mokhotlong – 318Thaba Tseka – 297Berea - 1424Botha-Bothe - 1794Qacha's Nek - 410

treatment in accordance to the WHO-recommended “Directly Observed Treatment Short course” (DOTS)

Intermediate Result indicator Nine: Pregnant women living with HIV who received ARV prophylaxis or complete course of ARV to reduce the risk of MTCT

Percent Aggregate – 4,972Leribe - 1977Quthing - 295Mafeteng – 601Mohale’s Hoek- 478Mokhotlong – 262Thaba Tseka – 297Berea - 568Botha-Bothe - 269Qacha's Nek - 225

5,000 10,500 16,000 21,000 Yearly HMIS MOH HPSD Number of pregnant women living with HIV who received ARV prophylaxis or complete course of ARV to reduce the risk of MTCT/Number of HIV positive pregnant women

Intermediate Result indicator Ten: Children under 5 years whose weight and height are monitored regularly49

X

Number Aggregate –Leribe -Quthing -Mafeteng –Mohale’s Hoek-Mokhotlong –Thaba Tseka –Berea -Botha-Bothe -Qacha's Nek -

Yearly HMIS MOH HPSD Number of children under 5 years whose weight and height are monitored regularly according to the following protocol(six times in the first year, four times in the second year, and thereafter three times yearly from 2 to 5 years)

Intermediate Result indicator Eleven: Number of health facilities with PBF contract50

X Number Aggregate – 0Leribe - 0Quthing - 0Mafeteng – 0Mohale’s Hoek- 0

25 61 100 1072051412

Yearly PBF Unit administrative records

PBF Unit Number of health facilities that have signed a PBF contract

49 Data is available in the under-five register but has not been collated in the central HMIS database. Baseline data will be collected in May 201350 Not all health facilities will sign contracts. The number of facilities in each district expected to sign contract are as follows: Leribe (26), Quthing (9), Mafeteng (18), Mohale’s Hoek (16), Mokhotlong (10), and Thaba Tseka (18), Berea (17), Botha-Bothe (12), and Qacha's Nek (12).

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Mokhotlong – 0Thaba Tseka – 0Berea - 0Botha-Bothe - 0Qacha's Nek - 0

101413910

Intermediate Result (Component Two): Training of health professionals and VHWs and improving Monitoring and Evaluation (M&E) capacity (US$2.3 million)

Intermediate Result indicator Twelve: Health facilities reporting stock-out of tracer medicines and medical supplies51 at the time of the health facility quality of care assessment

Percent Aggregate –LeribeQuthingMafeteng –Mohale’s Hoek-Mokhotlong –Thaba Tseka –Berea -Botha-Bothe -Qacha's Nek -

Less than 5% Yearly Health facility quality of care assessment


Number of health facilities that experience stock-out of tracer medicines and medical supplies at the time of the health facility quality of care assessment/numbers of health facilities surveyed

Intermediate Result indicator Thirteen: Health personnel receiving training in Advanced Midwifery and Neonatology

X

Number 0 2 10 10 20 Yearly PBF Unit administrative records

MOH Directorate of Nursing

Number of nurse midwives enrolled in a university in South Africa for Advanced University Diploma in Advanced Midwifery and Neonatology

Intermediate Result indicator Fourteen: Health personnel receiving pre-service nurse anesthetists training

X


MOH Directorate of Nursing

Number of health personnel enrolled in pre-service nurse anesthetists training

Intermediate Result indicator Fifteen: Nurses receiving training on the MOH adopted drug supply management manual

X


MOH Directorate of Pharmaceuticals

Number of nurses receiving training on the MOH adopted drug supply management manual

Intermediate Result indicator Sixteen: Hospital and DHMT X Number 0 2 4 9 18 Yearly PBF Unit

administrative MOH Directorate of

Number of hospital and DHMT

51 The tracer medicines and medical supplies are the following: Iron tabs, folic acid tabs, ORS, oxytocin, co-trimoxazole, tetanus toxoid vaccine, and injectable contraceptives. The baseline data to be collected in May 2013 in all 9 project districts.

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pharmacists receiving ESAMI training courses

records Pharmaceuticals pharmacists receiving ESAMI training courses

Intermediate Result indicator seventeen: Personnel receiving training in procurement and financial management


MOH Procurement Unit

Number of personnel receiving training in procurement and financial management

Intermediate Result indicator Eighteen: Village health workers trained

Number 0 100 500 750 1,500 Yearly PBF Unit administrative records

MOH Family Health Division

Number of village health workers trained

Intermediate Result indicator Nineteen: Monitoring and Evaluation officers and District Health Information Officers receiving formal M&E training X


MOH HPSD Number of Monitoring and Evaluation officers and District Health Information Officers enrolled in formal M&E training course

*Please indicate whether the indicator is a Core Sector Indicator (see further http://coreindicators)**Target values should be entered for the years data will be available, not necessarily annually.

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http://coreindicators/

Impact evaluation

The implementation of PBF has been designed to allow for rigorous impact evaluation, which will enable Government to judge the effects of PBF on health system performance, including health utilization, health outcomes and service quality indicators. In order to answer this question, the Bank-executed impact evaluation under complementary financing (HRITF impact evaluation grant) will conduct a randomized, controlled and prospective experiment that will be undertaken during the four years of the PBF project implementation.

During Phase II and Phase III, there will be “PBF treatment” and “PBF control” health centres in each district. The randomisation in the experiment will be at the facility level so that the impact evaluation will have sufficient statistical power to measure the impact of PBF. The randomization process will be blocked by district and facility type (GOL vs. CHAL) to increase the comparability of the treatment and control groups and increase statistical power. Hospitals will all be PBF treatment facilities due to their prominent role as secondary care institutions and their supervisory role. “PBF treatment” facilities will receive performance-based payments linked to the quantity and quality of health services provided.

In the “PBF control facilities”, payments will also be made, every 3 months based on the average of all performance-based payments made to the “PBF treatment facilities” for that quarter. “PBF control” facilities will receive equivalent additional budget increases, but the amount will not be linked to performance (as measured by quantity and quality of services). “PBF control” facilities will not be allowed to use the payments for staff motivation bonuses. This PBF mechanism ensures that all the facilities (treatment and control) receive comparable financial amounts. It allows measuring the effects attributable to the PBF mechanism.

The impact evaluation design will allow isolation of the impact of the PBF mechanism on the quantity and quality of health services delivered and ultimately on health outcomes. It will be prospective, with a baseline survey conducted by the Bank before implementation of PBF in the Phase II and Phase III districts. A follow-up survey and evaluation will be conducted at the end of year 4 for PBF treatment and PBF control facilities; subsequently, all facilities will become eligible to implement PBF activities with design and implementation changes as guided by the results of the impact evaluation endline survey.

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Annexes

Annex 1. REFERRAL AND FEEDBACK FORM

Ministry of Health Patient Referral FormPART A (to be completed by referring Health Centre)Health Centre: …………………………………………………………………………………………………………………………………….Patient Name: …………………………………………………… Patient’s No: ………………………………………………Age/DoB: …………………………………………………………… Sex: M/F………………………………………………………Address: ……………………………………………………………. Chief: ………………………………………………………….Mobile Phone No: ……………………………………………… Indigent: Yes/No

Letter: Yes/NoDate of referral: ………………………………………………… Referred to: ………………………………………………..Reasons for referral:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Provisional diagnosis/complaints:----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------History:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Examination:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Treatment received:……………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Referring Nurse:Signature: Stamp:

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PART B FEEDBACK(To be completed by Clinician/physician of referred District/local hospital)

Date patient was seen: ……………………………………. Date of discharge: …………………………………

Summary of findings:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Final diagnosis:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Medication on discharge:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Recommended follow-up:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Name of Clinician/physician: ……………………………………………………………………………………………………………Signature: …………………………………………………………………………………………………………………………………………Department: ……………………………………………………………………………………………………………………………………..Date: ………………………………………………………..Stamp:

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Form to hospital administrator to fileAdministrator sends copy to referring Health Centre

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Annex 2. PBF PILOT DISTRICTS’ HEALTH CENTRES STAFFING PATTERN

Nurse Clinician – N/C Nursing Officer – N/ONursing Sister – N/S Nursing Assistant – N/A

The minimum nursing staff complement for a health centre is one nursing officer (nurse clinician or nurse with advanced midwifery), one nursing sister (registered nurse with midwifery), and one nursing assistant.

Leribe Health Centres Staffing pattern

NO

HEALTH CENTRE

PROPRIETOR N/C N/S N/O N/A Remarks

1 Seshote GOL 0 2 1 12 Palama (Not

functioning)GOL 0 2 1 2 Currently

under construction & the nurses are still at Motebang Hospital.

3 Matlameng GOL 0 2 1 24 Pontmain CHAL 1 2 0 25 Thaba-Phatsoa GOL 0 2 1 16 Mahobong GOL 1 2 0 27 Holy Trinity CHAL 0 1 0 28 Lejone (not

functioning)GOL 0 0 0 0 3 R/N’s

placed at Motebang until Lejone opens

8 Seetsa GOL 0 2 1 19 St Margaret CHAL 1 2 0 210 St Denis CHAL 0 2 0 211 Khabo GOL 0 2 1

(Expatriate)2

12 Emmanuel CHAL 1 2 0 213 Maryland CHAL 1 2 0 214 St Monicas CHAL 0 2 0 215 Louis Gerald CHAL 1 2 0 216 Our Lady of

LourdesCHAL 1 2 0 2

17 Linotsing GOL 1 2 1 218 St Ann CHAL 1 2 0 219 Fobane CHAL 1 2 0 220 Little Flower CHAL 0 3 0 2

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21 Peka GOL 0 2 1 222 St Rose CHAL 1 3 0 223 Maputsoe SDA CHAL 1 3 0 324 Maputsoe Filter

ClinicGOL 0 4 3 4

25 Sepinare(not functioning)

GOL 0 0 0 0

Quthing District Health Centre Staffing Pattern

NO

HEALTH CENTRE

PROPRIETOR N/C N/S N/O N/A

1 Dilli Dilli GOL 0 2 1 – Expatriate

2

2 Tsatsane GOL 2 1 -Expatriate

2

3 Maqokho GOL 0 2 1 24 Makoae GOL 0 2 1 25 Mphaki GOL 0 2 1(expatriate

)2

6 St Gabriel CHAL 0 3 0 17 Villa Maria CHAL 0 2 0 38 St Matthews CHAL 0 1 0 2

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Annex 3. CRITERIA FOR THE SELECTION OF DISTRICTS TO SCALE UP IN YEAR 2

The selection of the scale up districts in year two was based on the performance on maternal health, namely the antenatal, postnatal and delivery care as well as the child health. All the information is based on LDHS (2009).

1. Maternal Health Antenatal Care CoverageNo. 1st Five districts with the lowest % of

woman receiving ANC from a skilled provider excluding Quthing, Leribe and Maseru

% of woman receiving ANC from the skilled provider

1. Mafeteng 90.42. Thaba-Tseka 90.73. Berea 91.44. Butha-Buthe 92.75. Mohale’s Hoek 93.3

Place of DeliveryNo. 1st Five Districts with the lowest % of

woman delivering in a health facility except Quthing, Leribe and Maseru

% of woman delivering in health facility

1. Thaba-Tseka 41.62. Mokhotlong 47.73. Mohale’s Hoek 50.64. Mafeteng 55.85. Butha-Butha 61.0

Assistance at DeliveryNo. 1st Five Districts with the lowest % of

woman delivering with assistance by a skilled provider except Quthing, Leribe and Maseru

% of woman assistant by a skilled provider during delivery

1. Thaba-Tseka 42.42. Mokhotlong 48.33. Mafeteng 59.44. Qacha’s Nek 63.55. Butha-Butha 63.9

Timing of the First Post Natal CheckupNo. 1st Five Districts with the lowest % of

woman presenting at the facility for postnatal checkup except Quthing, Leribe and Maseru

% of woman assisted by a skilled provider during delivery

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1. Butha-Buthe 33.02. Mohale’s Hoek 41.63. Berea 42.24. Mafeteng 43.85. Qacha’s Nek 45.2

Problems in accessing health careNo.

1st Five districts with the longest distance to the health facility excluding Quthing, Leribe and Maseru

Distance to Health Facility

1. Mokhotlong 50.52. Thaba-Tseka 47.53. Qacha’s Nek 38.74. Butha-Buthe 41.75. Mohale’s Hoek 29.5

6. Child Health

Vaccination CoverageNo.

1st Five districts with the lowest % of children who got all basic vaccinations excluding Quthing, Leribe & Maseru

% of children who got all basic vaccinations

1. Thaba-Tseka 52.72. Butha-Buthe 53.73. Mohale’s Hoek 59.54. Mafeteng 66.45. Berea 71.2

Child’s Size at BirthNo.

1st Five districts with the highest % of children born with the weight less than 2.5kg excluding Quthing, Leribe & Maseru

% of children who got all basic vaccinations

1. Mafeteng 12.12. Mohale’s Hoek 11.83. Thaba-Tseka 11.44. Mokhotlong 11.15. Qacha’s Nek 10.7

Criteria for selection in year twoThe district must be the lowest performing in a maximum of three areas

1. Thaba-Tseka; This is the lowest performing district with the lowest % of woman delivering in a health facility, those assisted by a skilled provider and also have the lowest % of children who got all basic vaccinations.

2. Mafeteng; This is the lowest performing district on ANC coverage and have the highest % of children born with weight less than 2.5 kg.

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3. Mokhotlong: This is the second lowest performing district on % of woman delivering in a health facility and assisted by a skilled provider. It is also the number one district with the longest distance to the health facility compared to others.

4. Mohale’s Hoek: This is the district with the second lowest % of woman presenting at the health facility for post natal check-up and the second one with the highest % of children born with the weight less than 2.5kg. Apart from that it is the third district with the lowest % of woman delivering in a health facility and % of children who got all the basic vaccinations.

Based on this, the districts to be considered in year two are Thaba-Tseka, Mokhotlong, Mohale’s Hoek and Mafeteng.

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Annex 4. TOR for PBF NATIONAL STEERING and NSRHSC

TOR PBF NATIONAL STEERING

1. BackgroundThe Lesotho Ministry of Health (MOH) will pilot a Performance Based Financing (PBF) project with funding from the World Bank (WB). The PBF project aims to improve maternal and newborn health outcomes through the increase the provision, uptake and improve the quality of maternal and newborn health (MNH) services at the primary health care (PHC) level and community health level in targeted districts. In the initial phase the project will be piloted in the two districts of Leribe and Quthing, and will subsequently be scaled-up to other districts of Lesotho. The National Sexual & Reproductive Health Steering Committee (NSRHSC) is a forum expected to provide national leadership and vision for results oriented, multi-sectoral and multidisciplinary implementation of the National Reproductive Health Policy.

The MOH will adopt the existing NSRHSC to fulfil the role of the PBF National Steering Committee (PBF NSC). With the inclusion of PBF-specific roles and responsibilities, the NSRHSC will be responsible for oversight on the PBF project pilot’s design and implementation, policy guidance, advice on the annual work programs and budget of the PBF Unit and the subsequent scaling up of the PBF project. The details below outline the existing and PBF-specific roles and responsibilities of the NSRHSC with respect to the PBF project. The MOH PBF Unit will serve as the NSRHSC Secretariat for matters related to the PBF project.

2. Tasks to be performed

EndorsementThe NSRHSC will endorse: The design of the PBF project as described in the Project Appraisal Document developed by

the World Bank, and as further expanded in the Project Implementation Manual and any future modifications to the manual.

Implementation of PBF projects and related initiatives, which include endorsing/approving the proposed incentive structure, indicators, supported interventions, performance monitoring, contracting, and community involvement in the implementation, and monitoring and evaluation arrangements;

PBF Project annual work plan and budget , and quarterly report before submission to the WB

Review and adviceThe NSRHSC will particularly monitor whether the PBF project is succeeding in increasing the provision, uptake and improving the quality of maternal and newborn health (MNH) services at the primary health care (PHC) level and community health level in targeted districts. It will therefore monitor and review:

districts PBF performance frameworks, incentive payments, and other progress reports on the performance of the PBF project

whether performance targets and timelines for activities under the different PBF components are met;

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trend analysis of the indicators (incentivized and non‐incentivised) in the PBF Districts and identified bottlenecks and address critical issues that could hinder project implementation and render advice accordingly;

3. CompositionThe NSRHSC will be chaired by the Director General of Health Services. The members of the Committee should be at decision making level and consist of:

Directors of key directorates within the MOH (PHC, Clinical Services/QA, FHD, HPSD, Finance) of which some members should have a medical or public health background, together with representatives from the MOF, the Ministry of Planning, Ministry of Local Government and Chieftainship, CHAL, Lesotho Red Cross Society and representatives from Development Partners

o The Director General for Health Services Chairo The Director of Primary Health Care Secretaryo Director Nursing Serviceso Director of Health Planningo Director Clinical Serviceso Director Social Welfareo Director Human Resourceso Director Financeo Director Pharmacyo Director Laboratoryo Director Human Resourceo Head of Family Health Divisiono Health Education Divisiono Head Quality Assurance

K. Executive Secretary of CHALo Burger controllero Heads of U.N Agencies (WHO, UNFPA, UNDP,UNICEF, UNAIDS) o Country Directors (Ireland AID,PEPFA,EU and other International NGOs)o Lesotho Planned Parenthood Associationo Lesotho Medical, Dental and Pharmacy Councilo Lesotho Nursing Councilo Ministry of Local Government &Chieftainshipo Ministry of Public Serviceo Ministry of Development Planning (Acting Director Sectoral Policies, Research

and Analysis)o Ministry of Justice, Human Rights and Rehabilitation and Law and Constitutional

Affairso Ministry of Education and Trainingo Ministry of Home Affairs and Public Safetyo Ministry of Gender, Youth, Sports and Recreationo Dean of the Faculty of Health Sciences (NUL)

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o Lesotho Red Cross Societyo Parliamentarian/Community membero Private sector

The PBF NSC will receive and consider report from the MOH PBF Unit. The Performance Purchasing Technical Assistance (PPTA) Agency will be an ex-officio member of the NSRHSC.

TOR NATIONAL SEXUAL AND REPRODUCTIVE HEALTH STEERING COMMITTEE

1. BACKGROUND

The National Reproductive Health Policy has made provision for setting up of the National Sexual and Reproductive Health Steering Committee (paragraph 12). A National Reproductive Health Steering Committee shall therefore be established and maintained by the Ministry of Health. It will act as a multi-disciplinary forum bringing together the different professions and organisations involved in provision of sexual and reproductive health care. It will monitor the implementation of SRH action plans and give oversight to all projects related to maternal and child care e.g. Performance Based Financing (PBF) project. etc.

2. ROLES

The steering committee will be responsible for:a. Providing oversight and overall guidance in the implementation of the National

Reproductive Health Policy. b. Approval of strategic plan for implementation of the National Reproductive

Health Policy and ensure that annual work-plans are aligned to the national strategy

c. Identifying resource implications for the sexual and reproductive health strategic plan, mobilisation and allocation of resources.

d. Reviewing the achievements in terms of goals and targets set in the National Reproductive Health Strategy and suggest appropriate corrective measures and recommend required outlay to achieve the targets.

e. Receive and review reports on implementation from the all National Technical Committees in relation to MNH.

f. Reviewing the functioning of sexual and reproductive health infrastructure and manpower in rural and urban areas and suggest measures for rationalizing, restructuring the infrastructure, strategies for improving efficiency of implementation of the programme and for the delivery of services.

g. Advocating for and sensitising relevant stakeholders at all levels to support access to and provision of quality sexual and reproductive health services.

h. Advising the Ministry of Health on policy review, law reform and or enactment of new legislation to address emerging sexual and reproductive health issues.

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i. Reviewing the lessons learned from implementation of different programmes including reports generated by the programmes and the resulting actions required.

j. Stimulating reflection on ethical issues surrounding sexual and reproductive health service provision

k. Coordination of stakeholders’ activities and inputs to avoid duplication.l. Coordination, monitoring and evaluation of the implementation of the National

Reproductive Health Policy against an agreed work plan/strategy.

3. COMMITTEE PROCEEDINGS

a. The Director General for Health shall be the Chair for the National Reproductive Health Steering Committee. In the absence of the Director General for Health Services, the Director: Primary Health/Clinical Services Care shall Chair for the duration of the meeting.

b. The Chair may invite individuals in an ad hoc basis to a meeting for particular items on the agenda.

c. Meetings shall be held quarterly and hosted by the MOH. d. The Director General for Health Services will have the prerogative to convene ad

hoc meetings for emerging issues that need to be urgently addressed.e. The agenda, technical working groups reports and other relevant documents shall

be circulated at least seven working days before each meeting Any member may ask for items to be included on the agenda.

f. The committee Secretary will be responsible for taking minutes of meetings and circulating them to all members within a week of the meeting.

g. A minimum of 61% of the Steering Committee members are required for decision-making purposes.

4. DECISION-MAKING PROCESSFor a course of action to be undertaken, there needs to be consensus amongst the Steering Committee Members. This implies that the majority of the committee members approve a given course of action/recommendation, but that the minority agrees to go along with the course of action, potentially with some modifications.

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Annex 5. TOR for TECHNICAL WORKING GROUP (TWG)

1. BackgroundThe Lesotho Ministry of Health (MOH) will pilot a Performance Based Financing (PBF) project with funding from the World Bank (WB). The PBF project aims to increase the provision, uptake and improve the quality of maternal and newborn health (MNH) services at the primary health care (PHC), referral level and community health level in targeted districts. In the initial phase the project will be piloted in two districts of Leribe and Quthing, and will subsequently be scaled-up to other districts of Lesotho.

The MOH has established a PBF Technical working Group (TWG) to support the preparation phase that is expected to lead to the launch of the PBF project in the beginning of 2013. The terms of reference of the TWG are being modified taking into consideration the role of the NSRHSC, the establishment of the PBF unit and the engagement of the Performance Purchasing Technical Assistance (PPTA) firm.

2. Main responsibilityThe TWG will provide technical support towards the overall implementation of the PBF project, on request when needed.

3. Scope of servicesThe TWG will provide technical advice on design features of the PBF project as described in the Project Implementation (User) Manual and will be required to work on necessary modifications of the design after the launch of the project if their advice is needed. These may refer to core features of the PBF design, such as the incentive structure, indicators, supported interventions, performance monitoring, contracting, and community involvement in the implementation, and monitoring and evaluation arrangements;

4. CompositionThe TWG is comprised of technical, working-level staff from MOH, MOF, MODP, CHAL, and LRCS. The TWG may be expanded to include additional technical and administrative units in the MOH and development partners as may be necessary for implementation. The core of the TWG will constitute of a selected number of experts, who will not be substituted during the course of the project.

5. Frequency of meetingThe TWG will meet on an ad hoc basis and on request to advice on issues to be discussed at the NSRHSC meetings.

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Annex 6. TOR of the PBF UNIT and JOB DESCRIPTIONS of PBF Unit Staff

a) National Level PBF Unit TOR

Background and FunctionsThe MOH will constitute an office at the central level, situated in the Department of Health Planning and Statistics (DHSPD), called PBF Unit. The Unit will manage the day-to-day implementation, monitoring and management of the project, in coordination with relevant technical units. The PBF Unit will endorse and make PBF payments to contracted service providers, i.e. district hospitals, health centres, and DHMTs, based on the invoices prepared according to the predetermined formula (i.e. PBF outputs adjusted for quality and remoteness).

Given that this is the first experience with implementing PBF services in the Lesotho health sector, the MOH will seek to enter into a contract with an independent (international) performance-purchasing technical assistance (PPTA) firm with experience in PBF implementation in the health sector in Africa. The PPTA will:

support the implementation of PBF in accordance with the MOH/World Bank endorsed design and provide capacity building and implementation support to the PBF Unit;

provide technical support and strengthen institutional arrangements for the PBF unit; and be supported by individuals or institutions contracted to undertake capacity building,

technical assistance, external data verification, impact evaluation, and other forms of technical support.

Reporting and Accountability The PBF Unit is accountable and will report to the Department of Health Planning and Statistics Department on all administrative and organizational matters. On technical issues related to the design and further development of the PBF project, the PBF unit will associate with the PBF National Steering Committee (NSC) for oversight on project implementation, policy guidance, and advice on the annual work programs and budgetThe PBF Unit will provide quarterly and annual reports related to the activities for which the unit is responsible. Notwithstanding its independent mandate and responsibility, the PBF unit will harmonize and synchronize its reporting with the PPTA in as far as is feasible and justifiable. This particularly refers to sections that will also feature in the PPTA progress reports, such as (i) progress in implementation of the PBF project; (ii) problems encountered and solutions undertaken; (iii) collaborations with relevant stakeholders at national and district levels. In view of its independent responsibility/mandate the PBF unit will report on (iv) contract management including an overview of disbursed funds against services purchased, (v) implementation of the main roles played by the PBF unit, i.e. in the areas of fund holding and purchasing and (vi) a reflection on the results of capacity building by the PPTA.

Main responsibilityThe PBF unit’s main responsibility is to administer the PBF project, comprising management, coordination and implementation support to PBF associated activities at national and district levels. In view of the fact that the PBF project is initiated as a pilot project, which is to be scaled-up over time, the PBF unit will also be intensively involved with providing technical oversight and strategic guidance, thereby at all times and in all functions preserving a focus on the

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realization of the aforementioned project objectives. The Unit will be staffed with the staff listed below at a minimum and with additional staff as PPTA personnel are withdrawn to undertake PPTA functions for the duration of the project.

Detailed Responsibilities will include:

LiaisonThe unit will liaise with:

National Sexual and Reproductive Health Steering Committee (NSRHSC): The NSRHSC responsible for endorsing the ultimate design of the PBF scheme, project implementation oversight, provide policy guidance to the PBF Unit, and approve the annual work programs and budget. The PBF Unit will act as the Secretariat to the NSRHSC.

The Performance Purchasing Technical Assistance (PPTA) firm: The PPTA’s main task is to provide implementation support to and capacity building of the MOH for the successful implementation of the PBF project. The PBF Unit will benefit from capacity building by the PPTA so that in due time the PBF unit will take independent charge of the PBF project.

The PBF Technical Working Group (TWG). The TWG consists of technical experts from the various MOH units relevant for implementation of the PBF project, which play a technical advisory role to the PBF unit.

MOH departments that are engaged with health service delivery, monitoring and evaluation, quality assurance, and procurement.

The Ministry of Local Government and Chieftainship on the decentralization process. Scope of ServicesThe PBF Unit will work closely with the PPTA and will be responsible for carrying out the following activities:

Operational tasks To support various administrative activities under the PBF project including the creation

of effective communication between the MOH, district councils, and health facilities on all aspects of the PBF project;

To prepare annual work plans and budgets on PBF in consultation with the PBF NSC, the MOH financial department and the Aid Coordination unit of the MOF;

To sign contracts with the District Councils and District Hospitals for the delivery of incentivized services, describing the performance framework as well as their roles and responsibilities in relation to PBF.

To endorse contracts signed by the District Councils with the GOL/CHAL health centres for the delivery of incentivized services, describing the performance framework as well as their roles and responsibilities in relation to PBF;

To review invoices prepared by the PPTA according to the predetermined formula, to send to the Director of HPSD for authorization and submit to the MOH Finance Department for payment.

To manage a PBF database at national and sub‐national levels and provide support in the strengthening of the existing HMIS in close collaboration with the M&E unit of the MOH and district level M&E personnel;

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Technical Leadership and project development To maintain the Project Implementation Manual and incorporate modifications to the

manual considered essential based on experiences generated and subject to the endorsement by the PBF NSC

To facilitate regular professional and institutional development among implementers and health facilities, respectively, by identifying training needs and institutional inadequacies as informed through regular monitoring and supervision visits;

To perform a trend analysis of the indicators (incentivized and non‐incentivized) in the PBF Districts and identify bottlenecks and address critical issues that could hinder project implementation;

To support the process of establishing and sustaining effective operations of District Councils to review PBF implementation as part of their health sector oversight;

To translate operational aspects of the PBF into the policy dialogue of the broader health sector agenda. This includes integration of the PBF into the broader health sector decentralization agenda at the MOH;

To ensure that PBF capacity building activities are designed, implemented and monitored in accordance with the project plans, budgets and expected outcomes at all levels of implementation;

To assist the MOH in the scale up of PBF-incentivized services and leverage discussions with other stakeholders for additional resources for PBF implementation.

Maintaining accountability To carry out quarterly comprehensive reviews of the overall performance of the PBF

Project, including preparing the progress reports, and monitoring and reporting on the results framework as well as the work done by the PPTA;

To conduct random or specially commissioned data audits aimed at ensuring the effective implementation of the PBF model at district level;

To ensure adherence to the project operating systems for due diligence, financial management and reporting, including the annual external audit of project activities.

To review reports prepared by the district councils on the actual use of PBF incentives paid out to contracted service providers.

Various To provide administrative support for all PBF project consultancies and World Bank

missions; To coordinate the PBF research agenda and facilitate the implementation of the Impact

Evaluation component of the PBF Project, Dissemination of best practices and lessons learned on the PBF in Lesotho to other

stakeholders within the country and other parts of the world.

PBF Unit staff compositionWhen the PBF Unit is fully installed, it will consist of a minimum of five (5) full time staff, including:

PBF Unit Director Financial Management Officer Monitoring and Evaluation officer

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Operations officer Accountant

All staff will be of senior level. The team will have amongst its staff at least one person with a public health expertise gained either through education or experience, preferably the Project Coordinator. The unit will furthermore draw on, subject to need, technical specialists such as Reproductive Health Specialist, HIV/AIDS/TB specialist and nutrition specialist.

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b) PBF UNIT STAFF JOB DESCRIPTIONS

Position: PBF Unit Director; Duty station: MaseruIntroductionThe PBF Unit Director executes his/her tasks and responsibilities in line with the PBF Unit Terms of Reference. More specifically s/he will be responsible for the overall managerial, administrative and day-to-day running of the PBF Unit, its capacity development and its contribution to the gradual up-scaling of PBF until all districts apply the PBF approach. The PBF Unit Director is also responsible for collaboration and liaison with internal (MOH) and a variety of external stakeholders including the World Bank.

In line with the MOH philosophy, the PBF Unit Director will have outstanding academic credentials and a strong record of leadership and analytical capabilities. S/he will have a number of personal attributes, such as resourcefulness, responsibility, tenacity, independence, energy, creativity and work ethic.

The PBF Unit Director reports to the Director of the Health Planning and Statistics Department within the MOH and will receive guidance from the National PBF Steering Committee.

ResponsibilitiesPBF Unit management and administration

To further develop and execute a planning and reporting system (both narrative and financial) that meets the requirements of the MOH and the WB

To report to and provide the secretariat to the National PBF Steering Committee To provide day to day management to the PBF unit staff, including personnel

management To support the effective the development and use of a (electronic) PBF database; To authorize payment of invoices for PBF benefits for Health Facilities and District

Health Management Teams (DHMTs). The invoices will subsequently be sent to the Finance Department of the MOH, which acts as PBF fund holder.

To perform supervisory visits to PBF districts as necessary

PBF program development To be involved and demonstrate leadership in all aspects of the PBF project design,

strategy and implementation, including but not limited to health care financing, resource mobilization, and monitoring and evaluation.

To devise appropriate strategies and plans for supporting Performance-Based Financing in Lesotho;

To build knowledge and learning across the project in the following areas: quality assurance and services delivery, health information, governance and leadership, human resources for health, health financing and supply chain management;

To assist in the design and implementation of analyses, assessments and evaluations related to PBF;

Liaison and collaboration To liaise with the PPTA for developing a program for capacity building of the PBF Unit

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To build strong, collaborative relationships and work closely with the different directorates, departments, units of MOH, District/local hospital and Local Government/District Councils, to identify priorities in terms of health performance and assist them to address the gaps identified especially in areas related to capacity building and performance improvement;

Under the supervision of the Director of Health Planning and Statistics Department, to maintain ongoing collaborations, participation in technical working and steering meetings with relevant development partners;

To liaise closely with technical partners in government (Ministry of Development Planning, Ministry of Finance, Minister of Local Government and Chieftainship , and Ministry of Social Welfare) to monitor and evaluate interventions against objectives and targets, bringing in technical expertise when needed;

To develop strong working relationships with key stakeholders in government, international partners, donors and NGOs, and ensure coordination of resources and efforts;

To liaise with other programs to use and adapt lessons learned in PBF projects globally to the Lesotho context.

