J.4_Contracting-In_Gruidelines.pdf

LIBERIA

MOH CONTRACTING IN GUIDELINES

READINESS REVIEW AND ASSESSMENT OF

COUNTY HEALTH AND SOCIAL WELFARE TEAM (CHT)

PERFORMANCE

W FOR PERFORMANCE-BASED CONTRACTS WITH THE

MIN

ISTRY OF HEALTH AIDELINES

Republic of Liberia Ministry of Health

April 2016 public of Liberia Ministry of Health and Social Welfare

MOH CONTRACTING IN GUIDELINES – A TOOL TO REVIEW, MONITOR AND ASSESS CHT PERFORMANCE

TABLE OF CONTENTS

Acronyms 4

Acknowledgements 6

Background and Context 7

OVERVIEW OF PERFORMANCE-BASED FINANCING 7

PERFORMANCE-BASED CONTRACTING 7

Performance-based Contracting in the Health and Social Welfare Sector in Liberia 8

GOVERNANCE AND ADMINISTRATIVE DECENTRALIZATION IN LIBERIA 9

LEGAL FRAMEWORK FOR DE-CONCENTRATION IN THE HEALTH AND SOCIAL WELFARE SECTOR IN LIBERIA 9

OPERATIONALIZING DECENTRALIZATION POLICY IN THE HEALTH AND SOCIAL WELFARE SECTOR 11

SEPARATION OF FUNCTIONS UNDER DE-CONCENTRATION 11

MOH Contracting In Guidelines: Readiness Review and Assessment of CHT Performance 14

Purpose 15

Objectives 15

Methodology 16

Step 1 Form Contracting In Technical Review Committee 18 Step 2 Conduct Pre-Qualification of CHTs 19 Step 3 Develop Ranking Master Tables 35 Step 4 Conduct CHT Self-Assessment 41 Step 5 Conduct Field Verification 42 Step 6 Convene Review Committee - Make Recommendations 53

Annex I Terms of Reference Technical Review Committee 56

Annex II - Draft Memo to CHT 59

Annex III – CHT Self-Assessment Form and Process 60

Annex III - Individuals Consulted Error! Bookmark not defined.

Annex IV – County Health Officers Consulted Error! Bookmark not defined.

List of Figures and Tables

Figure 1 - Overview of Decentralization in Liberia Figure 2 – MOH Contracting In Readiness Review and Assessment Process Figure 3 – MOH Contracting In Readiness Review Timeframe and Responsibilites

Table 1. Data Needed and Source for Contracting In Review and Assessment Table 2. Pre-qualification Criteria Indicators Table 3. Indicator 1 – Quarterly CHSW Board Minutes on File Table 4. Indicator 2 – County Record of Regular Scheduled Staff Meetings Table 5. Indicator 3 – Core CHT Administrative Positions Filled .................................... Error! Bookmark not defined.

Table 6. Indicator 4 – Timely and Complete Submission of Budget Monitoring ReportsError! Bookmark not defined.

Table 7. Indicator 5 – OFM Regular Quarterly Performance Analysis Scores Table 8. Indicator 6 – Timely and County Quarterly Reports Table 9. Indicator 7 – Health Facility Primary Care Accreditation Scores Table 10. Indicator 8 – Priority Service Delivery Coverage Rates as Compared with Targets Table 11. Indicator 9 – Accuracy in HMIS Reporting (Penta3) ....................................... Error! Bookmark not defined.

Table 12. Indicator 10 – Availability of Tracer Drugs ..................................................... Error! Bookmark not defined.

Table 13. Ranking Master Table Table 14. Illustrative Example of a Capacity-Building Plan Matrix Table 15. CHT Self Assessment – Leadership and Governance Table 16. CHT Self Assessment – Leadership and Governance MOH and GoL Laws, Policies, Plans, Procedures and

Guidance Table 17. CHT Self Assessment – Human Resource Management Table 18. CHT Self Assessment – Financial Management and Procurement Table 19. CHT Self Assessment – Health Services Management and Delivery Table 20. CHT Self Assessment – Availability of Treatment Guidelines, Clinical Standards and Protocols at County

Headquarters and HF Table 21. CHT Self Assessment – Health Management Information Systems, Monitoring and Evaluation, and Use of

Data for Decision-Making Table 22. CHT Self Assessment – Supply Chain Management of Essential Medicines and Supplies

ACRONYMS

ANC Antenatal care BPHS Basic Package of Health Services BMR Budget Management Report CBO Community-Based Organization CHDC Community Health Development Committee CHO County Health Officer CHT County Health and Social Welfare Team CHV Community Health Volunteer CSO Civil Society Organization DHIS District Health Information System DHO District Health Officer DHS Demographic and Health Survey EIO Expression of Interest EPHS Essential Package of Health Services EPI Extended Program for Immunization FBO Faith-based Organization gCHV General Community Health Volunteer GOL Government of Liberia EPHS Essential Package of Health Services EPSS Essential Package of SocialServices HF Health Facility HMIS Health Management Information System IAS International Accounting Standards IP Implementing Partner ITP2 2nd dose of Intermittent Preventive Treatment LMIS Logistics Management Information System MCH Maternal and Child Health M&E Monitoring and Evaluation MIA Ministry of Internal Affairs MOF Ministry of Finance MOH Ministry of Health and Social Welfare MOPEA Ministry of Planning and Economic Affairs NDS National Drug Service NGO Non-Governmental Organization NHSWPP National Health and Social Welfare Policy and Plan NFP Not For Profit providers OFM Office of Financial Management OIC Officer in Charge PBC Performance-based Contracting PBF Performance-based Financing Penta3 3rd dose of Pentavalent Vaccine PC Procurement Committee PHC Primary Health Care PFP Private For Profit providers PPCC Public Procurement and Concessions Commission

RFP Request for Proposal SCMU Supply Chain Management Unit UNICEF United Nations Children’s Education Fund USAID United States Agency for International Development WHO World Health Organization

ACKNOWLEDGEMENTS

The MOH Contracting In Guidelines:Readiness Review and Assessment of County Health and Social Welfare Team (CHT) Performanceis a tool intended for the Ministry of Health (MOH) to apply on a continuous basis in order to obtain evidence-based data to determine when CHTs are at an acceptable capacity to be recipients of performance contracts with the MOH; determine whether a CHT should receive future funding for contracts that are already in place; identify capacity-building needs of individual CHTs; and, provide publically accessible and transparent health system data on the use of Government of Liberia (GoL) funding for counties.

