Improving human resources for sexual and reproductive health and maternity services in Somaliland through performance-based pay
Author: Health Poverty Action
After years of war and under-investment, Somaliland’s health system is weak and under-resourced. The Government of Somaliland struggles to provide sexual and reproductive health (SRH) services due to a lack of resources, weak capacity and security issues that prevent outreach to fragile groups. Somaliland therefore has amongst the worst SRH indicators in the world. Although a large majority of Somalis live in poverty, Internally Displaced Persons (IDPs) often experience additional hardships and it has been estimated that around 1.5 million people in the country have been displaced during the war. Displaced women and children are particularly vulnerable to sexual exploitation and violence, making the provision of SRH services of even greater importance for those living in IDP camps.
The Ministry of Health and Labour (MOHL) faces great challenges in identifying and remunerating skilled health staff. Many of these staff are poorly paid and often do not receive their salaries on time. Consequently many MOHL health workers work in private clinics to supplement their incomes (resulting in many health centres only operating from 9 am to 12 noon) and suffer motivational problems.
Health Poverty Action is implementing a Sexual and Reproductive Health project to tackle some of these problems. The project goal is to improve reproductive and sexual health among IDPs through the provision of functional health facilities that provide basic and comprehensive Emergency Obstetric Care. An important aspect of this was the introduction of a performance-based pay scheme for health workers in mid-2009.
Pay schemes introduced in targeted health centres are based on performance at both the facility level as well as at an individual level. Salary top-ups for health care providers and community-based facilitators have been introduced that are dependent upon achieving predetermined performance targets. A health facility performance system has also been adopted to encourage team building and to introduce competitiveness between facilities. Extra payment for night duty has been introduced to encourage health facilities to offer 24/7 services. The project uses HMIS data, health facility reports and routine facility visits as a means of verifying the indicators, and delivers the top-up payments to health care workers accordingly. The information is analysed and the targets of the indicators are revised periodically.
This incentivised approach has already registered remarkable success by increasing health workers’ motivation as well as commitment to longer hours of operation in project-supported health facilities.
It has increased the quality and quantity of Emergency Obstetric Care and skilled birth attendance. Antenatal visits to health centres by displaced women have been increasing steadily (by 20% in eight months). Opening hours of health centres have increased from under 4 hours to 12 hours of service a day and one centre now offers 24/7 services. The 24/7 operation hours are to be extended to the remaining four centres with effect from April 2010. Data from health facilities indicate a consistent gradual increase in the uptake of family planning methods from the five health centres covered by the project.
The performance-based payment model is an innovative approach to incentives and motivation for HRH in a fragile state context. This approach continues to yield remarkable results, stimulating commitment and enthusiasm among staff and leading to improved quality of services. It has contributed to longer opening hours of health facilities, decreased absenteeism of health staff and increased use of health care facilities.