Recommendations for Nigeria, Zimbabwe, Lesotho, Liberia, South Sudan

The course participants in Mombasa

The 64th performance-based financing (PBF) course took place from Monday, November 20 to Friday, December 1, 2017, in Mombasa, Kenya.

Five country groups conducted an analysis of their health systems and produced detailed action plans on how to advance PBF in their respective countries. Hereby the detailed course report.

34 participants attended the course in Mombasa with 21 participants from Nigeria, 5 from Zimbabwe and Liberia, 2 from Lesotho and 1 from South Sudan. Participants were high-level from various Ministries of Health and agencies. 32 participants conducted the final exam and the average score was high with 79%. Five participants obtained distinctions. The Sai Rock Hotel is an attractive venue at the Mombasa beach, but there were concerns about the internet and the maintenance of the rooms with sometimes interruption of water supply. We aim to keep the PBF courses relatively low cost and organizing the courses in a 5-star accommodation would mean increasing the course fees. A very luxurious environment would also give the wrong signal whereby we promote the efficient use of public resources.

The Mombasa village chief and deputy from Nigeria and Liberia

The “village 64” chief, Dr. Daniel IYA together with his deputy Dr. Cuallau JABBEH-HOWE, the timekeeper Dr. Simon NYADUNDU and the tax collector Mrs. Lineo MOHLOMI, all actively supported the facilitation process and contributed to a congenial atmosphere and maintaining “order” in the village.

The daily evaluations resulted in scores, which when compared to previous courses were above average. The methods and facilitation scores were 93.9%, 7% above the average of the previous 20 English courses. The score for participation was ok with 87.2%, which is comparable with the previous courses. The organization of the course in Mombasa was with 90.7% 5% above the average of the previous courses. Yet, the participants this time were less satisfied with Sai Rock Hotel and in particular concerning problems with the water supply and the food, which was considered too monotonous. The subject of timekeeping scored 67.9%, which was 5% below the average of the previous courses.

The final evaluation showed the program answered the expectations of participants, but that improvement could be achieved in informing participants in advance about the course. The methodology of the course was considered good with an average score of 91%.


     Buffalo in Shimba Hills


  • States are encouraged to start PBF programs using several sources of financing. This was proposed in Mombasa by the Commissioner of Health of Nasarawa State, who is committed to launching a state-wide PBF program.
  • Transform the Safe One Million Lives (SOML) financing towards a pure PBF approach while still targeting the achievement of the state level disbursement-linked indicators.
  • The World Bank may match funding, on a 50% – 50% basis, for those States willing to start a pure PBF approach with Internally Generated Revenues, SOML funding, own State resources, or resources from other partners. This would also solve the problem of the fiscal space for the WB-financed PBF programs (preferably at least $US 4.00 per capita per year) and at the same time assure the buy-in from the States and the Federal Level authorities.
  • Review the institutional set-up of the federal level PBF program and identify the roles and profiles of staff for the NPHCDA and the FMOH.
  • Liaise with the 193 participants of the previous Mombasa PBF courses since 2010 in order to form a critical mass of people to lobby for purer forms of PBF in more States.


  • Review the PBF design and improve the PBF feasibility score.
  • Recommend the review of the policy on the abolition of user fees.
  • Advocate for competition between public and private pharmaceutical suppliers.
  • Advocate for more autonomy for health facilities such as for the use of cost-sharing revenues and buying inputs from accredited distributors.
  • Review and increase the number of indicators to at least 25. Separate quality and quantity indicators and ensure inclusion of community-based indicators.
  • Solve leadership problems at central level by the better description of the profile, outputs, and quality of services desired for each actor including at the top regulatory level of the Ministry. PBF contracts may formalize these relationships and incentivize with performance payments.
  • The regulatory health district authorities should be capacitated and empowered with performance contracts to implement PBF style reforms.

     A forest fruit in Shimba Hills Park


  • The South Sudan participant proposes to join hands with the previous Cordaid PBF course graduates from May 2017 and to form a critical mass to advocate with government and donors on the need for performance-based programs. An important partner may be the World Bank, which may also advocate for PBF style reforms.
  • Develop and implement a well-designed PBF pilot in areas where the INGO Cordaid is the lead partner. The PBF scheme should contain the full primary- and hospital level packages and have adequate funding.


  • Advocate for a purer form of PBF together with previous PBF course participants.
  • Advocate that the Ministry of Health changes input budget lines from GOZ funding, levies, taxes, and partners towards PBF performance funding.
  • Provide equal opportunity for obtaining PBF contracts to all health facilities whether public, religious or private; urban or rural.
  • Enable a more competitive environment in the supply of health commodities by removing the restrictions that favor monopolies.
  • Allow the Directorate of Pharmacy Services to work on accreditation of the public and private wholesale pharmaceutical companies including registration requirements and scope of work to allow entry into PBF.


  • Review the existing PBF institutional and implementation arrangements as well as the package of services to be subsidized.
  • Consider the possibility of introducing user fees and compensate the vulnerable with targeted equity bonuses.
  • Separate the functions through the “purchaser-provider split”.
  • Introduce PBF contracts not only with health facilities but also with the other actors in the health system.

These recommendations are similar to what previous groups from Liberia also proposed. Yet, by increasing the critical mass of PBF trained participants from Liberia the implementation of these recommendations should become possible.

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