A participatory method was used to review and revised these guidelines. Specifically the approaches used included use of the following: 1) Key documentation including policies, plans, guidelines, protocols, and reports generated by the Ministry of Health (MOH)as well as international documents; 2) Findings from the February 2012 assessment of the Bomi CHWT’s decentralization Performance-Based Contracting Pilot; 3) Information gathered during National Health Sector Review meetings and semi annual meetings of 2012 and 2013; 4) Consultative meetings held in Liberia in October 2012, April 2013, and November 2013 with the MOH senior management and staff, CHT teams, county Superintendents, Non-Governmental Organizations (NGOs), and international partners.

On behalf of the senior management of the MOH, I would like to extend our heartfelt thanks and appreciation to all institutions and individuals that made the development of these guidelines possible.

In particular I would like to express my gratitude to the United States Agency for International Development (USAID) for providing the resources for the development of these guidelines. In addition, I would like to thank all individuals and organizations that supported the process, including those from the MOH CHTs, Superintendents, Non-Governmental Organizations (NGOs) and international partners.

While it would be impossible to list each contributor by name, I want to mention the Collaborative Support for Health Program our key partner project in the review of the Contracting In Guidelines:

Readiness Review, Monitoring and Assessment of CHT Performance. CSH Provided technical support through who worked closely with the Ministry of Health to review and update this tool.

Dr. Bernice T. Dahn, BSc, MD, MPH Minister of Health Ministry of Health & Social Welfare Republic of Liberia

The MOH PBF Operations Manual states that, “Performance-Based Financing is an implementing strategy of the National Health Policy and Plan (NHPP). The overarching goal of the NHPP is to improve the health status of the population of Liberia on an equitable basis.1”

BACKGROUND AND CONTEXT

OVERVIEW OF PERFORMANCE-BASED FINANCING

Performance-Based Financing (PBF) is one of the cardinal financing schemes utilized under a Results- Based Financing Approach to health systems strengthening. The overall concept of PBFor Results-Based Financing (RBF) is payment (monetary and/or non-monetary) issued based upon achievement of a predetermined performance target or result. Performance payments may target supply-side (e.g., clinic, health center, health worker) and/or demand-side (e.g., patients, pregnant women, children under one year of age) recipients. The most common form of PBF is, however, a supply side scheme between levels of the health system, health management and providers, and/or through providers and community volunteers. Throughout both the industrial and developing world, a number of PBF schemes or mechanisms can be found. Examples of PBF include, but are not limited to, Performance-based Contracting (PBC), Pay for Performance (P4P), Results-based Financing (RBF), Performance-based Incentives, Output-based Aid (OBA), Fee-for-service (FFS), Vouchers, Conditional Cash Payments, and Conditional Cash Transfer (CCT) Programs. These mechanisms are different tools for PBF.

PBF is an output-based strategic purchasing concept that improves health worker productivity and morale and catalyzes actions of many individuals and service providers to find solutions from the bottom up. It also improves governance and accountability in the health and social welfare sector and promotes positive changes in how information is generated and used for decision-making.

PERFORMANCE-BASED CONTRACTING

A performance contract between different actors is a mechanism to “operationalize” PBF. Performance-based Contracting (PBC) is a supply-side output-based PBF tool, intended to improve health facility and worker performance. It differs from “input financing” in that payment of contract Implementing Partners (IP) is based upon progress against results delivered. Under PBC, a formal, legally binding contract or agreement is used as a mechanism or tool to tie payment to performance. The contract includes clear objectives, performance indicators and targets, mechanisms to collect and validate data, timeframes, and a budget. Performance indicators (service delivery and administrative) are measured to gauge performance under contracts. Rewards are paid for good performance and sanctions are applied for non-performance1.

In Liberia the bonus strategy that will be used specifies that 80% will be allocated to Health Facilities (HF) and 20% to the CHT.

The HF bonus will be split whereby individual HF staff will receive 50% of their allotted bonus and HF management and those involved in community mobilization will receive the other 50%.

PERFORMANCE-BASED CONTRACTING IN THE HEALTH SECTOR IN LIBERIA

Since 2008, the Liberian Ministry of Health (MOH) has had in place a national policy on Performance-based Contracting (PBC), under which Non-Governmental Organizations (NGOs) are hired under contract to provide and manage Primary Health Care (PHC) services in Liberia. The rationale for PBC in post-conflict Liberia was to take advantage of the already existing service delivery capacity of NGOs while public sector systems and capacity are gradually developed and strengthened. “Contracting Out” is when the MOH enters into a legal contractual arrangement with an independent private entity such as a NGO. The contracted entity is given complete authority over all resources (human, material and financial) to provide health services; this process involves the Ministries of Justice, Finance, and Health and Social Welfare.

