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September 11, 2017

Meet MCDI's Experts: Ismael Sued, Performance Based Financing



Ismael Sued, MCDI Lesotho

MCDI is proud to employ some of the world's top experts in numerous public health fields. In Lesotho, Ismael Sued leads MCDI in its role as the Performance Purchasing Technical Agency for a Performance Based Financing (PBF) project funded by the Government of Lesotho and the World Bank. In this project, MCDI works to improve the quality of health care provided throughout rural Lesotho. We spoke with Sued to discuss his personal interest in PBF and his work with MCDI.

Tell us a little bit about the evolution of your personal interest in PBF.

My professional experience was initially in the private, for-profit sector. Working mostly in administration, I became interested in contract and procurement issues. Thanks to my educational background (I have a law degree), I soon became entrusted with all matters contracts-related. In particular, I took a short course on Service Level Agreements (SLAs), which are commercial contracts that are output-based. More specifically, their purpose is to define what quality of service the customer will receive. Shortly after that, I was recruited by a non-profit US company that was implementing a USAID funded project in Rwanda, then called the HIV PBF, to work as a Contracts Specialist. I was attracted by the opportunity to become a pioneer in designing the contracting tools for PBF in Rwanda and being part of an innovative approach to address the health issues of Rwandans.

At first I was like a fish out of water, very unfamiliar with public health and health issues in general, not understanding any of the terms and acronyms, let alone the concepts. Little by little, however, I was hooked. Gradually I became involved in all aspects of the project, including training public health workers on PBF, budgets, procurement, donor and partner relationships, etc.

After 5 years in PBF, I returned briefly to the private sector, but when the opportunity to consult on PBF implementation on another international project came - this time funded by the World Bank - I could not resist the call. What I enjoy about working in PBF is being an agent of change, introducing such concepts as efficiency, profitability, business planning, and client satisfaction to the public health sector and health services delivery, which in many cases is a complete shift in mentalities. I enjoy pushing health managers to think and behave as efficient business people. In the best cases, some of them emerge as remarkable and very resourceful entrepreneurs for the benefit of their health facilities and their patients.

Where is your work with MCDI located?

I work in Maseru, the capital of Lesotho, in an office located on the premises of the Lesotho Ministry of Health.

How many people are benefitting from this PBF project?

The coverage of the project is 6 out of the 10 districts of Lesotho. We cover 100 Health Centers and 7 District Hospitals with a total catchment population of approximately 1,011,362 people.

What technical approaches are you using?

We are implementing a typical PBF intervention for health facilities. It provides output-based financing in the form of direct cash payments to health facilities on the basis of their performance. The performance is measured in terms of the quantity of services provided and the quality of these services. These incentives can then be used to provide direct cash incentives to staff on an individual basis on the one hand, and on the other hand they can be reinvested in the health facility through infrastructure or other necessities for the improvement of health services. Usually, the facilities choose to use 50% for staff bonuses and 50% on improvement of services.

What are the results you are getting?

The results are very encouraging. After some initial challenges at the start and a project redesign in 2016, we have seen improvement in a number of quantity Indicators, such as the number of health facilities based deliveries and number of outpatient consultations. At the same time, we have seen a constant and sustained increase in the quality of care scores achieved by all PBF implementing facilities, particularly secondary level facilities (District Hospitals). From June 2016 to June 2017, the District Hospital quality score average has gone from 55.3 % to 77.2 % (using the Hospital PBF quality checklist tool).

What are your major personal and professional satisfactions in working with MCDI on PBF?

I enjoy working in development in general and public health in particular. Knowing that my work in PBF will make a difference in the quality of care that patients will ultimately receive is very rewarding on both a personal and professional level. Having worked in the corporate world in my past life, in the future I will not consider any job that doesn't have an impact on the greater community.

What are some "lessons learned" from your experience in the design and implementation of PBF interventions which might be helpful to the global community?

In my experience, a successful PBF design can go through a lot of trial and error at its inception, but it only makes it more successful in the long run. Indeed, the project design will inevitably borrow from past experiences in other countries, but it takes time - and at times mistakes - to appreciate the specificities of each public health system and to manage expectations from all stakeholders. For example, when starting the implementation in Lesotho, we realized that the challenges were quite different as the infrastructure in that country is in relative good condition and health centers had all been recently renovated. The population is used to attending government and faith-based facilities, and there is little competition from traditional "healers" as we had experienced in other settings. Therefore, the increase in attendance of district hospitals following the introduction of PBF was not as striking as we had experienced in other African countries. After one and a half years of implementation, the donor and MCDI consultants worked on a redesign of the PBF project at District Hospital level in order to re-focus our incentives solely on the quality of care rather than the quantity of services provided. This has produced a great improvement in quality scores of hospitals, as well as greater health worker participation and enthusiasm.





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