Journal of Public Health Aspects
ISSN 2055-7205 | Volume 4 | Article 1
Original Research
Open Access
Benin experience of Decentralized Steering Committee in
the institutional framework of Results-Based Financing:
elements for players’ empowerment at local level
David Houeto1*, Graziella Ghesquiere2, Maurice Agonnoude1, Amavi Hounouvi2, Karel Gyselinck3 and Mohamed Lamine Drame2
*Correspondence: dhoueto@gmail.com
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School of public health, University of Parakou, Benin.
Belgian Development Agency (BTC), Cotonou, Benin.
3
Belgian Development Agency (BTC), Brussels, Belgium.
1
2
Abstract
Introduction: In 2012, Belgian Development Agency (BTC), at the request of Benin Authorities, introduced
a Results-Based Financing (RBF) mechanism in two Regions to improve health system performance. The
purpose is to grant subsidies to providers and managers of care and services on a performance basis. Two
regional steering committees (SC) chaired by mayors have been set up with health care and civil society
representatives. Mayors were given the position of buyer of performances on behalf of beneficiaries. The
aim is to study the institutional arrangements for the management of BTC’s RBF at the decentralized level
in relation to its effectiveness in the context of supply/demand dialogue, community empowerment, better
coordination between local Governments and Health, and improving care quality.
Methods: This is a cross-sectional study with retrospective and prospective data collection. The study
population is made up of players involved in the RBF. Data collection was carried out through the
documentary review of the RBF experiences in Benin. The analysis was conducted by identifying the
strengths, weaknesses, opportunities and threats of the SC at the decentralized level.
Results: Regular meetings of the SC focuses henceforth on the resolution of concrete problems through a
constructive dialogue between supply and demand; Community participation has shifted from information
to co-decision making; Enhanced accountability: providers and managers report on their performance to
the reporting line, mayors and the Civil Society; The presence of the Civil Society and the mayors ensures
compliance with the principle of performance-based payment and contributes to the fight against fraud and
impunity; Complaints management data and community verification feed into the supervision of the Health
zone management team; Progressive financing of the SC functioning by the municipalities and; Improving
satisfaction of health services users.
Conclusions: SC at the decentralized level promotes stakeholder engagement for people’s access to health
care; It shows the need for a permanent framework of exchanges among players at the decentralized level
to improve the provision of care; Involvement of mayors in a process of improving care quality and at a
decision-making level is a guarantee of responsibility and community involvement.
Keywords: RBF, decentralized steering committee, community empowerment, sustainability
Introduction
According to Canavan et al. [1], results-based financing (RBF) is
a method of financing focused on the assumption that linking
motivations to the performance would help to improve accessibility, quality and equity in the provision of health services.
Blanchett quoted by Canavan et al., [1] argues that its impact
would vary according to the providers’ demographic and organizational characteristics including the volume of activities,
existence or non-existence of a competitive local environment,
acceptance of wage subsidies and players trust to the merits
© 2017 Houeto et al; licensee Herbert Publications Ltd. This is an Open Access article distributed under the terms of Creative Commons Attribution License
(http://creativecommons.org/licenses/by/3.0). This permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Houeto et al. Journal of Public Health Aspects 2017,
http://www.hoajonline.com/journals/pdf/2055-7205-4-1.pdf
of this funding mechanism.
The institutional framework of the RBF is usually developed
around five main functions commonly recognized in the
mechanism implementation. The first function is the regulation which is to oversee the entire implementation process
and ensure its compliance with standards. It is provided by
the Ministry of Health (MoH), its central and technical departments as well as decentralized structures. The second function
is the quarterly assessment of the quality of health facilities.
It is provided by the decentralized structures of the MoH.
The third function is the funding provided by the Donors. The
fourth function is related to the purchase of performance which
comprises validation and payment of invoices provided by
the Project Coordination Unit (PCU) standing as the executive
structure. Finally, the fifth, the verification and certification
of invoices from different structures of suppliers of care and
services. It consists of the verification of quantities with the
RBF independent external control agency and community
verification provided by Community-Based Organizations (CBO).
The Steering Committee (SC) and its objectives
To improve project monitoring and validate the strategic
choices in order to help the project leader avoid making
decisions outside his prerogative, there is a need of setting
up a cross-functional team: the SC. The SC usually involves
a member of each line of the project work including the
product user.