Qualifications required University Degree in an appropriate field, with a post graduate degree in Public Health; At least ten (10) years professional experience in health and understanding of health

system in Lesotho; Experience in Government health system at national level; Strong program management skills and demonstrated ability to execute plans effectively

and efficiently; Demonstrated success in coordinating various stakeholders/interests and developing

strong relationships in order to drive a process successfully; Ability to work independently and effectively in high-pressure, fast-paced environment

and handle multiple tasks simultaneously whilst mentoring a team to perform consistently;

Strong communication skills, including the ability to prepare compelling presentations; Demonstrated strong analytical, organizational, leadership, and problem solving skills; High levels of proficiency in Microsoft Word, Excel, PowerPoint, and internet

applications; English (verbal and written) and Sesotho language fluency required.

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Position: Financial Management Officer; Duty station: Maseru

General responsibilitiesThe PBF Unit Financial Management Officer executes his/her tasks and responsibilities in line with the PBF Unit Terms of Reference. More specifically s/he will be responsible for managing the financial and accounting functions of the PBF unit as well as the PBF project in line with sound financial accountability practice. This will include among others annual financial work plans, budgets, monitoring of income and expenditure and reporting. Considering that the PBF unit is newly created, the Financial Management Officer is expected to have a strong development-minded attitude. S/he will be responsible for the development and application of practical financial procedures, guidelines and administrative systems of the PBF unit / PBF project. These should follow and uphold Government of Lesotho (GOL) regulations as well as World Bank (WB) financial budgeting and reporting requirements, and should support the gradual scaling-up of the PBF project to all districts in Lesotho.In line with the MOH philosophy, the PBF Financial Management Officer will have outstanding academic credentials in financial management combined with a strong record of leadership and analytical capabilities. S/he will be gifted with a number of personal qualities, such as resourcefulness, responsibility, tenacity, independence, energy, creativity and work ethic.

Line of authorityThe Financial Management Officer will report to the PBF Unit Director.

Specific responsibilities To develop and manage the financial functions and reporting formats of the PBF Unit in

compliance with GOL as well as World Bank Finance and Administrative procedures and guidelines, working closely with the MOH Department of Finance

To prepare – in close collaboration with the PBF Unit Director – annual and quarterly work plans, budgets and liquidity plans regarding the PBF unit and project, in close consultation with the PBF National Steering Committee (NSC), the MOH Financial Department, the AID Coordination unit of the Ministry of Finance and the Ministry of Development Planning and the World Bank.

To monitor the financial transactions of the PBF unit and project, and prepare monthly, quarterly and annual financial reports in a timely manner.

To review, under the responsibility of the PBF Unit Director, the monthly/quarterly invoices presented by contracted actors (health facilities and District Health Management Teams (DHMTs)) so that they can be processed for payment following authorization by the PBF Unit Coordinator

To monitor – in collaboration with the MOH Financial Department – the flow of funds channels (from MOH to contracted health facilities) that prior to the start of the PBF project have been designed by and agreed between the MOH and World Bank.

To analyze and interpret financial data for appropriate policy and management decisions and respond to questions from the PBF Unit Director the head of the Health Planning and Statistics Department (HDSP), the PBF NSC, the World Bank and any other person or authority relevant to the PBF unit/project.

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To provide consultations and support on financial management to persons or institutions involved in the implementation of the PBF project, including at district level as well as at facility level.

To oversee that minimum standards of accountability and transparency are applied by all contracted partners in the PBF project which either receive compensation for operating expenses or are entitled to PBF benefits based on their performance.

To arrange and facilitate audits of the accounts of the PBF unit / project as per GOL and World Bank requirements

To supervise the PBF unit accountant on all accounting procedures To apply a software package that is coherent with the package in use in GOL ministries,

and to modify the package to suit specific needs of the PBF unit and project. To liaise with the PPTA on matters arising regarding financial management of the PBF

project and collect advice on financial management issues based on good practice in other countries with PBF projects

Provide oversight on the financial costs of the PPTA in collaboration with the MOH Procurement Unit which will be responsible for the PPTA contract.

Education/experience requirements BA/BS in Finance, Accounting or Business Administration; Certified Public Accountant

or Chartered Accounting (ACCA) qualifications or post-graduate degree in Accounting or Finance will be an added advantage

At least 10 years’ experience in finance and accounting in public (Government of Lesotho) or an international organization

Experience working with organizations which manage World Bank funding or international agencies will be an added advantage

Demonstrated ability to set up and maintain accounting and financial management systems;

Demonstrated experience with accounting software, preferably multi-currency packages including Quick Books software required;

Demonstrated ability to build and review budgets; Demonstrated excellent personal integrity and confidentiality; Excellent interpersonal communication skills, demonstrated ability to work effectively in

team based environment, supervise a professional team and ability to interact with a variety of technical, clinical and other specialists;

Excellent written and oral communication skills in English; Demonstrated ability in Microsoft Word and Excel, and proficiency using online

financial systems and databases; experience with an international auditing firm a plus

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Position: Monitor and Evaluation (M&E) Officer; Duty station: Maseru

General responsibilitiesThe M&E Officer is responsible for results monitoring of the PBF project. S/hewill regularly monitor PBF project outputs including achievement of targets in business plans developed by contracted health facilities. S/he will also work closely with the PPTA in the verification of incentivized services, and in case of any deviations of target in business plans – regardless whether positive or negative – undertake an effort to analyze these deviations. The analysis will have to result in conclusion or recommendations that will inform the management of the PBF project at various levels.

The M&E Officer will also closely work together with and benefit in terms of M&E system development from the PPTA, and similarly will establish sound working relationships with the M&E Unit within the MOH Health Planning and Statistics Department (HPSD). S/he is expected to collaborate with any upcoming efforts to digitalize HMIS at facility, district and national level.

The M&E officer will also closely collaborate with and support the World Bank independent impact evaluation effort, which includes various health facility and household surveys.

Line of authorityThe M&E Officer reports to the PBF Unit Director.

Specific responsibilities: Based on the M&E procedures described in the Project Implementation Manual (PIM),

work closely with the M&E Unit of the HPSD to develop a system for data collection at facility level, analysis, reporting and dissemination.

To liaise with the M&E Unit in efforts to strengthen the Health Management Information System

To carry out routine monitoring of PBF project generated data (from quantity and quality assessments) at facility, district and project level for the purpose of trends analysis.

To produce monthly progress reports, with trend analysis in quantity and quality terms. To support provider data collection as well as independent verification strategies (by the

PPTA and by contracted agencies for counter-verification) to ensures maximum reliability and accuracy

To provide technical guidance and training in PBF data planning, data collection and entering, recording and reporting requirements at various levels in the PBF project.

To contribute – in close collaboration with the PPTA – to strengthening M&E capacity at facility, district level and national level

To ensure that monitoring and evaluation of PBF is harmonized with M&E systems practices by other donors or development partners.

To manage the PBF database, the PBF web-enabled invoicing and administrative processes website. This website will allow sharing of information on the Lesotho PBF

Participate in the M&E technical working group (which has representation from the MOH and Development Partners)

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Qualifications: BA in Economics and Statistics or BSc in Public Health or Epidemiology. A post-

graduate degree in Epidemiology or Public Health (Monitoring & Evaluation) will be an added advantage;

At least 4 years of professional experience in M&E of projects (including formulation of data collection tools, developing and supervising data collection, analysis and reporting systems);

Previous experience and progressively increasing responsibility in the areas of supervision and continuous quality improvement;

Extensive experience in Health Management Information System, including ability to develop and monitor database systems for data management and routine reporting, will be an added advantage;

Extensive experience in working with district leaders/officials in a decentralized setting; Strong interpersonal communication skills, resourcefulness, ability to work

independently, preserve high work ethics and trustworthiness; Strong computer skills including word, PowerPoint, excel and access; Experience in (web based) database management will be an added advantage; English (verbal and written) and Sesotho language fluency required.

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Position: Operations Officer; Duty station: Maseru

General responsibilitiesThe Operations Officer will support the PBF unit in all operational matters related to the primary task of the PBF unit, i.e. to lead the introduction and gradual up-scaling of the PBF project in Lesotho. A road map, which has been compiled during the preparation period, will guide a pilot phase, which entails introduction of PBF in two pilot districts. The pilot phase is expected to generate valuable experiences that will inform a detailed plan for the second phase. The Operations Officer will capture these experiences and prepare a detailed road map for this roll-out, drawing from technical guidance provided by the PPTA.

A secondary task refers to responsibility of various procurement matters in support of the PBF unit and the gradual expansion of the PBF project. One of the key components of this role is to oversee signing of performance-related contracts, referred to as “purchasing”, with suppliers of health care and various health care supporting services.

The Operations Officer will liaise with the MOH Procurement Department, to ensure that any procurement meet the regulations/procedures as stipulated by the Government of Lesotho and the World Bank. The Operations Officer will closely collaborate with the PPTA, which will technically support the purchasing functions in the PBF project and build the capacity of the PBF Unit to take over this purchasing function in due time.

Line of authorityThe Operations Officer will report to the PBF Unit Director.

Specific responsibilitiesOperations/logistics

To update and further refine the road map for the PBF Project pilot phase, which has prepared during the preparation phase, prior to the launch of the pilot.

To work closely with the PBF Unit Director and other Unit staff in preparing strategic and annual plans of the PBF unit

To regularly (at least monthly) review the planning and adjust as required To ensure that the PPTA plans and schedules are harmonized and synchronized with that

of the PBF unit To support compilation of monthly, quarterly and annual progress reports and plans as

per Government of Lesotho/World Bank requirements. To organise the logistics of the PBF unit and project, in particular transport and

communications to prepare a detailed plan for phase 2 (up-scaling PBF project) drawing from the lessons

learned during the pilot phase, in collaboration with the PPTA

Procurement of health services and supporting services To oversee that all service providers have valid contracts that meet legal requirements

and support the execution of the PBF project and its ambitions To organize and oversee the quarterly or annual renewal of contracts with health facilities

or district councils. The contracts are signed at two levels, i.e. (i) at district level by the

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District Councils -- service contracts for health centres, and (ii) at the national level by the MOH PBF Unit -- service contracts for Government of Lesotho and Christian Health Association of Lesotho district/local hospitals as well as for District Councils/District Health Management Teams

Procurement of all other goods, works and services To liaise with the MOH Procurement Unit for the procurement of goods, works and

services for the PBF unit and PBF Project in collaboration with various end users/beneficiary programs

Where procurement requires a competitive bidding/tendering process, ensure transparency, efficiency, economy, and competition in accordance with agreed Government of Lesotho and World Bank regulations and procedures

To compile contract documents for approval and signing by the appropriate authorities To monitor the progress of contract implementation, including verification of delivery of

goods and services in accordance with specifications and process invoices and timely payments of amounts due.

To collaborate with the MOH Procurement Unit to inspect goods delivered, work being done and completed to ensure that the specifications agreed to are strictly adhered to for the implementing health facilities.

Qualifications Bachelor’s degree in Business Administration, Economics, Engineering, Project

Management, Commerce, Supply Chain Management, Operations Management, or equivalent

Five year’s experience in operations, planning, logistics and procurement Experience working with organizations which manage World Bank funding or

international agencies will be an added advantage. Familiarity with Contract Management procedures Exceptional ethics and professional comportment Excellent interpersonal skills and organization skills Strong computer skills including MS Office and a software program to support planning Strong team player Fluent in Sesotho and English

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Position: Accountant Duty station: Maseru

General responsibilitiesThe PBF Unit Accountant executes his/her tasks and responsibilities in line with the PBF Unit Terms of Reference. More specifically s/he will execute the routine financial and accounting functions of the PBF unit as well as the PBF project in line with sound financial accountability practice. This will include among others supporting the production of annual financial work plans, budgets, and reports, and monitoring of income and expenditure. Considering that the PBF unit is newly created, the Accountant will support the Financial Management Officer in the development and application of practical financial administrative procedures, guidelines and administrative systems of the PBF unit / PBF project. These should follow and uphold Government of Lesotho (GOL) regulations as well as World Bank (WB) financial budgeting and reporting requirements, and should support the gradual scaling-up of the PBF project to all districts in Lesotho.

Line of authorityThe Accountant will report directly to the PBF Unit Financial Management Officer and ultimately to the PBF Unit Coordinator.

Specific responsibilities To enter all financial transactions into the financial administrative systems, following

verification and coding in line with official procedures and guidelines To assist with all routine financial planning and budgeting and financial reporting in

compliance with GOL and World Bank procedures. To conduct regularly reconciliation of bank accounts and prepare a liquidity planning for

the PBF unit and project To assist the transfer of funds from the MOH to individual health facilities or district

local government in a manner that meets GOL and World Bank procurement and financial procedures

To manage the PBF Unit petty cash fund To reconcile advances and any travel vouchers on a monthly basis To facilitate audits of the accounts of the PBF unit / project as per GOL and World Bank

requirements To provide consultations and support on financial management to persons or institutions

involved in the implementation of the PBF project, including at district level as well as at facility level.

To carry out tasks as requested for the PBF Project

Education/experience requirements Degree/diploma in Accounting At least 3 years of experience in finance and accounting Demonstrated ability to analyze financial data Demonstrated ability to set up and maintain accounting and financial management

systems

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Excellent interpersonal communication skills, demonstrated ability to work effectively in team based environment, resourcefulness, ability to work independently, preserve high work ethics and trustworthiness

Fluent language skills in Sesotho and English Computer skills (Microsoft Word, Excel, and accountancy software such as TomPro

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Annex 7. TOR for PPTA (as issued for RFP)

1. BackgroundThe Lesotho Ministry of Health (MOH) will implement a Maternal and Newborn Health (MNH) Performance-Based Financing (PBF) project beginning in April 2013. The overall project development objective is to improve the utilization and quality of maternal and newborn health services in selected districts in Lesotho. The project has two components and will be implemented in two phases. During Phase I (May 2013-April 2014), the project will be piloted in Leribe and Quthing and in Phase II (May 2014 – April 2017), the project will gradually scale-up to 4-6 additional districts. This two-phased approach will allow for adjustments in design based on lessons learned. Leribe district has two hospitals, 25 health centres and one filter clinic while Quthing has one hospital, 8 health centres and one filter clinic.

The MOH recruited a consultancy firm to work closely with the MOH Technical Working Group to undertake preparatory activities between April-October 2012 to: (i) build PBF competence and capacity at the various levels for both MOH and Christian Health Association of Lesotho (CHAL) through workshops, training sessions, sensitization activities and study tours (Rwanda and Zimbabwe); (ii) develop the list of services to be incentivized as well as quality checklists for health centres and hospitals; (iii) determine the use of incentives; (iii) compile a PBF User Manual; (vi) prepare a roadmap, including phasing of the pilot PBF project; and (vi) develop terms of references for various entities. Additionally, the World Bank provided a PBF technical expert to assist the Leribe and Quthing district teams in preparing to implement the PBF pilot.

The MOH is establishing an office at the central level, to be called the PBF Unit, to handle the day-to-day management of the MNH PBF Project. The PBF unit consists of five (5) full time staff, including: PBF Unit Director, Financial Management Officer, Monitoring and Evaluation officer, Operations Officer, and Accountant. Given that this is the first experience with implementing PBF services in the Lesotho health sector, the MOH would like to contract an independent Performance Purchasing Technical Assistance (PPTA) firm with experience in PBF implementation in the health sector in Africa and globally to support the PBF implementation in accordance with the MOH/World Bank endorsed project design. The recruitment will be done through a competitive bidding process in accordance with appropriate World Bank procurement procedures. The PPTA will be selected prior to the preparatory phase (January 2013) before initiation of the PBF project in the two pilot districts.

2. Project components: The project has two components: Component 1 is MNH service delivery at community, primary and secondary levels through PBF while Component 2 entails training of health professionals, and VHWs as well as improving M&E capacity. It will be implemented in two phases. In Phase I (May 2013-April 2014), the project will be piloted in Leribe and Quthing districts. In Phase II (May 2014- December 2017), the project will gradually scale-up to a total of 6 districts excluding Maseru district. This two-phased approach will allow for adjustments in design based on lessons learned during the pilot phase.

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Component 1: Improving Maternal and Newborn Health (MNH) Service Delivery at Community, Primary and Secondary levels through PBF (US$14 million).This component will be jointly financed by IDA (US$10 million) and the Health Results Innovation Trust Fund (US$4 million)52. The objective of this component is to improve MNH service delivery at health facility and community level through two sub-components.

Sub-component 1A: Delivery of MNH Services through PBF will support the provision of quality MNH services as well as selected services in the Essential Services Package at community, health centres and hospitals by providing performance-based incentives to VHWs, health centres, hospitals, and the District Health Management Teams (DHMTs) (which have become part of the District Councils with the decentralization of health services). In order to strengthen collaboration between the health centres and the VHWs in the respective catchment areas, they will be considered as one unit for the payment of incentives. The performance incentives for VHWs will be linked to the overall performance of the respective health centres to which they are mapped.

The incentivized services to be delivered by Health Centres (Minimum Package of Activities [MPA]) and hospitals (Complementary Package of Activities [CPA]) are shown in (Tables 1 and 2 in the main PIM text). Additionally, incentive payments will be made to DHMTs/district councils based on supervision of health facilities using a quality checklist, providing feedback to health facility staff, submission of quarterly overall reports to the District Council Secretary with lessons learned, identified constraints and suggested solutions, and other information related to service delivery within the district. The performance-based incentives linked to achievement of predefined quantity and quality indicators at the health facilities are expected to stimulate health worker motivation and productivity and provide additional cash to overcome obstacles affecting the quality or continuum of care of their patients. Performance-based incentives will be adjusted based on comparative isolation of a facility to provide additional incentives to hospitals and health centres in remote areas and influence retention of health personnel in remote areas.

Sub-component 1B: PBF Implementation and Supervision Support will provide critical support for: (i) PBF implementation and supervision; (ii) capacity building of the MOH and CHAL at central and district levels, district and community councils; and, (iii) best practice documentation and sharing. The MOH and CHAL have limited experiences with PBF and hence the appropriate capacity will have to be built at respective levels, both strategic as well as operational. The MOH has established a central PBF Unit to handle the day-to-day management of the MNH PBF Project. The PBF unit consists of five full time MOH staff. The project will also competitively recruit a performance purchasing technical assistance (PPTA) firm to provide technical assistance and to build in-country capacity to implement the PBF project. The PPTA’s key functions are: i) to provide technical and implementation support to the MOH PBF unit and other PBF implementing entities on managing performance-based contracts for the delivery of incentivized services; and ii) to verify delivery of the quantity and quality of services, prepare the invoices for incentive payments, and assist health facilities with preparing their PBF business plans. The role of the PPTA will gradually reduce as the implementing entities and facilities gain greater experience with PBF implementation.

52 If at Midterm review, the project has progressed satisfactorily and there is need for additional financing, the Government could use its own resources, seek funding from DPs, or put in an application for more HRITF funds.

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Component 2: Training of health professionals and VHWs and improving Monitoring and Evaluation (M&E) capacity (US$2 million)This component will be solely financed through IDA financing and have two sub-components.Sub-component 2A: Training health professionals and Village Health Workers will support the ongoing MOH program for training of doctors, nurse anesthetists and midwives to achieve an acceptable standard of competency in the delivery of MNH services including EmONC as well as the training of VHWs. In August 2012, the Bank engaged a consultant to review the turnaround in the working capital management of National Drug Service Organization (NDSO) and related processes at NDSO, MOH, GOL and CHAL health facilities53. Based on the report, the project will support the training of health centre nurses on completing internal requisition vouchers and accurate recording of medicines on internal requisition vouchers. Additionally, district pharmacists will also be trained on appropriate forecasting, consumption and requisition mechanisms for drugs and medical supplies. Refresher training will also be provided to MOH financial management and procurement staff.

The MOH together with UNFPA, UNICEF, and WHO plan to conduct EmONC assessments in 2013 which will inform the ongoing on-the-job training for nurse midwives and medical doctors providing obstetric services in districts outside of Maseru. The project will provide support for the assessment and in-service EmONC training of doctors and nurse midwives. The training could be onsite or entail refresher training at Queen ‘Mamohato Memorial Hospital. Further, given the shortage of nurse anesthetists, the project will support the ongoing MOH effort on pre-service training of nurse anesthetists in training institutions in African countries. About 10-15 nurse anesthetists are expected to be trained.54

The MOH with support from development partners has developed a VHWs training manual and curriculum and has been training VHWs. This sub-component will support the ongoing training of VHWs on basic services such as family planning and referrals as well as taking care of mothers and children in the postnatal period and promotion of exclusive breastfeeding. VHWs will also be supported to conduct community head count and periodically update the village health registers for more accurate health facility catchment area data.

Sub-component 2B: Improving M&E capacity will support the strengthening of the Health Management Information System (HMIS) in all districts and build the capacity of M&E personnel at the central and district levels. As part of project preparation, the MOH will engage a consultant to assist the Health Planning and Statistics Department (HSPD) to improve the quality of health data through the review and update of data collection tools in order to strengthen and harmonize data collection at health facilities. The project will support the printing, training and dissemination, and utilization of the updated data collection tools at all health facilities.

This sub-component will also build capacity of central MOH monitoring and evaluation (M&E) and District Health Information Officers (DHIO) through formal training on M&E. Impact evaluation of the project will be carried out with additional funding of US$ 1.5 million for the HRITF. The project will supplement this HRITF funding, where necessary, for

53 NDSO Working Capital Management Report. November 2012, prepared by Thiagarajah Veluppillai, FCCA54It is expected that the trained nurse anesthetists will sign a bond to work in Lesotho, outside of Maseru, for a period of not less than 3 years after the training.

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additional surveys and data collection for the monitoring of the indicators in the results framework.

3. Main responsibilityThe PPTA’s main responsibility is to provide technical and implementation support to the MOH PBF unit and other PBF implementing entities at national and district levels on managing performance-based contracts with health facilities for the delivery of incentivized services. The firm will also verify delivery of the services (through data), prepare the invoices for incentive payments, assist health facilities with preparing their PBF business plans, and provide capacity building support to MOH administrative and technical departments and PBF unit on PBF implementation. The PPTA will work according to the design of the PBF project as has been developed during the preparatory phase and endorsed by the MOH and the World Bank. The PPTA will be placed within the PBF Unit in the MOH and strengthen the PBF Unit to carry out its purchasing role.Moreover, it will liaise with the relevant MOH units and district level entities implementing the PBF program. The PPTA will have central level personnel but its main focus is at the district level, i.e. verification officers who will work closely with each district in verifying reported performance, in organizing ex-post-verification activities, capacity building of district and health facilities for their new roles and in facilitating the district level performance validation processes.

4. Scope of ServicesThe PPTA will work closely with the PBF unit and will be responsible for carrying out the following activities:Capacity building and technical advice

1. To provide technical and implementation support to the MOH PBF Unit contributing to institutional strengthening of the PBF unit so that it will be able to manage the MNH PBF project;

2. To provide technical support for the implementation of the PBF project which has already been designed and detailed in the Project Implementation Manual;

3. To propose modifications to Project Implementation Manual, based on accumulated experience with implementation of the PBF pilot, through organizing an annual consultative process with key stakeholders;

4. To provide technical assistance related to PBF operational procedures, including training of health workers, health centre committees, District Health Management Teams and District Councils, as described in the Project Implementation Manual;

5. To provide technical assistance in the maintenance and continuous development of the PBF database, on drafting the annual reports, and on assisting in advanced data analysis and reporting, including with triangulation with other databases.

Operational tasks6. To assist the PBF Unit in signing contracts with the District Councils and District

Hospitals for the delivery of incentivized services, describing the performance framework as well as their roles and responsibilities in relation to PBF;

7. To assist the District Council Secretary with signing contracts with the Government of Lesotho and CHAL health centres for the delivery of incentivized services, describing the performance framework as well as their roles and responsibilities in relation to PBF;

8. To assist health facilities to prepare business plans that are consistent with the incentivized services and with targets consistent with the facility and district

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catchment populations and to effectively use PBF earnings for the improvement of health service delivery;

9. To assist the PBF Unit with ex-ante verification of the delivery of incentivized services;

10. To assist the PBF Unit and District Councils in preparing and processing invoices for approval of services purchased so that payments to contracted health facilities can be effectuated according to the agreed Project Implementation Manual;

11. To support the District Health Management Team with its supervision tasks to assess the quality of care provided in participating facilities using a standardized quality assessment checklist which have already been developed;

12. To comply with existing MOH technical guidelines and procedures and those developed during the life of the contract;

13. To assist the PBF unit and the District Council in organizing its quarterly district PBF steering committee meetings, with a special focus on technical assistance in extracting invoices from a web-based application (which wlll be developed through a separate consultancy), and in the analyses of trends and the production of comparative tables and graphs for further analysis.

Contribution to project developmentTo design a system of ex-post verification that effectively and efficiently validates, on a quarterly basis, the quantity and quality of services provided, in collaboration with the PBF Unit, district councils and MOH M&E unit ensuring that the services that are being paid for have actually been delivered;

14. To consult regularly with PBF stakeholders and Development Partners on further improvement of the PBF design;

15. To contribute to the Monitoring and Evaluation activities undertaken by the PBF Unit (the World Bank will recruit a separate firm to undertake an independent impact evaluation of the project). ;

16. To develop a roadmap and implementation plan for scaling up the PBF project beyond the pilot districts;

17. To prepare the districts selected for the scaling up phase for implementation. It is to be expected that five or more districts in different parts of the country will be selected for the scale-up beginning in January 2014. In the second half of 2013, the PPTA is expected to start preparatory actions, which includes conducting sensitization and training workshops for communities, health centres and their committees, hospital management teams and District Health Management Teams/District Councils, collecting baseline data and setting performance targets.

18. To contribute to the dissemination of best practices and lessons learned on the PBF in Lesotho to other stakeholders within the country and other part of the world.

5. Qualifications and Experience of Key Staff It is expected that the PPTA will engage personnel with skills, qualifications and experience in line with the above mentioned scope of services, i.e. fulfill the role in providing technical assistance, implementation support and capacity building to the local institutions at national and district levels and further development of the project. The firm/organization should have at least three (3) years’ experience of providing Technical Assistance to health projects in sub-Saharan Africa on performance based financing, have a track record in capacity building and South-South knowledge transfer. The firm/organization should be experienced in partnering with local organizations. With due attention to cost-effectiveness, the PPTA will engage (local/national/regional/international) professionals who have the following minimum

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qualification & experience for the key positions as given below. Detailed curriculum vitae for all positions below are to be submitted as part of the proposal, however only the key staff CVs for Team Leader / Performance-based Contract Coordinator, Technical Advisor, Monitoring and data verification Specialist and Financial Management Specialist will be evaluated:

No. Position Number of positions

Minimum Qualification/Experience

1 Team Leader / Performance-based Contract Coordinator

1 1. At least 5 years mandatory experience with designing and implementing Performance Based Financing approaches in sub-Saharan Africa

2. University Degree in an appropriate field, with a post graduate degree in Public Health, MBA or Health Economics

3. At least 5 years of experience in health project management in different countries

4. Experience with leading teams5. Demonstrable track record of success6. Experience in the effective management

of contracts7. Ability to work independently and

effectively in high-pressure, fast-paced environment and handle multiple tasks simultaneously whilst mentoring a team to perform consistently;

8. Fluency in English (verbal and written) is required

2. Technical Advisor 1 1. MD or Economist with a Post-Graduate University degree, preferably in Public Health, MBA or Health Economics

2. At least 5 years of total post graduate qualification experience with the last 3 years in Health Sector projects

3. Expertise with economic analysis and costing of health services would be preferred

4. Demonstrable experience as leader in similar high profile assignments preferably in developing countries.

5. Demonstrable track record of success6. Mandatory experience with designing and

implementing Performance Based Financing approaches in sub-Saharan Africa

7. Ability to work independently and effectively in high-pressure, fast-paced environment and handle multiple tasks

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simultaneously whilst mentoring a team to perform consistently;

8. Fluency in English (verbal and written) is required.

3 Monitoring and data verification Specialist

1 1. University degree in an appropriate field, especially M&E, statistics, ICT management, data collection and analysis

2. Extensive experience in Health Management Information System Experience

3. At least 5 years of professional experience in M&E of projects (including formulation of data collection tools, developing and supervising data collection, analysis and reporting systems)

4. Experience in organizing community and/or client satisfaction surveys

5. Experience with innovative models in the health sector – e.g. contracting out, results based financing

6. Ability to work independently and effectively in high-pressure, fast-paced environment and handle multiple tasks simultaneously whilst mentoring a team to perform consistently;

7. Fluency in English (verbal and written) is required.

4 Verification officers(local professionals)

3 initially (1 for Quthing, at least 2 for Leribe)

1. 1 per 7-10 health facilities; typically about 1.5 Full Time Equivalent (FTE) per district;

2. Nurse with public health experience3. Willingness and ability to be trained in

PBF, ICT, data analysis4. Energetic and active personality5. Fluency in English (verbal and written) is

required.5 Financial

Management Specialist

1 1. University Degree in an appropriate field, especially Accounting, Finance, Economics, Business Administration, Commerce

2. A post graduate degree in Accounting or MBA will be an advantage

3. At least 5 years of experience managing public or private sector accounting systems

4. Experience with innovative models in the health sector – e.g. contracting out, results based financing, will be preferred

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5. Innovative and flexible personality6. Experience building capacity at

decentralized levels to improve public financial management

6 Administrative Support Staff(local staff)

2 1. Includes Secretary and Drivers, etc.

It is expected that the number of staff of the PPTA might reduce as the implementing entities and facilities gain greater experience with PBF implementation. It is noted that the Financial Management Specialist role will not require a full-time person but someone who can spend substantive periods of time in Lesotho to assist the PBF implementing entities and build the financial management capacity in terms of financial monitoring and reporting. However, if it is realized that additional PPTA staff will be needed for the first year of the scaling-up phase (from 2014), this will be separately negotiated during the annual renewal of the PPTA contract. The PPTA will assure that an appropriate solution to maintain the separation of functions between the purchaser and fund holder is identified for the MOH as PBF implementation proceeds, together with the PBF unit, against a prearranged schedule with clear milestones.

The PPTA will have full authority on management of its staff. The PPTA will only submit invoices for paying the health facilities in line with the performance based contracts.

6. Location and Duration of ServicesThe successful firm will support the implementation of the agreed PBF project as specified by the MOH. The program will be implemented initially in two pilot districts. It is expected that the PPTA will have an annual, renewable contract. Extension beyond the pilot phase depends upon performance during the first year.

7. Reporting and accountabilityThe PPTA will be accountable to the Head of the MOH PBF Unit and provide quarterly reports to the Director of the Health Planning and Statistics Department.

Quarterly Technical Reports: The PPTA will compile quarterly reports related to activities undertaken in fulfillment of these terms of reference in close cooperation with the PBF unit. The reports will be submitted to the Director of the Health Planning and Statistics Department, who will share them with all relevant stakeholders, including the World Bank.Notwithstanding its independent mandate and responsibility, the PBF unit will harmonize and synchronize its reporting with the PPTA as much as possible. The quarterly report will include the following sections:

(ix) progress in implementation of the PBF project; (x) problems encountered and solutions undertaken; (xi) relations and collaborations with stakeholders such as the district (health)

authorities, the community, and other NGOs operating in the assigned areas; (xii) a financial statement; (xiii) progress in transfer of knowledge activities to PBF Unit staff and decentralized

implementing entities; and

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(xiv) a summary of MOH HMIS forms with analysis. Such reports will be furnished within one month of the end of the quarter.

Financial Reports: The PPTA will maintain a separate set of accounts for the project and provide an annual externally audited financial report to the MOH/World Bank. Such audit report will be furnished within three months of the end of the year. The MOH/World Bank reserves the right to examine, or to have its designated agent examine, the accounts maintained by the PPTA for these World Bank -financed activities.

8. Data, Services, and Facilities Provided by the Government of Lesotho (GOL)The Government of Lesotho will provide the PPTA with the following inputs: (i) relevant available information about facilities, health-care status of population, and results of surveys and special studies; (ii) access to all participating health facilities in the areas of assignment; (iii) copies of technical guidelines and standard HMIS reporting and recording forms; (iv) access to MOH training courses; (v) copies of key reports (including PIM Annexes) and research carried out in Lesotho; and (vi) access to key GOL officials for consultation and discussions; and, (vii) office space near the PBF Unit, provided that it is available.