The 2011-2021 National Health and Social Welfare Policy and Plan (NHSWPP) states, “On an increasing basis, PBCs will be used between the central MOH and the County Health (CHTs).” This is known as contracting in; when one level of government or a public institution (i.e., the central-level MOH) contracts with a lower level of government (i.e., a county, district, province, or facility) to deliver services. This mechanism serves as a way to introduce private sector concepts and business strategies into public sector management in a non-threatening way, as decision-making and resources are retained within the public sector.2 PBC in the form of contracting in also helps to shape the decentralization policy of the MOH through defining through contracts, the functions of the central MOH, as well as the CHTs.

Contracting In, through the use of Performance-Based Contracts (PBC), is a tool for the public sector to provide financial incentive to encourage pre-determined results or output.

The MOH in Liberia began contracting in of a CHT as a pilot in 2009 in Bomi County. Based upon a 2012 assessment of the BOMI pilot experience, the MOH began to transition from performance contracts with NGOs to direct performance contracts with individual CHTs to deliver the Essential Package of Health Services (EPHS)3. It is the intent of the MOH to gradually transition all public sector service delivery at the primary care level to fall under performance contracts between the central MOH and individual CHTs.As such, the Ministry of Health (MOH) is in the process of transitioning its service delivery model from one under which Non Formal Providers(NFPs) or NGOs are contracted at the central level to provide the EPHS to a model whereby the CHT is responsible for all service delivery, either directly or through contracts with non-public entities.

The Ministry wishes to clarify that because the County Health Team is not an independent legal entity separate from the

Ministry of Health , the CHT may not legally bring suit against the MOH. Therefore the term “contract” may have multiple meanings depending upon requirements of particular funding sources. Nevertheless, the CHT is obligated to under a

“performance contract” to perform in accordance with contract terms, and financial incentives in the form of bonuses will be provided depending upon performance.

GOVERNANCE AND ADMINISTRATIVE DECENTRALIZATION IN LIBERIA

In January 2011, the GoL approved the Liberian National Policy on Decentralization and Local Governance4. The Inter-Ministerial Committee for Decentralization, Decentralization Task Force and the Governance Commission, in collaboration with the Ministry of Internal Affairs (MIA), have assumed leadership on matters of implementing decentralization on a national scale.

The Superintendent’s office receives funding on an annual basis from the MIA for development projects5.Additionally the Superintendent’s office also provides technical guidance and support to relevant line Ministries’ efforts towards decentralization. The Decentralization Policy includes a long-term goal of devolving authority over several fiscal and administrative responsibilities directly to County Administrations. Currently the CHT budget remains independent from County Administration, although it is mandated that the Superintendent’s office be aware of both activities and budgets for each of the line ministries operating in the county, since the Superintendent’s office is responsible to the President of the Republic for reporting on progress of line ministries at the county level.6

LEGAL FRAMEWORK FOR DE-CONCENTRATION IN THE HEALTH SECTOR IN LIBERIA

Guided by the Liberian National Policy on Decentralization and Local Governance, the 2011-2021 National Health and Social Welfare Policy and Strategic Plan (NHSWPP), the Public Sector Reform Statement (2010), the Amended Chapter 30 of the Executive Law of 1972, and with external technical and financial assistance, the GoLhas undertaken a number of relevant activities representing the roadmap towards decentralization. In particular, the GoL has begun a process of decentralization of the health and social welfare sector beginning with a de-concentration and delegation of authority and responsibilities to CHTs.

The second objective of the Liberian NHSWPP refers to the transfer of management and decision-making to lower administration levels. The NHSWPP states that by increasing access and utilization of the EPHS, CHT has been empowered to serve as “… its (MOH’s) operational arm and to manage all Ministry-owned facilities, Ministry-employed human resources, and Ministry-provided material resources in their county.”7

Part VI Section 6.0 falls under a Constitutional Amendment for “The implementation of this National Policy on

Decentralization and Local Governance and framework for the devolution of political, fiscal and administrative powers to county governments under Chapter V Articles 29 and 34, and Chapter VI, Article 54 and all relevant provisions of the Constitution of the Republic of Liberia shall be amended through national referendum for the purpose of implementation of this decentralization policy.”

3.6.2 “The District Commissioner shall be responsible for the implementation of county policies and programs in the districts as well as for leading a process of grass-root based priority setting and project identification which shall be submitted for the consideration in the district plan. The plan shall be submitted with cost estimated annually to the superintendent in time for the superintendent to consider developing the annual county plan and budget.”

3.4.3 “The Superintendent shall keep collaborating line ministries and agencies and all such national authority institutions informed on matters regarding status of their national programs and projects; similarly, the line ministries and agencies shall keep the superintendent informed of matters regarding operations of their national programs in the county; the

Superintendent shall have authority to supervise their condition and effective administration.

National Health & Social Welfare Policy & Plan 2010-2021, MOH, 2011

FIGURE 1 - OVERVIEW OF DECENTRALIZATION IN LIBERIA

OPERATIONALIZING DECENTRALIZATION POLICY IN THE HEALTH SECTOR

The National Decentralization Policy and Plan, like the NHSWPP, articulates a transfer of certainfunctions and responsibilities from the central to the county level. In the Liberian Health Sector, decentralization policy is operationalized through performance contracts between the central MOH and the CHTs.

“The intent is to gradually reduce the role of NFPs [Not for Profit providers] and increase the role of CHTs in managing government facilities. CHTs may, in turn, contract directly with government health facilities for service delivery as well as with privately owned facilities (primarily non-governmental and faith-based). In all instances where contracts are used, emphasis will be placed on establishing distinct catchment populations in a given health system to ensure appropriate allocation of resources and measurable performance.”8

SEPARATION OF FUNCTIONS UNDER DE-CONCENTRATION

In order to avoid any misunderstanding or conflicts of interest, and in an effort to create a transparent health system that ultimately works to improve health outcomes, it is vitally important that there be clarity on separation of functions between the different levels of the Liberian health care system, including central, county, district, HF, and community. Transparency as to which level of the health care system is responsible for various functions of health systemperformance promotes accountability and ultimately efficiency in the use of resources.