For complex projects/programs such as those of health, we
can distinguish: (i) an operational SC (regular monitoring of the
project progress, decision-making in a delegation process,...);
(ii) a SC more strategically orientated which often involves the
company or organization leaders, able to make decisions that
go beyond the responsibilities of the operational SC.
As part of the RBF, the following have been set up: (i) at
the central level, policies development and global resources
mobilization; (ii) at the intermediate level, the interpretation
of the standards and policies and coaching of the peripheral
level of the health system for their implementation; (iii) at
the operational level, the effective implementation of these
policies with adaptation to realities on the ground. Lessons
learned get back to the central level through the intermediate
level in order to feed thoughts on various reforms. This is to
support the different levels of the health system to become
a learning organization. RBF implementation should take
into account these data in order to be able to contribute to
strengthening the health system.
This study proposes to answer the question: what is the
contribution of a decentralized SC in improving dialogue
between care providers and communities, community empowerment and care quality?
Study area and methods
Study area
Benin, like all developing countries, is characterized by high
doi: 10.7243/2055-7205-4-1
mortality rates at all ages. According to estimations, infant
mortality rate dropped from 89‰ in 2001 (DHS-II) to 67‰
in 2006 (DHS III) and maternal mortality rate was estimated
at 397 per 100,000 live births (DHS-III) [2]. Life expectancy at
birth was 56.5 years in 2012.
Methods
It is a cross-sectional study with retrospective and prospective
data collection. The study population consists of stakeholders of the RBF decentralized SC in Benin. Data collection is
performed through two techniques:
1. Document review on the RBF experience in Benin fed
when necessary with RBF experiences in other countries
in similar context;
2. In-depth interview with field stakeholders involved in the
implementation of the experience.
Selection of interviewees was based on expert choice from the
central level of the health system to the local level including
local government authorities. Data were collected using an
in-depth semi-structured interview guide. Topics discussed
include the effectiveness of the model in the health care
providers and caregivers’ dialogue, taking into account the
communities’ point of view through their representatives
or local leaders, empowering these communities; improving care quality; and the sustainability of both RBF and its
achievements in terms of health outcomes for the population.
These topics have been chosen based on the empowerment
process [4] that needs community participation and control
of the action under implementation, a process that leads to
sustainability. The RBF effects in terms of health outcomes
have been also taken into account. Because the timeframe
of the RBF implementation is too short, health outcomes
have been assessed through users’ satisfaction only using the
percentage of people in the community that have received
care with satisfaction. We used results of the quarterly assessments made by the RBF team.
Data processing was manual by thematic grouping taking
into account the above topics. Data analysis was made with
emphasis on the strengths, weaknesses, opportunities and
threats of the decentralized SC model.
Results
In the case of Benin, the RBF beneficiary is the health facilities,
and results are quantity and quality of the care provided. It aims
to improve the health system performance in the provision of
quality care to populations, especially the poorest and vulnerable.
There were ten stakeholders interviewed from the central
to the local level including a Mayor.
Description of the BTC SC experience and its institutional framework
The BTC experience of RBF started in 2012 with the main
aims of (i) strengthening national healthcare structures in
their mission, mandate and activities; (ii) empowering com-
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munities through the right to health approach; (iii) creating
an accountability process between all the local health system
(LHS) players and; (iv) developing LHS through the togetherness of its different players and improving the care quality.
In regard to the RBF, the BTC experience has some specificities such as: (i) involvement of the regional health directors
(RHD) in the peers evaluation (which comes as part of the 2nd
function), (ii) Mayors as the buyers of the performance (as
part of the 4th function, and (iii) the verification at community
level by the PUSS (Figure 1).
Figure 2. Schema recommended for the RBF.
PUSS=Platform of Health Services Users.
Figure 1. The main functions of the RBF/BTC.
BTC: Belgian Development Agency; HF: Health Facility;
HZH: Health Zone Hospital; MA: Medical Advisor; MMG:
Mutual Monitoring Group; MoH: Ministry of Health;
PUSS=Platform of Health Services Users; RHB: Regional
Health Board.
ber. It conducts, among others, data collection on complaints
and in the verification at community level and ensures their
return to HFs. Counter-verifications are organized and integrated supervisions (pools of expertise) are called upon to
speak based on significant and concrete elements. It thereby
establishes a permanent dialogue between the supply and
demand of care.