9. Performance monitoring of PPTA and extension of contractIn order to gauge the success of the PBF project and the performance of the PPTA, key performance indicators will be agreed upon during the contracting process for monitoring purposes; initial indicators for discussion are provided below. Extension of the contract will be dependent upon the performance of the PPTA and progress made towards the selected indicators.

The following KPIs will be used to measure PPTA’s performance annually throughout its engagement in the MOH PBF project.

Indicator Approximate Target 1

Means for Data Collection2

1) Number and percentage of health facilities that submitted quarterly report on time (progress, financial and HMIS data) to the MOH during the year

36 Quarterly reports

2) Number and percentage of health facilities that submitted completed quarterly reports


3) Number and percent of health facilities that received quarterly performance payment on time during the year


4) Number and percent of health facilities that received payment of performance incentives in line with the fees for services and quality incentive formula set for the selected geographic area


5) Number and percent of health facilities where third party verification was carried out on both quantity of services reported and the quality of care index


6) Proportion of PPTA key personnel tasks fully transferred to PBF Unit staff member for implementation (measured annually for each key personnel person vs shadow PBF Unit staff member that works on similar area with PPTA key personnel person)

(firms to propose target)

(firms to provide means)

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7) Number and percent of health facilities able to independently complete adequate business plans per quarter


1 Targets should be seen as approximate rather than exact given the limits of precision in measurement of these indicators and uncertainties about the actual baselines at the beginning of the contract. What is important is statistically and programmatically significant changes in these parameters.2 HMIS=health management information system, HH Survey = Household survey, HF survey = health facility survey, QSC=Quantitative supervisory checklist, AuditNote: 36 health facilities refer to 26 Leribe health centres and 1 hospital and 8 Quthing health centres and 1 hospital.

Administrative Monitoring Indicators – relevant for Year 1 pilot and to be adapted on annual basis



1. Project documents reviewed and modified accordingly as required

2

2. Schedule for the supervision of health centres and the national and district PBF steering committees developed

1

3. Ex-post verification system designed to ensure that the services paid for have been delivered

1 Household survey

4. Availability of roadmap for scaling up 15. Number and percentage of scale up districts trained

on PBF4

6. Number of case studies and/or best practice examples identified, documented and adapted into Lesotho PBF implementation,

7. Number of case studies and/best practices disseminated locally, regionally and internationally

8. Number and percentage of district steering committee meetings held with PPTA support

4 per year per district

Minutes

9. Number and percentage of health centres supervised by DHMT with PPTA support

4 supervisory visits per health centre

Supervisory checklist

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Annex 8. TOR for PBF DISTRICT STEERING COMMITTEE

1. BackgroundThe Lesotho Ministry of Health (MOH) will pilot a Performance Based Financing (PBF) project with funding from the World Bank (WB). The PBF project aims to improve maternal and newborn health outcomes through the increase the provision, uptake and improve the quality of maternal and newborn health (MNH) services at the primary health care (PHC) level and community health level in targeted districts. In the initial phase the project will be piloted in the two districts of Leribe and Quthing, and will subsequently be scaled-up to other districts of Lesotho.

2. Main responsibilityThe District Steering Committees will be a multi-stakeholder committee, which will have a monitoring, coordinating and advisory role on strategy, dialogue, management support and evaluation of the PBF approach in the district.

3. Tasks to be performedIts responsibilities include:

Monitor the project at district level and make recommendations to the District Council about the progress of the PBF project at the district level;

PBF strategy: To present and discuss the data and information related to the PBF health facilities including activity level, quality of care level and other relevant information; to review the different strategies in place for the improvement of results and follow-up on previous decisions of the committee.

PBF dialogue : to give opportunity to every member of the committee and representatives of the health facilities to express any challenges or difficulties in implementing the program or their own strategies; to address disputes members or stakeholders refer that to it.

PBF invoice validation : To discuss and review the final consolidated quarterly invoices of health facilities together with the quarterly progress report compiled by the DHMT. The DHMT prepares the facility invoices after receiving the verified PBF performance data from the PPTA and consolidating these with the quality of care assessments done by the DHMT. After discussion and approval by the PBF district steering committee the invoices are forwarded to the MOH-PBF Unit for further processing and payment authorization.

PBF management support/evaluation: To review and discuss the performance of the DHMT: the DHMT will be under a performance contract with the MOH-PHC department to carry out certain functions related to the well-functioning of the PBF system, in a timely and correct manner. The MOH-PHC department, representatives from the District Council and the PPTA (national level; with a standing invitation to the PBF Unit to attend too) has scored the DHMT performance using the performance evaluation tool.

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4. Composition and the launch of the District PBF Steering CommitteeThe PBF Unit held a meeting with the two pilot district officials to discuss the composition and the launch of the PBF Unit. The Leribe district officials comprised of the District Administrator (DA), District Council Secretary (DCS), the District Medical Officer and the Hospital Manager while Quthing district officials comprised of the District Administrator (DA), District Council Secretary (DCS), Administration Officer District Council and Matron.

The following composition was agreed upon but the composition may vary depending on the district needs;

District PBF Steering Committee1. District Administrator Chairperson2. District Council Secretary Alternate chair 3. Representation of the District Council 4. District Director of Health Services 5. Matron/Hospital Manager 6. Public Health Nurse Secretary 7. Ministry of Social development 8. Ministry of Finance (Sub-Accountancy) 9. Pharmacist 10. District Health Information Officer 11. Representation of the Area Chiefs 12. Security Representation i.e Police13. NGO

The following Ministries can be invited to the steering committee as when necessary. 1. Ministry of Gender2. Ministry of Agriculture3. Ministry of Education 4. Mayor/Town Clerk

For the representation of the health centres, the agreement is that the representation will be selected on monthly meetings between the DHMTs and the health centres. The health centres will be expected to nominate the health centre nurse who will represent them on the next district PBF steering committee quarterly meeting.

The agreement was that the launch of the Leribe PBF district steering committee will be on the last week of January while that of Quthing will be in the first week of February, 2013.

5. Frequency of meeting and functioningThe Steering Committee shall meet at least once every quarter upon invitation to its members by the Committee chairperson. The DHMT focal point shall act as the committee’s secretary. The chairperson shall invite participants with at least 14 days’ notice, and will ensure that the next quarter’s meeting will be planned during a current meeting. The quarterly PBF Steering Committee meetings shall be held before the third week of the fourth month.

The minutes of the PBF Steering Committee meeting, signed by the chairperson, and the consolidated quarterly district invoices, shall be sent in hardcopy to the MOH/PBF Unit. These deliverables ought to be received by the MOH before the fourth week of the fourth month, enabling the MOH to process the payment within 6 weeks of the last quarter.

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The minutes of the meeting should conform to the norms related to agenda content and reporting format.

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Annex 9. CONTRACT FOR DHMT

Contract between the MOH and the District Health Management Team

Ministry of Health

PERFORMANCE BASED FINANCING (PBF) CONTRACTFOR THE QUALITY SUPERVISION OF HEALTH SERVICES

No _________________

THIS CONTRACT is dated [……..] 201….

BETWEEN:

The MOH represented by the Dir. PHC

Dr /Ms /Mr.…………………………………………:

And

The [Name] District of …………………

Represented by: Ms / Mr: [Name] Director DHMTs

Chairperson/Secretary of […………] District Steering Committee

CC. MOH-PBF Unit

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IT IS AGREED as follows:

1. Principles of Performance Based Financing

1.1 The present contract is a performance contract between the MOH Dir.PHC and the District Health Management Team (DHMT) in the District of………………. in the context of the Performance Based Financing (PBF) program.

1.2 The goal of PBF is to increase the provision of quality Basic Health Services to the population by increasing financial incentives for health workers and by increasing health facilities’ decisional rights on the management of their own operations.

1.3 The Performance Based Financing strategy emanates from National Public Health and Poverty Reduction policies. The MOH reserves the right to amend the applicable policies that serve as the basis of its support to the DHMT prior to the expiry of the present contract.

2. Purpose of the Contract

2.1 The purpose of this contract is to establish a performance contract for the DHMT to undertake Supervision of the Quality of Care at the [Name of the District]’s PBF contracted Health Facilities based on the applicable Performance Framework.

2.2 Part of the payments received under these terms may be used by the DHMT to pay for performance related motivation bonuses; while the bulk of the PBF benefits is intended to contribute to the DHMTs core activities and functioning. (see also section 6)

3. Mission of the DHMT within the PBF System

3.1 The DHMT shall ensure that Health Centres and Health Posts/Village Health Workers in the [Name of the District] provide adequate quality health care services in the general interest of improvement of public health in the community.

3.2 In doing so, the DHMT hereby commits to undertake the following: Overall technical coordination of PBF at the district level Supervision of health facilities, which includes minimally a quarterly meeting with all

HC representatives; investigate and document for the District PBF Steering Committee any change in HF personnel, technical skills and equipment at the facility that which could hamper its capability to render the Services remunerated by the present PBF contract;

Process the contracting of health centres, including endorsement of business plans. This shall entail

o review on a quarterly basis the level of implementation of the Business plans developed by the HFs which form part of their PBF purchase contracts. The Business Plans evaluation shall form part of the PBF Quality Verification

o verification that the business plans do not contradict but support the district health plans or strategies

o suggest changes to the business plans in close collaboration with the Health Centre Committees and Heads of facilities. The DHMT has an important technical supportive and advisory and capacity strengthening role in this aspect;

Conduct, assisted by the PPTA, timely quarterly quality assessments of and reporting on health centres in the district. This activity includes:

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o Making use of the PBF Quality Checklisto conducting quarterly Quality Assessment at all PBF facilities and reporting as

indicated in the checklist; The original of all quality supervisory checklists shall be sent to the MOH/PBF Unit

o preparing a synthesis report on the quality assessment outcomes for the whole district for review and validation by the PBF District Steering Committee;

o failure to conduct the quarterly HF quality assessments will result in non-payment of the quality bonus to health centres not assessed

regularly participate in the (quantity) data verifications performed by the PPTA (at least once per quarter per facility in addition to the quarterly quality assessment)

Investigate at facility level any activities in contradiction with national health policies and/or accepted medical ethics and solve these, and bring these to the attention of the District PBF Steering Committee if necessary;

Facilitate the procurement of larger items and ensuring that the necessary resources (e.g. equipment, drugs) which healthcare workers will need to perform their duties are available.

Preparation of quarterly progress reports to the MOH – a standard short reporting form will be provided for this purpose

Ensure complete transparency and access to information relating to the use of funds received from the MOH in relation to the present contract.

Documentation of challenges and successes Supervise the Health Facilities regularly (as stipulated in Section 4 herein),

Investigate and Report in writing any case of fraud or attempted fraud committed by HF staff members to the MOH/PBF Unit and the District PBF Steering Committee;

4. Performance Remuneration of the DHMT

4.1 The level of remuneration shall be directly proportional to the score obtained by the DHMT in accordance with the performance framework tool. For instance, if the PHCD obtains 75% score in a given quarter, the DHMT shall receive 75 % of the total available performance budget for that quarter.

4.2 The PBF benefits accrued by the DHMT shall be used as follows: Incentives (motivation bonuses) to DHMT staff: range 0-20% of total Resources for improvement of DHMT functioning range 80-100% of total

4.3 Individual motivation bonuses will only be paid out to DHMT staff who have signed a motivation contract, whereby the conditions in the contract entitle the staff to such bonuses.

5. Evaluation of the DHMT Performance

5.1 The MOH-Dir. PHC with assistance from the PPTA and the representative of the District Council shall evaluate the DHMT’s performance every quarter, not later than the 15th day of the month immediately following each concerned quarter and using the Performance Assessment Framework;

5.2 The MOH-Dir. PHC shall sign 1 original of the quarterly performance assessment, the original will go to the MOH/PBF Unit for filing and entry in the web-enabled application; a copy will remain at the DHMT and will be presented during the following PBF steering committee meeting;

5.3 In case of systematic underperformance, such as not carrying out the quality supervision in a timely and complete manner, or in the case of fraud with the quality

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assessments, the MOH-Dir. PHC in consultation with the PBF Unit retains the right to unilaterally stop this contract, and to provide this contract to another party.

6. Terms of payment

6.1 The PBF unit will prepare a payment advice for every DHMT which received a performance assessment, based on the invoice received and the supporting performance assessment report. The payment advice will be forwarded to PBF-Unit for authorisation by Dir. HPSD after which the MOH fund holder will effectuate payments

6.2 The MOH/PBF Unit shall directly pay the DHMT by way of bank transfer in the designated DHMT bank account.

6.3 Payments will be executed along with the performance payments for health facilities, and will follow the same system of validation, due diligence and approvals (review in the District PBF Steering Committee; submission of minutes of the meeting and invoices to the MOH/PBF Unit; due diligence of the MOH/PBF Unit on the deliverables; payment for performance by the MOH Finance Department);

7. Dispute resolution

7.1 In the case of dispute relating to the interpretation of the present contract, both parties agree to refer to the most current applicable Performance Based Financing User Manual, and attempt to resolve the issue in the District PBF Steering Committee meeting;

7.2 In the case of dispute relating to the implementation of the present contract, both parties agree to refer to the matter to the arbitration of the National PBF Steering Committee, which acts as the regulator of the PBF system at the national level. The arbitration decision in the matter shall be final and binding towards all parties.

7.3 However, in case of systematic underperformance, as documented in section 7.3, the MOH-Dir. PHC in consultation with PBF retains the right to stop the current contract unilaterally and to contract with another party.

8. Duration of the Contract

The present contract is signed on [date] for a period of 12 months. It shall be renewed tacitly for an additional 12 months subject to the terms stipulated in section 1 of the present contract.

Done at …………………………….. On ……/………/201…

For MOH-Dir.PHC

Ms/Mr/Dr. ______________________________

Signed ______________________________

And

Secretary of the District Council DHMT Director

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Ms/Mr _____________________ Ms /Mr/Dr_____________________

Signed ______________________ Signed ______________________

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Annex 10. TOR FOR HEALTH CENTRE COMMITTEE

1. IntroductionThis Terms of Reference describes the role and responsibilities of the Health Centre Committee (HCC). The HCC is an important institution that oversees the performance of the lowest level of the health system in Lesotho. At the same time it exemplifies community ownership and accountability through its composition and its tasks and responsibilities. The HCC plays an important role in the decentralization process of the Government of Lesotho, and is instrumental for the implementation of Performance Based Financing (PBF).More concretely, the HCC provides oversight to the HC and sees to it that the HC accommodates the health care needs of the community that depends on the HC. The HCC is therefore an important link between the HC and the community. HCC will consist of representatives of the community, including a representative of the cooperative of VHWs.

2. Composition and functions Health Centre Committee

a. CompositionThe following statements can guide the HCC composition:

Relevant groups within the health centre catchment area will elect a representative and the alternate person.

Members could be selected from the following relevant stakeholders: Area Chief, VHWs, traditional Healers, agricultural extension officer, nutrition assistant, schools, police, CBOs, community councilor, businessmen, faith based organisations, youth, representation of the disabled, Nurse in charge (Secretary), (there should be alternates who should also be appointed).

Community councilor and the area chief are ex-officio members if they are not elected as committee members. because of their administrative roles;

The Chairperson and his/her deputy shall be elected by the committee in its first sitting. The committee will sit at least once a month and keep records of the proceedings. The Committee should be gender sensitive.

The Nurse in charge of the health centre shall be the secretary of the committee. The committee shall report to the DHMT.

b. RolesThe roles played by HCCs include the following

facilitate people in the area to identify their priority health problems, identify what they think can be done about them, using participatory approaches and information from technical personnel;

plan how to raise their own resources, organise and manage community contributions, and tap available resources for community health activities;

Support the VHW in the execution of their activities including community mobilization

use information from the health information system and from communities in planning and evaluating their work and should be trained to do this;

assess whether the health interventions in the area are making a difference to people’s health using health information system and community information;

be a channel for information flow from the community to the community and district councils/DHMT and back to the community;

be informed about the activities of different health providers in the area

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raise and discuss aspects of patient care and represent communities on issues they raise on services offered, to see how these can be addressed;

obtain information from the community/district councils and DHMT on budget allocations for health, on village level allocations, give input and feedback to the CC/DC and DHMT on budget planning and keep communities informed on health budget issues, particularly where this relates to local resource mobilization such as for transportation of emergencies and other necessities; and

work with the community/district council to motivate and implement public health standards, such as for water supply and sanitation

c. ResponsibilitiesHealth Centre Committees have a range of roles and responsibilities, some of which refer to the PBF project:

to serve as the board of the Health Centre, which implies provision of leadership to the HC staff and representing the HC to the community and the local government

to advise and support the health facility in the provision of Health Services including outreaches, VHPs and scheduled community/home visits

to oversee operations of the facility; to oversee security of the facility to participate in the development, implementation and monitoring of the health centre

annual plans to contribute to developing the business plan for the HC in close collaboration with

the in-charge of the HC and eventually endorse the business plan to be co-signatory (chair) to the HC in charge in respect to signing PBF contracts with

the District Council to be present at HCs quality assessments and other actions that are part of the PBF

control systems to be signatory (chair or other nominated person) to the HC bank account and

overseeing accountability for use of PBF for the purposes stated in the business plans

Health Centres/Clinics Committees Inventory

District: LERIBE

Health Centre/Clinic Name

Health CommitteeAvailable /Not Available

Active /Not Active

Remarks(Kindly state by when the committee will be in place)

Fobane Available Active -St. Ann Available Active -Holy Trinity Mahobong CHAL

Available Active -

Matlameng Available Active -Pontmain Available Not active Needs motivationThaba - Phatsoa Available ActiveSeshote Available NewSepinare Not available - Non-functioning

facilityLejone Not available - Non-functioning

facilityPalama Not available - Non-functioning

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facilitySt Denis Available - Some conflicts to be

resolved as it was established by Priest

Khabo Available NewEmmanuel Available ActiveMaryland Available NewLouis Gerald Available NewOur Lady of Lourdes Available NewLinotsing Available ActiveSt Monicas Available NewMaputsoe FC Available NewMaputsoe SDA Available NewSt Magaret Available NewSeetsa Available NewMahobong GoL Available NewThaba-Phatsoa Available New

District: Quthing

Health Centre/Clinic Name

Health CommitteeAvailable /Not Available

Active /Not Active

Remarks(Kindly state by when the committee will be in place)

Dilli Dilli Available New As much as the committees are have now been revived, there is a need for the training as they are not clear of the scope of their work or generally their terms of reference.

Tsatsane Available NewMaqokho Available NewMakoae Available NewMphaki Available NewSt Gabriel Available NewVilla Maria Available NewSt Matthews Available New

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Annex 11. COMMUNITY MAPPING TOOL AND QUARTERLY VHW PERFORMANCE MONITORING TOOL

1. IntroductionPublic Health Management requires the availability of reliable community data to set targets and monitor performance, more in particular to know whether the community makes optimal use of the services. Although for health centres catchment population have been defined, these numbers are usually based on estimates, extrapolation of statistics collected during the last census with 1% added for anticipated population growth. At times surveys provide additional, relevant information, but are nevertheless estimates based on extrapolation.In order to have a comprehensive overview of health care needs and in particular on reproductive health and various diseases, such as HIV/AIDS and TB, it could be very helpful to conduct community mapping.

Community Mapping is a way of gathering “inclusive” information about who lives in the community, what the needs of the community are and how to bring everyone together to talk about the problems they face. Community mapping is the process of depicting visually what is happening in a given community. It can be used as a method of enhancing partnerships between the community, the Village Health Workers (VHWs) and the health facility and increasing the demand for ( priority/vital) services such as deliveries supervised by a professional as well as understanding the reasons for underutilization of services that are offered by health facilities. Conducting community mapping requires backing from local community leaders, mobilization of the community and may be expected to lead to intensified contact between the community and VHWs and also contribute to the esteem of VHW as health agents in their community.

There are five (5) phases in the community mapping process.1. Joint Commitment: members who are to undertake the mapping exercise (i.e.

VHWs) agree on a common purpose; that is; why the mapping needs to be done. Boundaries are defined and agreement is reached on what the group wishes to accomplish together. Support from local community leaders is sought.

2. Creating Community Profile: information is gathered about the community; the information is mapped (in graphics) and; the maps are supplemented with narratives and numbers.

3. Community Engagement: the HCC, Chief and Community Council are invited to review the community profile created; as agreed, the profile is revised and/or enhanced; community needs, strengths, gaps and resources are identified and; an action plan is created.

4. Action: Implementation5. Reflection: successes and challenges in working together are identified and

documented; successes and challenges in achieving expected outcomes are identified and documented. And the cycle starts again with a discussion regarding ongoing joint commitment to planning together.

2. Objectives of Community Mapping in MNH PBF projectThe following objectives can be considered:

Defining boundaries for each HC catchment area, i.e. based on actual health care seeking behavior

Gathering information on the number of households per village/ catchment area

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Identifying and locating target groups per household for different services as per the indicator list.

Making a sketch of the mapped area with landmarks, showing the boundaries and households with target groups for PBF interventions.

3. The Mapping Toolsa. Community Mapping toolb. Aggregating the data collected to specify totals for all villages HC catchment

populationc. Follow-up – quarterly update

PilotThe community mapping tool will be piloted in a number of facilities to generate experiences, which if required will improve on the design, the execution of the community mapping and the processing of the outcomes.

First Community MappingThis tool is designed to collect information that will contribute to the (HMIS) database of each health facility. The information collected will be on the catchment population per health facility; this includes the number of households per village found within the catchment area, the number of members in each household and the characteristics of people found in each household (e.g. sex, age). The target groups will also delineated/aggregated as per the indicator list.

The villages, households, and the household members will be allotted codes for ease of reference. A very simple tool is to give a six digit code: two digits identifying the villages in the catchment area of a HC, two digits for identifying the household in that village; two digits to identify individuals of each household. Use of such a code eases comparison of VHW generated data and HC records. Moreover it greatly facilitates patient tracing for counter-verification practices.

Total for All VillagesThe sheet will show per health facility the total number of villages, Village Health Workers, households as well as the totals per indicator. (baseline information prior to the start of the project).

Quarterly Follow upThis tool is a working document that will capture on a quarterly basis the status of the indicators as per the VHW target coverage of 20 households.

Village Health Worker’s InvolvementThe VHWs will carry out the actual community mapping exercise. The health centre with the support from the district will conduct the community sensitization sessions for the key stakeholders including the VHWs committees, Health Centre committee, the Chief and the community council on the PBF project and the need for community mapping to solicit their full support. The VHWs will be oriented on the community mapping exercise and supplied with the resources needed for undertaking the mapping.

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MethodologyAll the households in the villages in the Health Facilities catchment areas will be assessed to find out the number and composition of the members. The households will be numbered and the Village Health Workers will each be allocated a selected number of households. Depending on the situation on the ground/prevailing situation, i.e. the household: VHWs ratio, some VHWs might be allocated more households than the others (additional households should be those with few members to balance the workload).

OrganizationEach HC will have a focal point for the VHWs. This staff member will be actively involved in the community mapping exercise, will assist the VHWs (or its representative) to plan and execute the community mapping. The staff will also support the cleaning and processing of data collected in order to produce a report that will be informative for public health management at various levels.

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Community Mapping - HH per Village

DateDistrictCommunity Council

Health Facility

Health Facility Code

Village

Village Code

ChiefVHW

House Hold HeadHouse Hold code

Women of Child Bearing Age

House Hold MemberCode no dob/age

relation to House Hold Head

Gender

Ante Natal Care

Delivery in Health Facility

Post Natal Care

Family Planning

< 1 Children

< 5 children

TB treatment

HIV/ART

Comments

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Community Mapping Total for All VillagesHealth CentreDistrict NameCommunity CouncilGOL/CHAL HC

Women of Child Bearing Age (WCBA)

Date

Total Villages

Total Village Health Workers

Total House Holds

Total Ante Natal Care

Total Health Centre Deliveries

Total Post Natal Care Clients

Total Family Planning Clients

Total < 1 Children

Total <5 Children

Total Patients on TB treatment

Total HIV Positive Clients

Total clients on Anti-Retroviral Therapy

Comments

Signature

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QUARTERLY FOLLOW UP

DistrictCommunity Council

Health FacilityHealth Facility Code

Village/ Villages Village CodeVillage ChiefVHW Name

House Hold Member Code no

dob/age

Gender Jan

Feb

Mar

April

May

June

July

Aug

Sept

Oct

Nov

Dec

Comments

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Indicators KeyTotals per Month

Total

Total

Pregnant Women 1Deliveries in Health Facility 2 Post Natal Care 3Under One Children 4 Under Five Children 5 Family Planning 6TB Patients 7 HIV Clients 8ART Clients 9 Referral 10 Community Mobilization 11

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ANNEX 12. MEMORANDUM OF UNDERSTANDING BETWEEN HEALTH CENTRE AND VHWS

Name: Health CentreRepresented by the Nurse in Charge: ………………………………………………..ANDVillage Health WorkersRepresented by: ………………………………………………..

This MOU is valid from …………… to ……………………. (Maximum one year)

BackgroundThis MoU rests on the assumption that the Village Health Workers (VHWs) associated with the health centre will have selected one or more VHWs who represent their interest to the Health Centre and discuss opportunities for health services improvement. Preferably these VHWs are elected from those that are members of village health committees.

The MoU complements the signing of a Performance Based Financing (PBF) contract by the Health Centre representatives (Nurse in charge and the Chair of the Health Centre Committee). The PBF contract offers financial benefits for health services provided by the health centre, measured in quantity and quality. In view of the underutilization of primary health care services by the population and the associated unfavourable health outcomes Health Centres need to work closely together with the VHWS on a variety of activities such as: community mapping, community mobilization, health promotion, preventive activities, basic curative care, referral to the health centre and onwards to the hospital, provision of basic (reproductive health) commodities and counselling.

The presumption is that improved collaboration between a health centre and the VHWs attached to that health centre will lead to an increase in the utilization of primary care services offered by the HC. The PBF project offers financial benefits for quantity of services provided, besides a bonus for quality of care. Seen from this perspective it is of utmost interest that HC and VHWs closely collaborate to improve health services delivery to and uptake by the communities, and subsequently jointly benefit from the PBF project.In the PBF contract of the HC, it is mentioned that 20-45% of the financial benefits earned by the HC can be allocated to the VHWs. The exact percentage will be reflected in the quarterly HC business plan (percentage can also change from quarter to quarter); the exact amount of funds available will be known each quarter after payment has been effectuated based on the invoice submitted by the HC for health services delivered.

Reason for MOUThere will be no formalized contracts between VHWs and the Health Centre and between the elected VHW Representative and the Health centre. VHWs are persons who have been chosen by their communities; they are volunteers and not contracted employees. Mutual working relationships, including the exchange of benefits to the VHW as a group or to individual VHWs, will therefore be based on mutual understanding rather than based on formalized entitlements. Since the HC will benefit financially from the activities by VHWs it is essential to sign a Memorandum of Understanding with the HC on the allocation of the resources earned by the HC to VHWs.

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Resources allocationVHWs may expect to receive the following resources from the HC they report to:

o Training, refreshers and supervisiono commodity supply (i.e. a basic stock of essential medicines)o financial incentives

The Health Centre will allocate VHW incentives to the VHWs as a group. The VHW rrepresentative will design and agree with the VHWs on a mechanism to divide the “group” benefits between individual VHWs. The VHW representative will also arrange with the HC how the financial benefits will be offered to the VHW, preferably through their bank accounts.

Through this MOU the HC, represented by the nurse in-charge, and the VHWs, represented through one or more persons, who have been elected by the VHWs themselves, jointly pledge that:

- they will collaborate intensively to promote the health of the villagers in general and maternal and newborn health in particular

- they will discuss and agree on the allocation of the financial resources made available to the HC under the PBF contract

- between 20 and 45% of the PBF benefits that has been earned by the HC will be allocated to the VHWs ; the exact percentage to be reflected in the business plan that will be compiled by the nurse in charge under the auspices of the Health Centre Committee

- the elected VHW representative(s) will take the responsibility to divide PBF resources among the VHWs, preferably taking into consideration the level of activity demonstrated by VHWs, and to do so in a manner that will boost the morale of the VHWs. The VHW focal point at the HC may provide assistance here.

- The HC and representative(s) of the VHWs will meet regularly, at least quarterly, to evaluate the collaboration between the VHWs and the HC and propose options for improvement that will be included in the HC business plan.

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Annex 13. CONTRACT FOR HEALTH CENTRES

PERFORMANCE BASED FINANCING (PBF) CONTRACTFOR THE PURCHASE OF HEALTH SERVICES

No ______________

THIS CONTRACT is dated [……..]

BETWEEN:

The Ministry of Health represented by the Director DHMT

Ms. /Mr /Dr.…………………………………………:

And

[Name] Health Centre, herein referred to as the “facility” or “HF”

In case of non-GOL (CHAL) facility: state name of legal proprietor: [Name]Address:

HF represented by: Ms. / Mr. [Names]

Position held [Name]

Ms. / Mr.: [Names]

Chair Health Centre Committee [Name]

C.C. MOH/ PBF Unit

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1.1 The present contract is a performance contract between the DHMTS and the Health Centre in the context of the national Performance Based Financing (PBF) program.

1.2 The goal of PBF is to increase the provision of quality Basic Health Services to the population by increasing health facilities’ decisional rights on the management of their own operations.

1.3 The Performance Based Financing strategy emanates from National Health Sector Policy. The MOH reserves the right to amend the applicable policies that serve as the basis of its support to the health centres prior to the expiry of the present contract.

1.4 The PBF Implementation Manual (as published by MOH) serves as the principle reference document for all mechanisms agreed to herein and shall be referred to for further details and interpretation.


2.1 This purchase contract is valid from [Date ………….] for period of [12] months until [Date………………].

2.2 This contract may be revoked unilateral by the DC in consultation with the MOH-PBF Unit at any time, in case of fraud, or continued underperformance, as documented during data verification and quality assessment exercises. The annexes and Business Plan (as stipulated in Section 15 herein) form an integral part of the present contract.

2.3 The MOH/PBF Unit reserves the right to re-negotiate the service fees each 3 month period, however, the MOH/PBF Unit can also decide to keep the fees at their current levels. If such amendment is not produced on the last working day of the end of the quarter, the current fee set will be used for the following quarter. After re-negotiation, an amendment with a new set of negotiated fees will be produced, including a new business plan.


This contract defines the rights and obligations of both parties within the context of the PBF system: The Health Facility, as the provider of health services and the MOH, represented by the DHMTS, purchaser of Health Services.

4. Performance Payments

4.1 The MOH-Financial department on payment advice of the MOH-PBF Unit shall make performance payments to the HF according to a fee –for – service / case based provider payment mechanism, which is also conditioned on the quality of care. The services that are purchased and corresponding unit fees are listed in Tables 1 and 2 in the main text of the PIM.

4.2 The payments received by the Health Facility under these terms may be used as incentives in the form of salary bonuses to its staff members, incentives to Village Health Workers (VHWs) and as reinvestments in activities, equipment, commodities or infrastructure that contribute directly to the attainment of improved performance targets and enhanced quality of care to the population.

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4.3 The budget for worker’s motivation bonuses and improvement of the health facility are as follows:

a. Resources for improvement of service delivery minimum 25% of totalb. Incentives (motivation bonuses) to HC staff range 20-45% of totalc. Incentives to Village Health Workers range 20-45% of total

Violation of this basic rule may lead to the termination of the present contract by the Chairperson of the District Steering Committee in consultation with the DHMTs. The quarterly business plan should contain guidance on the percentage of the quarterly PBF benefits that will be allocated to each of the three destinations indicated.

4.4 Motivations bonus payments by the facility to its workers shall be done quarterly and only in case the worker has signed a valid motivation contract and if the worker has received a performance assessment.

4.5 The HF may decide to forfeit bonuses for a limited period and to invest in its infrastructure or equipment, provided the business plan supports this and is approved by the DHMT (de facto an exception to sections 4.2 and 4.3). The HF may choose to invest part of its earnings in expanding its health workforce through local labour contracts, and invest also in fringe benefits to attract and retain qualified health staff.

