PBF in Gabon

Gabon aims to start in early 2018 a new PBF program that will cover a substantial number of regions. Preparations are still under way with the government and the World Bank about the size and the scope of the program. A particularity of this PBF program is that it aims to integrate and strengthen the existing obligatory insurance program, which is suffering from cost-overruns, moral hazard, quality assurance problems and verification problems. Preparations for the PBF program have started during 2017 with a feasibility study, a mapping and rationalization exercise of catchment areas, a two-day seminar with decision makers and, two 14-day PBF courses with in total 70 health professionals.

The second International PBF Course (the 62nd in total) was held in the Solf Hôtel in Lambaréné from the 10th to the 22nd of July 2017. Forty participants took part with eight facilitators and one staff dedicated to the Secretariat. All participants were of Gabonese nationality. 39 participants took the final test of the course and there was 1 distinction of 90% and 3 participants scored 87%.

Hereby the course report (rapport du cours).

In general, the international PBF course in Lambaréné was successful. The PBF gives hope for change and the principles of the PBF fit well with the spirit of transparency. One of the main conclusions of the course was that the separation of functions between the different stakeholders (regulation, contracting & verification, payment, provision and strengthening the voice of the population) is crucial to improving the Gabonese health system and its transparency. The two groups of the National Health Insurance Organisation (CNAMGS) with 7 people and the Special Treasury with 4 people proposed practical recommendations on how the CDV Agency can be integrated into the CNAMGS and how to implement the changes in the financial aspects of PBF. Other groups also made valid recommendations on how to proceed with PBF in Gabon.

Strong points of the course:

  • We have better managed the time compared to previous courses. We added one extra day, which was used to better achieve the teaching objectives;
  • In general, the participants thought there was enough time for discussions during the course, which is an improvement compared to previous courses.

Sixty-meter tall trees in the rain forest of Gabon

Points for improvement

  • Several participants found the microeconomics module difficult. Yet, we believe that this module remains crucial for health professionals to better understand the notions of efficiency and how to allocate scarce public resources.
  • 40% of the participants found the course too short and too tight and for future courses, we must further identify and present only the key messages.
  • It is important to send the electronic version of the course manual several days or weeks in advance to participants and ask them to start reading before the start of the course ;
  • Some participants were very satisfied with the course’s methodology and content but others criticized the quality of the book and the fact that the presentations of the modules did not follow exactly the chronological order of the book’s summary.
  • For a future course, we would have to identify a more spacious hotel.

Main recommendations from the course participant’s groups

Group 1: National Health Insurance Organisation (CNAMGS)

  • Separate within the CNAMGS the activities of those responsible for medical verification and of those responsible for the payment of subsidies ;
  • Integrate the (PBF) medical and community verification procedures in the CNAMGS system and thereby reduce fraud ;
  • Establish the required legal, technical and financial arrangements for the implementation of the PBF CDV Agencies within the CNAMGS. Sign a partnership agreement between the CNAMGS and the PBF. Host the PBF CDV Agency within the CNAMGS and thereby pool human, material and financial resources to improve the efficiencies of both activities;
  • Revise the agreements signed between the CNAMGS and health providers based also on the lessons learned and advantages of the PBF system ;
  • Redefine the tasks of the DCMLF (direction against fraud) within the CNAMGS by adopting some of the PBF verification mechanisms.

Group 2: Budget and Special Treasury

  • The implementation of the PBF approach is important because it introduces the concepts of microeconomics in the management of public services ;
  • Equally important is the autonomy of health facilities, taking into account the opinions of the local NGOs representing the consumers and the feed back mechanisms to the providers of the results of the satisfaction surveys ;
  • It is good that PBF payments are based on performance already achieved and not on inputs;
  • Draft and sign by the Minister of Public Accounts a decree granting management autonomy for health facilities and authorize the opening of the main PBF account at the National Treasury and secondary accounts for health facilities in the private banking structures ;
  • Develop a software application for the use of the health facility indices management tool.

Group 3: Central level of the Ministry of Health

  • Develop and sign a decree by the Minister of Health on the organization and the implementation modalities of the PBF Program in Gabon;
  • Establish the list of PBF output indicators and quality indicators;
  • Develop the PBF Manual and the PBF administrative procedures manual;
  • Recruit a consultant for the drafting of the PBF manual and the procedures manual.

Group 4: Ministry of Health Inspectorate

  • The rain forest and the river

    At the central level the Health Inspectors in collaboration with the CTN will:

  • Inspect the pharmaceutical wholesale distributors;
  • Sign performance contracts with the Ministry (Secretary General?);
  • Contribute to the quarterly regional reviews (with the Regional Directorates of Health, CDV regional agencies);
  • Counter verify the accreditations after the quarterly quality assurance reviews of the providers;
  • Contribute to the drafting and updating of the PBF Manual and PBF Procedures Manual;
  • Facilitate national and international PBF courses.

At the regional level the Inspectors will together with the Regional Directorate :

Contribute to the mapping and annual rationalisation of the health catchment areas;

  • Contribute to the inspections of the retail pharmacies;
  • Contribute to the coordination meetings after the quality evaluation of the FOSA;
  • Contribute to the monthly regional validation meetings.

Group 5: Regional Directorate of Health

Develop the legal texts that define the autonomy of the CDV Agency within the CNAMGS. Involve the Ministry of Social Affairs in the implementation of the PBF program ;

  • Update the mapping and rationalisaton of the public and private health facilities ;
  • Limit the health catchment areas by selecting among the candidate structures the main contractors and the secondary contracts based on economies of scale criteria ;
  • Organize the regional validation meetings for validating the output and quality results;
  • Identify, inspect and accredit the retail pharmacies.

Groups 6 & 7: Departments (= service providers)

The decision makers should validate the new PBF approach;

  • The Department health facilities should start conducting the peer-group evaluations of their health facilities;
  • Restitute the main lessons and recommendations of this PBF course to the main regional stakeholders ;
  • Organize a meeting with health facilities how to set the tariffs for cost-sharing fees ;
  • Ensure the empowerment of health facilities ;
  • Initiate the mapping and rationalization of the health facility catchment areas.

 

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