Hereby the report (rapport du cours) of the PBF course that took place in Bukavu from 9 to 21 October with 19 participants from the DRC (16), the Republic of Congo (2) and the Central African Republic (1).
The 63rd PBF course was a success. The action plans proposed by the working groups are of a high standard. The course had relatively few participants (19), which allowed for intense exchanges between the participants and the facilitation team. This was appreciated by the participants and their satisfaction with the facilitation was 90% and their satisfaction for participation was 93%. The economics module was considered difficult by a large part of the participants. We regret that economics and health economics is not considered important in the curriculum of most health sector training institutes. We consider this to be a major challenge in making health systems more efficient. Several participants also indicated that the indices management tool module requires more time. Another wish of the participants was that it is necessary to develop a PBF course more specifically for the PBF in the administration sector.
The presence of Dr. Paul Pilipili Hangi and Dr. Claude Ntabuyantwa of the PBF Unit from Kinshasa was a great asset to share their national experiences as well as to discuss the challenges of the PBF system in the DRC.
The course produced two distinctions and the average posttest result was slightly above the scores of previous PBF courses.
Strengths and challenges of PBF in the DRC
PBF in the DRC covers 27.5 million (= 35% of the total) inhabitants with World Bank funding of US $ 390 million for the period 2015-2019, which corresponds to $ US 3.00 per person per year. There are 169 Health Districts covered by the PBF program and the PBF provinces have created CDV Agencies (Contract Development and Verification Agencies). The program supports 180 hospitals and 2,818 primary health facilities and is the largest PBF program worldwide.
The PBF approach in DRC has achieved the following results:
- Overall output and quality of care indicators show good progress between Q1 2017 and Q2 2017;
- The national PBF manual first published in 2015 is of excellent quality and there were already two improved versions;
- The national PBF Unit with the support of the World Bank team succeeded in making PBF (or strategic purchasing) the national policy
- A growing number of partners also adopted PBF and harmonized their activities such as USAID, Global Fund, GAVI, UNICEF, and UNFPA;
- The PBF Unit has successfully introduced a package of 22 indicators for the primary level and of 24 indicators for the hospital level. The selected indicators take into account high-impact interventions, there is geographic equity between health facilities, articulates with flat-rate pricing and includes poor people.
- The PBF approach emphasizes several values: the separation of functions, contracting, verification of output before payment, community verification through local NGOs, management autonomy, the involvement of the private sector, etc.
- Harmonization to use a single PBF web portal. The PBF management platform is accessible from fbp-rdc.org The public space to view project results can be found at front.fbp-rdc.org Project data is available in a DHIS2 database which also hosts the HMIS system of DRC;
- The country applied cascade and large-scale PBF training by training 16 national trainers; training of 515 provincial trainers in 11 provinces in 4 waves of 14 days; training of 2952 primary and hospital level health providers in 4 waves.
However, the PBF program in DRC is also confronted according to the PBF Unit members attending the PBF course in Bukavu with the following problems:
- Low coverage by banks in DRC;
- The enormous geographical spread between the provincial capitals and the Health Districts aggravated by the deterioration of roads make access difficult. Some health districts are 500 km from the provincial headquarters;
- The payment cycle is long with over 60 days for the transfer of subsidies into the health facility accounts;
- The web portal is still under construction and it is still impossible to generate invoices online. Data are sometimes unstable;
- Some actors do not master their working tools such as the quality evaluation questionnaire implemented by the district regulators. Some health providers do not master the indices management tool;
- Some Provincial CDV Agencies are inexperienced organizations that still need support and coaching. The operationalization of the CDV Agencies is often slow.
The facilitation team would like to share some suggestions for improvements based on the discussions during the course:
- The main problem is the continuation of the monopolies for inputs such as essential drugs. According to all participants in the course, this considerably decreases the efficiency of the PBF system. Some even suggest it to be a killing assumption. Drugs stock-outs returned to South Kivu province after that the 2005-2010 impact study written by Pacific Mushagalusa, Celestin Kimanuka, Peter Bob Peerenboom and Robert Soeters funded by Cordaid in the Katana and Idjwi health districts showed that with competition and the accreditation of distributors these problems can be solved. This study was published in the scientific journal Health Affairs in 2011. So we ask on the basis of what scientific evidence the DRC government has decided that monopolies can better serve the population compared to the approach with the competition? The argument that only a monopoly can guarantee the quality of drugs is wrong. The regulators in DRC have marginalized themselves from the reality that the population is already dependent on the informal pharmaceutical sector where the vast majority of transactions take place and where there is no quality control. The best solution will be to strengthen the regulatory function and the accreditation process, including the entire pharmaceutical sector while at the same time stimulating competition.
- Another suggestion from the PBF course was that the accompanying CDV Agency budget of US $ 0.50 per year per person is too low and should be increased to facilitate better verification, coaching and action research.
- Considering the current debates that the PBF approach is the best strategy for achieving Universal Health Coverage, the budget of US $ 3.00 per year per person in DRC might also be too low and could increase to US $ 5 or US $ 6 per person per year by increasing the number of primary and hospital package indicators (currently only 22 and 25) as well as to enlarge the number of beneficiaries for exemptions by the targeted PBF free health care approach.
- Many provincial CDV Agencies are extremely weak. They could benefit from the support of, for example, a pool of people and organizations in the province of South Kivu (and Kinshasa) who have developed experience with the PBF since 2003.
The use of Quality Improvement Bonuses (Investment Units) could be used as an instrument for the continuous improvement of infrastructure, equipment, human resources at all levels (service providers and regulators) and not only for the initial support. The QIB could also be used as a variable part of the subsidy budget applied by the CDV Agencies so that in the case of an underutilization of the subsidy budget, there is the possibility of investing the available gap with the QIB in the accelerating infrastructure rehabilitation, purchase of equipment, means of transport, etc.
- The PBF management web platform is only partially functional and the public space for viewing health facility results seems not to work. In addition, the CDV Agency in South Kivu cannot produce any invoices online and are thus obliged to prepare the invoices manually.