5. Health Facility Institutional Arrangements

5.1 The Health Facility shall be jointly represented by the Head of the Facility and the Chairman of the Health Facility Committee.

5.2 The Head of the Facility is responsible for daily management of the facility. S/he shall review individual staff performance and distribution of the funds generated through PBF and the present contract. This Internal Management Committee shall use (a) the indice tool for integrated financial management and performance bonus payments; and (b) a motivation contract signed by each employee and providing guidance to the entitlement of part of the PBF incentives for staff motivation bonuses. See the PBF Implementation Manual for further details.

6. Mission of the Health Facility 6.1 The Health Facility must ensure that funds generated through PBF are managed in the

general interest of the health centre and, in general, contribute to the improvement of public health in the community.

6.2 In doing so, the health facility (HF) hereby commits to undertake the following: Develop strategies designed to achieve the overall goals of Performance Based

Financing at HF and community level; Avoid any activities in contradiction with national health policies and/or accepted

medical ethics; Inform the DHMT change in HF personnel, technical skills and equipment at the

facility that which could hamper its capability to render the Services remunerated by the present PBF contract;

Ensure the permanent availability of all data recording registers and all management tools at the HF, and ensure that such documents are accessible to the MOH, DHMT and research companies during the execution of the present contract;

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Report in writing any case of fraud or attempted fraud committed by HF staff members to the DHMTs with copy to MOH/PBF Unit and the Chairperson of PBF District Steering Committee;

Ensure complete transparency and access to information relating to the use of funds generated through PBF and all others sources;

Distribute part of the revenues generated through PBF and the present contract its staff in the form of “bonuses” and in accordance with set guidelines. The indice tool will assist to direct resources to health staff;

Allocate part of the revenues generated through PBF and the present contract to operational expenditure and investments in quality of care improvement (other than personnel remuneration and trainings).

7. Quantity audits and provisional PBF invoices

The PPTA verification teams shall conduct monthly Quantity audits by reviewing all entries made in the designated registers. They will compare their review with the provisory monthly invoice as prepared by the HF management. Such monthly quantity control shall be conducted not later than the 15th day of each month, or in some instances bi-monthly depending on local conditions.

In case of non-intentional misreporting and a discrepancy of more than 5% between reported and verified cases, the particular service may not be “bought” during that month. In case of intentional misreporting in view of higher PBF benefits a report will be made and forwarded to the PBF District Steering Committee for a verdict (see PBF Implementation Manual).

8. Data Collection Registers

8.1 For the purpose of the present contract, each Register and its contents/entries register constitute a financial records document and will be treated as such. Non-adherence to strict registration norms herein, non-completeness or non-legibility of the data in the columns, will lead to non-remuneration of the concerned services.

8.2 The Facility shall adhere to the norms for Registers as described in the applicable Performance Based Financing User’s Manual. In the event pre-printed PBF registers are not available, the health facility shall design hand-written registers using the available office stationery according to the above mentioned norms. .

8.3 Routine Health Management Information System (HMIS) data shall align with data from the PBF registers

9. External Counter-verification . 9.1 A third party organization shall be contracted by the PPTA to conduct random

counter-verifications at community level (the so-called community client satisfaction surveys) on a periodic basis in order to confirm the results of the facility as perceived by its users or clients. In that event, the Health Facility hereby agrees to grant full access to the relevant records as may be required.

9.2 In case of any irregularities discovered in the course of such counter-verification (including, but not limited to, inaccurate reporting and “ghost” patients), the Health Facility shall repay the MOH/PBF Unit all PBF funds earned through the present contract. In addition, the Health Facility may be barred from participating in the PBF program.

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10. Quality audits/assessment

10.1 In order to ensure that the services performed by the HF meet satisfactory quality standards, specific Quality Indicators (as described in the PBF Implementation Manual) will be assessed every quarter by the DHMT.

10.2 The results of these Quality Audits will be factored in the calculation of the overall performance of the HF and the final PBF invoice as follows:

a. 25% of the total claimed earnings over the preceding months shall be added as “quality bonus” if the quality score for that quarter is 100%.

b. If the HF’s quality score is 49% or less, the quality bonus is automatically ‘0’ for the evaluated quarter. The same applies if for whatever reason the quality assessment is not performed during the quarter.

c. A quality score higher than 50% will be prorated as follows: Quality Bonus = % Quality Score (made up 80% of the quality assessment score and 20% of a client satisfaction score) * (total earnings for all contracted services over the past three months).

d. The client satisfaction will be determined by an independent CBO/NGO, who will interview clients traced during counter verification exercise described in section 10.

10.3 The quality audits shall be counter-verified regularly by an independent third party to be determined by the MOH/PBF Unit. If fraud is detected with the quality score, the present purchase contract may be terminated immediately by the MOH/PBF Unit, cc to DC.

11. Validation of the Quarterly Consolidated PBF invoices

11.1 The District PBF Steering Committee shall, on a quarterly basis, validate the Health Facility’s monthly PBF invoices and the quality score obtained.

11.2 The District PBF Steering Committee shall determine the amount earned by the Health Facility on the basis of the scores obtained in both the quality and quantity controls conducted respectively by the PBF Unit, MOH and the PPTA verification teams as described in Section 8 herein.

12. Terms of payment

The amount of each Quarterly Validated final PBF invoice shall be paid into the Health Facility bank account (or temporary deposit account with the District Council until the HF has a bank account) not later than 6 weeks after the quarter in which they were earned. For that purpose, the Health Facility shall operate autonomously its own bank account in which the funds will be transferred. Guidance on the management of the bank account is available in the PBF Implementation manual (PIM), Chapter 5 on Financial Management Arrangements.

13. Utilization of funds received through PBF, and through all other sources

13.1 The utilization of funds earned through PBF, and through all other sources, and the present contract shall be at the discretion of the Health Centre Nurse in

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charge/manager under auspices of HCC, within the limits fixed in Section 4 of this contract.

13.2 Against this background, the health centre shall ensure that all documents are well secured. All payments made to staff and other beneficiaries should be clearly signed or thumb printed. Fraud in financial management will be dealt with according to applicable Government Laws. Fraud in financial management may lead to immediate termination of the present contract by the chairperson of the District Steering Committee in consultation MOH/PBF Unit.

14. Business Plan

Before signing the contract, the HF shall submit a Business Plan for the following twelve months of activities (see format in the PBF manual). The Business plan will outline the strategies considered in order to increase the quantity and the quality of its services. The Business Plan shall then be reviewed and approved by the DHMT and form an integral part of the present contract. The absence of Business Plan or the non-compliance with its strategies may lead to the termination of the present contract by the DC/DHMT in consultation with MOH/PBF Unit.

Done at …………………………….. On …………./…………/201x

For District Council of ………………….

Ms. / Mr. ______________________________

Signed ______________________________

And

Chairperson of the Health Centre Committee Head/In charge Nurse of the Health Facility

Ms/Mr/ _____________________ Ms/Mr/_____________________

Signed ______________________ Signed ______________________

Annexes

1. List of Essential Services Packages PBF purchase contractNote: list of service package as well as unit price per service may change, which is only valid if added to a NEW contract.

2. Provisionary PBF invoice: see for example PBF Implementation Manual, Annex 18

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Annex 14. CONTRACT FOR DISTRICT/LOCAL HOSPITAL

PERFORMANCE BASED FINANCING (PBF) CONTRACTFOR THE PURCHASE OF HEALTH SERVICES

No ______________

THIS CONTRACT is dated [……..]

BETWEEN:

The GOL Ministry of Health/represented by the Dir. Clinical Services

Ms/Mr/Dr.…………………………………………:

And

[Name] District / Local Hospital, herein referred to as the “facility” or “HF”

(In case of Local (CHAL) Hospital: state name of proprietor: [Name]address

Represented by: Ms/Mr /Dr [Names] DMO of [Name] Hospital

Ms/Mr/Dr: [Names] Chairperson [Name] Hospital Board

CC. MOH-PBF Unit



1.1 The present contract is a performance contract between the MOH-Dir. Clinical Services and the Health Facility in the context of the national Performance Based Financing (PBF) program.

1.2 The goal of PBF is to increase the provision of quality Basic Health Services to the population by increasing health facilities’ decisional rights on the management of their own operations.

1.3 The Performance Based Financing strategy emanates from National Health Sector Policy. The MOH reserves the right to amend the applicable policies that serve as the basis of its support to the hospital prior to the expiry of the present contract.

1.4 The Performance Based Financing User Manual (as published by MOH) serves as the principle reference document for all mechanisms agreed to herein and shall be referred to for further details and interpretation.

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2.1 This purchase contract is valid from [Date ………….] for period of [12] months until [Date………………].

2.2 This contract may be revoked unilaterally by the MOH-Directorate Clinical Services in consultation with thePBF Unit at any time, in case of fraud, or continued underperformance, as documented during data verification and quality assessment exercises. The annexes and Business Plan (as stipulated in Section 15 herein) form an integral part of the present contract.

2.3 The MOH/PBF Unit reserves the right to re-negotiate the service fees each 3 month period, however, the MOH/PBF Unit can also decide to keep the fees at their current levels. If such amendment is not produced on the last working day of the end of the quarter, the current fee set will be used for the following quarter. After re-negotiation, an amendment with a new set of negotiated fees will be produced, including a new business plan.


This contract defines the rights and obligations of both parties within the context of the PBF system: The Health Facility, as the provider of health services and the MOH-Dir. Clinical Services, the purchaser of Health Services.

4. Performance Payments

4.1 The MOH-Financial department on payment advice of the MOH-PBF Unit shall make

performance payments to the HF according to a fee –for – service / case based provider payment mechanism, which is also conditioned on the quality of care. The services that are purchased and corresponding unit fees are listed in Table 1 and 2 in the mina text of the PIM. 4.2 The hospital will be incentivized for selected primary care services (delivered to its

immediate catchment area) and secondary care services, delivered to the whole district (or

part of the districts in case of more than one hospital).4.3 The payments received by the Health Facility under these terms may solely be used

asreinvestments in activities, equipment, commodities or infrastructure that contributed directly to the attainment of improved performance targets and enhanced quality of care to the population.

5. Health Facility Institutional Arrangements

5.1 The Health Facility shall be jointly represented by the DMO of the Facility and other members of the hospital Management Team. In case of a CHAL facility, the hospital shall be jointly represented by the Medical Superintendent and the Chair and members of the Hospital Governing Board.

6. Mission of the Hospital

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6.1 The Health Facility must ensure that funds generated through PBF are managed in the general interest of the Health Facility and, in general, contribute to the improvement of public health in the community.

6.2 In doing so, the health facility (HF) hereby commits to undertake the following: Develop strategies designed to achieve the overall goals of Performance Based

Financing at HF and community level; Avoid any activities in contradiction with national health policies and/or accepted

medical ethics; Inform the Ministry of Health of any change in HF personnel, technical skills and

equipment at the facility that which could hamper its capability to render the Services remunerated by the present PBF contract;

Ensure the permanent availability of all data recording registers and all management tools at the HF, and ensure that such documents are accessible to the MOH, DHMT and research companies during the execution of the present contract;

Report in writing any case of fraud or attempted fraud committed by HF staff members to the MOH-Clinical Services with cc to PBF Unit.

Ensure complete transparency and access to information relating to the use of funds generated through PBF and all others sources;

Allocate all revenues generated through PBF and the present contract to operational expenditure (other than personnel trainings).

7. Quantity audits and provisional PBF invoices

The PPTA in cooperation with Dir. Clinical Services unit verification teams shall conduct monthly Quantity audits by reviewing all entries made in the designated registers. They will compare their review with the provisory monthly invoice as prepared by the HF management. Such monthly quantity control shall be conducted not later than the 15th day of each month, or in some instances bi-monthly depending on local conditions.

In case of non-intentional misreporting and a discrepancy of more than 5% between reported and verified cases, the particular service may not be “bought” during that month. In case of intentional misreporting in view of higher PBF benefits a report will be made and forwarded to the PBF District Steering Committee for a verdict (see PBF Implementation Manual).

8. Data Collection Registers

8.1 For the purpose of the present contract, each Register and its contents/entries register constitute a financial records document and will be treated as such. Non-adherence to strict registration norms herein, non-completeness or non-legibility of the data in the columns, will lead to non-remuneration of the concerned services.

8.2 The Facility shall adhere to the norms for Registers as described in the applicable Performance Based Financing User’s Manual. In the event pre-printed PBF registers are not available, the health facility shall design hand-written registers using the available office stationery according to the above mentioned norms. .

8.3 Routine Health Management Information System (HMIS) data shall align with data from the PBF registers.

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9. External Counter-verification . 9.1 A third party organization shall be contracted by the PPTA to conduct random

counter-verifications at community level (the so-called community client satisfaction surveys) on a periodic basis in order to confirm the results of the facility as perceived by its users or clients. In that event, the Health Facility hereby agrees to grant full access to the relevant records as may be required.

9.2 In case of any irregularities discovered in the course of such counter-verification (including, but not limited to, inaccurate reporting and “ghost” patients), the Health Facility shall repay the MOH/PBF Unit all PBF funds earned through the present contract. In addition, the Health Facility may be barred from participating in the PBF program.

10. Quality audits

10.1 In order to ensure that the services performed by the HF meet satisfactory quality standards, specific Quality Indicators (as described in the latest PBF manual) will be assessed every quarter by peer reviewers, organised by Dir. Clinical Services/QA in cooperation with PBF-Unit. The Quality assessment form used will have three parts: one part about general management and services, one part referring to primary care services and one part referring to clinical and diagnostic services.

10.2 The results of these Quality Audits will be factored in the calculation of the overall performance of the HF and the final PBF invoice as follows:

a. 25% of the total claimed earnings over the preceding months shall be added as “quality bonus” if the quality score for that quarter is 100%.

b. If the HF’s quality score is 49% or less, the quality bonus is automatically ‘0’ for the evaluated quarter. The same applies if for whatever reason the quality assessment is not performed during the quarter.

c. A quality score higher than 50% will be prorated as follows: Quality Bonus = % Quality Score (made up 80% of the quality assessment score and 20% of a client satisfaction score) * (total earnings for all contracted services over the past three months).

d. The client satisfaction will be determined by an independent CBO/NGO, who will interview clients traced during counter verification exercise described in section 10.

10.3 The quality audits shall be counter-verified regularly by an independent third party to be determined by the MOH/PBF Unit. If fraud is detected with the quality score, the present purchase contract may be terminated immediately by the MOH/PBF Unit.

11. Validation of the Quarterly Consolidated PBF invoices

11.1 The MOH/PBF unit shall, on a quarterly basis, review the Health Facility’s monthly PBF invoices and the quality score obtained.

11.2 The MOH/PBF unit shall determine the amount earned by the Health Facility on the basis of the scores obtained in both the quality and quantity controls conducted respectively by the peer review and the PPTA verification teams as described in Section 8 herein.

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12. Terms of payment

The amount of each Quarterly Validated final PBF invoice shall be paid into the Health Facility bank account not later than 6 weeks after the quarter in which they were earned. For that purpose, the Health Facility shall operate autonomously its own bank account in which the funds will be transferred. Guidance on the management of the bank account is available in the PBF manual. Guidance on financial management including management of the bank account is available in the PBF Implementation Manual.

13. Utilization of funds received through PBF, and through all other sources

13.1 The utilization of funds earned through PBF, and through all other sources, and the present contract shall be at the discretion of the Hospital Management Committee within the limits fixed in Section 4 of this contract.

13.2 Against this background, the hospital shall ensure that all documents are well secured.. Fraud in financial management will be dealt with according to applicable Government Laws. Fraud in financial management may lead to immediate termination of the present contract by the MOH Dir. Clinical Services in consultation with PBF Unit.

14. Business Plan

Before signing the contract, the HF shall submit a Business Plan for the following twelve months of activities (see format in the PBF manual). The Business plan will outline the strategies considered in order to increase the quantity and the quality of its services. The Business Plan shall then be reviewed and approved by the Dir. Clinical Services in consultation with MOH/PBF Unit and form an integral part of the present contract. The absence of Business Plan or the non-compliance with its strategies may lead to the termination of the present contract by the MOH-Dir. Clinical Services in consultation with PBF Unit.

15. Care for the Indigents

The MoH Health Facility will provide free care to patients who are unable to pay, provided the following conditions are met:

o Clients report to the Social Worker in the hospital whenever it is necessary.o If already in the data base, they are given the exemption letter which they

present to the hospital so that they get free services.o If patients admitted are not in the database, the Social Worker take a full

history of the client and goes to the village where the client lives to assess their families for eligibility of social services

o Clients are classified according to their problems and those who require urgent assistance are given first priority for assessment by the Social Worker.

o There are two categories of clients being assessed, those who qualify for temporary and those who qualify for permanent social services support

The CHAL facility will provide free services in a similar arrangement:o For indigent clients a claim form is filled for clients who received services

from CHAL facilities.o CHAL office authorize all claims made by their hospitals and sends the claims

to the Ministry of Social Development

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o Ministry of Social Development Reimburse funds to CHAL facilities based on the claim forms received.

o Temporary clients are assessed each time they seek services so that they can be removed from the program if they have other means of paying for health care services

In order to stimulate removal of financial barriers, hospitals, whether MOH or CHAL, are incentivized for each indigent patient they serve, both outpatients and inpatients with a particular emphasis on patients referred by health centres.

The district/local hospitals are required to record indigents in a separate register. It is recommended to have an indigent committee in place to review the

appropriateness of the mechanisms for assisting indigents. It is suggested that this committee meets quarterly.

Done at …………………………….. On …………./…………/201x

For MOH-Dir. Clinical Services of ………………….

Ms./Mr/Dr ______________________________

Signed ______________________________

And

Chairperson of the Hospital Board District Medical Officer of the Health Facility

Ms/Mr/Dr _____________________ Ms/Mr/Dr_____________________

Signed ______________________ Signed ______________________

Annexes

1 List of Essential Services Packages PBF purchase contractNote: list of service package as well as unit price per service may change, which is only valid if added to a NEW contract.

2. Provisionary PBF invoice: see for example PBF User Manual

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Annex 15. MOTIVATION AGREEMENT HEALTH CENTRE STAFF

The Health Centre Committee (HCC) of................................................................ Health Centre, represented by its Chair person (Name, Signature) …………………………………………………………………………………………………….….……; andHealth Centre Nurse in charge: (in case of nurse in charge, DHMT countersigns)(Name, Signature) …………………………………………………………………………………………….55, and Mr / Ms ..................................Occupying the position of ...................................................., and hereafter called employee, declare to have concluded an agreement on the payment from the motivation bonuses related to the performance of the employee according to the following modalities:

Article 1: General information This agreement lies within the scope of the Performance Based Financing (PBF) set up in the health system in Lesotho. One of the main aims is to boost health worker motivation and productivity so that health services may be better utilized by the community. By signing this agreement the employee declares him/herself familiar with the PBF project and its aims. More specifically motivation contract is associated with the framework of the Performance Contract concluded between the HCC of .............................Health Centre, and the District Council, administered through the District Health Management Team (DHMT) l of the district of...........................................It is understood that the payment of any benefits based on the Performance Contract between the District Council and the Health Centre constitutes an advantage and not a right. In the event of major force, the Government of Lesotho could decide to cease the payment of PBF benefits before the expiry date of the contract.

The motivation agreement is different from the labour contract. It institutes a mode of conditional remuneration to the employee. The variable bonus is based on the following: (i) the performance of the health centre as a whole, (ii) the quarterly Health Centre Business Plan56 and (iii) of his/her personal performance measured during quarterly performance assessments.

Article 2: Limits of the agreement The employee admits having taken knowledge of the limiting conditions of this agreement. These include the conditions of services of the health centre in general and in respect to the PBF project in particular57 as well as the description of his/her position in the health centre besides the tasks assigned to him/her.

55 With CHAL facilities the ownership of the health centre may be arranged differently from what is mentioned here, i.e. the chair of the HCC and the in-charge of the HC. This is acceptable.56 The Health Centre is set to compile a Business Plan which is an obligatory annex to the Health Centre Performance Contract. The quarterly renewable business plan, which is formally signed by the representatives of the HC and countersigned by the DHMT, determines the part of PBF benefits to be paid to the staff as performance bonuses.57 Reference is made to the PBF Project User Manual, which describes the tasks of the Health Centre related to the PBF project. The employee is entitled to take notice of the content of the User Manual.

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Article 3: Validity The validity of this agreement is strictly subordinated to the existence and the duration of the Health Centre Performance Contract as mentioned in article 1. In case, regardless the reason, the Health Centre Performance Contract is cancelled in accordance with clauses included in the Health Centre Performance Contract, this motivation agreement will have to be regarded as null and void. The motivation agreement ends automatically and without royalty as soon as the work contract is broken by one or the other, i.e. the employee or the employer (MOH or District Council58, or CHAL institution). Motivation bonuses will only be paid to employees who finish one full quarter (3 months). Hence; employees whose contract covers part of the quarter only due to the date of commencement of employment or date of disengagement will not be entitled to receive the motivation bonus for part of the quarter.

Article 4: Engagement of the parties The employee commits him/herself to respect the various obligations which are assigned to him/her by this agreement and its annexes. He/she in particular commits him/herself to promote the access of the population to health care of better quality, working in harmony and in a team spirit with his/her colleagues of the health centre and other relevant persons from outside the Health Centre with which the Health Centre collaborates.He/she thus commits him/herself personally to ensure the transparency and truthfulness of information that will be transmitted to the Health Centre in-charge and/or the HCC. He/she knows that he/she will be held responsible for the errors or frauds made by him/her, and that the errors or frauds made by one or the other of the members of the team of the health centre could have a negative effect on his/her motivation agreement. The Health Centre engages itself moreover, within the limits of its abilities, 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, through the aforementioned representatives, commits itself to evaluate quarterly, in an objective and transparent way, the performance of the employee in respect to the tasks which are assigned to him/her. The representatives and employee will make use of the individual performance evaluation form. In case in a quarter no performance evaluation has been done, the employee will not be entitled to a motivation bonus.

Article 6: Determination of the amount to be allocated with the motivation bonusBefore the end of each quarter the performance of the Health Centre is assessed by the DHMT and the Performance Purchasing Technical Assistance (PPTA) firm59. Use is made of two checklists, i.e. a Health Centre Quality Assessment form and the HC quantity performance form. Such will be done in a manner that is in accordance with the PBF user manual. The quantity and quality scores will determine an amount intended for the motivation bonuses of Health Centre staff as a team. The percentage to be allocated to motivation bonuses is mentioned in the business plan, which is an annex of the aforementioned Health Centre Performance Contract. The individual performance bonuses will be calculated by the representative of the Health Centre making use of the so-called Indices Card (annex to this agreement).

58 Employer may change due to decentralization. 59 The PPTA is appointed to technically support the PBF project and build up capacity in relevant government entities to manage the PBF project.

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Article 7: Maximum amount of motivation bonusIn order to avoid excessive payments and preserve the equity between health centre staff it is agreed that the employee quarterly motivation bonus will not exceed the gross salary of one month, i.e. the salary excluding any bonuses or other supplements earned in the same period. The employee will have neither current nor future rights on any amount calculated for performance in excess of the maximum as indicated.

Article 8: Payment of the motivation bonusThe Health Centre will quarterly receive a payment of performance benefits based on its performance contract. The amount determined for the employee will be paid by the Health Centre to the employee within two weeks after receipt of the Health Centre performance benefits.

Article 9: Temporary suspension of the motivation bonusesIn the event of fraud, record falsification, or any other serious irregularity by the employee, the Health Centre representative shall decide to suspend the bonuses of an employee during three months maximum duration.

However this decision will have to be presented to and subjected to the approval of the DHMT; the chair of the PBF District Steering Committee will be informed about the decision

Article 10: Resolution of disputes In the event of disputes as for the application of this agreement, either party shall resort to lodging a complaint with the District Council.

Article 11: Duration of the agreement This agreement is signed for the duration of 12 months, from.................. onwards. Except contrary notification, it is due for renewal, on the condition of a legally valid PBF agreement between the DHMT and the Health Centre.Done in duplicate at .............................. On ...…. /....../...........

The employee, …………………………………………………………………..

For the health Centre: (Names, signatures and seal of the Health facility)

Chair HCC:

In-charge HC Annexes: Individual Performance Assessment toolIndices tool

168

Annex 16. MOTIVATION AGREEMENT DHMT STAFF

The District Health Management Team (DHMT) of....................................District represented by (Name, Signature) ……………………………………………………………………………………………., and Dr/Mr. / Ms. /Miss ................................................................................Occupying the position of ......................................................................................, and hereafter called employee, declare to have concluded an agreement on the payment from the motivation bonuses related to the performance of the employee according to the following modalities:

Article 1: General information This agreement lies within the scope of the Performance Based Financing (PBF) set up in the health system in Lesotho. One of the main aims is to boost health worker motivation and productivity so that health services may be better utilized by the community. By signing this agreement the employee declares him/herself familiar with the PBF project and its aims. More specifically this motivation agreement is associated with the framework of the Performance Contract concluded between the DHMT of…………………………………District and the Director PHC. It is understood that the payment of any benefits based on the Performance Contract between the Director PHC and DHMT constitutes an advantage and not a right. In the event of major force, the Government of Lesotho could decide to cease the payment of the PBF benefits before the expiry date of the contract. The motivation agreement is different from the labour contract. It institutes a mode of conditional remuneration to the employee The variable bonuses is based on the following: (i) the performance of the DHMT as a whole; (ii) the quarterly DHMT Operational Plan60 and (iii) his/her personal performance, measured during quarterly performance assessments.

Article 2: Limits of the agreement The employee admits having taken knowledge of the limiting conditions of this agreement. These include the conditions of services of the DHMT in general and in respect to the PBF project in particular61 as well as the description of his/her position in the DHMT besides the tasks assigned to him/her.

Article 3: Validity The validity of this agreement is strictly subordinated to the existence and the duration of the DHMT Performance Contract as mentioned in article 1. In case, regardless the reason, the DHMT Performance Contract is cancelled in accordance with clauses included in the DHMT Performance Contract, this motivation agreement will have to be regarded as null and void. The motivation agreement ends automatically and without royalty as soon as the work contract is broken by one or the other, i.e. the employee or the employer (MOH)62. Motivation bonuses will only be paid to employees who finish one full quarter (3 months). Hence; employees whose contract covers part of the quarter only due to the date of commencement of employment or date of disengagement will not be entitled to receive the motivation bonus for part of the quarter.

60 The DHMT does not write a Business Plan , like PBF contracted health facilities, but uses its current Operational Plans to highlight its additional roles, tasks and responsibilities in view of the PBF project.61 Reference is made to the PBF Project User Manual, which describes the tasks of the DHMT related to the PBF project. The employee is entitled to take notice of the content of the User Manual.62 With progressive decentralization the contracting parties may change.

169

Article 4: Engagement of the parties The employee commits him/herself to respect the various obligations which are assigned to him/her by this agreement and its appendices. He/she in particular commits him/herself to promote high quality of work, working in harmony and in a team spirit with his colleagues of DHMT and other relevant persons from outside the DHMT, with which the DHMT collaborates. He/she will prevent that his/her action will in any manner negatively impact on the performance of the DHMT as a whole and the services the DHMT provides to the health centres in the district within the framework of the PBF project. He/she thus commits him/herself personally to ensure the transparency and truthfulness of information that will be transmitted to the DHMT manger and/or the District Council. He/she knows that he/she will be held responsible for the errors or frauds made by him/her, and that the errors or frauds made by one or the other of the members of the team of the DHMT could have a negative effect on his/her motivation agreement. The DHMT engages itself moreover, within the limits of its abilities, to place at the disposal of the employee the essential resources to the achievement of his/her tasks.

Article 5: Individual performance evaluation The DHMT, through the aforementioned representative, commits itself to evaluate quarterly, in an objective and transparent way, the performance of the employee in respect to the tasks which are assigned to him/her. The representative and employee will make use of the individual performance evaluation form (annex to this agreement). In case in a quarter no performance evaluation has been done, the employee will not be entitled to a motivation bonus.

Article 6: Determination of the amount to be allocated with the motivation bonusBefore the end of each quarter the performance of the DHMT as a team is assessed by the District Council and the Performance Purchasing Technical Assistance (PPTA) firm63 DHMT Performance Evaluation Checklist. Such will be done in a manner that is in accordance with the PBF user manual. The quality score will determine a PBF performance benefit, part of which is intended for the motivation bonuses of DHMT staff as a team. The percentage to be allocated to motivation bonuses is mentioned in the business plan, which is an annex of the aforementioned DHMT Performance Contract.The individual performance bonuses will be calculated by the representative of the DHMT, making use of the so-called Indices tool (annex 2 to this agreement).

Article 7: Maximum amount of motivation bonusIn order to avoid excessive payments and preserve the equity between DHMT staff it is agreed that the employee quarterly motivation bonus will not exceed the gross salary of one month, i.e. the salary excluding any bonuses or other supplements earned in the same period. The employee will have neither current nor future rights on any amount calculated for performance in excess of the maximum percentage as indicated.

Article 8: Payment of the motivation bonusThe DHMT will quarterly receive a payment of performance benefits based on its performance contract. The amount determined for the employee will subsequently be paid by the DHMT Accountant to the employee within two weeks after receipt of the DHMT performance benefits.

63 The PPTA is appointed to technically support the PBF project and build up capacity in relevant government entities to manage the PBF project.

170

Article 9: Temporary suspension of the motivation bonusesIn the event of fraud, record falsification, or any other serious irregularity by the employee, the DHMT representative shall decide to suspend the bonuses of an employee during three months maximum duration. However this decision will have to be presented to and subjected to the approval of the District Council; the chair of the PBF District Steering Committee will be informed about the decision

Article 10: Resolution of disputes In the event of disputes as for the application of this agreement, either party shall resort to lodging a complaint with the District Council.

Article 11: Duration of the agreement This agreement is signed for the duration of 12 months, from.................. onwards. Except contrary notification, it is due for renewal, on the condition of a legally valid PBF contract between the District Council and the DHMT.Done in duplicate at .............................. On ...…. /...... /...........

The employee, ………………………………………………… For the DHMT ………………………………………….….

(Name and signature) (Name, signatures and seal of the DHMT)

Annexes: Individual Performance Assessment toolIndices tool

171

ANNEX 17. LERIBE AND QUTHING HEALTH FACILITIES CATEGORIZED FOR REMOTENESS

Category Remoteness bonus percentage

1 HCs are those where health professionals prefer to work, mostly centrally located in the town centre, or within one hour travelling by vehicle

0%

2 HCs located in the district, but needs between 1 and 2 hours travel to the centre of the district by vehicle

10%

3 HCs located in the district, but needs 2 hours and more to reach the centre of the district by vehicle

20%

4 Geographically hard to access.HCs located in areas where health providers do not want to work, far from the main roads, irregular transport, bad roads, difficulty to reach in rainy season, where sometimes there is no water, electricity in HC and village, schools and so on

30%

District Health Centre Category Distance By Hours RemarksQuthing Villa Maria Cat 1 < 1hr

St Mathews Cat 2 1 hr +St Gabriel 1hr +Mphaki Cat 3. 2hrs +Dilli-Dilli Cat 4. 1hr 30min These facilities are categorized 4 because even though

they can be reached within the specified hours, they are located in areas where health providers do not want to work, far from the main roads, with irregular transport, bad roads, difficulty to reach in rainy season, where sometimes there are no schools

Maqokho 2hrsTsatsane 2hrs 30minHa Makoae 2hrs 30minMphaki 2hrs

Leribe Pontmain Cat 1. 45minSt Margaret 45minFobane 45minLittle Flower 45min

172

Peka 40minSt Rose 35minLinotšing 25minMaputsoe SDA 25minMaputsoe FC 20minEmmanuel 20minHoly Trinity (Mahobong CHAL)

20min

Maryland 20minMahobong GoL 20minSt Monica’s 20minLejone Cat 2. 1 hourSeshote Cat 4. 5 hourPalama 5 hours and 30minMatlameng 1hour These facilities are categorized 4 because even though

they can be reached within the specified time, they are located in areas where health providers do not want to work, mainly with irregular transport, bad roads, difficulty to reach in rainy season and even rivers with no bridge in cases of facilities like Louis Gerald and Our Lady of Lourdes.