The following are some frequently used terms to delineate functions:

Financier pays for services (e.g. GoL through Ministry of Finance, donor, or private sector);

Purchaser buys services (or results) from providers (e.g. MOH from CHT or CHT from an IP /

NGO) and negotiates targets, monitor progress and verifies results.

Provider (in Liberia IP) delivers services (e.g. CHT delivers management of services, Health

Facilities and Community provide direct services) and is primarily responsible for implementing health care services. It is important that providers are given sufficient authority to be able to

National Health & Social Welfare Policy & Plan 2010-2021, MOH, 2011

NATIONAL DECENTRALIZATION POLICY AND PLAN

“…Decentralization of authority from the central level of government (MOH) to the county level of the health system (CHT) requires a reallocation of authority and responsibility for health sector performance.”

“…County level shall be responsible for service delivery; and partner oversight, while the Central level will focus on establishing policies and standards, resource mobilization and allocation, aggregate planning, monitoring and evaluation, and research and development.”

“…The MOH will intervene in strengthening the operational capacities of County health bodies such as the CH Board, the CHTs, the Community Health Development Committee (CHDC) and general Community Health Volunteers (CHV).”

MOH FUNCTIONS

FINANCING BODY

Ensure financing of health services

Allocate resources

Mobilize resources

PUCHASING / PROCUREMENT / CONTRACTING BODY

Determine needs, develop ToR

Design and negotiate contract terms

Collect financial, administrative, and service delivery data

Track performance data

Monitor, Evaluate and Pay CHT based upon Performance

REGULATORY, NORMATIVE AND OVERSIGHT BODY

Set clinical standards and norms

Regulate health care providers

Accreditation of health facilities

POLICY AND PLANNING BODY

Set National Policies and Standards

Carry out Research

Set National Targets and Priorities

CAPACITY-BUILDING CHT

Identify areas for improvement

Facilitate capacity-building efforts effectively plan, operate, and allocate resources under any guidelines or budgetary parameters as specified under contract.

Verifier or Monitor provides oversight of services (e.g. MOH at the central level and CHSW Board or sub-committee of the Board at the county or district level).

In particular, “…the MOH has committed itself to decentralization in broad terms, wherein the County level shall be responsible for service delivery and partner oversight…” Furthermore, reference to formalization of partnerships between the CHTs and Implementing Partners is articulated in Section

4.1.2. It states, “Because relationships gain in transparency, efficiency and effectiveness when they are formalized into mutual binding commitments, contracts [with Not for Profit (NFP) providers] will be used for the provision of public health and social welfare services.” These providers include International Non-Governmental Organizations (INGOs), Non-Governmental Organizations (NGOs), and Faith-Based Organizations (FBOs).

In Liberia under a contracting in model whereby the central ministry contracts with the CHT, the county provides oversight, monitoring, and management of service provision, whereas the MOH serves to make policy and plan, provide oversight and regulatory enforcement, purchase and procure goods and services, and monitor and evaluation CHT performance9.

The role of the CHT to perform these distinct though inter-related functions could present a conflict of interest; PBC “in” needs to be designed in such a manner to avoid possible gaming of the system.

CHT FUNCTIONS

IMPLEMENTING BODY (CONTRACTOR)

Manage finances, administer services

Procure goods and services

Manage Human Resources

Provide health service delivery

Monitor and Evaluate performance

Manage Supply Chain for Essential Medicines and Supplies

OVERSIGHT AND PLANNING

Health system Leadership, Governance

Coordination

Develop operational plans and budgets

Set County Targets

PURCHASING / PROCUREMENT (PERFORMANCE-BASED

CONTRACTING) BODY

Prepare contract proposals

Design and negotiate contract terms

Lead and Manage a Competitive Bidding Cycle for Sub-Contracting out of partners

Oversee and Monitor Sub-Contract performance data

Pay sub-contract IPs

CAPACITY-BUILDING HF

Identify areas for improvement

THE PBF UNIT

The PBF Unit, within the MOH, is charged with oversight of the PBF strategy in Liberia, in coordination and partnership with the Office of Financial Management (OFM), the Monitoring and Evaluation (M&E) Department, the External Aid Coordination Unit, and County Health Services among others in the Ministry. Its main mission is to provide technical oversight for the development of PBF schemes at the national level;build the capacity of county-level institutions and structures; guide the decentralized implementation of PBF principles, concepts and tools; and propose strategies and activities for PBF implementation. The Unit falls under the supervision of the MOH Deputy Minister/Chief Medical Officer for Health Services.

COUNTY HEALTH SERVICES

County Health Services (CHS) Unit is responsible for the monitoring and supervising of the implementation of the EPHS. One of the main components of the EPHS is Joint Integrated Supportive Supervision (JISS) on a quarterly basis and accreditation on all health facilities in the country (public and private); the CHS is responsible for this. Desk officers who are assigned to oversee regional clusters of counties are responsible for analyzing all health service delivery reports, identifying gaps and challenges, and providing feedback to the CHT supervisors. Based upon these analyses, the CHS department works with the rest of the ministry to develop and fine-tune capacity-building plans for the CHTs. The Contracting In process, including the selection of counties eligible for performance contracts, falls under the jurisdiction of this unit.