Contribution to strengthening decentralization and
communities’ empowerment
According to stakeholders, practices are based on the local
level HFs performance analysis. The result is a process of
The health zone management team (HZMT), although not compensation of HFs and HZMT by the SC members including
quite in the spirit of the “district health” as declared by the demand represented by PUSS and mayors. Moreover, the SC
Dakar conference [3], has other missions through the six pil- members are involved in a process of capacity-building while
lars of the district development namely: governance, human implementing the SC activities in order to play their role to
resources, healthcare delivery, funding, drugs and vaccines the best of their ability.
and logistics as well as the health information system. A
performance contract focusing on these six pillars is signed Improvement of care quality
between the SC and the HZMT.
RBF stakeholders reported that community participation
Tables 1 and 2 display the characteristics of the BTC/RBF to the SC through PUSS and mayors weighs in the process
experience compared to the centralized one.
of HFs services purchasing. Moreover, counter-verification
The Figure 1 summarizes the distribution of the different through the effectiveness of care is assigned to the PUSS and
functions of RBF in the context of the BTC experience.
is part of care quality assessment. Since the beginning of RBF
In summary, with regard to RBF implementation, BTC implementation in the BTC concentration areas, the trend is
experience is moving towards the scheme recommended the users’ satisfaction improvement over evaluations, with a
by Toonen and Coolen [4] (Figure 2) as part of West African stagnation over 80% since the 2nd quarter of 2015. Charts 1 and
decentralization and experience and focuses on decentralized 2 below present the trend of the scores of peoples’ satisfaction.
piloting with community participation in order to take into
account the local context and realities.
Discussion
We discuss these results through three main elements related
Effectiveness of the model in the supply-demand of to the empowerment process as mentioned earlier [3,4] and
care dialogue
which are: effectiveness of the decentralized SC model in the
The PUSS, as representative of the community is the SC mem- supply-demand of care dialogue; contribution to strengthening
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doi: 10.7243/2055-7205-4-1
Table 1. Framework of compared centralized and decentralized (BTC) SC implementation models.
Bodies
SC
Centralized
Level
Composition
Activities
Regulator
Level
Composition
Activities
Providers
Level
Composition
Activities
Buyer
Level
Composition
Activities
Auditor
Level
Composition
Activities
Donors
Level
Composition
Activities
Decentralized (BTC)
Central
Members of the HSS platform
Regional
- Deliberative voice: mayors, ITA/BTC, RHB, medical advisor, PUSS
- Consultative voice: Health Committee (HC), RTA/BTC
- Resource-persons according to the needs
- Discuss and validate the RBF implementation tools;
- Strategic decisions;
- Validate eligibility of health facilities;
- Monitoring;
- Validate results of assessments;
- Implementation coordination
- Validate the list of benefits to be financed taking into account public
at all levels;
health priorities defined by the MoH;
- Provide strategic guidance for
- Validate the maximum of amount of benefits purchasing with regard to
implementation;
the agreements with donors;
- Validate the implementation
- Inform the RDH of the administrative and/or technical faults perperedesigning ;
trated by health care providers;
- Mobilize resources from Gov- Validate the list of financial and other punishments based on informaernment and Donors for RBF.
tion transmitted by the pool of the RBF technicians;
- Arbitrate in the event of conflict between stakeholders;
- Develop strategies that encourage other donors to fund RBF;
- Report to the regional committee of projects/programs monitoring and
evaluation.
Central/Regional
Regional
Central departments of the MoH, Regional health boards
MI and others e.g. regional
health boards
- Take into account health policy norms and standards enacted by the
- Monitors implementation of
central level;
the system on a daily basis;
- Participates in HF evaluations - Proceed with the allocation of resources;
- Assess the performance;
at peripheral level;
- Guarantee quality insurance;
- Assures compliance with the
- Proceed to accreditation (integration of private HFs in the RBF by
standards;
checking their conformation with required standards);
- Supervises the process;
- Proceed with the training and supervision;
- Participates in the quality
- Participate in the verification of the quality and quantity.
verification.
Peripheral
Peripheral
HFs, peripheral hospitals
HFs, HZH
- Provide care to the population. - Preventive, curative, promotional, and re-adaptive healthcare delivery;
- Development of business plan;
- Organize the mutual monitoring group with the involvement of the comanagement bodies.
