HEALTH facilities in the Leribe district are reporting an upturn in staff morale and general improvement in the quality of health services courtesy of a new World Bank-funded performance-based financing model the government is currently piloting.
The government of Lesotho introduced the Health System Performance Enhancement (HSPE) project in 2014 to respond to challenges of the low utilisation of health facilities due to the poor quality of services.
World Bank Lesotho’s Communication Specialist, Elita Banda, said the PBF scheme was first implemented in Quthing district in January 2016 before being extended to Leribe.
To date, the project is being successfully implemented in six districts namely, Quthing, Leribe, Mokhotlong, Thaba-Tseka, Mafeteng and Mohale’s Hoek.
Ms Banda said it would soon be extended to the remaining four districts of Berea, Butha-Buthe, Maseru, and Qacha’s Nek.
“The five-year project is funded as per the following arrangement: a concessional credit from the World Bank of US$ 12 million, a grant from the World Bank of US$ 4 million, and funding from the Government of Lesotho of US$ 4 million. Some co-funding is also provided by UNICEF and UNFPA.
“It is hoped that the experiences and lessons learnt from the ongoing implementation of the PBF initiative, as well as the technical assistance being provided to the Government will contribute to the institutionalisation of the PBF in the health sector.”
The five- year project also recognises that the quality of service is undermined by staff shortages, lack of equipment and a poor referral system between health centres and hospitals.
To tackle these issues, the project employed the Performance Based Financing (PBF) system which ties payment to achievement of agreed measurable performance targets.
The PBF aims to increase utilisation and quality of health care by rewarding health providers according to a set of indicators.
The health facilities receive performance incentives on a quarterly basis. Half of these are distributed to staff to boost their morale and incentivize them to improve service delivery.
The other half is invested in the health facility to increase utilisation and quality of service.
According to one of the beneficiaries of the initiative, Dr Malitaba Litaba who is the District Medical Officer in Leribe, things have changed for the better at Motebang District Hospital.
“There are two types of major impacts that PBF has had Dr Litaba explained.
“One is the motivation of staff as everybody is motivated to work hard because they know they will get bonuses in addition to their salaries.
“Secondly, it has helped us to improve the behaviour and the attitude of staff.
“So in simple terms, we are now an empowered hospital because when you speak as a superior, the staff listen because they know you hold the power of the money.”
She further added there has been an improvement in terms of the hospital’s surroundings which used to be untidy.
She also said they were now able to procure supplies more quickly and cheaply.
“With PBF I can procure supplies over the counter which is much faster and cheaper. For example, if something costs M12 000 I will immediately procure it at that price but with government expenditure I will purchase it for M50, 000 and get it after three months.
“So, with PBF, that cumbersome procurement process is avoided.”
The Ministry of Health employs quantity and quality indicators for the project. The quantity indicators cover the minimum package of services provided at the health centres such as general consultations, institutional deliveries, antenatal care, post-natal care, immunisation, family planning, HIV and tuberculosis specific indicators.
For quality indicators the District Health Management Teams (DHMTs) assess health centres while hospitals assess each other. This is commonly known as Peer Assessments, where a hospital from one district assesses another hospital from another district.
When the Lesotho Times crew recently visited Leribe last month, staff from Mafeteng Hospital were at Motebang Hospital to conduct the peer assessment. All participating hospitals assess each other on a quarterly basis.
However, as Dr Litaba revealed, it has not been smooth sailing for the project as there have been some challenges.
“Where money is involved there is bound to be trouble. You will find that some workers fight to get the bonus even though they do not deserve it.
“For example, if you do not get appraised, you get no money. So two people did not come for appraisals but now they want a share of the money but I can’t give them the money.
“We have also found that some workers commit fraud by selling sick leave days while others steal medical supplies. These are some of the irregularities which lead to some workers’ bonuses being suspended,” Dr Litaba said.
‘Mamoratuoa Motseki, the Nurse-In-Charge of Khabo Health Centre, said the centre remained acutely understaffed due to absenteeism, and resignations among other reasons.
She said there were only two nurses at the hospital.
She further said indicated that the PBF money helped them procure small office needs such as heaters, air conditioners as well as hire cleaners. She however, said they needed more funds to hire additional staff to ease the workload.
Another employee who spoke on condition of anonymity, said instead of motivating the workers, the PBF model was contributing to in-fighting over the funds.
“Again, you will notice that the management gain more bonuses than subordinates whereas the latter put in more work. Also, it does not address the numerous unfair labour practices the staffers are subjected to in the workplace,” the employee said.