Performance-based Financing in Mozambique
ThinkWell is the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)’s health systems strengthening partner on a $100 million, CDC–funded health project operating in Gaza and Nampula provinces of Mozambique. ThinkWell proveded strategic technical assistance to guide the implementation of EGPAF’s PBF program, which provides $3.5 million in annual incentives to over 170 health facilities across two provinces of Mozambique. In addition, ThinkWell supported the strengthening of human resources management in both provinces. Finally, ThinkWell served as EGPAF’s key partner in producing rigorous evidence through research and program evaluation.
Since the aftermath of the civil war, Mozambique has made remarkable progress on MDGs 4 and 5. Between 1997 and 2011, it has halved infant mortality from 147 to 71 deaths per 1000 live birth and reduced maternal mortality from 692 to 408 per 100,000 live births. While these gains are impressive, the devastating impact of the generalized HIV epidemic have stagnated progress in the health sector. In 2009, 11.5% of the adult population were living with HIV, accounting for 18.2% of maternal deaths. At the same time, low motivation and poor retention of health workers have crippled the country’s ability to respond to its health challenges. Like many post-colonial countries, Mozambique’s health system has traditionally been financed through centralized input provision, which does not directly incentivize productivity. Human resources management systems are weak, further exacerbating motivation and retention issues.
Supporting the implementation of performance-based financing
In 2012, EGPAF implemented the world’s first HIV-focused PBF program as a response to the systemic challenges in the health system. ThinkWell provided overall strategic support to guide the direction of the EGPAF PBF program. Leveraging our wealth of expertise gained from supporting PBF globally, ThinkWell supported the incorporation of global best practices, both strategic and operational. We provided on-going program assessment and review, as well as data analytics for program management.
Strengthening human resources for health
ThinkWell implemented a multi-pronged approach to ensure that well-managed, highly motivated, well-resourced health workers are available. Beyond PBF, ThinkWell worked to improve availability of human resources by developing an innovative HRH Distribution tool. To ensure human resources remain motivated, we worked at the policy level to develop career management systems, supporting the institutionalization of routine in-service training. We also supported the provincial governments of Nampula and Gaza to analyze policy options to provide allowances such as hardship grants, housing, and transport. Finally, ThinkWell supported the development and deployment of a HR management dashboard that contains analytics including workload, attrition rate, transfer rate, and deployment speed.
Providing evidence for policy action
ThinkWell has a large research portfolio that aims to answer critical questions about the effectiveness and impact of various health systems interventions. Our research portfolio included impact evaluation, qualitative analysis, and cost-effectiveness analysis. Studies included:
- Impact evaluation of PBF program
- Qualitative study on factors influencing PBF indicator responsiveness
- Qualitative study on impact of PBF on human resources motivation and retention
- Qualitative study on the system-wide effects of PBF
- Cost-effectiveness analysis of SMS reminders for HIV patients
- Cost-effectiveness of index-case tracing of HIV patients
- Impact evaluation of point-of-care data capture
Supporting the development of the national health financing strategy
ThinkWell worked with the national Ministry of Health to support the development of the National Health Financing Strategy. Our work includes the policy options analysis, synthesis of evidence, costing, and overall capacity development. Examples of analyses produced for the MOH include resource allocation methodologies, provider-payment mechanisms, performance-based financing, and health insurance.