Central
Local
PCU
Mayors (from a common basket of funds from various sources (currently
the BTC)
- Contract;
- Checks operations (quantity,
- Payment.
quality, accuracy)
- After checking, subsidizes the
claimant
Central
Peripheral
Technical assistant (TA) and CBO PUSS, Regional technical assistant (RTA) - peers (from HFs, hospitals,
Consortium
RHB and the HZMT (from another region)
- Technical audit;
- Technical audit;
Verification at community
- Verification at community level (counter-verification and satisfaction
survey);
level.
- Complaints management.
Central
Central
Donors/HSS/MoH
BTC
- Funding and supervision.
- Funding;
- Technical support.
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Table 2. Cycle of the RBF with centralized and decentralized SC.
Activities
Annual
Centralized SC
- RBF contract negotiation;
- Communication on RBF
contracts;
- Accounting audit of RBF
expenditures.
Semi-annual
Quarterly
Quality cross-checking
- Measures and checking of
RBF results;
- Determination of the amount
of the credit RBF;
- Payment of the credit;
- Allocation of the credit;
- Spending on credit.
BTC decentralized SC
Interdepartmental workshop:
- Assesses RBF implementation in its main functions;
- Shares experiences among different players;
- Revises the RBF framework of implementation;
- Harmonizes practices in the two sub-territories;
- Identifies the alternatives of accompaniment of HFs, HZH and HZMTs in
connection with the end of the RBF funded by the BTC;
- Revises the assessment grids.
- Checks that HFs take their commitments in implementing their plan of
results, transparency in management, respect for the rules and procedures of
the agreement;
- Checks that various SC members are fulfilling their commitments in terms of
support to the RBF implementation;
- Validates the weighting of the results obtained after the audit reports;
- Validates the amount to be transferred by the payer to the contracting
structures HZMT, HZH, HF, etc.);
- Monitors the SC recommendations;
- Presents the results of community verification and complaints management
to the executive committees expanded to co-management bodies.
decentralization and communities’ empowerment and the
care quality improvement.
Effectiveness of the model in the supply-demand of
care dialogue
Chart 1: Trend of the satisfaction scores in Mono-Couffo
2015-2016. Q=Quarterly.
Chart 2. Trend of the satisfaction scores in Mono-Couffo
2013-2014. Q: Quarterly
To make care available to patients, it is important that people
are an integral part of the implementation process for healthcare provision according to primary health care (PHC) [7].
PHC are so fundamental that any program that sidelines the
basic principles of strengthening the LHS, e.g., the demand
participation, intersectorality, improving living conditions,
etc. is condemned to failure [5].
Experience supported by BTC shows the process of the complaints management implemented by the PUSS, the mayors
and the provision of care is a contributor to the supply-demand
dialogue. In the case of Rwanda reported by Morgan [8], SC is
placed at the District level with involvement of communities’
representatives and thus allowed the mixing between the
supply and demand of care. The BTC experience based on
Figure 2 [6], in the long term is a contributor to RBF rooting.
According to McFarlane and Fehir [9], it will take two to five
years for the community to get control of the whole process.
As far as we are concerned, we think that this term will also
depend on the initial level of powerlessness of each community
or the quality of its assets, its willingness to change, its health
status and quality of life, and also will depend on the strength
of the role the professionals played at the beginning of the intervention process by really giving power to the community [3].
Contribution to strengthening decentralization and
communities’ empowerment
Decentralization of the health system and its effect on com-
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Houeto et al. Journal of Public Health Aspects 2017,
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munity empowerment are concepts well acquired and supported for example by the Harare and Dakar declarations [5,10].
The effectiveness of the health system in terms of action on
the social determinants of health depends deeply on it [5]. A
strong and sustainable RBF needs thereby to be based on these
concepts. Considering the BTC experience, positioning the SC
at a local level could facilitate the learning of the exercise of
responsibility by local authorities and eventually contributes
to their empowerment. Learning how to solve issues raised
up by the RBF implementation, knowing the mechanisms of
the RBF funding and learning how to get the Donors support for that funding are all elements contributing to local
stakeholders empowerment and which deserve to be taken
into account in this initial phase of the RBF implementation
[11]. In this sense, the SC structuring in the BTC experience
could at long term be an asset in contributing to the health
system decentralization and local authorities’ empowerment.
Nationally, as it is the case in Rwanda, the SC at decentralized
level in the structuring of the RBF institutional framework
depends largely on the structuring of the health system in
place. It is certainly easier to use such a design as long as the
health system is engaged in the process of district health.