Thaba-Putsoa 45 minKhabo 45 minSt Ann 45 minOur Lady of Lourdes 45 minSeetsa 30 minLouis Gerald 25 minSt Dennis 1 hour

173

Annex 18. MONTHLY PBF INVOICE FOR HEALTH CENTRES

Provisory Monthly Invoice for Health Centre Services

District: Month:

Health Centre: Year:

ServiceQuantity reported

Quantity verified

Quantity reported/verified in %

Quantity for PBF payment (95 – 105%) correct reporting(= Q verified)

Unit Fee PBF benefits earned in LSL




4 Number of women delivering in health facilities5 Number of women with 2 postnatal care visits

within 1 weekSubtotal in LSLSubtotal brought forward from page 1




174





Grand Total for the month

The current invoice for the month of …………… of ………………………..Health Centre is totaled at [………………………………………………] LSL

In words:

Date…………. Location……………

Health Centre Committee representative(s): HC in charge: name signature1…name, position, signature……………………………………….

2…………………………………………. Verifier (PPTA): name, signature

175

DHMT representative (if present): name, position, signature

Before forwarding to MOH PBF business unit, approved by:District PBF Steering Committee: name, position:

176

Annex 19. MONTHLY PBF INVOICE FOR DISTRICT/LOCAL HOSPITALS

Provisory Monthly Invoice for Hospital Services (secondary care only)

District: Month:

Hospital: Year:

ServiceQuantity reported

Quantity verified

Quantity reported/verified in %

Quantity for PBF payment (95 – 105%) correct reporting(= Q verified)

Unit Fee PBF benefits earned in LSL


2 Number of counter referral letters returned to health centres

3 Number of indigent inpatient admissions4 Number of pregnant women having their first

antenatal care visit in the first trimester5 Number of major obstetric complications treated6 Number of assisted vaginal deliveries7 Number of Caesarean deliveries

177







Grand Total for the month

The current invoice for the month of …………… of ………………………..Hospital is totaled at [………………………………………………] LSLIn words:

Date…………. Location……………

Hospital Board/ Management Team representative(s): DMO: name signature

1…name, position, signature……………………………………….

2…………………………………………. Verifier (PPTA): name, signature

DHMT representative (if present): name, position, signature

To be forwarded to MOH PBF business unit

178

ANNEX 20. QUARTERLY QUALITY CHECKLIST FOR HEALTH CENTRES

PBF LESOTHO

The quality assessment will be carried out by a team from the District Health Management Team, assisted by the Performance Purchasing Technical Assistance Team. The assessments will be done against a roster which is communicated in advance.

The protocol prescribes that a HC quality assessment will have the following elements: An introductory meeting with the facility staff to explain the procedures of the quality

assessment Use of the designated HC quality assessment checklist Review of the latest HC business plan and review progress made against set targets at date

assessment Review of the latest HMIS reports and analyze trends in service utilization Meeting with the chair of the VHW committee to discuss VHW performance Meeting with the chair of the HCC to discuss overall HC performance Compilation of the quality assessment report, which each section duly filed including

recommendations section Report is filled out twofold; each copy duly signed by assessment team supervisor and

countersigned by in charge health facility and one copy left in HC File the original (signed) HC assessment report in the appropriate folder and forward one

copy to the DSC and one copy to national PBF unit

No Service Max Points Score %

179

1 General Management 24

2 Child Survival 43

3 Environmental Health 26

4 General Consultations 22

5 Reproductive Health 15

6 Essential drugs Management 17

7 Tracer Drugs 25

8 Maternal Health 58

9 STI, HIV and TB 21

10 Community based services 21

Total 272

Name Supervisor Signature:

Name In charge of Facility Signature:

Date: Final Score:

180

Date:……. /........... / 20....

Name(s) supervisors:…………………………………………………………………………………………………………..

District:……………………..………….….

Community Council:………………………………….… …………

Facility Name:……………………………………………………………………………………………………………..

Facility Proprietor:GOL/ CHAL/ LRCS/ PRIVATE

Facility Type:HEALTH CENTRE/FILTER CLINIC

Catchment Population:……………………………………………………

Number of beds:…….……

Staffing: Number and CategoryNurse Clinician Nursing Officer: Nursing SisterNursing Assistant:Nr: EHT (D1, D2, E2) Nr Other (Non-medical staff or

unqualified)Tot. Qualified staff: …

Tot other staff: …

181

1 General Management Criteria

Possible max score

Obtained score

Comments/action taken?)

1.1. Staffing 11

1.1.1Duty roster present and guarantees qualified staff present during all official working hours and on call 7/24h (including for obstetric services)

All or nothing 5

1.1.2Staff clocking sheet updated and kept by in charge. If applicable, actions taken for leave without permission? All or

nothing 3

1.1.3Staff meeting conducted monthlyEach monthly minutes contain: (1) date of the meeting; (2) signed list of participants; (3) follow-up of decisions taken during the previous meeting; (4) there is a list of developed recommendations or decisions taken; (5) each month the monthly financial balance is discussed; (6) minutes of the meeting are signed by the chair.

At least three

meetings

One point per

meeting

3

1.2 Records, information management and planning 13

1.2.1

HMIS reports are filled, updated and submitted to the DHMT on scheduleThe report is submitted by the 7th day of the following month to the DHMT.

If the report misses,

give zero.

2

1.2.2 HMIS data analysis report for the quarter being assessed concerning priority problems according to the business planThree priority health problems are followed each quarter and data have been updated up to the month prior to the supervisor's visit

Each priority problem met

is 1 point

3

1.2.3 Business plan Each 3

182

The HC business plan is complete and provides sufficient analysis translated into action. The HC convincingly demonstrates that it implements plans expressed in last business plans according to 3 strategies.

criteria met is 1

point

1.2.4

Financial and accounting documents in relation to PBF available and well kept(Bank statements, receipts, invoices etc.) (1)Filed in clearly labelled files. (2)Cashbook is well balanced and indicates both receipts of PBF benefits and expenditures; (3)data last quarter have been correctly reflected in business plan

Each criteria met is 1

point

3

1.2.5 Weekly schedule of health education sessions visible on the wall All or nothing 2

Total Points General Management 24

2 Child survival including IMCI and EPI Criteria

Possible max score

Obtained score


2.1 Integrated Management of Childhood Illnesses strategy is applied 7

2.1.1 Protocol is available and accessible to the staff in the consultation room

All or nothing 1

2.1.2 Observe three children in consultation room if they are diagnosed and treated according to IMCI strategy/protocol One 3

2.1.3Under 5 services (EPI, growth monitoring, curative care, health promotion) are available every day (at least five days a week). Verify with Under 5 register

If not 5 days, 0 points

3

2.2

Stock of Child health booklets (bukana) availableNo of child health booklet should correspond to U 5 target population, and at least 1/3 of the target population in the 3 months stock

All or nothing 1 Check if there is any stock of

bukana at the facility

183

2.3

Baby weighing scale available and in working conditionsSalter scale available and in good stateBalance calibrated to zero + pants available, clean and in good conditions

All or nothing 1

2.4 Nutrition management 11

2.4.1 The nutrition policy guidelines are available All or nothing 1

2.4.1 Screening record of nutritional status both for Weight for Height and Weight for Age (1) updated and (2) properly filled out


point2

2.4.2 Vitamin A administered every 6 months to all children from 6 to 59 months which is 9 doses (U5 register and/or VHW records)

All or nothing 5

2.4.3

In case of diagnosed malnutrition is the case managed according to protocol or referred to the hospital? Verify 3 cases either from U5 register or from children in waiting room with a growth monitoring chart

Each case

met is 1 point

3

2.5 Conditions in waiting area for child servicesSufficient benches and or chairs, protected against sun, rain and cold?

All or nothing 5

2.6 Immunization and cold chain 22

2.6.1

Child immunization register well maintained(1)System is capable of identifying drop outs and Fully Vaccinated Children (2) action taken for drop outs?(Schedule and record of appointments in register, action taken also to be noted in register)


point

2

2.6.2 EPI refrigerator2.6.2.1 Presence of a fridge – temperature monitoring form at fridge

available, filled twice a dayIf both not met

2

184

0 points2.6.2.2 Temperature remains between +2 and +80C on temperature monitoring form

2.6.3 Appropriate storage of vaccines

2.6.3.1 Freezing compartment: Polio All or nothing 1

2.6.3.2 Non-freezing compartment: BCG, Pentavalent, TT, HPV, measles All on nothing 1

2.6.3.3 Absence of vaccines which are expired All or nothing 1

2.6.3.4 Readable labels on all vaccines All or nothing 1

2.6.3.5Vaccine Vial Monitor (VVM)The VVM shows the temperature exposure hence the potency of the vaccines; if not favourable appropriate action has been taken

All or nothing 1

2.6.4 Appropriate stock of vaccines

2.6.4.1BCG, Polio 3, Pentavalent 3, Measles and Diluent according to Under 1 population Tetanus (pregnant women), HPV (9-13yr F). Minimum stock=Target population + 25% reserve stock (Quarterly)

If any vaccine below

minimum stock then 0 points

6

2.6.4.2 Presence of bin cards for all vaccines; concordance paper and physical stock verified (balance of in and out)

All or nothing 1

185

2.6.5

Cold Chain maintenanceCold chain sources

1. If having electricity, have gas fridge and full gas cylinder stand by

2. If not having electricity having two gas cylinders (48 Kg): one functioning and another full standby

All or nothing 2

2.6.6 EPI supplies

(1)Syringes (according to vaccine stock) (2). sharps container, (3). Cool boxes, (4). Vaccine carriers ( 5).Polio droppers,( 6). Refuse bags (black and red), (7). Emergency tray (hydrocortisone, adrenaline ...) and (8). Cold packs

All or nothing 4

Total Points Child Survival 43

3 Environmental Health Criteria

Possible max score

Obtained score


3.1 Health facility with fence available and well-maintainedFence with gate, can be closed at night and there are no holes

All or nothing 2

3.2Availability of a garbage bin in the courtyardBin lined with black plastic accessible to clients which is not full All no

nothing 2

3.3 Presence of sufficient latrines/toilets which are well-maintained 4

3.3.1 At least two latrines (VIP)/toilets and one for staff All or nothing 1

3.3.2 Floor without fissures All or nothing 1

3.3.3 Clean toilet All or nothing 1

3.3.4 Door lockable from the inside, super structure with roofing, without flies and no smell

All or nothing 1

186

3.4 Presence of at least one bathing facility which is well-maintained 2

3.4.1 Bathing facility with running water, or container with at the least 20 L of water

All or nothing 1

3.4.2 Evacuation of the waste water in a sanitation pit All or nothing 1

3.5 Placenta pits available All or nothing 5

3.6 Courtyard cleanNo waste or medical waste in the courtyard

All or nothing 2

3.7 Sterilization according to norms using a pressure sterilizer 2

3.7.1 Sterilizer functional All or nothing 1

3.7.2 Sterilization protocol available and utilized – control sterilised packs/tape

All or nothing 1

3.8 Hygienic conditions assured during wound dressing and injections 3

3.8.1 Bins for medical waste with lid and foot pedal, lined with red plastic All or nothing 1

3.8.2 Sharp container for needles well positioned, and used All or nothing 1

3.8.3 Container/bowl with lid containing disinfectant used for putting used instruments after washing with soap and water.

All or nothing 1

3.9 Disposal of Medical Waste according to National Norms 4

3.9.1 Waste disposal of general waste in Bin with lid and foot pedal, lined with black plastic

All or nothing

1

3.9.2 Waste disposal of contaminated medical waste in Bins with lid and foot pedal, lined with red plastic

All or nothing

1

3.9.3 Waste disposal of organic medical waste in Red plastic container with lid

All or nothing

1

3.9.4 Protective gear for personnel managing medical waste available; boots, long plastic trousers, thick plastic/rubber gloves and goggles

All or nothing

1

187

Total Points Environmental Health

26

4 General Consultations (common illnesses ) Criteria

Possible max score

Obtained score


4.1 Good conditions in waiting area 2

4.1.1 Sufficient benches and or chairs protected against sun and rain and cold

All or nothing 1

4.1.2 General waste bin for waiting clients, lined with black plastic All or nothing 1

4.2 Existence of waiting card system with numbers All or nothing 1

4.3 Consultation room in good condition 4

4.3.1 Walls with durable materials well painted, floor paved with cement without fissures, undamaged ceiling

All or nothing 1

4.3.2 Consultation room and waiting space separated assuring confidentiality All or nothing 1

4.3.3 Unbroken windows with clean curtains All or nothing 1

4.3.4 Functional door with lock All or nothing 1

4.4 Consultation room (where emergencies are received) has 24/7 lightfunctioning electricity or solar light or paraffin/gas light present

All or nothing 1

4.5 Consultations are done by skilled staff (RNM)Identification of consulting staff in register

All or nothing 1

4.6 Consulting staff is well-dressedPrescribed uniform

All or nothing 1

188

4.7 Correct patient registersCorrect numbering and closed at the end of the month

All or nothing 1

4.8Stethoscope, BP machine and thermometer, weighing scale and Otoscope (diagnostic set) available and functional


point

5

4.9Examination bed available with mattressNon-torn, plastic cover, clean sheet, specific for the OPD consultations only

All or nothing 1

4.10

Common illnesses management(Observe 5 patients during consultation and/or collect bukanas from patients present)

Each case

correctly

diagnosed and treated met is 1

point

5

Total Points General Consultation 22

5 Reproductive health Criteria

Possible max score

Obtained score


5.1 Confidentiality in consultancy room assuredRoom with closed and lockable doors, curtains at windows or non-transparent glass

All or nothing 1

5.2

Family planning methods available for demonstration potential usersContraceptive Injections; Implants; Intrauterine Contraceptive Device (IUCD); oral contraceptives, penis model and condoms (F and M) are available for demonstration (the latter also for HIV education)

All or nothing 2

189

5.3 Stock of oral and Injectable contraceptives in adequate quantity3 months stock available

All or nothing 1

5.4 IUCD available and staff trained to use it(1)At least five IUCDs and (2) at least one staff trained to use it


point

2

5.5Implant method available and staff trained to use it(1) At least five implants available and (2) at least one staff trained to use it


point

2

5.6 Women referred to hospital for permanent method with a medical indication or voluntarily.

All or nothing 2

5.7

Equipment available and workingScales, sphygmomanometer, vaginal specula, light source, gloves, decontaminants/disinfectant, Ayre’s spatula, cervical brushes, slides & fixative (also for PAP smears), IUCD insertion kits

For each

missing/

non functio

nal item,

deduct 0.5

point

5

Total Points Reproductive Health 15

6 Essential Medicine (EM)Management Criteria

Possible max score

Obtained score


190

6.1.Staff maintains stock cards for EM showing security stock levels = monthly average consumption x 3Supply in register corresponds with 3 monthly physical supply: random sample of three EM


point

3

6.2 Main pharmacy of the Health Centre delivers medicines to health facility departments according to requisition 6

6.2.1 Supervisor verifies whether quantity requisitioned equals quantity served

All or nothing 3

6.2.2 Drugs to clients are uniquely dispensed through prescriptions. Prescriptions are found in OPD register and in Bukana for patients

All or nothing 3

6.3 Drugs stored correctly 2

6.3.1 Clean place, well ventilated with all drugs on cupboards, labelled shelves

All or nothing 1

6.3.2 Drugs and medical consumables stored on alphabetical order, first to expire - first out basis

All or nothing 1

6.4 Absence of expired medicines or medicines with unreadable labels 6

6.4.1

Supervisor verifies randomly 3 medicines and 2 consumables Each criteria met is 1

point

5

6.4.2 Expired medicines well separated from stock 1 1Total Points EM management 17

7 Tracer Drugs and supplies (Minimum Stock = Monthly Average Consumption x 3)

Criteria

Possible max score

Obtained score


7.1 Minimum stock (3 month supply) 25

7.1.1 All 33 drugs have a minimum stock 15

7.1.2 Only half of the medicines have a minimum stock 10

7.1.3 Less than half of the drugs have a minimum stock 0

191

Total Points Tracer Drugs and Supplies 25

8 Maternal health Criteria

Possible max score

Obtained score


8.1 ANC register for HF available and well filled in: last five records verified 14

8.1.1 All: Examinations: Size, Parity, Date of last menstruation All or nothing 2

8.1.2 All: Laboratory: HB, results available All or nothing 2

8.1.3 All: Obstetrical examination done: Uterine height, recorded All or nothing 2

8.1.4 All: Minimum Tetanus 2 administered All or nothing 1

8.1.5 All: Tested for Syphilis ((VDRL test)at first visit All or nothing 1

8.1.6 All: Tested for HIV at first ANC visit All or nothing 1

8.1.7 All HIV- re-tested at 36 weeks All or nothing 1

8.1.8 All pregnant women received their MBP (ARV prophylaxis or complete course of ARV to reduce the risk of MTCT)

All or nothing 3

8.1.9 All columns well filled including the identification of problems if any, and actions taken

All or nothing 1

8.2 Lesotho Obstetrical Record (LOR) booklets for mother available: at least 50 in stock 1

8.3 Did women pay for any of the services (LOR), Ferrous Sulphate or other items). Ask 4 women in the waiting room ad randomly

If any woman paid, then 0 points

2

192

8.4 ANC conducted by qualified personnelRegistered nurse midwife, verified in ANC register

All or nothing 1

8.5

Functional equipmentWeighing scale and calibrated to zero, Stethoscope and BP machine available and functional in ANC room

All or nothing 1

8.6 ANC shelter, being utilised and clean All or nothing 5

Delivery Room

8.7 Water with soap in delivery room availableA functioning water source or at the least 20L

All or nothing 2

8.8

Light in delivery room 24 hoursElectricity, solar light or rechargeable battery lamp or gas/paraffin lamp filled with paraffin/gas

All or nothing 2

8.9 Waste from Maternity correctly handledPlacenta is disposed in a red plastic container with lid

All or nothing 1

8.10 Delivery room is well-maintained 5

8.10.1 Walls with durable materials and painted All or nothing 1

8.10.2 Curtain between delivery bed and door All or nothing 1

8.10.3 Delivery room cleaned with disinfectant. Ask for proof/disinfectant bottle

All or nothing 1

8.10.4 Floor without fissures and ceiling not damaged All or nothing 1

8.10.5 Unbroken windows with clean curtains and functional door All or nothing 1

193

8.11Availability of a tape to measure length and an aspirator (plunged into a non-irritating disinfectant or functional manual/electric aspirator) functional

2

8.11.1 Tape to measure length All or nothing 1

8.11.2 Aspirator plunged into a non-irritating disinfectant or functional manual/electric aspirator

All or nothing 1

8.12 Availability of at least 10 pairs of sterile gloves All or nothing 1

8.13

Availability of at least 2 sterilized delivery packs with as contentContent at the least 1 pair of episiotomy scissor, 2 artery forceps non toothed, 2 artery forceps toothed 1 kidney dish, 2 bowls (medium and large), 4 dressing towels, and one needle holder,

All or nothing 2

8.14 Under buttocks drapes 1 box in stock All or nothing 1

8.15Delivery table in good stateTable in two parts with removable non-torn plasticized mattress and two functional leg supports

All or nothing 1

8.16Use of the Partogramme in the Lesotho Obstetric RecordVerify three randomly selected partogrammes whether filled according to the norms


point

3

8.17 Deliveries performed by skilled personnelIdentification of the Registered Midwife from names in the register

All or nothing 1

8.18 Newborn Care 3

8.18.1 Sterile clip for umbilical cord All or nothing 1

8.18.2 1% tetracycline eye ointment All or 1

194

nothing

8.18.3 Vitamin K All or nothing 1

8.19APGAR during delivery notedFilled in the partogramme 1st , 5th and 10th minutes. Supervisor verifies 3 partogrammes with APGAR scores

If not correct

0 points

3

8.20 Adequate in-patient rooms 28.209.

1 Mattress covered in impermeable plastic All or nothing 1

8.20.2 Sheets, and blankets on each occupied bed All or nothing 1

8.21 Postnatal Care 58.21.1 Post Natal care register available, including Infant feeding options,

vaccination, Family Planning, PMTCT, pap smear etc. according to guidelines

All or nothing 1

8.21.2 Postnatal care register with PNC visits examinations within 6 hours, 48 hours, 6-8 weeks and 14 weeks indicated

All or nothing 4

Total Points Maternal Health 58

9 STIs, HIV and TB Criteria

Possible max score

Obtained score


9.1 Guidelines available, accessible to staff and followed 10

9.1.1 HIV/AIDS Protocol. Verify with 3 patients if HIV testing and counselling was provided (after consultation)


point

3

9.1.2 ART Protocol Identify 3 HIV+ patients on ART and check if protocol was followed properly


point

3

9.1.3 Post exposure protocol for sexual assault survivors, ask nurse if All or 1

195

knowing the procedure nothing

9.1.4 STI management. Check 3 patients from OPD register for proper classification of STIs


point

3

9.2 Existence of a HTC register and lab register according to norms All or nothing 1

9.3 Staff trained in HIV rapid testing and counsellingCounselling and testing is done by a trained provider

All or nothing 1

9.4 Referral system and follow up for HIV clients 3

9.4.1 Monitoring tracking tool is used and All or nothing 1

9.4.2 CD4 cell counts available 1

9.4.3 PCR register for infant follow up, especially for infants born to HIV positive mothers is available

All or nothing 1

9.5

TB Register (take 3 ad random patients)National TB Control Guidelines. Check 3 TB cases from TB register whether (1) sputum was taken and (2) results known (3) HIV test taken (4) initiated treatment (5) End of treatment/cured is recorded


point

5

9.6

Referral system and follow up for TB patientsEach (AFB PTB )patient has a person attached to him/her who supervises DOTS: proof of in register; mobile phone number of such a supervisor is registered

All or nothing 2

Total Points STIs, HIV and TB management 21

10 Community Based services and involvement Criteria

Possible max score

Obtained score


10.1 Is community mapping implemented by VHWs at start of PBF project All or 10

196

and quarterly updated ? nothing

10.2

Monthly reporting by VHWsIs the information in the village register counter verified and copied to the HC register according to HouseholdsID numbers

All or nothing 2

10.3

Monthly meetings with VHW with training topics – minutes available(1) date of the meeting; and signed list of participants; (2 )follow-up of decisions taken during the previous meeting; (3) there is a list of developed recommendations or decisions taken; (4) Training topics (5) minutes of the meeting are signed by the chair.


point

5

10.4

Monthly meetings with HCC(1) date of the meeting; and signed list of participants; (2 )follow-up of decisions taken during the previous meeting; (3) there is a list of developed recommendations or decisions taken (4) minutes of the meeting are signed by the chair.


point

4

Total Points Community Based Services 21

197

Annex: List of tracer medicines

The following Tracer medicines and supplies are available

Criteria Max score

Score Obtaine

d

Comment

1 AmoxycillinEach criteria met is 1

point 1

2 CotrimoxazoleEach criteria met is 1

point 1

3 ErythromycinEach criteria met is 1

point 1

4 CeftriaxoneEach criteria met is 1

point 1

5 Diazepam injectionEach criteria met is 1

point 1

6 Gentian violet or nystatin

Each criteria met is 1 point 1

7 Paracetamol syrupEach criteria met is 1

point 1

8Oral iron preparation (Ferrous gluconate or ferrous lactate)


9 Folic AcidEach criteria met is 1

point 1

10 Vitamin A


11 Albendazole


12

Salbutamol MDI and Appropriate Spacers


13

Salbutamol solution for nebuliser


14

Adrenaline + solution for nebulisers


15 Atropine


16 Prednisone tablets


17 ORS packets


18

IV solution : N Saline, 5% dextrose, Ringer Lacate


19

Sterile syringes and needles


20

Swabs and skin disinfectant


21 Cannulae 24G, 22G


22 IV sets (60drops/ml)


23

Naso gatric tubes (5,8,10 FG)


198

24

Medicine measures and glasses


25

Paediatric nebulizer mask, chamber and tubing


26 HIV test kits


27 PCR kit


28

Rifampicine-isoniazide-pyrazinamide : cp120+50+300mg TB Skin Test


30

Streptomycin 1 gr Each criteria met is 1 point 1

30

Ethambutol tabs 400 mg


31

Oxytocin Each criteria met is 1 point 1

32

Ergometrine Each criteria met is 1 point 1

33

Lignocaine Each criteria met is 1 point 1

TOTAL 33

199

ANNEX 21. QUARTERLY QUALITY CHECKLIST FOR DISTRICT/LOCAL HOSPITALS

PBF LESOTHO

The quality assessment will be carried out by an assessment committee consisting of key technical and administrative staff from other hospitals, with representatives from the MOH (Clinical Services), CHAL, and civil society, assisted by the Performance Purchasing Technical Assistance Team. The assessments will be done against a roster which is communicated in advance.

The protocol prescribes that a hospital quality assessment will have the following elements: An introductory meeting with the facility staff to explain the procedures of the quality

assessment Use of the designated hospital quality assessment checklist Review of the latest hospital business plan and review progress made against set targets

at date assessment Review of the latest HMIS reports and analyse trends in service utilization Meeting with the hospital board/hospital management team to discuss overall hospital

performance Compilation of the quality assessment report, which each section duly filed including

recommendations section Report is filled out twofold; each copy duly signed by assessment team supervisor and

countersigned by the in charge of the hospital board/hospital management and one copy left in hospital

File the original (signed) hospital assessment report in the appropriate folder and forward one copy to the MOH (Clinical Services and M&E) and one copy to national PBF unit

200

Service Max ScoresObtained

score %Part A - General Hospital Services 144

1 General Management 36

2 Hygiene & Medical Waste Disposal 27

3 Essential Medicine Management 17

4 Tracer Drugs and supplies 505 Emergency services 14

Part B - Primary Care Services 1376 Child survival 437 General consultation 228 Reproductive Health 239 ANC en PNC 2710 STI/HIV/TB 22

Part C - Secondary Care Services 153

11 In-patients wards 3212 Delivery room 29

13 In-patient ward gynaecology/obstetrics 7

14 Surgery 2615 Laboratory 2016 Radiological Services 1417 Specialized services 25

Total 434

201

Name Team leader Evaluation: Signature:

Name Director (Board) DH: Signature:

Date: Final Score:

202

Staffing

Date:………/........ / 20......

Name(s) supervisors:……………………………………………………………………………………………………………..

District:……………………………………………………..

Hospital Proprietor:GOL / CHAL / PRIVATE

Name Hospital:…………………………………………………………………………………………………………….

Number of beds:………………………………

Facility Type:DISTRICT/LOCAL/SPECIAL/REFERRAL

Catchment Population:……………………………………………………

Staffing: Number and CategoryDoctors: SNO NO :Nurse Anaesthetist RN (midwife): RN (no midwife):NC: NA: Ward attendants:Pharmacist: Dispensers: Radiography:EHT: Bookkeeper/Accountant: Administration staff:cleaners: Guards: GardenersDrivers: Counsellors/mentors: Focal persons:Others (specify): Lab, nutritionist, dental, dietician, physiotherapist, orthopaedics, maintenance, office assistant, hospital assistant…………………………………………………………………………………………………………………………………………………………………………….

203

PART A – GENERAL HOSPITAL SERVICES

1 General ManagementCriteria Possibl

e max score

Obtained score

Comments/action taken

1.1.

Quality Assurance committee meets once per monthEach monthly minutes contain (1) Date of the meeting and agenda (2)Signed list of participants (3) Follow-up/implementation of decisions taken during the previous meeting (4) On each issue there is a description of the problem and list of recommendations or decisions taken (5)On each issue there is a responsible person named and deadline for solving the problem (6) Minutes of the meeting is signed by the chairman

At least three

meetings

One point per meeting

3

1.2 Staffing 11

1.2.1Duty roster present and guarantees qualified staff present during all official working hours and on call 7/24h (including for obstetric services)

All or nothing 5

1.2.2 Staff clocking sheet updated and kept by in charge. If applicable actions taken for leave without permission?

All or nothing 3

1.2.3

Staff meeting conducted monthlyEach monthly minutes contain: (1) date of the meeting; (2) signed list of participants; (3) follow-up of decisions taken during the previous meeting; (4) there is a list of developed recommendations or decisions taken; (5) each month the monthly financial balance is discussed; (6) minutes of the meeting are signed by the chair.

At least three

meetings

One point per meeting

3

1.3

Social worker and hospital management team meets monthlyThe committee meets monthly to review the care for the indigent category use. Each monthly minutes contain: (1) date of the meeting; (2) signed list of participants; (3) follow-up of decisions taken during the previous meeting; (4) there is a list of developed recommendations or decisions taken; (5) each month the monthly financial balance is

At least three

meetings

One point per

3

204

discussed; (6) minutes of the meeting are signed by the chairman. meeting1.4 Records, information and financial management and planning 11

1.4.1HMIS reports are filled, updated and submitted on scheduleTo the DHMT (PHC) and MOH-M&E (Secondary Care). The report is submitted and documented by the 7th of the following month

If the report

misses, give zero.

2

1.4.2

HMIS data analysis report for the quarter being assessed concerning priority problems according to the business planThrough a chart, follow up on monthly (i) average length of stay; (ii) average bed occupancy rate, (iii) Bed turnover rate and (iv) income/expenses

If the report

misses, give zero.

3

1.4.3

Business planThe Hospital business plan is complete and provides sufficient analysis translated into action. The Hospital convincingly demonstrates that it implements plans expressed in last business plans according to 3 strategies.


point

3

1.4.4

Financial and accounting documents in relation to PBF available and well kept(bank statements, receipts, invoices etc.) (1)Filed in clearly labeled files. (2)Cashbook is well balanced and indicates both receipts of PBF benefits and expenditures; (3)data last quarter have been correctly reflected in business plan


point

3

1.5 Availability of transmitter or mobile phone for communication between the DH and Health Centres 2

1.5.1 Transmitter or mobile phone functional with batteries and call credit All or nothing

1

1.5.2 List of phone numbers of all HCs in the catchment area and up to date All or nothing

1

1.6 Ambulance management and maintenance 4

205

1.6.1 Vehicle log book available and maintained/filled All or nothing

1.6.2 Vehicle maintenance register available, filled and maintenance carried out according maintenance plan

All or nothing

1.7 Security guard duty roster available with names and signaturesAll or

nothing

1.8 Hospital has power back up system (functional generator) with fuel that kicks off automatically

All or nothing

Total Points General management 36Remarks

2 Hygiene and Medical Waste DisposalCriteria Possible

max score

Obtained score

Comments/action taken

2.1 Health facility with fence available and well-maintainedFence with gate, can be closed at night and there are no holes

All or nothing

2

2.2 Availability of a garbage bin in the courtyard All or nothing

1

Bin with lid accessible to clients which is not full, one for each ward

2.3 Presence of sufficient latrines/toilets which are well-maintained 7

2.3.1 One toilet/latrine per 10 beds working flush or water container with All or 1

206

sufficient water (water reservoir) nothing

2.3.2 Floor without fissures with single hole and lid (latrine) or lid with functioning cover (seating style toilet)

All or nothing

1

2.3.3 Recently cleaned toilet/latrine without visible fecal matter All or nothing

1

2.3.4 Door lockable from the inside but not from the outside, super structure with roofing, floor clean

All or nothing

1

2.3.5 Functional lighting All or nothing

1

2.3.6 Water container/functioning tap and soap for hand washing available for each toilet block

All or nothing

1

2.3.7 Cleaning schedule next to toilet, and toilet/latrine smells clean, no offensive smell

All or nothing

1

2.4 Presence of sufficient showers which are well-maintained 5

2.4.1 At least one shower/bath per ward All or nothing

1

2.4.2 Shower /bath with running water, or water reservoir All or nothing

1

2.4.3 Door lockable from the inside but not from the outside, super structure with roofing, without flies, floor clean

All or nothing

1

2.4.4 Functional lighting All or nothing

1

2.4.5 Cleaning schedule next to shower and shower smells of disinfectant or deodorant

All or nothing

1

2.5 Incinerator for medical waste is available and according to the norms

3

2.5.1 Incinerator minimum 2 meters deep, lined with clay, concrete or brick or plastic, it is fenced and has a danger sign.