MOH CONTRACTING IN GUIDELINES: READINESS REVIEW

ANDASSESSMENT OFCHT PERFORMANCE

The purpose of the Liberian MOH initiative of transitioning from management “contracting out”with NGOs by the Ministry and by partners to a model whereby the central MOH “contracts in” directly with individual CHTs, is to ultimately improve performance of the Liberian health system. In order to do this, the CHT in Liberia needs to have sufficient capacity as leaders, managers and public health practitioners to effectively provide the EPHS to the population.

CHT Contracting In Guidelines: Summary of Systems, Procedures, and Core Competencies

In line with the overall guidance tools on decentralization and management of the health system and the PBF operational manual, the CHT is to have basic systems, processes, and procedures in place in the areas of Leadership and Governance, Financial Management and Procurement, Human Resource Management, Service Delivery, Monitoring and Evaluation (M&E) and Use of Health Management Information System (HMIS), and Supply Chain Management of Essential Medicines and Supplies.

As such, theContracting In Guidelines: Summary of Systems, Procedures and Core Competencies for the County Health and Social Welfare Team (CHT) May 2013 were created to provide an overview of the main functions, or competencies, which must be operational for effective contracting “in” of key public health functions through a performance contract10. These guidelines are intended to serve the CHTs as a functional tool that provides an orientation on procedures and processes leading to an effective decentralization of the health care delivery system employing the health system11 approach. They provide minimum standards under which the CHT is expected to operate under performance contracts with the MOH.

In May 2013 the guidelines were disseminated, validated, and capacity was built in a national workshop held in Sanniquellie Nimba. The extent to which these functions are fully operational is directly tied to the capacity of the CHT to deliver effective health services, increase the quality of care, and harmonize data through transparent public health management practices.

Note: These guidelines do not cover the essential capacities that the MOH will need in order to be an informed and responsive purchaser / contractor of health services from the CHTs.

Health System includes the institutions, human resources, financing, commodities, information, management and governance strategies, systems, and processes.

PURPOSE

In the past decisions onwhich counties to “contract in” were based upon emergency funding constraints of individual counties rather than on whether a county hadthe basic competencies necessary for proper and transparent management of public sector funds. The MOH Contracting In Guidelines: Readiness Review and Assessment of CHT Performance have been created so that Liberian public health authorities can make resource allocation decisions based upon objective measures of a CHT’s real capacity and “readiness” to handle large sums of money in a fiscally responsible manner that produces desired results.

These guidelines serve as a tool to assist the Ministry to gradually move from the present health service delivery system to one whereby counties enter into performance contracts with the ministry based upon an objective analysis of their current real capacity to manage and implement performance contracts and oversee sub-contracts at the county level.

In addition, as the Government of Liberia (GoL) proceeds with de-concentration in the health and social welfare sector, the Ministryneeds to monitor and assess CHT performance in a standardized manner across Liberia’s 15 counties to determine whether to contract a CHT, if an already contracted CHT is performing at a sufficient level to receive future funding under a performance contract, identify capacity-building needs of individual CHTs, and provide publically accessible and transparent health system data on the use of GoL funding for counties.

The purpose of the MOH Contracting In Guidelines is to determine which CHT are performing at a level that would qualify them to be contracted “in” by the MOH. They serve as companion guidelines to the CHT Contracting In Guidelines: Summary of Processes, Procedures and Core Competencies that was validated in Saniqueillie Nimba in May 2013.

OBJECTIVES

To provide evidence for MOH decision-making for future funding of CHTs through performance contracts as well as continued funding of already contracted counties;

To promote public transparency in decision-making on county selection and funding for PBCs;

To identify gaps in performance and create capacity-building plans for strengthening of individual CHTs that will steer them to deliver effective health services through transparent public health management practices;

To measure progress and compare CHT capacity and performance over time through a step-by-step review process of key public health functions expected from the CHTs;

To track the use of systems, processes, procedures, and results of sector de-concentration of authority under performance contracts; and, To provide evidence of the CHT’s development and capacity for further decentralization of functions and authority to the local level in the health sector.

METHODOLOGY

The MOH Contracting In Guidelines: Readiness Review and Assessment of CHT Performance considers the six building blocks of a health system framework as defined by the World Health Organization (WHO)12. The reviewprocess encompassesthese building blocks, and it focuses specifically on the key competencies necessary for good public administration through a PBC mechanism between the MOH and the CHT. Those core competencies include:

County Leadership and Governance;

Financial Management andProcurement;

Human Resource Management;

Health Service Delivery Management;

Use of Health Management Information Systems and Monitoring and Evaluation; and, Supply Chain Management for Essential Medicines and Supplies.

Figure 2 depicts the sixsteps in the Contracting In Readiness Review and Assessment Process.

FIGURE 2–MOH CONTRACTING IN READINESS REVIEW STEPS AND ASSESSMENT PROCESS

Step 1:

Commi ee

Step 2:

Pre-qualify

CHSWTs

Step 3:

Step 4:

Conduct CHSWT Self-Assessment

Step 5:

Conduct Field Verifica on

Step 6:

Make Recommenda ons

World Health Organization,Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Available at:http://www.who.int/healthinfo/systems/monitoring/en/index.html

The process ideally takes place bi-annually with the same people participating during each cycle of review. Figure 3 indicates approximate timeframe and responsible parties for each of the six steps in the review process:

FIGURE 3–MOH CONTRACTING IN READINESS REVIEW TIMEFRAME AND RESPONSIBILITES

The following is an overview of the steps involved in the review process.