Improvement of care quality
Although it would take time before to be able to assess the
effect of RBF on the improvement of care quality, we could
still note elements contributing to this end. For instance, the
process of complaints management involving the return of
data to the weakest HFs, the counter-verification and pools of
expertise who meet to resolve the various problems identified
are meaningful and concrete elements involved in improving
care quality. Furthermore, community participation both by
the PUSS and by the individuals in the community to verification and counter-verification activities is likely to contribute
to care quality improvement. Counter-verification weighs
in retribution to HFs, and so is a factor that contributes to
questioning HFs regarding the quality of their services. Also,
strengthening decentralization and empowerment [5] in the
implementation of the RBF is an important factor in improving
care quality by strengthening demand as a valid interlocutor
towards the supply of care. Indeed, community participation
in its type of community development allows to give to local stakeholders the opportunity to take an active role in an
intervention (here RBF), to benefit from capacity-building
activities and thereby aim community building. With the
acquired skills, the community is able for example to require
proper care from health care providers. The decentralization of
SC with a role for local stakeholders is part of improving care
quality [3]. The Rwandan experience [8] of decentralized SC has
been successful in the implementation of the RBF with significant results in terms of improved maternal and child health.
doi: 10.7243/2055-7205-4-1
ized the SC with positive consequences on the quality of the
supply-demand dialogue, the strengthening of decentralization and communities’ empowerment and the care quality
improving. But in a process of scaling it up, it should be better
to consider the reform of the health system structure in terms
of its decentralization.
With regard to prospects and recommendations for community empowerment, strengthening decentralization leads
to greater empowerment with consequences for communities, among others, a much greater demand for care quality
in the case of RBF and the sustainability of the action [4].
Local stakeholders being involved in the process and, at the
same time, in a learning situation through capacity-building
activities, it is highly likely that they pursue the approach and
therefore its sustainability [10].
This tendency to conform to the pattern recommended
for RBF [6] could, over time, lead to a community empowerment in the health system. That is the purpose of RBF scaling
up in Benin to follow the scheme recommended in the West
African context in general and Benin in particular (Figure 2).
In view of the foregoing, it is important to take the health
system as a whole with as corollary the empowering participation of communities through effective decentralization
process. Considering the RBF implementation process with
a decentralized SC should make a great contribution in improving dialogue between care providers and communities,
community empowerment and care quality. The RBF/BTC in
Benin seems to favor such a process that should be put on a
scale with a view to sustainable results in this case.
List of abbreviations
BTC: Belgian Development Agency
CBO: Community-Based Organizations
COP: Community of Practice Health Service Delivery
RTA: Regional Technical Adviser
DHS: Demographic and Health Survey
HC: Health Committee
HF: Health Facility
HSS: Health Service Strengthening
HZH: Health Zone Hospital
HZMT: Health Zone Management Team
ITA: International Technical Assistant
LHS: Local Health System
MA: Medical Advisor
MI: Ministerial Inspection
MMG: Mutual Monitoring Group
MoH: Ministry of Health
PCU: Project Coordination Unit
PHC: Primary Health Care
PUSS: Platform of the Health Services Users
RBF: Results-Based Financing;
RHB: Regional Health Board
RHD: Regional Health Directors
SC: Steering Committee
TA: Technical Assistant
Conclusion
Competing interests
In Benin, the RBF process that is implemented by BTC decentral- The authors declare that they have no competing interests.
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Authors’ contributions
Authors’ contributions
Research concept and design
Collection and/or assembly of data
Data analysis and interpretation
Writing the article
Critical revision of the article
Final approval of article
Statistical analysis
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doi: 10.7243/2055-7205-4-1
Citation:
Houeto D, Ghesquiere G, Agonnoude M, Hounouvi
A, Gyselinck K and Drame ML. Benin experience of
Decentralized Steering Committee in the institutional
framework of Results-Based Financing: elements for
players’ empowerment at local level. J Public Health
Aspects. 2017; 4:1.
http://dx.doi.org/10.7243/2055-7205-4-1
Acknowledgement and funding
The authors are grateful to the Belgian Development
Agency for its support in undertaking this study.
Publication history
Editor: Nicola Shaw, Algoma University, Canada.
Received: 25-Apr-2017 Final Revised: 19-May-2017
Accepted: 23-May-2017 Published: 04-Jun-2017
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