All or nothing

1

2.5.2The incinerator is a minimum of 15 meters from the health facility, minimum of 50 meters from a household, and 100 meters from a water source

All or nothing

1

207

In absence of an incinerator a standard vehicle should be available and functioning

2.5.3 Medical waste is not visible (covered by at the least 10 cm of soil or lime)

All or nothing

1

2.6 Courtyard cleanNo waste or medical waste in the courtyard

All or nothing

1

2.7 Hygienic conditions assured during wound dressing and injections All or nothing

3

2.7.1 Red Bins for medical waste with lid and foot pedal, lined All or nothing

1

2.7.2 Security box/plastic containers for needles well positioned, and used All or nothing

1

2.7.3 Container/bowl with lid containing disinfectant used for putting used instruments after washing with soap and water

All or nothing

1

2.8 Disposal of Medical Waste according to National Norms 4

2.8.1 Waste disposal of non-contaminated waste in black plastic bag in bins with lid and foot pedal, lined

All or nothing

1

2.8.2 Waste disposal of contaminated medical waste in red plastic bag in bins with yellow stock lid and foot pedal, lined

All or nothing

1

2.8.3 Waste disposal of organic medical waste in red bucket with lid.All or

nothing1

2.8.4Protective gear for personnel managing medical waste available; boots, plastic shorts, thick plastic/rubber gloves, goggles and a trolley to transport the medical waste

All or nothing

1

Total Points Hygiene and medical waste disposal 27Remarks

208

3 Essential Medicine (EM)Management CriteriaPossible

max score

Obtained score


3.1.Staff maintains stock cards for EM showing security stock levels (buffer) = monthly average consumption x3Supply in the bin card corresponds with 3 monthly physical supply: random sample of three EM


point

3

3.2 Main pharmacy store (NDSO) delivers medicines to Hospital according to requisition 6

3.2.1 Supervisor verifies whether quantity requisitioned equals quantity served

All or nothing

3.2.2 Medicines to clients are uniquely dispensed through prescriptions (copies). Prescriptions are found in IPD files or OPD bukana’s.

All or nothing

3.3 Medicines stored correctly 2

3.3.1 Clean place, well ventilated with all medicines on labelled shelves All or nothing 1

3.3.2 Medicines and medical consumables stored in alphabetical order, first to expire - first out basis

All or nothing 1

3.4 Absence of expired medicines or medicines with unreadable labels 6

3.4.1

Supervisor verifies randomly 3 drugs and 2 consumables Each criteria met is 1

point

5

3.4.2 Expired/unreadable label medicines well separated from stock and disposed of according to protocol

All or nothing 1

209

Total Points EM management 17

Remarks

4 Tracer Medicines and supplies (Minimum Stock = Monthly Average Consumption x 3) List in annex – See the priority list

Criteria Possible max score

Obtained score


4.1 Minimum stock (3 month supply of all medicines) 50

4.1.1 All (100%) drugs/supplies have a minimum stock 50

4.1.2 Between 75% and 100% of the tracer medicines have a minimum stock 25

4.1.3 Less than 75% of the medicines have a minimum stock 0

Total points tracer drugs and supplies 50

Remarks

5 Emergency ServicesCriteria Possible

max score

Obtained score


210

5.1

Is the following equipment available and functional? Suction machine, airways, bag and mask (ambubag), oxygen and oxygen gauge.If not functional was a report made? Equipment should be easily accessible not stored under lock and key.

All or nothing

2

5.2 Emergency tray, with all the necessary medicines e.g. 50% dextrose, adrenaline, lignocaine, diazepam, atropine

All or nothing

2

5.3Important Accessories: cannula, giving sets, syringes and needles, drip stand, swabs, strapping, disinfectant, gloves, face mask, specimen bottles. Should be available as part of emergency services

All or nothing

2

5.4 IV fluids (ringer lactate, 5% dextrose, normal saline), blood and blood products.

All or nothing

2

5.5 Labelling: the tray should be labelled including the medicines and accessories, with clearly legible and durable labels

All or nothing

2

5.6 Functional ambulance, communication systemsAvailable 24/7

All or nothing

2

5.7Medical doctor on call.Duty roster/ on call for support staff (lab, x-ray, anaesthetist, theatre nurse).

All or nothing

2

Total points emergency services 14

Remarks

211

PART B - PHC SERVICES

6 Child survival including IMCI and EPI CriteriaPossible

max score

Obtained score


6.1 Integrated Management of Childhood Illnesses strategy is applied 7

6.1.1 Protocol is available and accessible to the staff in the consultation room

All or nothing 1

6.1.2 Observe three children in consultation room if they are diagnosed and treated according to IMCI strategy/protocol

Each case correct,

one point3

6.1.3Under 5 services (EPI, growth monitoring, curative care, health promotion) are available every day (at least five days a week). Verify with Under 5 register

If not 5 days, 0 points

3

6.2Stock of Child health booklets (bukana) availableNumber of child health booklets should be at least one hundred (100)

All no nothing 1

6.3

Baby weighing scale available and in working conditionsSalter scale available and in good stateBalance calibrated to zero + pants available, clean and in good conditions

All or nothing 1

6.4 Nutrition management 11

6.4.1 The nutritional policy guidelines are available All or nothing 1

6.4.2 Screening record of nutritional status both for Weight for Height and Weight for Age (1) updated and (2) properly filled out.


point2

6.4.3 Vitamin A administered 6 monthly to all children from 6 to 59 months which is 9 doses (U5 register and VHW records). Verify 5

212

5 cases

6.4.4In case of diagnosed malnutrition is the case managed according to protocol? Verify 3 cases either from U5 register or from children in waiting room with a growth monitoring chart

Each case met is 1

point3

6.5Conditions in waiting area for child servicesSufficient benches and or chairs, protected against sun, rain and cold?

All or nothing 1

6.6 Immunization and cold chain 22

6.6.1

Child immunization register well maintained

(1)System is capable of identifying drop outs and Fully Vaccinated Children (2) action taken for drop outs?

(Schedule and record of appointments in register, action taken also to be noted in register)


point

2

6.6.2 EPI refrigerator

6.6.2.1Presence of a fridge – temperature monitoring form at fridge available, filled twice a day

If both not met 0 points

1

6.6.2.2 Temperature remains between +2 and +8 C on temperature monitoring form 1

6.6.3 Appropriate storage of vaccines

6.6.3.1 Freezing compartment: Polio All or nothing 1

6.6.3.2 Non-freezing compartment: BCG, Pentavalent, TT, HPV, measles

All or nothing 1

6.6.3.3 Absence of vaccines which are expired All or nothing 1

6.6.3.4 Readable labels on all vaccines All or nothing 1

6.6.3.5 Vaccine Vial Monitor (VVM) All or 1

213

The VVM shows the temperature exposure hence the potency of the vaccines; if not favourable appropriate action has been taken nothing

6.6.4 Appropriate stock of vaccines

6.6.4.1BCG, Polio 3, Pentavalent 3, Measles and Diluent according to U1 population, Tetanus (pregnant women), HPV (9-13yr F). Minimum stock=Target population + 25% reserve stock.

If any vaccine below

minimum stock then 0 points

6

6.6.4.2 Presence of stock control cards for all vaccines; concordance paper and physical stock verified (balance of in and out)

All or nothing 1

6.6.5

Cold Chain maintenanceCold chain sources

3. If having electricity, have gas fridge and full gas cylinder stand by

4. If not having electricity having two gas cylinders (48 Kg): one functioning and another full standby

All or nothing 2

6.6.6 EPI supplies(1)Syringes (according to vaccine stock) (2). Sharps container, (3). Cool boxes, (4). Vaccine carriers (5).Polio droppers, (6). Refuse bags (black and red), (7). Emergency tray (hydrocortisone, adrenaline ...) and (8). Cold packs

All or nothing 4

Total Points Child Survival 43Remarks

214

7 General Consultations (common illnesses ) CriteriaPossible

max score

Obtained score


7.1 Good conditions in waiting area 2

7.1.1 Sufficient benches and or chairs protected against sun and rain and cold

All or nothing 1

7.1.2 General waste bin for waiting clients, lined with black plastic All or nothing 1

7.2 Existence of waiting card system with numbers All or nothing 1

7.3 Consultation room in good condition 4

7.3.1 Walls with durable materials well painted, floor paved with cement without fissures, undamaged ceiling

All or nothing 1

7.3.2 Consultation room and waiting space separated assuring confidentiality

All or nothing 1

7.3.3 Unbroken windows with clean curtains All or nothing 1

7.3.4 Functional door with lock All or nothing 1

7.4Consultation room (where emergencies are received) has 24/7 lightFunctioning electricity or solar light or paraffin/gas light present

All or nothing 1

7.5 Consultations are done by skilled staffIdentification of consulting staff in register

All or nothing 1

7.6 Consulting staff is well-dressedPrescribed uniform

All or nothing 1

7.7 Correct patient registersCorrect numbering and closed at the end of the month

All or nothing 1

7.8 Stethoscope, BP machine and thermometer, weighing scale and Each 5

215

Otoscope (diagnostic set) available and functional criteria met is 1

point

7.9Examination bed available with mattressNon-torn, plastic cover, clean sheet, specific for the OPD consultations only

All or nothing 1

7.10

Common illnesses management(Observe 5 patients during consultation and/or collect bukanas from patients present)

Each case correctly diagnosed

and treated met is 1

point

5

Total Points General Consultation 22

Remarks

8 Reproductive health CriteriaPossible

max score

Obtained score


8.1 Confidentiality in consultancy room assuredRoom with closed and lockable doors, curtains at windows or non-transparent glass

All or nothing 1

8.2 Family planning methods available for demonstration potential usersContraceptive Injections; Implants; Intrauterine Contraceptive

All or nothing 2

216

Device (IUCD); oral contraceptives, penis model and condoms (F and M) are available for demonstration (the latter also for HIV education)

8.3Stock of oral and injectable contraceptives in adequate quantity3 months stock available

All or nothing 1

8.4 IUCD available and staff trained to use it(1)At least ten IUCDs and (2) at least one staff trained to use it


point

10

8.5Implant method available and staff trained to use it(1) At least ten implants available and (2) at least one staff trained to use it


point

2

8.6 Women referred to hospital for permanent method with a medical indication/voluntarily

All or nothing 2

8.7

Equipment available and workingScales, sphygmomanometer, vaginal speculae, light source, gloves, decontaminants/disinfectant, Ayre’s spatula, cervical brushes, slides & fixative (also for PAP smears), IUCD insertion kits

For each missing/

non functional

item deduct 0.5

point

5

Total Points Reproductive Health 23

Remarks

217

9 ANC and PNC CriteriaPossible

max score

Obtained score


9.1 ANC register for HF available and well filled in: last five records verified 14

9.1.1 All: Examinations: Size, Parity, Date of last menstruation All or nothing 2

9.1.2 All: Laboratory: HB results available All or nothing 2

9.1.3 All: Obstetrical examination done:, Uterine height, recorded All or nothing 2

9.1.4 All: Minimum Tetanus 2 administered All or nothing 1

9.1.5 All: Tested for Syphilis ((VDRL test)at first visit All or nothing 1

9.1.6 All: Tested for HIV at first ANC visit All or nothing 1

9.1.7 All HIV- re-tested at 36 weeks All or nothing 1

9.1.8 All pregnant women received their MBP (ARV prophylaxis or complete course of ARV to reduce the risk of MTCT)

All or nothing 3

9.1.9 All columns well filled including the identification of problems if any, and actions taken

All or nothing 1

9.2 Lesotho Obstetrical Record (LOR) booklets for mothers available: at least 100 in stock

All or nothing 1

218

9.3 ANC conducted by qualified personnelRegistered nurse midwife, verified in ANC register

All or nothing 1

9.4Functional equipmentWeighing scale and calibrated to zero, Stethoscope and BP machine available and functional in ANC room

All or nothing 1

9.5 ANC shelter, being utilised and clean All or nothing 5

9.6 Postnatal Care 5

9.6.1 Post Natal care register available, including , Family Planning, PMTCT, etc. according to guidelines

All or nothing 1

9.6.2 Postnatal care register with PNC visits examinations within 6 hours, 48 hours, 6-8 weeks and 14 weeks indicated

All or nothing 4

Total Points ANC and PNC services 27Remarks

10 STIs, HIV and TB CriteriaPossible

max score

Obtained score


10.1 Guidelines available, accessible to staff and followed 10

10.1.1 HIV/AIDS Protocol. Verify with 3 patients if HIV testing and counselling was provided (after consultation)

Each criterion met, one

point

3

10.1.2 ART Protocol Identify 3 HIV+ patients on ART and check if protocol was followed properly

Each criterion 3

219

met, one point

10.1.3 Post exposure protocol for sexual assault survivors, ask nurse if knowing the procedure

All or nothing 1

10.1.4 STI management. Check 3 patients from OPD register for proper classification of STIs

Each criterion met, one

point

3

10.2 Existence of a HTC register according to norms All or nothing 1

10.3 Existence of a lab register correctly completed according to norms

All or nothing 1

10.4 Staff trained in HIV rapid testing and counsellingCounselling and testing is done by a trained provider

All or nothing 1

10.4 Follow up for HIV clients All or nothing 3

10.4.1 Monitoring tracking tool is used All or nothing 1

10.4.2 CD4 cell counts available All or nothing 1

10.4.3 PCR register for infant follow up, especially for infants born to HIV positive mothers is available

All or nothing 1

10.5

TB Treatment Register (take 3 ad random patients)National TB Control Guidelines . Check 3 TB cases from TB register whether (1) sputum was taken and (2) results known (3) HIV test taken (4) initiated treatment (5) End of treatment/cured is recorded


point

5

10.6

Referral system and follow up for TB patientsEach (AFB PTB )patient has a person attached to him/her who supervises DOTS: proof of in register; mobile phone number of such a supervisor is registered

All or nothing 2

220

Total Points STIs, HIV and TB management 22

Remarks

PART B - SECONDARY CARE SERVICES

11 In-patient Wards Criteria Possible max score

Obtained score


11.1

Medical equipment and linen available and in good stateEach bed has a (1) standard hospital mattress, (2) clean sheets, (3) bedside cupboard


point

3

11.2 Patient comfort and hygiene 3

11.2.1 The wards are clean: no debris on the floor; and no smells All or nothing

1

11.2.2 Space between the beds is at least one meter All or nothing

1

11.2.3 Each ward has access to drinking water in the ward All or nothing

1

221

11.3 Light available in each wardElectricity; solar light or rechargeable battery lamp

All or nothing

1

11.4 ConfidentialityWomen in separate ward from men; the inside of the wards are not visible from the outside

All or nothing

1

11.5 In patient register available and is well maintained 1

11.5.1 Check the patient identity All or nothing

0.5

11.5.2 Check the hospital bed days in the register All or nothing

0.5

In-patient wards (Pediatric, Surgery, Medical)

11.6

In-patient Care Pediatric ward: systematic random sample of 5 patient files from discharged patients from the admission register from the last quarter. Each of the files is subject to the following criteria:

7

11.6.1

Each patient file meets key standard requirements: (1) full personal data of patient; (2) date and time of admission; (3) Contact details (address or mobile phone number, if applicable);; (4) date and time of first examination by medical doctor; (5) Past medical history

All or nothing

1

11.6.2

Notes on Drs daily examinations which include clinical examinations (blood pressure; frequency and rhythm of heartbeat; body temperature; weight; height; respiratory rate; physical examination; differential diagnosis)

All or nothing

2

11.6.3Scope of laboratory and other examinations corresponds to clinical diagnosis and is compliant with clinical protocols and national 'treatment guidelines'.

All or nothing

2

11.6.4 Copy of discharge summary in file with final diagnosis on discharge and treatment follow-up

All or nothing

2

222

11.7

In-patient Care Surgical ward: systematic random sample of 5 patient files from discharged patients who had major surgical procedures from the admission register from the last quarter. Each of the files is subject to the following criteria (if 0 operations then 0 score):

9

11.8.1

Each patient file meets key standard requirements: (1) full personal data of patient; (2) date and time of admission;( 3) Contact details (address or mobile phone number, if applicable); (4) date and time of first examination by midwife/Dr; (5) Past medical history;

All or nothing 1

11.8.2

Notes on Drs daily examinations which include clinical examination (blood pressure; frequency and rhythm of heartbeat; body temperature; weight; height; respiratory rate; assessment of surgical condition; clinical diagnosis and justification)

All or nothing 2

11.8.3 Report on surgical procedure and anesthetic method and record of patient’s monitoring used, record

All or nothing 2

11.8.4 Copy of discharge summary in file with final diagnosis on discharge and treatment follow-up

All or nothing 2

11.8.5 Registration of post-operative conditions and complications All or nothing 2

11.9

In-patient Care Medical ward: systematic random sample of 5 patient files from discharged patients who have delivered from the delivery register from the last quarter. Each of the files is subject to the following criteria:

7

11.9.1

Each patient file meets key standard requirements: (1) full personal data of patient; (2) date and time of admission; (3) Contact details (address or mobile phone number, if applicable); (4) date and time of first examination by medical doctor; (5) Past medical history;

All or nothing 1

11.9.2Notes on Drs daily examinations which include clinical examination. (blood pressure; frequency and rhythm of heartbeat; body temperature; weight; height; respiratory rate; physical

All or nothing 2

223

examination; differential diagnosis )

11.9.3Scope of laboratory and other examination corresponds to clinical diagnosis and is compliant with clinical protocols and compliance with national 'treatment guidelines'.

All or nothing 2

11.9.4 Copy of discharge summary in file with final diagnosis on discharge and treatment follow-up.

All or nothing 2

Total points in-patients wards 32Remarks

12 Delivery Room Criteria Possible max score

Obtained score


12.1 Running Water and liquid soap in delivery room availableA functioning water source.

All or nothing 2

12.2Light in delivery room 24 hoursElectricity, solar light or rechargeable battery lamp or gas/paraffin lamp filled with paraffin/gas

All or nothing 2

12.3 Waste from Maternity correctly handledPlacenta is disposed in a red plastic container with lid

All or nothing 1

12.4 Delivery room is well-maintained 5

12.4.1 Walls with durable materials and painted All or nothing 1

12.4.2 Curtain between delivery bed and door All or nothing 1

12.4.3 Delivery room cleaned with disinfectant. Ask for All or 1

224

proof/disinfectant bottle nothing

12.4.4 Floor level cement, without fissures and ceiling not damaged All or nothing 1

12.4.5 Unbroken windows with clean curtains and functional door All or nothing 1

12.5 Availability of a tape to measure length and an aspirator functional 2

12.5.1 Tape to measure length All or nothing 1

12.5.2 Aspirator plunged into a non-irritating disinfectant or functional manual/electric aspirator

All or nothing 1

12.6Availability of a functional vacuum extractorPlus a nurse/doctor trained in its use, and vacuum extractor effectively used

All or nothing 3

12.7 Availability of at least 100 pairs of sterile gloves All or nothing 1

12.8

Availability of at least 10 sterilized delivery packs with as contentContent at the least 1 pair of episiotomy scissor, 2 artery forceps non toothed, 2 artery forceps toothed 1 kidney dish, 2 bowls (medium and large), 4 dressing towels, and one needle holder,

All or nothing 2

12.9 Under buttocks drapes 2 boxes in stock All or nothing 1

12.10Delivery table in good stateTable in two parts with removable non-torn plasticized mattress and two functional leg supports

All or nothing 1

12.11 Use of the Partogramme in the Lesotho Obstetric RecordVerify three randomly selected partogrammes whether filled

Each criteria

3

225

according to the norms met is 1 point

12.12Deliveries performed by skilled personnelIdentification of the Registered Midwife from names in the register

All or nothing 1

12.13 Newborn Care 3

12.13.1 Sterile clip for umbilical cord All or nothing 1

12.13.2 1% tetracycline eye ointment All or nothing 1

12.13.3 Vitamin K All or nothing 1

12.14APGAR during delivery notedFilled in the programme 1st , 5th and 10th minute. Supervisor verifies 3 programmes with APGAR scores

If not correct 0

point3

Total points delivery room 29Remarks

13 In-patient Gynaecology/Obstetric Ward Criteria Possible max score

Obtained score


13.1

In-patient Care Gyn/Obs ward: systematic random sample of 5 patient files from discharged patients who have delivered from the delivery register from the last quarter. Each of the files is subject to the following criteria:

7

13.1.1 Each patient file (for CS) otherwise LOR meets key standard All or 1

226

requirements: (1) full personal data of patient; (2) date and time of admission; (3) Contact details (address or mobile phone number, if applicable); (4) date and time of first examination by midwife/Dr; (5) Past medical history

nothing

13.1.2

Notes of midwife/Dr daily examinations which include clinical examination (blood pressure; frequency and rhythm of heartbeat; body temperature; weight; height; respiratory rate assessment of obstetrical condition)

All or nothing 2

13.1.3Justification of clinical diagnosis and elaborate description of obstetrical proceedings (including post - partum hemorrhage; pre-eclampsia; premature birth etc). Compliance with EmOC manual

All or nothing 2

13.1.4 File with final diagnosis on discharge and treatment kept and LOR. (summary sheet or LOR to the women)

All or nothing 2

Total points Gynaecology/Obstetrics Ward 7Remarks

14 Blood Bank and surgery Criteria Possible max score

Obtained score


14.1 Blood bank and emergency preparedness 6

14.1.1 One transfusion certified/ laboratory staff member on call All or nothing

1

14.1.2 Sufficient supply of reagents for grouping and X-matching, properly stored

All or nothing

1

227

14.1.3 Minimum units of fresh blood O rhesus negative type, non- expired available (Guideline for minimum to be checked)

All or nothing

1

14.1.4 Blood stored according to the norms (between 2 to 4C); refrigerator is functional temperature measured twice daily

All or nothing

2

14.1.5 Test kits for HIV, VDRL and HepB tests available, and stored blood tested

All or nothing

1

14.2 Sterilization according to the norms 4

14.2.1 Functioning sterilizer available All or nothing

1

14.2.2 Sterilizer in separate room from theatre All or nothing

1

14.2.3 Use of chemical heat indicators All or nothing

1

14.2.4 Register for sterilizations used and completely filled All or nothing

1

14.3 Minor surgery done in a separate room from the major surgical procedures

All or nothing

1

14.4 Functioning theatre lamp and mobile lamp All or nothing

1

14.5 Functioning theatre table All or nothing

1

14.6 Emergency Preparedness 8

14.6.1 At the least 5 sterilized major surgery sets available, with date of sterilization indicated on the pack

All or nothing

1

14.6.2 At the least 10sterilized CS set available, with date of sterilization indicated on the pack

All or nothing

1

14.6.3 At the least 50 L of Ringers Lactate available in the theater All or nothing

1

14.6.4 At the least 10 bags of Colloids (haemacel) available in the All or 1

228

theater nothing

14.6.5 Daily theatre cleaning schedule is available and signed and weekly totally cleaned

All or nothing

1

14.6.6 Nursing/technical staff trained in anesthesia is presently on duty (at least for ketamine or spinal)

All or nothing

1

14.6.7 Nursing Staff trained in theater procedures presently on duty All or nothing

1

14.6.8 Trained Medical Doctor with experience doing CS on duty or call All or nothing

1

Total Points Surgery 26

Remarks

15 Laboratory Criteria Possible max score

Obtained score


15.1 Laboratory technician or technologist is available All or nothing

1

15.2Laboratory is open every day of the week or on callSupervisor verifies the last 2 Sundays in laboratory register

All or nothing

2

15.3 List of laboratory tests/investigations visible for the public with fees

All or nothing

1

15.4Results recorded correctly in laboratory register and match with results in inpatient sheets or OPD examination cardsSupervisor verifies last five results

Each criteria

met, one point

5

229

15.5 Availability of parasites demonstrationsOn plastic paper, in a color book, or put on wallStools: entamoeabae, flagellates:

All or nothing

1

15.6 Microscope available and functionalfunctional objectives; immersion oil available, mirror or electricity, blades, cover glass,

All or nothing

1

15.7 HIV tests available 2

15.7.1 At the least one HIV rapid kit (sealed) available in the laboratory; non-expired

All or nothing

1

15.7.2 CD4 counts performed All or nothing

1

15.8. TB tests are available 2

15.8.1 At the least 20 (sputum) tests available in the laboratory; non-expired

All or nothing

1

15.8.2 DST (Culture and drug susceptibility) performed (for regional laboratory)

All or nothing

1

15.9 Centrifuge available and functional All or nothing

1

15.10 Waste evacuation correctly carried out 2

15.10.1 Organic waste in a bin with lid All or nothing

1

15.10.2 Security container for sharp objects available and destroyed according to waste disposal guidelines

All or nothing

1

15.11 Availability of a functional safety cabinet in the laboratory All or nothing

2

Total Points Laboratory 20

Remarks

230

16 Radiological Services Criteria Possible max score

Obtained score


16.1 Radiological department manned by qualified staff

All or nothing

2

16.2

Frequent monitoring for radiological exposure according to protocol. Monitors sent to SA for reading exposure.

All or nothing

3

16.3

Radiological equipment available and functional (x-ray, ultrasound scan)

All or nothing

3

16.4

Availability of protective clothing and necessary safety precautions in place

All or nothing

3

16.5

Availability of 3 month stock of consumables (x-ray films, fixers, envelopes etc. ) Daily consumption known?

All or nothing

3

Total points Radiological Services 14

Remarks

17 Specialized Services: Physiotherapy, dentistry, ophthalmology, ENT, and mental health Criteria Possible

max scoreObtained score


17.1 Quality of consultation of each of the five specialized services: A sample of 5 will be drawn from all patients that had the services the past quarter, from the register, using a standard

231

random sampling methodology. All the below conditions have to be met:

17.1.1. At least one qualified staff availableAll on

nothing1

17.1.2

A register exists in which are registered all new cases and which contains: date, name and first name of patient, address (phone number, district, community council, village, diagnosis and treatment)

All or nothing

1

17.1.3 Consultation card for new cases with an indication for the specialised service which is clearly formulated

All or nothing

2

17.1.4 As above and which has a description of the treatment provided by the qualified staff

All or nothing

1

Total points specialized l Services 25

Remarks

232

Annex: Priority list of tracer medicines

Priority Program

The following tracer medicines are available Criteria Max score Score

ObtainedHIV and AIDS

1. Lamivudine Each criteria met is 1 point 1

2. Zidovudine Each criteria met is 1 point 1

3. Nevirapine Each criteria met is 1 point 1

4. Tenofovir Each criteria met is 1 point 1

5. Abacavir Each criteria met is 1 point 1

6. Efavirenz Each criteria met is 1 point 1

7. Didanosine Each criteria met is 1 point 1

8. Lopinavir Each criteria met is 1 point 1

9. Atazanavir Each criteria met is 1 point 1

10. Darunavir Each criteria met is 1 point 1

11. Ritonavir Each criteria met is 1 point 1

12. Etravirine Each criteria met is 1 point 1

Tuberculosis

13. Cotrimoxazole DS Each criteria met is 1 point 1

14. Isoniazid/Rifampicin(RHZ)


15. Pyrazinamide Each criteria met is 1 point 1

16. Ethambutol Each criteria met is 1 point 1

17. Streptomycin Each criteria met is 1 point 1

18. Isoniazid Each criteria met is 1 point 1

19. Rifampicin(RH) Each criteria met is 1 point 1

20. Pyridoxine Each criteria met is 1 point 1

21. Dapsone Each criteria met is 1 point 1

22. Cat 1 & 3 Each criteria 1

233

met is 1 point23. Cat 2 Each criteria

met is 1 point 1

Reproductive Health

24. Magnesium Sulphate Each criteria met is 1 point 1

25. Oxytocin Each criteria met is 1 point 1

26. Ergometrine Each criteria met is 1 point 1

27. Male Condoms Each criteria met is 1 point 1

28. Female condoms Each criteria met is 1 point 1

29. Copper - T Each criteria met is 1 point 1

30. Noristerate Each criteria met is 1 point 1

31. Microgynon Each criteria met is 1 point 1

32. Lofeminal Each criteria met is 1 point 1

33. Nordette Each criteria met is 1 point 1

34. Microlut Each criteria met is 1 point 1

35. Solo Shot Each criteria met is 1 point 1

36. Depo Provera Each criteria met is 1 point 1

37. Microval Each criteria met is 1 point 1

Others38. Amoxycillin


39. CotrimoxazoleEach criteria met is 1 point 1

40. ErythromycinEach criteria met is 1 point 1

41. CeftriaxoneEach criteria met is 1 point 1

42. Diazepam injectionEach criteria met is 1 point 1

43. Gentian violet or nystatinEach criteria met is 1 point 1

44. Paracetamol syrupEach criteria met is 1 point 1

45. Oral iron preparation (Ferrous gluconate or


234

ferrous lactate)

46. Folic AcidEach criteria met is 1 point 1

47. Vitamin AEach criteria met is 1 point 1

48. AlbendazoleEach criteria met is 1 point 1

49. Salbutamol MDI and Appropriate Spacers


50. Salbutamol solution for nebuliser


51. Adrenaline + solution for nebulisers


52. AtropineEach criteria met is 1 point 1

53. Prednisone tabletsEach criteria met is 1 point 1

54. ORS packetsEach criteria met is 1 point 1

55. IV solution : N Saline, 5% dextrose, Ringer Lacate


56. Sterile syringes and needles


57. Swabs and skin disinfectant


58. Cannulae 24G, 22GEach criteria met is 1 point 1

59. IV sets (60drops/ml)Each criteria met is 1 point 1

60. Naso gatric tubes (5,8,10 FG)


61. Medicine measures and glasses


62. Paediatric nebulizer mask, chamber and tubing


63. HIV test kitsEach criteria met is 1 point 1

64. PCR kitEach criteria met is 1 point 1

65. Lignocaine Each criteria met is 1 point 1

PMTCT 66.IMCI 67.Diabetes 68.Hypertension

69.

Oral Health 70.

235

Annex 22. PERFORMANCE FRAMEWORK FOR DHMT AND INVOICE

The amount invoiced will be solely based on the outcome of the performance assessment of the DHMT in accordance with the DHMT Performance Framework.

Maximum budget for PBF incentives available for the district is quarterly: LSM .…………... This corresponds with a 100% score on the performance assessment. Lower scores will lead to proportionally lower allocations.

EVALUATION OF THE DISTRICT HEALTH OFFICE DISTRICT:__________________________________QUARTER 20_____N ASSESSED ACTIVITIES Maxim

um score possible

Attributed score

Difference

% Observations

1 100% of Health Centres have received at least once per quarter a comprehensive quality assessment applying the appropriate checklist and protocol, and providing adequate feedback

25


20

3 100% of health centres have received once per quarter a visit for data verification jointly with PPTA

15

4 DHMT prepares quarterly progress report 155 At least one Meeting at district headquarters with

Health Centres staff during the past quarter20

6 At least one hour training on a specific topic, offered after the quarterly HC staff meetings

10


20

8 DHMT activity planning well organized 5

237

9 Participation in the quarterly district PBF Steering Committee Meetings

15

10 HCs have 100% of qualified staff as per minimum criteria based on HC establishment list and assessed actual presence

20

11 Management of the District Pharmacy 2012 Communication with health facilities 513 PBF funding is made available to HCs in a timely

mannerand accountability for use of PBF funds is ensured

10

TOTAL 200

No Indicator/Performance Measure

Primary/Secondary Data Sources

Composite Criteria/Validation Criteria Available points

Attributed Score

Justification of score

1 100% of Health Centres have received at least once per quarter a comprehensive quality assessment applying the appropriate checklist and protocol, and providing adequate feedback

DHMT quarterly work plan

File containing HC quality assessment reportsTravel request forms signed

HC assessment reports will be reviewed to verify that the DHMT has performed quality assessments of each HC according to the agreed protocol mentioned in quality checklist health centres. In case HCs have not been assessed during the quarter in line with above requirements, there will be 5 points deduction for each HC not assessed during quarter.

25


File containing HC contracts with business

HCs will have contracts that have a 3 month duration equal to the quarters in a year. These contracts should be: complete and duly signed as per approved

20

238




Attributed Score


plans annexed

format should have a business plan as an annex,

duly signed should be signed and filed within 2 weeks

after the start of a quarterIn case HC contracts are missing or have not been signed in time, there will be a penalty clause: 5 points subtraction per HC not meeting this requirement

3 100% of health centres have received once per quarter a visit for data verification jointly with PPTA

File containing reports on HC data verification / supervision visitsTravel request forms signed

DHMT staff will join the PPTA on quarterly data verification visits on site at each HC to conduct a supervision visit. Such visits are complementary to the quality assessment visits, so that each HC should be visited by the DHMT at least twice per quarter, once for quality assessment and once for data verification/supervision.A report is made on each supervision visit. Observations and recommendations are shared with HC staff verbally and in writing. Two copies of the report will be presented, the HC in-charge to sign report for receipt.In case the DHMT failed to meet this frequency there will be 3 points deduction per HC not visited as per requirement

15

4 DHMT prepares quarterly progress report

Synthesis progress report

DHMT will compile a synthesis report based on available information collected from all HCs through data verification visits, quality of care assessments and supervision visits done.

