Outcomes of a performance-based contracting strategy in south Sudan

Background: The USAID-funded Sudan Health Transformation Project II (SHTP II) developed performance-based contracts (PBCs) with 9 sub-contracting partners (SCPs) in 14 counties to support rapid expansion of the basic package of health services (BPHS). Methodology: Through SHTP II a performance matrix was developed that linked key indicators of BPHS achievements by the SCPs to payments using a select group of 11 project indicators covering both program and management activities. Scores < 80% paid only 95% of the scheduled payment (a 5% penalty); 80-100% resulted in full payment; and > 100% generated a 6% performance bonus. Results: After implementing this payment formula, SHTP II demonstrated a rapid and significant increase in the provision of the key BPHS, eg, coverage of DPT 3 increased from 30% to 86% in just two years. ANC 1 visits increased 287% and ANC 4 716% and IPT 2 increased from 29% to 53% of PW during this time period. Conclusion: In the first Q of implementation, only 2 counties received a performance bonus compared with 7 (50%) in the last quarter. Tying payment to indicator performance improved access to BPHS services by incentivizing program acheivements and rewarding good performance. PBCs can play a strong role in rapid expansion of access to services even in a fragile, post-conflict state like South Sudan.