STEP 1FORM CONTRACTING INTECHNICAL REVIEW COMMITTEE

Step 1:

Commi ee

Step 2:

Pre-qualify

CHSWTs

Step 3:

Step 4:

Conduct CHSWT Self-Assessment

Step 5:

Conduct Field Verifica on

Step 6:

Make Recommenda ons

STEP 1FORM CONTRACTING IN TECHNICAL REVIEW COMMITTEE

A Contracting In Technical Review Committee (“the Review Committee”), comprised of the various MOH departments each with expertise in their particular competency area under review, is formed. Leadership for convening and facilitating the review and assessment process comes the County Health Services Office. It is comprised of the following representatives from across the ministry as well as one representative from a partner organization:

Administration –Office of Financial Management (1 individual) Administration –Office of Personnel (2 individuals) Planning – Monitoring and Evaluation Unit (1 individual) Planning –Health Management Information Systems Unit (1 individual) Health Services – County Health Services (2 individuals) Health Services –Supply Chain Management Unit (1 individual)

This committee is responsible for participating in all steps laid out in these guidelines. Annex I contains Terms of Reference (ToR) for the MOH Contracting In Technical Review Committee.

STEP 2 CONDUCT PRE-

QUALIFICATION OF CHTTS

1. Select CHTs to be reviewed

2. Send out memo from CMO to

Deputy Ministers, Assistant Ministers, Technical

Review Committee with

Copies to partners to:

a. Gather data (1 week)

b. Input data (1 week)

c. Convene Review

Committee meeting to conduct

Step 3 (1/2 day)

STEP 2 CONDUCT PRE-QUALIFICATION OF CHTS

The first exercise of the Review Committee involves an analysis of a number of core competencies and functional areas with corresponding indicators to determine CHST capacity for contracting. During this step, an initial pre-qualification of the CHTs takes place through a review of routine data already collected by the MOH and, to a lesser extent, through requests for routinely collected information from the CHTs13.

The individual members of the Committee are tasked with obtaining and analyzing those data corresponding to their area of expertise. For example, analysis of the financial indicator is the responsibility of the OFM, analysis of service delivery indicators is the responsibility of the Department of M&E, analysis of the leadership and governance data is the responsibility of the Office of County Health Services, and so on.

Table 1 below contains the list of data to be collected for the review, the amount of data to be collected and inputted, and where it can be found within the Ministry.

TABLE 1. DATA NEEDED AND SOURCE FOR CONTRACTING IN REVIEW AND ASSESSMENT

DATA NEEDED QUANTITY OF DATA DATA SOURCE

Quarterly CHSW Board Meeting minutes Previous 4 quarters Health Services/County Health Services

CHTs Senior MGT Meetings Minutes Weekly / Bi-Weekly CHT/County Health Services

HMIS timely reporting Rates Previous 2 years Planning/HMIS – DHIS2

Operational Plan Targets for indicators Previous 2 years Planning/HMIS health facilities with evidence of updated performance charts or tables on key health service indicators

Previous 4 quarters Planning/HMIS health system review meeting minutes Previous 2 4 quarters

Planning/HMIS

Quarterly Narrative Reports Previous 4 quarters Health Services/County Health Services

Accreditation Scores Previous 2 year Health Services/County Health Services

Monthly Budget Monitoring Reports Previous 6 months Administration/OFM

OFM Financial Analysis Scores Previous 4 quarters Administration/OFM

CHT Positions Staffing need report

Current/actual Administration/Personnel

Supply Chain TWG meeting minutes Previous 6 months Health Services/SCMU

Supply Chain detail implementation plan Previous 2 year Health Services/SCMU

The two important pieces of information that not periodically collected and that will need to be readily available at the central ministry include: CHT Board Meeting minutes and CHTT Staff Meeting minutes. Ideally these should be sent by the CHTTs to the County Health Services central MOH on a regular basis.

The indicators, chosen by the Ministry, are in accordance with ministry priorities and are deemed as the most representative of those priorities. They reflect the minimum requirements for measurement of a CHT readiness for Contracting In. Table 2 below indicates the Pre-qualification Criteria Indicators against which the CHTs are assessed.

TABLE 2. PRE-QUALIFICATION CRITERIA INDICATORS

Specific indicator definition, source, methodology, examples, and instructions for analysis of each follow below.

CONTRACTING IN REVIEW - PRE-QUALIFICATION CRITERIA / INDICATORS BY CORE COMPETENCIES

Leadership and Governance

Quarterly CHSW Board Meeting Minutes

Record of Regular Weekly CHT Staff meeting Agendas and Minutes(Note: The content of these meetings also serves as an indicator of all expected Competencies listed below)

Human Resource Management

All CHT Positions be filled as per the organogram Financial Management

Timely and Complete Submission of the Budget Monitoring Reports (BMRs)

Office of Financial Management (OFM) Regular Quarterly Performance Analysis Scores Health Services Management and Delivery

Timely and Complete Quarterly Reports

Health Facility Primary Care Accreditation scores Health Management Information Systems and Monitoring and Evaluation

[# and %] of expected HMIS report submitted on time counties meeting minimum threshold for data accuracy score

[# and %] of planned health system review meeting conducted

[# and %] of sampled health facilities with evidence of updated performance charts or tables on key health service indicators

[# and %] of counties with updated Monitoring framework

[# and %] of sampled health facilities covered by county M&E supportive supervision

Supply Chain Management of Essential Medicines and Supplies

Supply Chain staffers with well-defined job descriptions at county level;

Supply Chain Technical Working Group (SCWTG) meeting conducted (must meet at least once a month);

County Supply Chain with annual work plan (component of the bigger County Operations Plan)

LEADERSHIP AND GOVERNANCE

INDICATOR 1

QuarterlyCHSW Board Meeting Minutes on File

The Superintendent’s office is required by law to prepare annual county development plans and budgets for submission to the President of the Republic14. Under Liberia’s Administrative and Governance policy15regular reporting by the CHT to the Superintendent’s office is mandated.