15

239




Attributed Score


The report provides an overview of the progress made in public health terms and in respect to advancing PBF.

The report should contain conclusions and recommendations

The report is forwarded to the District Council and discussed in district PBF Steering Committee and also put on agenda of quarterly meeting with HCs

For every criterion met 5 points is offered5 At least one Meeting at

district headquarters with Health Centres staff during the past quarter

Meeting Minutes,Signed participants Listpayment voucher for compensation travel expenses HC staff provided

The minutes should meet the following criteria Date and time indicated Approved agenda, with at least three

standard sections: discussion on DHMT synthesis report on HC performance in last quarter, data sheet with quantity performance in last quarter for district and each HC; follow up of recommendations and tasks from previous meeting

List of action points with dates and tasks assigned

List of participants Action points listed with tasks attributed

If one or more criteria are lacking: 3 points deduction; for each HC not represented: 2 points deduction

20

6 A training of at least one hour on a specific topic is offered immediately

Training report available

Training report, providing at least the following Objective of the training

10

240




Attributed Score


following the quarterly HC staff meetings Signed

participants List

Presentations given and/or short description of the session

Feedback received from participants suggestions collected for topics upcoming

training sessionsIn case training report is missing: nil points. For each HC not attending: 2 points deduction


Printed HC HMIS Monthly / Cumulative (per quarter) ReportData available in the HMIS DBMonthly HC HMIS reports (original)

HMIS/PBF reports received from HCs are “cleaned” in case of errors and complemented in case of missing items. Subsequently the following needs to be done: Processed monthly HC HMIS/PBF Report

available and filed; one copy sent to PPTA for routine data verification

Original HC HMIS/PBF reports submitted by HC available and filed

Monthly cumulative HMIS/PBF reports available

Report printed within 7 working days after end of the month

Routine HMIS data monthly reports compared and harmonised with PBF indicators data report

For each HC report not processed, filed, etc. as indicated within the stated time limit: 3 points deduction.

20

8 DHMT activity planning well organized

Activity planActivity calendar

Annual plan is available and displays the regular pattern of reviews and meetings

Monthly Activity Plan is available

5

241




Attributed Score


Brief activity report

according to set format at the start of each month

Activity Calendar for the current Month is visible on the wall of the District Health Office

Report is available on activity plan carried out indicating any deviations between plan and execution and underlying reasons

If one or these criteria not met: 2 points deductionIf two criteria are not met: nil points

9 Participation in the quarterly district PBF Steering Committee Meetings as per TOR

District RBF Steering Committee Meeting MinutesParticipants List

Minutes of district PBF Steering Committee meeting available, meeting following criteria:o Date and time indicatedo Approved agenda with at least

following items: district report on HC performance with trends analysis; validation of PBF invoices prepared by DHMT/PPTA; follow up of recommendations and tasks from previous meeting

o List of action points with dates and tasks assigned

o List of participants, indicating that quorum as per District PBF Steering Committee guidelines has been met

o Action points listed with tasks attributed

15

242




Attributed Score


In case one or more criteria are not met nil points.

10 HCs have 100% of qualified staff as per minimum criteria based on HC establishment list as endorsed by district and assessed actual presence

Data sheet with per HC staff establishment and actual staff

HCs should meeting minimum staffing level as per officially approved HC establishment list

For 100% HC meeting staff levels 20 pointsFor 75% -100% HCs meeting staff levels: 15 pointsFor 50-75% HCs meeting staff levels: 10 pointsFor less than 50% HCs meeting staff levels: 0 points

20

11 Management of the District Pharmacy

Stock control cardsList of expired drugsOrder book for timely ordering of drugs according to schedule

100% stock control cards filled in all entries

list of expired drugs present, reporting done, removed from shelf timely and disposed off as per medical waste guidelines

ordering of drugs according to schedule, which refers to timely receipt of orders from HCs (before date communicated to HC) and forwarding them to NDS after verification on or before set date

timely (within one week) distribution of drugs to HCs after NDS supplies have arrived.

For each criterion met 5 points

20

12 Communication with List with The DHMT is able to have dual way 5

243




Attributed Score


health facilities phone numbers or radio codes

communication with all HCs. Thirty percent of HCs is selected randomly and it is tested that indeed communication is feasible.

In case communication fails with any HC, nil points

13 PBF funding is made available to HCs in a timely mannerand accountability for use of PBF funds is ensured

Copies of PBF funds notificationAccounts records of transfers to HCsVerified accounts HC indicating use of funds

All HCs are timely (within 2 days after funds arrived) informed about the PBF funding they are entitled to

In case HCs have no bank accounts, the DHMT/District Councils will provide funding through the district accounts.

DHMTs will oversee the use of PBF funds by HCs in line with the guidelines and take corrective action if necessary

In case all criterion is met no deductionIn case one criterion is not met 5 points deductionIn case two or three criterions are not met no points

10

TOTAL score available and attributed after performance assessment 200

244

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 regarding the identified weak points

Total amount earned = Actual score divided by 200 (max score) x available quarterly budget …………………LSM

__________________________________ _________ ____________________________ _________Evaluators Team Leader/Name & Signature Date Signature & Stamp

245

Annex 23. INDIVIDUAL PERFORMANCE EVALUATION FOR HEALTH CENTRE STAFF

Individual Performance Evaluation for Health Centre Staffname Health Centre DistrictName Employee: position held:In case of Health Centre In-charge: the Health Centre Committee will decide how to appraise the individual performance of the in-charge in cooperation with the DHMT. However, an in-charge will have one extra performance criterion to be met: all staff should have had their performance evaluation done in each quarter. For each member of staff who has not receive a performance review: the in charge will face a deduction of her/his performance score of 10 points.Quarter assessed:

Individual Performance Evaluation for Health Centre StaffCriteria 25% Score 50% Score 100% Score Max Score

Professional Awareness includes the following: (20 points) (see note on last page)Timeliness Arrived frequently late

(at the least four times past monthArrived sometimes late(1 to 3 times per month)

Was always on time 8

Availability Has been frequently absent from his/her service without any clear motive(at the least four times past month)

Has been a few times absent from his service without clear motive(1 to 3 times per month)

Was never absent from his/her service without known and valid motive

8

Uniform Did not wear a uniform during working hours(even once per month)

Neglected uniform (dirty or torn or not ironed)

Uniform always worn and proper (washed ; ironed and not torn)

4

Team spirit includes the following: (30 points) (see note on last page)Interpersonal Relationship

Frequently in conflict with colleagues (reported more than once to his/her superior during the past month)

Sometimes in conflict with colleagues (reported once to his/her superior)

Never in conflict with colleagues

6

246

Collaborative spirit

Frequently refused to assist colleagues when asked(more than once per month)

Sometimes refused to assist colleagues(even once)

Never refused to assist colleagues

6

Dedication Frequently left work unfinished without somebody taking over under the argument that official working hours were up (more than 3 times past month)

Sometimes left work unfinished without somebody taking over using the argument that official working hours were up(1 to 3 times per month)

Never left work unfinished without somebody taking over

6

Initiative Has never done any additional work Has always awaited a command from higher up to carry out additional work

Has at least once done additional work without supervisor asking him/her to do so

6

Care 0ff duty hours to guarantee 24/7 care

Not applicable (staff not on off-duty roster) or very hesitant to participate in off duty roster, on three or more occasions not available during last month, leaving duty to colleague

Most of the time willing to participate in off duty roster, but on two occasions last month was not available and left duty to colleague

Always willing to participate in off duty roster and is always available when patient care demands this

6

Technical Competency and flexibility during work: (40 points)Organization Never has a daily work schedule

(assessed during internal work supervision)

Not always has a daily work schedule (at least once during internal supervision)

Always has a daily work schedule

10

Quality of work Never adheres to specific work related norms and standards(assessed during internal supervision)

Not always adheres to work related norms and standards(found at least once during internal supervision)

Always adheres to specific work related norms and standards

14

Quantity of work

Never finishes his/her daily work based on his/her own daily work schedule(assessed during internal supervision)

Not always finishes his/her work based on his/her own daily work schedule(found at least once during internal supervision)

Always finishes his/her work according to his/her daily work schedule

16

247

Willingness and aptitude for personal development : (10 points)Takes into account advice and recommendations from previous internal and external supervisory visits

Never takes care of such recommendations (concluded during internal and external supervisory visits)

Not always takes care of such recommendations(if this happens once or more)

Always takes into account recommendations of internal and external supervisory visits

10

TOTAL POINTS 100Participation to Results and the Past Monthly Performance ScoreParticipation to Results and the past quarter’s performance score (quantity and quality) through presence during working days during the past month :NB: We take into account actual working days without taking into account any valid reasons for absence such as vacation, leave, sickness, absence through disciplinary action, formal trainings etc. An exception to this rule are Rest and Recuperation days (allocated by the health facility management), which, when accorded, are considered official working days.

Number of official working days = (N);number of days actually worked = (n); (max 5 days absence due to workshops/training/meetings allowed per month, if exceeding corrections have to be made)Percentage of days performed = (P) (P) = ( n/N) * 100

100% P =

Result of the individual monthly performance evaluation = (Total of the Scores for items 1 to 4) * P

Prepared at:

248

Date………………………………...

For the internal performance evaluation team, (Names, functions, and signatures)

…………………………………………………………………………………

…………………………………………………………………………………

Employee (Name and signature)

…………………………………………………………………………………

Since it is hardly feasible to recall all events over a period of three months, reference is made to what transpired during the last month only. However, this should not be seen as a limitation: if the in-charge has a good overview over the full three months then this overview should prevail.

249

Annex 24. INDICES TOOL FOR ALLOCATION OF MOTIVATION BONUSES TO HC STAFF

Introduction Health Centres (HC) will receive a PBF benefit based on three scores:

Quantity of services produced Quality of services produced Remoteness bonus (if applicable).

The PBF benefit will be made available to the HC and the HC will use it in line with what has been discussed in the quarterly renewable HC business plans. There are three optional allocations whereby it has been decided to allow the HC partial freedom to use the PBF benefits:

Resources for improvement of service delivery minimum 25% of total Incentives (motivation bonuses) to HC staff: range 20-45% of total Incentives to Village Health Workers range 20-45% of total

It is up to the HC committee to decide on the actual % of the benefits received – an amount expressed in LSM – that will be allocated to motivation bonus for DHMT staff.

1. Who will qualify for staff motivation bonuses?Staffs who are employed by the Health Centre may receive a motivation bonus. In case of a Government of Lesotho (GOL) HC, the staff will be employed by either the Ministry of Health (MOH) or the Ministry of Local Government (MOLG) and posted to the HC. In case of a Christian Health Association Lesotho (CHAL) institution alternative options exists. What is similar for both groups of employees is that they have a formal labor contract that mentions either the name of the HC or there is other formal communication that proves that the staff is posted to the HC. The following staff will not qualify for the motivation bonus:

Staffs with any other type of contract, e.g. on locum, seconded or temporarily hired by the DHMT itself

Staffs who have been employed during part of the quarter only, due to the date of commencement of their contract or due to the date of disengagement

Staffs without a signed motivation agreement for the whole quarter for which the PBF benefits have been calculated.

Staffs whose performance has not been evaluated during the quarter using the appropriate performance evaluation form.

2. How should the indices tool be used?See model of the INDICES Tool below and an example which follows

The amount to be allocated for staff motivation bonuses (A) will be decided on in line with what is stated above.

All staff befitting the employment status mentioned above will be listed in a spreadsheet, with for every full 100 LSM of gross salary 1 points will be used in the spreadsheet (amount B). Two persons will receive a mark-up for specific responsibilities (amount C), if there has been no salary increase to compensate for such responsibilities. This may apply to the HC in-charge (20 points) and the HC focal point for VHWs (10 points). This will lead to amount D.

Each staff member will have had a quarterly individual performance score, (See individual performance assessment form), which will determine per quarter the performance score which is corrected for days not worked. (% E)

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The points allocated per staff member will be multiplied with the performance score to arrive at a points score per person in (amount F).

Amount F is divided by the total points score for all HC staff (amount G), to arrive at a relative score per individual (% H). This percentage is equal to the percentage of the available amount for bonus that the individual will receive.

This percentage score per individual is multiplied by the amount available for motivation bonuses to arrive at the individual bonus (amount H)

The amount due to an individual for one quarter should not exceed the gross salary for one month. If so, the excess money will be allocated to the resources for improvement of service delivery.

3. Transparency and accountability The HC in charge will apply the indices tool to determine individual bonuses. A meeting will be staged with all HC staff to discuss how the individual bonuses have

been calculated. All employees have the right to be shown the calculation sheet. In case of consensus,

o a payment sheet will be filled out for each employee with the name of the employee, the position held, the quarter to which the allowance applies, the actual allowance allocated and the mode of payment.

o The in-charge and the employee will both sign the payment sheet and the money will be allocated, either through cash payment or through bank transfer within two weeks after the HC has received its performance benefit.

o In case of cash payment the employee will sign also for receipt of the money; o in case of a bank transfer a bank statement is considered proof of payment.

In case no consensus is reached the matter will be forwarded to the chair of the Health Centre Committee for settlement.

If also after involvement of the HCC chair no consensus is reached the matter will be left to the PBF District Steering Committee to decide.

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INDICES CARD Tool for allocation of individual motivation bonu s(see text for explanation and guidance)

Health centre name:Health centre in/chargeperiod for which bonus is allocated

maximum bonus for HC staff motivation in LSM set aside Amount A LSM …………

name position held

Per full gross salary (with allowances) 100 LSM 1 points allocated

additional 20 points for In/ch and 10 points for focal point VHW total

Individualperformance score during last quarterin%

total score relative score in%

Bonus in LSM

B C D=B+C EF=D*E H= F/G I=H*A

TOTAL (G) 100% (A)

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EXAMPLEINDICES CARD Tool for allocation of individual motivation bonu s(see text for explanation and guidance)

Health centre name: xxxxHealth centre in/charge Ms Aperiod for which bonus is allocated 3rd Q 2013

maximum bonus for HC staff motivation in LSM set aside (A)LSM 5000

Amount based on decision taken in business plan

name (staff who completed one full quarter) position held

Per full gross salary (with allowances) 100 LSM 1 points allocated; rounded

additional 20 points for In/ch and 10 points for focal point VHW total

Individualperformance score during last quarter

total score relative score bonus


Ms A

Nurse clinician in Charge 122 20 142 84%

119.28 0.49 2441

Ms B Midwife 89 89 79% 70.31 0.29 1439

Ms C

Nurse assistant (focal point) 43 10 53 66% 34.98 0.14 716

Mr D Cleaner 10 10 90% 9 0.04 184

Mr ENight watchmen 12 12 90% 10.8 0.04 221

TOTAL 294233.57 100% 5.000

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Annex 25. INDIVIDUAL PERFORMANCE EVALUATION DHMT STAFF

Individual Performance Evaluation for District Health Management Team StaffDHMT: District

Name Employee

In case of (acting) DHMT Director: the District Council will decide how to appraise the individual performance of the DHMT director in cooperation with PHC Directorate of the MOH. However, the director will have one extra performance criterion to be met: all staff should have had their performance evaluation done in each quarter. For each member of the DHMT staff who has not receive a performance review: the DHMT director will face a deduction of her/his performance score of 10 points.Quarter assessed

Criteria 25% Score 50% Score 100% Score Max ScoreProfessional Awareness includes the following: (15 points) (see note on last page)

Timeliness Arrived frequently late or left early without proper reason(at the least four times past month)

Arrived sometimes late or left early without proper reason(1 to 3 times per month)

Was always on time and left at the regular end of duty time

7

Availability Has been frequently absent from his/her service without any clear motive(at the least four times past month)

Has been a few times absent from his service without clear motive(1 to 3 times per month)

Was never absent from his/her service without known and valid motive

8

Team spirit includes the following: (30 points) (see note on last page)Interpersonal Relationship

Frequently in conflict with colleagues (reported more than once to his/her superior during the past month)

Sometimes in conflict with colleagues (reported once to his/her superior)

Never in conflict with colleagues

8

Collaborative Frequently refused to assist colleagues Sometimes refused to assist Never refused to assist 8

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spirit when asked(more than once per month)

colleagues(even once)

colleagues

Dedication Frequently left work unfinished without somebody taking over under the argument that official working hours were up (more than 3 times past month)

Sometimes left work unfinished without somebody taking over using the argument that official working hours were up(1 to 3 times per month)

Never left work unfinished without somebody taking over

7

Initiative Has never done any additional work Has always awaited a command from higher up to carry out additional work

Has at least once done additional work without supervisor asking him/her to do so

7

Technical Competency and flexibility during work: (40 points)Organization Never has a daily work schedule,

including fieldwork (assessed during internal work supervision)

Not always has a daily work schedule including fieldwork (at least once during internal supervision)

Always has a daily work schedule, including field work

10

Quality of work Never adheres to specific work related norms and standards(assessed during internal supervision)

Not always adheres to work related norms and standards(found at least once during internal supervision)

Always adheres to specific work related norms and standards

14

Quantity of work

Never finishes his/her daily work based on his/her own daily work schedule(assessed during internal supervision)

Not always finishes his/her work based on his/her own daily work schedule(found at least once during internal supervision)

Always finishes his/her work according to his/her daily work schedule

16

Willingness and aptitude for personal development : (10 points)Takes into account advice and recommendatio

Never takes care of such recommendations (concluded during internal and external supervisory visits)

Not always takes care of such recommendations(if this happens once or more)

Always takes into account recommendations of internal and external supervisory visits

10

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ns from previous internal and

TOTAL POINTS 100Participation to Results and the Past Monthly Performance ScoreParticipation to Results and the past month’s performance score (quantity and quality) through presence during working days during the past quarter :NB: We take into account actual working days without taking into account any valid reasons for absence such as vacation, leave, sickness, absence through disciplinary action, formal trainings etc. An exception to this rule are Rest and Recuperation days (allocated by the health facility management), which, when accorded, are considered official working days.

Number of official working days = (N);number of days actually worked = (n); (max 5 days absence due to workshops/training/meetings allowed per month, if exceeding corrections have to be made)Percentage of days performed = (P) (P) = ( n/N) * 100

100% P =

Result of the individual monthly performance evaluation = (Total of the Scores for items 1 to 4) * P

Prepared at:

Date………………………………...

For the internal performance evaluation team, (Names, functions,

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and signatures)

…………………………………………………………………………………

…………………………………………………………………………………

Employee (Name and signature)

…………………………………………………………………………………

Since it is hardly feasible to recall all events over a period of three months, reference is made to what transpired during the last month only. However, this should not be seen as a limitation: if the in-charge has a good overview over the full three months then this overview should prevail.

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Annex 26. INDICES TOOLFOR ALLOCATION OF MOTIVATION BONUSSES DHMT STAFF

Introduction District Health Management Team (DHMT) will receive a PBF benefit for the performance during the last quarter based on the outcome of the DHMT performance assessment.The PBF benefit will be made available to the DHMT and the DHMT will use it in line with what has been written in the DHMT business plan for the CURRENT PERIOD (which is the quarter following the quarter for which the performance benefits were calculated). There are two optional allocations, leaving the DHMT partial freedom to decide on the use of the PBF benefits earned based on its assessed performance:

Resources for improvement of DHMT functioning range 80-100% of total Incentives (motivation bonuses) to DHMT staff: range 0-20% of total

It is up to the DHMT and the District Council to decide on the actual % of the benefits received – an amount expressed in LMS – that will be allocated to motivation bonuses for DHMT staff.

1. Who will qualify for staff motivation bonuses?Staffs who are employed by the DHMT may receive a motivation bonus. DHMT staff will be employed by either the Ministry of Health (MOH) or the Ministry of Local Government (MOLG). The following staff will not qualify for the motivation bonus:

Staffs with any other type of contract, e.g. on locum, seconded or temporarily hired by the DHMT

Staffs who have been employed during part of the quarter only, due to the date of commencement of their contract or due to the date of disengagement

Staffs without a signed motivation agreement for the whole quarter for which the PBF benefits have been calculated.

Staffs whose performance has not been evaluated during the quarter using the appropriate performance evaluation form.

2. How should the indices tool be used?See model of the INDICES Tool below.

The amount to be allocated for motivation bonuses (A) will be decided on in line with what is stated above.

All staff befitting the employment status mentioned above will be listed in a spreadsheet, with for every full 100 LSM of gross salary 1 points will be used in the spreadsheet (amount B). In case of the position of DHMT Director being vacant, one other DHMT will become acting director, which will lead to a mark-up for additional responsibilities of 20 points (amount C), if there has been no salary increase. This will lead to amount D.

Each staff member will have had a quarterly individual performance score (See individual performance assessment form), which will determine per quarter a performance score, corrected for days not worked. (% E)

The points allocated per staff member, will be multiplied with the performance score to arrive at an amount per person (amount F).

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Amount E is divided by the total points score for all DHMT staff (amount G), to arrive at (% H). This percentage is equal to the percentage of the total HC performance bonus to be allocated to motivation bonuses that the individual will receive.

This percentage score per individual is multiplied by the amount available for motivation bonuses to arrive at the individual bonus (amount I)

The amount due to an individual for one quarter should not exceed the gross salary of that individual for one month. If so, the excess money will be allocated to the resources for DHMT functioning.

3. Transparency and accountability The DHMT Director will apply the indices tool to determine individual bonuses. A meeting will be staged with all DHMT staff to discuss how the individual bonuses

have been calculated. All employees have the right to be shown the calculation sheet. In case of consensus,

o a payment sheet will be filled out for each employee with the name of the employee, the position held, the quarter to which the allowance applies, the actual allowance allocated and the mode of payment.

o The DHMT director and the employee will both sign the payment sheet and the money will be allocated, either through cash payment or through bank transfer within two weeks after the DHMT has received its performance benefit.

o In case of cash payment the employee will sign also for receipt of the money; o in case of a bank transfer a bank statement is considered proof of payment.

In case no consensus is reached the matter will be forwarded to the District Council for settlement.

If also after involvement of the District Council no consensus is reached the matter will be left to the PBF District Steering Committee to decide.

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INDICES CARD Tool for allocation of individual motivation bonu s(see text for explanation and guidance)

DHMT of DistrictName DHMT Directorperiod for which bonus is allocated

maximum bonus for DHMT staff motivation in LSM set aside (A) LSM

name position held

Per full gross salary (with allowances) 1000 LSM 10 points allocated

Additional 20 points for acting director (if applicable) total

individual performance score during last quarter

total score relative score bonus


TOTAL (G) 100% (A)

See for a calculation example the form for HC.

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Annex 27. BUSINESS PLAN FOR HEALTH CENTRES

HEALTH CENTRE:.......................................Agreement No :Agreement Period :Approval date :

District :Ownership :Catchment population :

Year : 2013

Signed at………………………………. the ……./……./2013

Name HCC chairman……………… Name HC in charge…………………………….

Signature Signature

Name DHMT……………………………… Name PPTA………………………………………

Signature SignatureCopies : HC, DC-DHMT/PBF Unit-PPTA

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Target Population Catchment area=No Incentivized indicator % of

catchment population

Yearly target populationin numbers

Per quarter(target population divided by 4)



3%


3%


2.71%


2.71%








1. GENERAL INFORMATION HEALTH CENTRE STATISTICS 2. OPD CONSULTATIONS

What is the quarterly target for (new) OPD consultations (for new conditions/illness) in your catchment area?

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No Incentivized indicator 1st Q 2012

2nd Q 2012

3rd Q 2012

4th Q 2012

1st Q 2013Target













………………………………………………………………………………………………………………………………………………………..Which are the problems concerning (new) OPD consultancies attending your health centre? Analyze the possible factors: Lack of medicines, distance for patients (remote villages), unable to diagnose illnesses, lack of qualified staff, (too) many patients from outside catchment area, patients attending untrained and/or non-licensed practitioners, lack of transport for referrals. Any other problems?…………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What are the strategies proposed to solve above mentioned problems? How to get more medicines, consider outreach strategies (define), involve DHMT if you know about untrained or non-licensed practitioners in your area. Other strategies you can think about?…………………………………………………………………………..……..………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………..For second contract and following:Which strategies have you successfully implemented in the previous quarter? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………If you have not reached or exceeded your target, what would be the reason?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..3. REFERRAL OF PATIENTS/PREGNANT WOMEN

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Which problems do you encounter with referring seriously ill patients and high risk pregnant women/or women with a complicated delivery, post-partum complications or women who have had an abortion in your catchment area? How is transport organized? Availability and costs of transport, communication, etc. Are patients willing to be referred? Do you write referral letters to accompany the patient? Is feedback received from referral centre? Other problems you can think about?……………………………………………………………………………….……….………………………………………………………………….……………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………….………………………………………………….Which strategies do you propose to solve above mentioned problems? ……………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………4. SEXUALLY TRANSMITTED INFECTIONS (STIs)Are you able to diagnose and to treat STIs in your HC?……………………………………………………………………………………..…………………………………………………………………….……………………………………………………………………………………………………………………………………………………………Which problems are you facing with STIs in your HC?……………………………………………………………………………………………………………………………………………………………

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…………………………………………………………………………………………………………………………………………………………..What strategies do you propose to solve above mentioned problems?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5. TUBERCULOSIS (TB)What are the problems you encounter with the TB detection and treatment?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Are you able to do sputum smear examinations? …………………………………………………………………………………………………………………………………………………………..Do you apply DOT therapy in your clinic? ..............................................................................................................................................................….………………………………………………………………………………………………………………………………………………………Which are the strategies you propose to improve TB detection and treatment (cured patients)? ……………………………………………………………………….……………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

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For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..6. ANTENATAL CAREWhat is your target for the number of women having to attend 4 times ANC or more per quarter?...................

What are the problems concerning the targets and the quality of care in antenatal care and having women attend their first visit in the first quarter? (think about not enough qualified staff, pregnant women not attending ANC or too late during their pregnancy, not having all tests available in the clinic, referred women do not go to hospital etc. Other?)…………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What strategies do you propose to achieve above mentioned targets and to improve services for ANC? (think about collaboration with VHWs)…………………………………………………………………………………….....………………………………………………………………..…………………………………………………………………………………..….……….…………………………………………………………………………………………………………………………………………………………….……………………………………………………….

For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..If you have not reached or exceeded your target, what would be the reason?………………………………………………………………………………………………………………………………………………………………………………………………………………

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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

7. HIV/AIDS/PMTCTDo you know the prevalence of HIV + patients in your catchment area? .........................................................................................................................................How does the number of HIV+/Aids patients influence your workload?....................................................................................................................................................................................................................................................................................................................................What is the quarterly target for HIV tests and counseling for pregnant women in your catchment area? ……………………………………………………………………………………………………………………………………………….Do you have an (outreach) clinic for opportunistic infections?..........................................................If so, is the collaboration optimal?………………………………………………………………………………………………………………………………………………………….What are the problems with testing and ARV prophylaxis for HIV + pregnant women?(not enough women are reached or informed, women do not want to be tested or treated or do not show up for their treatment, not enough tests, drugs etc.)……………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………….What strategies do you propose to solve above mentioned problems?…………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………For second contract and following:Which strategies have you successfully implemented in the previous quarter? ………………………………………………………………………………………………………………………………………………………………………………………………………………

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……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….If you have not reached or exceeded your target for PMTCT, what would be the reason?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

8. DELIVERIES How many women you expect to deliver quarterly in your facility, if all pregnant women in your catchment area would deliver in your facility?……………………………………………………………………………………………………………………………………………………..What are the problems encountered in your catchment area? None or too few qualified staff? Difficulties with referrals? Too many home deliveries and why?No clean delivery room with confidentially assured, equipment not available (delivery kit, sterile delivery boxes, sutures etc.), No functioning sterilization equipment or procedure, no running water, no electricity. .Other?……………………………………………………………………………..…………………………………………………………………………..……………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What strategies do you propose considering the above factors and to improve your service? Outreach campaigns, intensify contacts with VHWs/TBAs (discuss what?) increase qualified staff, organize midwifery training for nurses with DHMT, buy equipment, find solution for referrals, consider investments in water and electricity improvements, other?…………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………….………….………………………………………………………….……………………………………………………………………………………………..…………………………………………………………….……………………………………………………………………………………………………………………………………………………………

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What are the problems concerning unsafe abortions in your catchment area? Maternal deaths after illegal abortions, cases of pregnancy after rape, lack of access to safe abortions? …………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………….…………………………………………………………………………………………………………………………………………………………………………………………………………………….What strategies do you propose to solve above mentioned problems?………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following:Which strategies have you successfully implemented in the previous quarter? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………If you have not reached or exceeded your target, what would be the reason?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………9. POST NATAL CARE (PNC)What is your target for the number of women having to attend 2 times PNC within one week per quarter?..................................................................................................................................................Will you be able to having the women 4 PNC visits? If not what will be the reasons?..........................………………………………………………………………………………………………………………………………………………………….Which are the problems concerning reaching the targets and the quality of care in postnatal care?(insufficient qualified staff, women not attending or not in time, (most problems occur directly after delivery) etc.

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…………………………………………………………………………………………..…………………………………………………………………………………………………………..………………………………………………………………………………………………………………What strategies do you propose to achieve the above targets and to improve the PNC service?…………………………………………………………………………………….....……………………………………………………………………………………………………………………………………………………..….……….…………………………………………………………………………………………………………………………………………………………….……………………………………………………….For second contract and following:Which strategies have you successfully implemented in the previous quarter? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………If you have not reached or exceeded your target, what would be the reason?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………10. FAMILY PLANNINGWhich is your quarterly target for family planning, consider that 80% of the eligible women (women of child bearing age) would like or are able to use one of the family planning methods?..............................................................................................................................................Which methods can be provided by the clinic staff? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Which problems do you encounter concerning the use of FP modern methods in your catchment area?………………………………………………………………………….………………………………………………………………………………………………………

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…………………………………………………………………………………………………………………………………….……………………………………………………………….…………………………………………………………………………………………..Which strategies you propose to achieve the target? ………………………………………………….…………………………………………………..………………………………………………………………………………………………………….………………………………………………..…………………………………………………..……………………………………………………….…………………………………………………………………………………………………..Do you have developed strategies for tuba ligations (and vasectomy) in your catchment area in collaboration with the district hospital?……………………………………………………………..……………………………..…………………………………………………………….………………………………………………………………………………………….……...………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..If you have not reached or exceeded your target, what would be the reason?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………11. IMMUNISATION What is your quarterly target for immunising all children under 1 year? …………………………………………….Did you reach your target last year?......................................................................................................Which problems do you encounter with immunizing children in your catchment area?…………………………………………………………………………….………………………………………………………………………………

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…………………………………………………………………………….……………………………………………………………………………..What strategies have you developed to achieve the target? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………

For second contract and following:Which strategies have you successfully implemented in the previous quarter? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………If you have not reached or exceeded your target, what would be the reason?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..12. DISTRIBUTION OF VITAMIN A (children between 6 and 59 months)

What is your quarterly target for vitamin A distribution every 6 months to children between 6 and 59 months? …………………………………………………………………………………………………………………………………………………………..What strategies have you developed to achieve the target? (Visits to schools, visits to villages, involving VHWs etc)………………………………………………………………………………………………………...………………….............................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………….

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For second contract and following:Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..If you have not reached or exceeded your target, what would be the reason?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

13. GROWTH MONITORING/NUTRIONAL PROGRAMMESWhat would be your quarterly target for growth monitoring of children between the ages of 0-5 years?............................................................................................................................What strategies have you developed to achieve the target? (Visits to schools, visits to villages, involving VHWs etc. ) .………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………What action do you take if a child or woman is malnourished? .................................................................................................................................................................

