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Evaluation report

2012 Liberia: Evaluation of MoHSW & Bomi CHT Performance based contracting



Author: Wendy B. Abramson

Executive summary

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Background:

This assessment reviews the two-year Performance-Based Contracting (PBC) “In” pilot between the Bomi County Health and Social Welfare Team (BCHSWT) and the central level Ministry of Health and Social Welfare (MOHSW) to identify areas needing strengthening, and to present lessons learned and suggestions for scaling up the PBC “In” model elsewhere in Liberia.

There are three types of contracts used in Bomi County’s health sector: PBC “in” between the central MOHSW and the county BCHSWT; PBC “out” between the BCHSWT and a Non-Governmental Organization (NGO) African Humanitarian Action (AHA); and service contracts between the county and locally hired staff and a vehicle maintenance company. Although there are mechanisms for accountability written into the PBC “in” contracts, they are not consistently employed. There has been poor verification of contract performance by the Purchaser (MOHSW) to date.

Purpose/Objective:

To identify areas needing strengthening, and to present lessons learned and suggestions for scaling up the PBC “In” model elsewhere in Liberia.

Methodology:

The Bomi Assessment methods included extensive document review, key informant interviews, focus groups, and observation visits to health facilities. Interviews were conducted with 14 MOHSW staff, 21 BCHSWT staff, 1 county government leader (Superintendent) and 12 Officers in Charge (OIC) of health clinics. A total of 12 health clinics were visited (eight publically run, two AHA managed and county financed, and two private). Three focus groups were held (two at the community level and one with the four District Health Officers). The design of the assessment tools included a common set of themes to be explored across levels of the health system including Governance and Decentralization; Leadership and Transparency; Financial Management and Administration; Public Health Management, Performance and Oversight; and Monitoring and Evaluation.

Findings and Conclusions:

The county team has learned to budget well and anticipate its real needs costs down to the health facility and Community Health Volunteer (CHV) levels. One of the main problems encountered is inconsistent financial reporting requirements and confusion over formats for the liquidation of accounts on a quarterly basis.

Management and supervision in the county is strong and there is a universal recognition of the importance of supervision and collection of data amongst the county team and the health facility staff. BCHSWT has instituted regularly scheduled meetings across levels of the system as a management tool for increased communication, coordination and problem-solving. Supervision is one of the county’s strongest areas at all levels of the system. 

Although there are no written reports on data verification and M&E, there is a large effort on the part of the county to collect HMIS data to report to the central level. However the analytical capacity and use of real time data is still weak at the county level. Such is also the case at the central MOHSW, where there is a gap in sharing and use of data for decision-making and planning on a regular basis.

Recommendations:

In order for the counties to be ready to serve as providers under contracting “in” mechanisms, they must have the capacity to manage and lead the county. Minimally, the CHSWT should have the following competencies in order to ensure strong management: Management and Leadership, financial management and accounting, public health planning, and an understanding of Performance-Based Financing (PBF)/PBC. It should be a requirement that all CHOs or at least the Deputy have formal public health training prior to signing of contracts. The importance of county leadership should not be underestimated for the success of contracting “in”. The County Health Officer (CHO) needs to not only be well versed in public health management but also a strong leader with a vision for the county.



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