Reporting is done through quarterly CHT Board Meetings chaired by the Superintendent or his/her designee, whose purpose is to advise on county-level policy and planning, assist with resource mobilization and coordination, and monitor CHT performance.16 The County Health Officer (CHO) serves as the secretary to the board; the CHO or County Health Services Administrator (CHSA) participates in these meetings, and is responsible for taking meeting minutes; copies of the minutes are given to the Superintendent’s office and County Health Services at the central MOH, and the original kept on file at the CHT office.

INSTRUCTION FOR VERIFICATIONS

Note: For those counties that have not submitted records, ask the CHTs to submit copies of the minutes from the county quarterly board meetings. This is to be done through a written request from the Deputy Director of Health Services MOH to the County Health Officer (CHO)/County Health Services Administrator (CHSA) asking for copies of minutes of all board meetings over the past four quarters. This request states that in the event of missing board minute meetings the counties are to provide a completed and signed written statement by the CHO and CHSA with an explanation as to why the board minutes are not forthcoming in order to explain any gaps in reporting. There could be various explanations for lack of records of meeting, and these are to be explained in the response to the request (i.e., weak Administrative leadership, political upheaval, changing of office locale, etc.).

County Health Services is responsible for conducting this exercise in consultation with the Office of Personnel. An example is provided in Table 3 below.

EXAMPLE

Part III, Sect. 3.4.1, 3.4.2Liberian National Policy Decentralization and Local Governance. Governance Commission. Jan. 2010.

Part III, Section 3.4.3Liberian National Policy on Decentralization and Local Governance, Governance Commission. Jan. 2010.

Chapter II, Section 2.10 NHPP. 2011-2021 MOH.

TABLE 3. INDICATOR 1 – QUARTERLY CHSW BOARD MINUTES ON FILE

COUNTY Q

st

Q nd rd Q th

TREND MEETING

QUALITY

CONTENT

TOTAL COMMENTS / EXPLANATION

Meeting Minutes

0 1 1 1 +1 3 3 +1+3=7 FOCUS ON PROBLEM-SOLVING, &

ACTION STEPS. CONSISTENT EFFORTS BY

CHO / CHSA TO COORDINATE,

DISRUPTION IN OCT DUE TO CHANGE IN

CO. OFFICE LOCALE NO MINUTES TAKEN

TOTAL POSSIBLE

SCORE

0 1 1

1 3 8

TOTAL SCORE 0 1 1 1 1 3 7

TOTAL SCORE

(TOTAL / TOTAL

POSSIBLE) X 100

88%

INDICATOR 2

Record of Regular Bi-weekly CHSTs Staff Meeting Agendas and Minutes

CHTS/ SENIOR STAFF BI-WEEKLY WITH MEETING MINUTES

Quality of Content:

County Health Team Senior Staff meetings minutes should include: County health teams senior management updates for each departments, achievements agendas, attendance, challenges and action points and upcoming activities.

COUNTY HEALTH TEAMS MONTHLY MEETINGS (All members of CHT) Quality of Content:

County health Team monthly meetings minutes include: county operational achievements at all levels, (EPI, Eye care, MCH, TB, HIV Aids, logistic and administration) agendas, attendance, challenges, action points and upcoming activities

PARTNERS COORDINATION MEETINGS

Quality of Content:

Partner’s coordination meetings minutes include: review of partner’s work plans, CHT’s and partners updates on planned activities, shared field experience, plan for joint supportive field integrated supervisions and other activities.

Good management practice includes regular communication, coordination, and collaboration amongst CHT Team members. Although staff meeting agendas and minutes have not been previously required nor collected from the CHT, for the purpose of this review it is important that they are obtained.

Note: Although data to analyze this indicator may not be readily available and needs to be requested directly from the CHT, the content and substance of the weekly staff meetings is an important indicator as it reflects how the county is performing across all of the essential core competencies and functions.

INSTRUCTION

It is the responsibility of County Health Services to obtain the meeting minutes and agendas. If the county holds weekly meetings, the total possible score would be twelve (12) for the quarter (100%).Table 4 below provides and example of how this indicator is scored.

INDICATOR 2: RECORD OF WEEKLY STAFF MEETING AGENDAS AND MINUTES

1. 1. Send memo from Deputy Minister for Health Services to the CHTT to request weekly staff meeting agendas and minutes be sent to County Health Services.

Note: Although in the past there has not been any official guidance on frequency of CHTT staff meetings, the CHTT Contracting In Guidelines require that weekly action-oriented meetings be held in order to keep abreast of progress and perform ongoing decision-making. Guidance for content and methodology of staff meetings is found in the CHTT Contracting In Guidelines

2. Read agendas and minutes and quantify content in the first column

BONUS POINTS

PERIODICITY AND INCLUSIVENESS OF COMMUNICATION

3. Award bonus points for periodicity and inclusiveness of communication (+ or -). If the county consistently holds weekly meetings involving key staff, including the CHO, CHSA, CHDD, Clinical Supervisor, Finance Manager or Accountant, Human Resources Manager, Pharmacist, M&E Officer, Pharmacist, M&E Officer, DHOs, and if the ministry is able to obtain the majority of agendas and minutes from each meeting, then the county is given an additional five (5) points.

TABLE 4. INDICATOR 2 – COUNTY RECORD OF REGULAR SCHEDULED STAFF MEETINGS

HUMAN RESOURCE MANAGEMENT

INDICATOR 3

CHT Positions filled as per the organogram

There are a number of key CHT positions that are to be filled in order for a CHT to exercise proper financial management of GoL funds and procurement of goods and services. These positions are non-negotiable and include: the County Health Services Administrator (CHSA), an Accountant, Finance Assistant, a Human Resource Officer, a Procurement Officer or Logistician and other vacant positions based on the CHT approved organizational chart

Instruction

COUNTY WEEKLY BONUS POINTS TOTAL COMMENTS / EXPLANATION

# Staff Meetings during Quarter w/minutes

Zero participation of HR Officer.