For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..If you have not reached or exceeded your target, what would be the reason?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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……………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..14. WATER AND SANITATIONWhich activities do you undertake to construct latrines your catchment area? …………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………Which activities do you undertake to secure clean water in your catchment area?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Which are the problems you encounter to improve the water and sanitation situation in your catchment area? ……………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………….……………………………………………………Which strategies do you propose to improve the water and sanitation situation in your catchment area?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………

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……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

15. Collaboration with Village Health workers

What have been the lessons learned derived from the most recent community mapping? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….How was the information used to improve the performance of the health centre and of the VHW?. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Which of the plans in the previous period have been implemented successfully?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Which plans from the previous period could not be implemented? What was the main reason for this? How will re-occurrence be prevented?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………

What actions are planned in this contract period?VHW training and refreshers……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Increasing the number of VHWs in order to have optimal coverage ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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……………………………………………………………………………………………………………………………………………………………..VHW motivation and productivity ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Provision of essential commodities to VHWs……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

16. HUMAN RESSOURCE MANAGEMENT

What is your current staffing?

Staff categories Current staff numbers

Staff required

Nurse clinician (NC)Registered Nurse Midwife (RNM)Trained Nurse Assistant (TNA)Data Clerk?Environmental health technician (EHT)Security?Others, specify

Do you have adequate housing for your staff? ………………………………………………………………………………………………………If not state the problems…………………………………………………………………………….Do you have problems with staff motivation? If yes, why? .............................................................................................................................................What would motivate staff? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Is there a need for additional training? ..................................................................................................…………………………………………………………………………………………………………………………………………………………..Which are your strategies to improve the staff situation? ………………………………………………………………………………………………………

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…………………………………………………………………………………………………………………………………………………………………………………………………………………

For second contract and following:Which strategies have you successfully implemented in the previous quarter? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

17. OTHER RESOURCES Describe the situation regarding the availability of essential drugs (including for family planning) and how will you improve it during the contract period? ………………………………………………………………………………………………………………………………………………………………………………………………………………………......................................................................................................................................................................................................................................................................Describe the situation concerning the availability of medical equipment and how will you improve it during the contract period? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Describe the situation regarding the availability of furniture and office supplies and how will you improve it during the contract period? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………Describe the situation with regard to infrastructure and how will you improve it during the contract period?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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………………………………………………………………………………………………………………………………………………………………

For second contract and following:Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

18. Quality Review

Did you take the report of the last quality of care review (date ………...) into consideration when compiling this business plan?Name four areas of attention from the quality of care review that have been inserted in this business plan:1………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………2………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………3……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..4……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

19. FINANCIAL PLANNINGDid you experience difficulties in financial accounting during the last quarter? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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……………………………………………………………………………………………………………………………………………………………….If so, what are your plans to address these difficulties?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Estimate your financial needs based on the above proposed strategies WHICH YOU CAN IMPLEMENT WITH PBF BENEFITS RECEIVED or benefits from other resources, i.e. EXCLUDING expenditures that are met by regular MOH/MOLG contributions:Expenditures last quarter

expenditures in LSM

PBF BENEFITS ONLY

Proposed next quarter expenditures

in LSMPBF BENEFITS

ONLYStaff benefitsTrainingStationeryUtilities (water, electricity)Fuel for sterilizationCleaning and office costsCommunicationTransport cost health centreContribution to transport cost referred patientsSocial marketingInfrastructure rehabilitationEquipment, furnitureSalary cost staff not on MOH pay rollOther (specify) …………………………………..TOTAL

Estimate the revenues that you expect to receive from PBF and other resources, i.e. EXCLUDING benefits that may be expected through regular MOH/MOLG contributions

Revenues Last quarter revenues

Expected next quarter revenues

Community contributionIncentives from PBF programCash contribution other aid agenciesCash contribution from private companies and persons (local business men)Other ….TOTAL

280

Cash balance Last quarter Next quarterBalance cash at start of quarter

Net gain/loss during quarter

Balance cash at hand at the end of last quarter

Cash reconciliation done? Yes No

By whom: state name/position/date

Total next quarter revenuesTotal next quarter expendituresBalance of revenues minus expendituresCash Balance last quarterReserveBalance

281

Annex 28. BUSINESS PLAN FOR DISTRICT/LOCAL HOSPITALS

District/Local hospital:Contract No : Contract Period : Approval date :

District : Ownership :

Catchment population : Year : 2013Signed at………………………………. the ……./……./2013

Name Superintendent of Hospital Name DMO:(if applicable)

Signature Signature

Name MOH :

Signature :

Copies : Hospital, MOH, District Council, PBF Unit-PPTA

282

HOSPITAL SERVICESTarget Population Catchment Area =

No Incentivized indicator % of catchment population

Yearly target populationin numbers

Per quarter(target population divided by 4)













283


284

1. GENERAL INFORMATION

HOSPITAL STATISTICS

No Incentivized indicatorHospital referral services

1st Q 2012

2nd Q 2012

3rd Q 2012

4th Q 2012

1st Q 2013Target














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2. OPD/MCH SERVICESWhich problems do you encounter with the OPD/MCH services ?Heavy work load, too many self referred patients from the district, other ?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Which strategies do you propose to solve above mentioned problems and which concrete actions will you take? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………For second contract and following :Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract ?…………………………………………………………………………………………………………………………………………………………….......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. REFERRALS OF PREGNANT WOMEN

How many pregnant women you expect to be referred to your hospital from the HCs? (See calculations above)?…………………………………………………………………………………………………………………………………………………………….Does this number correspond to actual average no of referrals in previous quarters?…………………………………………………………………………………………………………………………………………………………….If not, what are the reasons?

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……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Which problems do you encounter with referred high risk pregnant women/or women with a complicated delivery, post-partum complication or complication due to abortions in your catchment area? How is transport organized? Availability and costs of transport, communication at HC and hospital level? Are patients willing to be referred, do they arrive in time at the hospital? Are the indications for referral correct? Too many self-referred? Other problems you can think about?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Which strategies do you propose to solve above mentioned problems and which concrete actions will you take? (Put budget in financial planning section)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following :Which strategies have you successfully implemented in the previous quarter ? ………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract ?…………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………

4. DELIVERIES

What are the problems you encounter with performing deliveries in your hospital?

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No clean delivery rooms or insufficient rooms with confidentially assured? Shortage of proper equipment? Not functioning or poor sterilization equipment, no running water, no electricity. Other?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Are you able to conduct all complicated deliveries (not needing surgery) and post natal complications (e.g. multiple and breach pregnancies, episiotomy, vacuum extraction, induction of labour, hemorrhage, infections etc.)? If not, what are the problems?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Are you able to perform caesarian sections in your hospital? If not, what are the problems?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Which strategies do you propose to solve above mentioned problems and which concrete actions will you take? (Put budget in financial planning section)…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

What are the problems concerning unsafe abortions in your catchment area? Maternal deaths after illegal abortions, cases of pregnancy after rape, lack of access to safe abortions? …………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………

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…………………………………………………………………………………….………….…………………………………………………………………………………………………………………………………………………………………………………………………………………….What strategies do you propose to solve above mentioned problems?………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following :Which strategies have you successfully implemented in the previous quarter ? …………………………………………………………………………………………………………………………………………………………...……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

5. NEONATAL CAREHow many neonatals are usually be referred to your hospital from the HCs? ………………………………………………………………………………Does this number correspond to what you expect? .........................................................................If not, what would be the reasons? ...................................................................................................………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………….Which problems do you encounter with referred neonatals in your catchment area? …………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What strategies do you propose to improve the neonatal care service?……………………………………………………………………………………………………………………………………………………………

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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………For second contract and following:Which strategies have you successfully implemented in the previous quarter? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract?…………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6. POST NATAL CARE (PNC)Which are the problems you encounter with the quality of postnatal care for women and their children?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What strategies do you propose to improve the PNC service?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………For second contract and following :Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

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What would you do differently from the previous contract?………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7. FAMILY PLANNINGAre you offering Family Planning (all methods) after delivery?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Are you actively offering Tuba Ligations to women attending the hospital (e.g. when visiting for OPD, ANC, PNC, FP etc.) Are you promoting long term FP methods? Are you cooperating with the HCs on this?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..If not, what are the problems?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….What strategies you propose to improve your and HCs FP services?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………For second contract and following :Which strategies have you successfully implemented in the previous quarter ? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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…………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract ?…………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………

8. IMMUNISATION

Do you give BCG immunization to newborn at birth ?..................................................If not, what are the problems?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Which strategies do you propose to solve above mentioned problems?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following :Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract ?…………………………………………………………………………………………………………………………………………………………….......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. NUTRITION

Do you admit many malnourished children? ……………………………………………………………………………………Do you encounter also malnourished adults?What will be the cause of malnutrition? .....................................................................................................................................

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............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...............................................What treatment do you offer? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Which other measurements do you propose to solve above mentioned problems and which concrete actions will you take? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following :Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract ?…………………………………………………………………………………………………………………………………………………………….......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

10. TB TREATMENTDo you encounter many problems with co-infections of HIV and TB and treatment resistant patients?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What kind of diagnostics and treatment you offer?

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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Which other measurements do you propose to solve above mentioned problems and which concrete actions will you take? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following :Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract ?…………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

11. OTHER HOSPITAL SERVICES NEEDING URGENT ATTENTION Besides above mentioned services, which other hospital services need to be urgently improved in your hospital?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Which strategies do you propose for improvement?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

294

………………………………………………………………………………………………………………………………..What action will or did you undertake?(Put budget for improvements in financial planning section)……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following:Which strategies have you successfully implemented in the previous quarter? ………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… What would you do differently from the previous contract?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

12. HUMAN RESOURCE MANAGEMENTWhat is your current staffing for the hospital?Staff categories Current staff

numbersStaff required

DMO/SuperintendentAdministration staffFinance staffMatronMedical doctorsPharmacy staffLaboratory staffX Ray staffOperation Theatre nurses/assistantsAnaesthetic nursesNurse/MidwivesPaediatric nursesTrained nursing assistantsWard attendantsCleaners

295

MaintenanceSecurityOthers, specify

Do you have adequate housing for your staff? ……………………………………………………………………………………………………If not state the problems ……………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Do you have problems with staff motivation? If yes, why ? .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................What would motivate staff? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Is there a need for additional training?If yes, specify.........................................................................................................................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Which are your strategies to improve the staff situation? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...................................For second contract and following:Which strategies have you successfully implemented in the previous quarter? …………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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What would you do differently from the previous contract?…………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

13. OTHER RESOURCES Describe the situation regarding the availability of essential medicines and consumables and how will you improve it during the contract period? ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Describe the situation concerning the availability of medical equipment and how will you improve it during the contract period? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Describe the situation regarding the availability of furniture and office supplies and how will you improve it during the contract period?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Describe the situation with regard to infrastructure and how will you improve it during the contract period?……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….For second contract and following:Which strategies have you successfully implemented in the previous quarter?…………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

297

………………………………………………………………………………………………………………………………………………………………What would you do differently from the previous contract?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

14. QUALITY REVIEWDid you take the report of the last quality of care review (date ………...) into consideration when compiling this business plan?...........................................................................................................Name four areas of attention from the quality of care review that have been inserted in this business plan:1………………………………………………………………………………………………………………………………………………………..2…………………………………………………………………………………………………………………………………………………………3………………………………………………………………………………………………………….………………………………………………4…………………………………………………………………………………………………………………………………………………………

15. FINANCIAL PLANNINGDid you experience difficulties in financial accounting during the last quarter? ………………….If so, what are your plans to address these difficulties?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Estimate your financial needs based on the above proposed strategies WHICH CAN BE COVERED FROM EXPECTED PBF BENEFITS ONLY(and should not be provided under regular support from MOH or various externally financed programs) Set priorities for next quarter! Keep in mind that not everything can or need to be done now,

ExpendituresLast quarter

expenditures in LSM

Proposed next quarter expenditures in LSM

Staff benefitsTrainingStationeryCleaning and office costsCommunicationTransportInfrastructure rehabilitation

298

Equipment, furnitureOther (specify) …………………………………..TOTAL

Revenues Last quarter revenues

Proposed next quarter revenues

FeesCommunity contributionGovernment (telephone, utilities , stationery etc.)SalariesSubsidies from PBF programContribution other aid agenciesContribution from private companies and persons (local business men)Other ….TOTAL

Cash and Bank balancePBF BENEFITS ONLY

Last quarter Next quarter

Balance cash and bank at start of this quarter

Net gain/loss during quarter

Balance cash and bank at the end of last quarterCash reconciliation done? Yes No

By whom: state name/position/date

Total next quarter revenuesTotal next quarter expendituresBalance of revenues minus expendituresCash Balance last quarterReserveBalance

299

Annex 29. CONTRACT FOR CBOs

CONTRACTBETWEEN

Name: as the PPTA (Performance Purchasing Technical Assistance Firm)

Represented by the Manager Mr/Ms : ………………………………………………..

AND

Community Based Organisation …………………………..In District:………………….In catchment area of HC: …………………………………………….Represented by Chairperson Mr/Ms:…………………………………

I. The terms of the agreement

Article 1The PPTA, under contract with the Ministry of Health, strives to increase the qualitative and quantitative output of health facilities that have been contracted as part of the implementation of the Maternal and Newborn Health (MNH) Performance-Based Financing (PBF).

Article 2The PPTA has a variety of objectives and associated tasks, which includes the verification of quantity and quality of agreed services performed by District Hospitals, Local (CHAL) Hospitals, and CHAL and MOH Health Centres, hereafter to be referred to as health facilities.

Article 3In view of preserving maximal accountability and transparency, counter-verification will be undertaken of the quantity of services that have been reported by contracted health facilities. The counter-verification is contracted out by the PPTA to a district based independent organisation, referred to as CBO. The CBO will trace randomly selected patients from the health facilities covered and among others verify their existence and the uptake of services as recorded in the facility registered.

Article 4In addition to the counter-verification the PPTA will also conduct the CBO referred to in the previous article to conduct client/patient satisfaction assessments.

II. The commitments of the two parties

II.1. The Community Based Organisation (CBO)Article 5

300

The CBO is responsible for patient interviews in the catchment area of the following health facilities: name: ................................

location:.............................

name: ................................ location:.............................

name: ................................ location:.............................

Article 6The interviewers are selected from the members of the CBO, and meet the following criteria:

chair person or one member being able to read and write English and to translate relevant documents/forms in the local language

available 20 days / trimester to do interviews willing to move to any households within the catchment area of the health facility committed to confidentiality does not have any form of “association” with any of the health facilities that are

targeted under this contract, which may affect the objectivity of the interviewer will have followed a training offered by the PPTA

Article 7The CBO is committed to do the interviews correctly and in a transparent way within 14 days after reception of the questionnaires

Article 8 The CBO is committed to sensitise the target population on the Performance Based Financing Project and on any other message as communicated by the contact person of the PPTA

Article 9After completion of the interviews, the CBO presents the questionnaires to the PPTA with a summary report on the most important findings and the challenges encountered

Article 10The CBO is committed to present a half yearly report with recommendations from the target population for improvements. The report is sent to the PPTA, with a copy to the DHMT. The chairperson of the CBO will present the findings at a half yearly review meeting that gathers representatives from all health facilities.

Article 11 The CBO accepts that it will not be entitled to payment for a questionnaire if it is incomplete or incorrect. Moreover, there may be deductions of the payments in case the filled questionnaires are submitted too late.

Article 12The CBO is obliged to open a bank account for payments made by the PPTA

II.2. PPTA

Article 13PPTA is obliged to

301

- monthly select a random sample of users of the health services of health facilities mentioned in this contract

- provide names and addresses that enable the CBO to trace the user- verify if questionnaires are filled in correctly- Compile a summary of all CBO reports and present it to the CBO and the RHC during

half half-yearly meetings- Insert the patients satisfaction score into the quality subsidy- Pay a sum of .....LSM per completed questionnaire

Article 14 If all questionnaires are correctly filled in and timely submitted, a quality bonus of maximal 20% will be paid to the CBO III Payment modalitiesArticle 15a. Payment will be done within 25 days after submission of the questionnaires depending on availability of fundsb. Payment will be transferred in a bank account of the CBO.

IV. DurationArticle 16The present agreement has duration of three months renewable

.It will take effect from the first of (date) onwards and will expire on (date)

V. Sanctions, suspending or no renewal of the agreementArticle 17The present agreement might be suspended in case of:a) Fraudulence in completing the questionnaires. In case of suspected fraud, the contract and

all payments will be suspended until fraud mitigating measures have been put in place and verified and approved by PPTA. In a first fraud case, 50% of the payment will be withheld. A second fraud cause will lead to termination of the contract.

b) Non-respect of the commitments assigned to each party: The claimant party shall notify the other party of the suspending of the agreement and give in writing an explanation of what reasons led to this suspension

VI. Settlement of disputes, disagreementsArticle 18Any dispute regarding the interpretation and the execution of the present agreement will be referred to the District Council, and if still cannot be resolved will be filed to the RBF District Steering Committee to decide.Article 16Both parties are bound to carry out in good faith this agreementArticle 17There will be no provision for indemnification at the end of the agreementPlace………………………… date…………

302

CBO ……........... PPTA...................................................

Chairperson of CBO ……………………………….. Representative …………………………

Signature Signature

303

Annex 30. CBO/NGO PATIENT TRACING AND SATISFACTION SURVEY FORMAT FOR HEALTH CENTRES

COMMUNITY VERIFICATION ACTIVITY FOR HEALTH CENTRES

A. Part Completed by the VerifierHC: ……………………… District: ……………………………Verifier: ……………… Name of CBO/NGO: ……………DATA’S IDENTIFICATION

No Name and surname Sex Ward Area Village Head HH

B. Part Completed by the verifierDate of the verification: …. / … / 2013

Confirmation of the existence of the patientCircle one of the options

1. Does the person exist? Yes / No

If yes, by whom has his/her existence been confirmed?By the village chief / by a family's member / by a neighbor / directly by the patient or the parent. (circle one of the options)

2. How old is he/she ? …………. years If the person exists, interview held with: the person or the mother/father when child < 12 yrs. answers the question (circle one of the options)If the person is absent during the following week, ask a member of the household if they can show the bukana of the person who visited the Health Centre.

Circle one of the options3. Can the person (or the member of the household) confirm the

visit to the HC ? Yes / No

3.1 If yes, does the person have a bukana? Yes/ No

3.2 If yes, when did she/he last visit the health centre? ….../2013

304

PATIENT SATISFACTION WITH THE SERVICEOnly the person him/herself or the mother/father when child < 12 yrs. answers the question:

(circle one of the options)

1. How were you received by the staff at the HC? Friendly/Normal/ Rude

2. How long was your waiting time before being helped? ….hr / ….min

3. How do you judge the time that you waited before being assisted? Reasonable/too long

4. Did this waiting time at the HC affect your health or that of your child? Yes / No

5. Were the medicines prescribed for you available at the HC? Yes / No/ Partly

6. Did you have to pay anything? Yes / NoIf yes, for what did you pay for:

Children health booklets (Bukana), Lesotho Obstetrical Record (LOR), Iron tablets or other medicines, consultation, tests (circle one or more options)

Other specify………………………………………………………………………………………How much did you pay? ........ MalotiWere you give a receipt of the payment Yes/No

7. What do you think about this payment? Could not afford/Reasonable

8. Were you satisfied with the services that you were offered? Very

satisfied/satisfied/dissatisfied9. Do you have any comments or suggestions for the improvement of the services?

…………………………………………………………………………………………...

…………………………………………………………………………………………...

…………………………………………………………………………………………...Name of the verifier ………

Signature………………………….

305

Patient satisfaction score1. Received: Points Max points Obtained points

Friendly 10 10Normal 5Rude 0

2. Waiting time < 30 min 5 5> 30 min 0

3. Judgment of waiting time Reasonable 5 5Too long 0

4. Waiting time affect health Yes 0No 5 5

5. Medicines availableYes 10 10No 0Partly 5

6. Payment for servicesYes 0 No 5 5

Receipt of the payment Yes 5 5No 0

7. Opinion about payment Could not afford 0Reasonable 5 5

8. Satisfaction with services Very satisfied 10 10Satisfied 5Dissatisfied 0

Total maximum points 60 ……….Obtained points% of maximum score

306

Annex 31. CBO/NGO PATIENT TRACING AND SATISFACTION SURVEY FORMAT FOR HOSPITALS

COMMUNITY VERIFICATION ACTIVITY FOR HOSPITALS

C. Part Completed by the Verifier

Hospital: ……………………… District: ……………………………Visit to OPD/MCH: Yes/NoVerifier: ……………… Name of CBO/NGO: ……………

DATA’S IDENTIFICATION

No Name and surname Sex Ward Area Village Head HH

D. Part Completed by the verifierDate of the verification: …. / … / 2013

Confirmation of the existence of the patientCircle one of the options

1. Does the person exist? Yes / No

If yes, by whom has his/her existence been confirmed?By the village chief / by a family's member / by a neighbor / directly by the patient or the parent. (circle one of the options)

2. How old is he/she ? …………. years If the person exists, interview held with: the person or the mother/father when child < 12 yrs. answers the question (circle one of the options)If the person is absent during the following week, ask a member of the household if they can show the bukana of the person who visited the hospital

Circle one of the options

3. Can the person (or the member of the household) confirm thevisit to the hospital ? Yes / No

3.1 If yes, does the person have a bukana? Yes/ No

3.2 If yes, when did she/he last visit the hospital? ….../2013

307

PATIENT SATISFACTION WITH THE SERVICEOnly the person him/herself or the mother/father when child < 12 yrs. answers the questions (circle one of the options)

1. How were you received by the staff at the hospital? Friendly/Normal/ Rude

2. How long was your waiting time before being helped? ….hr / ….min

3. How do you judge the time that you waited before being assisted? Reasonable/too long

4. Did this waiting time at the hospital affect your health or that of your child? Yes / No

5. Were the medicines prescribed for you available at the hospital? Yes / No/ Partly6. Did you have to pay anything? Yes

/ NoIf yes, for what did you pay for:Children health booklets (Bukana), Lesotho Obstetrical Record (LOR), Iron tablets or other medicines, consultation, Delivery (normal, caesarian) / consumables (gloves, cotton wool, suture etc.) /blood and blood products / Hospital admission fee/ Laboratory tests(circle one or more options)Other specify………………………………………………………………………………………………How much did you pay? ........ MalotiWere you give a receipt of the payment Yes/No

7. What do you think about this payment? Could not afford/Reasonable

8. Were you satisfied with the services that you were offered? Very

satisfied/satisfied/dissatisfied9. Do you have any comments or suggestions for the improvement of the services?

…………………………………………………………………………………………...

…………………………………………………………………………………………...

…………………………………………………………………………………………...Name of the verifier ………

Signature………………………….

308

Patient satisfaction score9. Received: Points Max points Obtained points

Friendly 10 10Normal 5Rude 0

10. Waiting time < 30 min 5 5> 30 min 0

11. Judgment of waiting time Reasonable 5 5Too long 0

12. Waiting time affect health Yes 0No 5 5

13. Medicines availableYes 10 10No 0Partly 5

14. Payment for services if for OPD/MCH servicesYes 0 No 5 5

Receipt of the payment Yes 5 5No 0

15. Opinion about payment Could not afford 0Reasonable 5 5

16. Satisfaction with services Very satisfied 10 10Satisfied 5Dissatisfied 0

Total maximum points 60 ……….Obtained points% of maximum score

309

Annex 32

CHAL HEALTH CENTRES MANUAL OF PROCEDURES

Table of Contents

A. CASH AND BANK PROCEDURES.........................................................................................................311

1. RECEIVING CASH FROM SALES ETC...............................................................................................................3112. RECEIVING OF SUBVENTION AND PBF FUNDS................................................................................................3133. PAYMENTS..............................................................................................................................................313

3.1 Petty cash requisition......................................................................................................................3133.2 Petty cash disbursement.................................................................................................................3143.3 Petty cash reconciliation.................................................................................................................3143.4 Petty cash end of day balancing.....................................................................................................3153.5 Payroll.............................................................................................................................................3153.6 General Payments...........................................................................................................................3173.7 Bank Reconciliation........................................................................................................................318

B. INVENTORY...................................................................................................................................... 318

4. DRUGS...................................................................................................................................................3184.1 Receipts..........................................................................................................................................3184.2 Issues..............................................................................................................................................319

310

INTRODUCTION

This manual is intended to apply to CHAL health centres. In terms of the Memorandum of Understanding (MOU) between CHAL and GOL; the health centres are providing all health services free of charge, however, they still collect miscellaneous revenues (very little) from sale ‘libukana’ and rentals as the case may be.

Health centres are expected to keep proper books of accounts and they have been supplied with Analysis Cash Books, Ledger books and Journal books. The nurses, who run these centres, have been exposed to training in basic book-keeping to equip them with the necessary skills. A few clinics do have bookkeepers who are mostly ex high school students.

It has become apparent that record keeping is very poor because the nurses cannot cope with the record keeping and the increased patient population as a result of free medical service. The bookkeepers, where available, are greatly under employed because of the volume of transactions which occur at the centers and they are also not skilled enough to go beyond the production of a trial balance. This has resulted in disclaimer reports from the external auditors.

Simple forms (CHC001 and CHC002) have been designed to assist the health centres to gather financial information which will be used by a professional accountant to prepare proper books and financial statements for audit purpose. The importance of this exercise is that it has a great impact in the budget preparations where audited financial statements are the foundation of the budget process.

CASH AND BANK

This chapter is intended to guide the users on how to ensure that all cash transactions including PBF funds are recorded in the books of the CHAL health centres on a daily basis. It also ensures that proper controls are in place to safeguard the collected cash, ‘libukana’ in store and the government subvention received.

311

Activity Performance Procedures

Documentation or Instructions

Processing Time

Accounting Books for Entries

Responsibility

A. CASH AND BANK PROCEDURES1. Receivin

g cash from sales etc.

a) Issue a receipt for all cash/cheque received

b) Give change if applicable

c) Count all the cash collected at the end of the day

d) Balance the Cash with the receipt book.

e) Transfer the amount to the Daily and Weekly worksheet (CHC001).

f) Lock the cash in a cash box.

Receipt

Cash

Cash

Cash/receipt book

Daily and Weekly worksheet (CHC001).None

Same time

Same time

End of day

End of day

End of day

End of day

Receipt book

None

None

Cash book

None

None

Nurse-in-charge.

Nurse

Nurse

Nurse

Nurse

Nurse

312



Processing Time


Responsibility

2. Receiving of Subvention and PBF funds

a) Check if funds have been transferred into the health centres bank account.

b) If transferred issue a receipt to the amount credited in the bank account

c) Enter the transaction in the Daily and Weekly worksheet (CHC001)

Bank Statements

Receipt

Worksheet CHC001

Same time

Same time

Same time

None

Receipt Book

Worksheet

Nurse-in-charge

“

“

3. Payment

s

3.1 Petty cash requisition

a) Determine the cash requirement and complete the petty cash requisition form

b) Present to the nurse in charge or authorised official for authorisation

c) Present the authorised requisition form to the designated

Form CHC003/1

Form CHC003/1

Form CHC003/1

Same time

“

“

None

None

None

Requesting officer

Requesting and authorising officers

Requesting officer and cashier

313



Processing Time


Responsibility

cashier to obtain cash

3.2 Petty cash disbursement

a) Obtain a completed petty cash requisition form from the requesting officer

b) Check and verify the validity and authenticity of the requisition form submitted

c) Obtain payee’s signature on the requisition form and disburse the amount requested

d) Process the payment in either the Daily and Weekly workbook or the petty cash book

e) Obtain cash and retain the petty cash reconciliation form for subsequent reconciliation

Petty cash requisition form CHC003/1

Petty cash requisition

Cash, petty cash requisition form CHC003/1

Daily/weekly workbook CHC001, petty cash requisition CHC003/1Cash, petty cash form CH003/2

Same time

Same time

Same time

Daily

Same time

None

None

Cash book or petty cash book

Daily workbook or petty cash book

None

Cashier

Cashier

Cashier

Cashier

Payee

3.3 Petty cash reconciliation

a) Enter details of payments on the petty cash reconciliation form to reconcile cash and receipts

b) Return the reconciled form CHC003/2 plus receipts and change to the

Petty cash form CHC003/2

Petty cash form CHC003/2, receipts

Petty cash

Daily

Daily

Daily

None

None

None

Payee

Payee

Payee, cashier

314



Processing Time


Responsibility

cashier

c) Append signatures with the cashier to confirm receipt and conclusion of the transaction

form CHC003/2

3.4 Petty cash end of day balancing

a) Count the total cash in the petty cash box

b) Find the total for all the supporting disbursement receipts for the day

c) Add the total cash count to the total receipts to balance with the maximum petty cash limit

d) Check the hospital cashier’s petty cash for verification and control

e) The above procedures in 3.4 are only relevant for institutions that will opt for a standalone petty cash system. We otherwise recommend a system without a designated petty cash box

Cash

Payment receipts

Cash, payment receipts

Cash, payment receipts

End of day

End of day

End of day

Monthly

None

None

None

None

Cashier

Cashier

Cashier

Accountant

3.5 Payroll a) Obtain and prepare the

Payroll Worksheet

Month end

None Nurse-in-charge

315



Processing Time


Responsibility

payroll on Monthly Payroll Worksheet (CHC002).

b) Make PAYE deduction per tables supplied by Lesotho Revenue Authority (LRA).

c) Enter all other deductions under their respective columns on the Payroll Worksheet

d) Cross check for arithmetic errors.

e) Send the form for checking and authorization to the manager.

f) Draw a cheque equal to the net pay in the form.

g) Cash the cheque and pay staff or send to the bank for payment into the staff accounts.

h) Complete the Nominal Roll form required by CHAL Secretariat

form CHC002

LRA Tax Tables

Deductions schedule,Payroll form CHC002

“

Payroll form CHC002

Cheque

Cheque

Nominal Roll, Payroll Worksheet CHC002Nominal Roll

Payroll form

Month end

Same time

“

Same time

“

“

“

“

Same time

“

None

None

“

None

“

None

“

“

None

“

Nurse-in-charge/Accountant

“

“

Nurse-in-charge/Accountant

“

“

“

“

Nurse-in-charge/accountant

“

316



Processing Time


Responsibility

i) Obtain the staff members signatures on the form and send to CHAL Secretariat

j) File the Payroll Worksheet form carefully by the date sequence.

k) Draw a cheque to LRA for payment of PAYE, and cheques for deductions to other institutions.

l) Post or send the cheque to LRA and other beneficiary institutions.

m) File the receipts from LRA and other beneficiary institutions accordingly

CHC002, file

Cheques

Cheque, staff list

Receipt, file

“

“

“

““

“

3.6 General Payments

a) Prepare a payment voucher before a cheque is written (CHC003).

b) Attach supporting documentation e.g. Invoice or Monthly Payroll Form.

c) Write a cheque

Payment voucher CHC003

Invoice, Payment voucher CHC003

Cheque

Same time

“

Same time

None

“

None


“


317



Processing Time


Responsibility

to the amount on the voucher and fill in the cheque counterfoil.

d) Send the cheque for signature with the supporting documentation.

e) Deliver or cash the cheque as the case may be.

f) File the documents by numerical sequence

Cheque

Cheque

File

“

“

“

“

“

“

“

“

“

3.7 Bank Reconciliation

a) Obtain (Monthly) bank statement from the bank.

b) Check if the cheques written have gone through.

c) Keep the statement safe for the accountant who will perform the reconciliation.

Bank statement

Bank statement

File

Month end

Month end

“

None

None

“

Nurse-in-charge

Accountant

Nurse

B. INVENTORY4. Drugs4.1

Receipts

a) Record receipt of drugs into a bin card showing quantity received.

Delivery note, bin card CHC005

Same time

“

Bin card

“

Nurse –in-charge

“

318



Processing Time


Responsibility

(CHC005)

b) Update the balance with new receipts. (CHAL005)

Invoices

4.2 Issues a) The dispensary prepares drugs requisition

b) Send the request to the Nurse-in-charge for approval and issue from stores.

c) Issue requested drugs using First In First Out (FIFO).

d) Record the drugs issued to the dispensary in the Bin card.

e) Update the balance with the issues.

e) Number and file the requisition in the drug issues file.

f) Lock the stores for unauthorized access.

Drugs requisition form CHC006

“

Bin card

Bin card

File

Lock and key

Same time

“

“

“

Same time

“

“

None

None

“

“

None

“

“

Nurse-in-charge

“

“

“

Nurse-in-charge

“

“

319

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