Question actual existence of resource.

TOTAL SCORE 2 0 2 Urgent need for TA in good management and communication practice

TOTAL POSSIBLE SCORE 12

TOTAL SCORE (TOTAL /

TOTAL POSSIBLE) X 100

17% COUNTY SAYS THEY HOLD REGULAR WEEKLY

MEETINGS,BUT THEY ONLY SUBMITTED RECORDS

FOR TWO.

Note: Flexibility is important in some of the less populated counties in order to ensure staff is not underutilized. In a smaller county for example, there would be a Finance Manager/Accountant, who reports to the CHSA, and a Procurement Officer, who also reports to the CHSA. The Accountant would pay the bills. In this situation, there are a total of four positions, so the county would receive 1.25 points for each as each one is worth 25%.

Data for this indicator is collected and analyzed by the Human Resource Officer. An example can be found in Table 5 below where four positions are filled, and the fifth position is in the process of being filled; therefore, the county receives a 100% score.

INDICATOR 3: CHT POSITIONS FILLED AS PER THE ORGANOGRAM

1. The Human Resource Office requests a current organizational chart with a list of all CHT positions.

2. Review the organizational chart; the county is to clearly demonstrate that key administrative positions are filled including: CHSA; Accountant, Finance Assistant, Procurement Officer or Logistician and Human Resource Officer. Note: If these positions are not filled, the county must demonstrate that thy will be within a three-month time frame in order to receive points for this. If the county does not have one or more of these positions filled and it is apparent that no efforts are being made to fill these positions, no points are awarded. If a county has these positions filled, or shows that they are working towards filling these positions (either through proof of public job announcements, training of current staff to fill these positions, or other means); the county receives points. In particular, this is for the Accountants Assistant and the Procurement Officer, since they have not been specified to the CHTs up to now.

3. Enter data on all vacant administrative positions filled. For each position filled, the county receives one (1) point. If all of the positions are filled, the county receives five (5) points (with each point representing 20% of the total).

4. For unfilled positions, request documented evidence of efforts to fill these positions.

BONUS POINTS

IF ALL CHT ADMINISTRATIVE POSITIONS ARE FILLED, THE COUNTY RECEIVES POINTS TO BE DETERMINED BY THE TEAM IN FIELD

FOR ASSESSMENT.

SEPARATION OF FUNCTION

5. If the county has both a CHO and a Hospital Medical Director as two separate individuals, then the County receives one (1) extra point.

6. Add up total points and multiplied by 100% to calculate total percentage (%) score

7. Fill out Comments / Explanation column

TABLE 5. INDICATOR 3– ALL CHT ADMINISTRATIVE POSITIONS FILLED

COUNTY FILLE

D

IN

PROCESS

NOT IN

PROCES

S

TOTA

L

BONU

S

COMMENTS / EXPLANATION

CHSA 1

ACCOUNTANT 1

FINANCE ASSISTANT 1

PROCUREMENT OFFICER/

LOGISTICIAN

1 IN PROCESS OF TRAINING LOGISTICS

OFFICER IN PPCC AT THE LIPA IN

MONROVIA

HUMAN RESOURCE OFFICER 1 PERSON IS NEW, NEEDS

ORIENTATION. STAFF APPRAISALS

NOT TAKING PLACE. NEED FOLLOW

UP.

TOTAL POSSIBLE SCORE 5

TOTAL SCORE 4 1 5

TOTAL SCORE (TOTAL / TOTAL

POSSIBLE) X 100

FINANCIAL MANAGEMENT

INDICATOR 4

Timely and Complete Submission of the Budget Monitoring Reports (BMRs)

Indicator:

The OFM tracks submission of the quarterly BMR by the CHTs reflecting expenditures as well as requests for funding for the following quarter

Criteria: Cash Plan

Spent in line with planned activities

Submission of monthly budget execution to top management of the CHT (for budget execution review)CHT should ensure that form A and B are prepared monthly and OFM should ensure quarterly financial report which includes: Bank reconciliation, cash book ledger etc.

Data analysis for this indicator is conducted by the OFM. Table 6 below provides an example of how this is to be done.

Example Table 6. Indicator 4– Timely and Complete Submission of Budget Monitoring Reports

COUNTY 1

nd rd th st nd rd th

TREND RECOMMEND

-ATION

BMR N/S N/S I/C I/C C C C C UP = 2 NO = 0

TOTAL SCORE 0 0 1 1 2 2 2 2

10 + 2

=12

TOTAL POSSIBLE

SCORE (2 X 8)

2 2 2 2 2 2 2 2

TOTAL SCORE

(TOTAL / TOTAL

POSSIBLE) X

75%

INDICATOR 5

Office of Financial Management (OFM) Regular Quarterly Performance Analysis Scores

The OFM conducts quarterly financial analysis by county and gives each county a score. This score is a composite indicator comprised of eight(8) financial variables.

INDICATOR 4: TIMELY AND COMPLETE SUBMISSION OF THE BUDGET MONITORING REPORTS

Obtain and review the last eight (8) quarters of BMRs

2. Score each BMR report with either a Complete “C”, and Incomplete “I/C” or a Not Submitted “N/S” score. Each “C” receives a two (2), each “I/C” receives a one (1), and each “N/S” receives a 0.

BONUS POINTS

IMPROVEMENT IN REPORTING

3. Award bonus points in the “trend”…