OVERVIEW OF THE NINE PBF COURSES DURING 2017
There were nine 14-day PBF courses in 2017, during which we welcomed 344 participants from 18 countries. Of these seven were French spoken courses with 285 participants and two were English spoken with 59 participants.
Five courses were open to any participant who applied (Douala, Cotonou, Bukavu, and Mombasa 2x). The other four courses were organized for participants selected by their respective governments (Gabon 2x, Cameroun Ngaoundéré and in the Central African Republic).
In 2017, during the Bukavu October course in DRC, we celebrated that 10 years ago the first PBF course took place. Since then, close to 2000 participants attended 65 courses.
The first 2017 course was organized by the Gabonese government in Lambaréné in January and once again in July. The second course was organized with the Regional Fund for Health Promotion of Littoral in Douala in March. The other courses were organized with the Regional Fund for Health Promotion of Adamaoua in Ngaoundéré in Cameroun in July; with BEST-SD in Cotonou Benin in August; with the Agence d’Achat de Performance of South Kivu province in DRC in October and with the CAR government in Boali in November.
The participants in 2017 came from Cameroun 94x, Gabon 73x, the Central African Republic 47x, Nigeria 30x, Thad 19x and the Democratic Republic of Congo 18x. Smaller groups came from Guinea 11x, Zimbabwe 8x, Senegal 7x, Burkina Faso 6x, Ivory Coast 6x, South Sudan 5x, Liberia 5x, Congo Brazzaville 4x, Lesotho 4x, Uganda 3x, Niger 3x and Ethiopia 1x. The details of the PBF programs in these 18 countries can be found in the course reports to be found at this website.
- The proportion of female participants to the PBF courses of 25% remains too low. We do not fully understand the reason why but we should make efforts to improve.
- The final exam during the PBF courses has become more difficult during the last years. This we did to respond to the demand of several organizations such as the World Bank that have passed the course successfully with a certificate of merit or a distinction has the value that it means that the participant has understood what is PBF. The average score during the 2007-2015 courses was 78% and reduced to 72% in 2017. The proportion of participants, who failed the exam increased from 3% during the 2007-2014 courses towards 12% in 2017. The proportion of distinctions reduced from 23% during the 2007-2014 courses towards 12% in 2017.
THE CHANGES IN THE COURSE CONTENT DURING 2017
The facilitation team continuously updates the course content with the latest developments that take place in the PBF reform approach. Most facilitators also work with PBF in the field so that their experiences and the lessons learned are immediately introduced into the course content. This hands-on experience and exchanges during the courses are appreciated by the participants and their organizations and the demand for the PBF courses remains strong, also for 2018.
The following developments in PBF were integrated into the course content during 2017:
- PBF countries such as Cameroun and CAR developed and tested better equity strategies to target vulnerable districts, health facilities, minority groups, and individuals as well as how to respond when there is a humanitarian crisis. This development makes the PBF approach more attractive so that has become a preferred strategy to achieve Universal Health Coverage in low- and middle-income countries. It incorporates ideas such as to assure first of all the quality and the efficiency of health systems but then also target free health care for specific activities and vulnerable groups. Yet, the equity objectives can only be achieved when there are enough and stable public financial resources. The quality and efficiency-oriented approach are better than generalized free health care that is still promoted by some organizations but whereby quality suffers, health staff become demotivated and which creates corruption and uncontrolled informal activities.
- The PBF equity approach is also more efficient in achieving the objectives of the classical demand-side strategies such as vouchers by targeting similar groups of patients with increased subsidies to health facilities. In the PBF scenario, health facilities must develop the strategies to identify the beneficiaries in their catchment area.
- Voluntary community-based health insurance has lost its attractiveness but pilots are underway in Cameroun and Gabon to find out about how far obligatory health insurance can be incorporated in the more efficient PBF system of contracting and verification.
- Several PBF countries developed during 2017 strategies to promote more sustainable PBF systems. This is done by:
- Transform existing MOH input budget lines into PBF performance budget lines;
- Promote PBF as the national health reform approach fully integrated into the policies of the Ministry of Health and the government. This requires abandoning the PBF project approach, whereby partner organizations such as the World Bank set up independent Project Implementation Units. The problem with this “project” approach is that the Ministries of Health and governments do not “own” it.
- Sign performance contracts not only with health facilities and peripheral regulatory authorities but also with the central MOH Directorates. The central regulatory authorities should also receive variable performance payments based on the achievement of output and quality indicators instead of just receiving fixed salaries and money for fixed input budget lines such as per diems or operational costs.
- Improvements in the PBF community approach were achieved during 2017 by systematically injecting 15-20% of the total PBF budget for social marketing and community voice strengthening. One community PBF indicator that has become popular is “household visit following a protocol”. The idea is that primary level health staff visit twice per year each household in their catchment area. During these visits, about 20 health-related points are checked such as the status of immunization, nutrition, family planning, use of bed nets, availability of latrines, waste disposal, maternal or child deaths, etc. Community PBF also incentivizes the follow up on dropouts of TB, immunization, malnutrition, HIV patients, etc. Moreover, community PBF actively identifies vulnerable patients and groups.
- Apply the PBF best practices not only for the health sector but also for broader civil service reforms. The World Bank and IMF during discussions with the governments of Gabon and Cameroun used some of the PBF best practices as a conditionality for budget support. The idea behind this is that budget support should go hand in hand with improving the efficient use of those resources.
- Another development is the expanded use of the indicator Quality Improvement Bonus or Investment Unit. This has been tested extensively in the Central African Republic and the Northern Regions of Cameroun whereby during the first year of PBF up to 50% of the subsidies are paid against improvements in infrastructure, equipment, or the recruitment of qualified staff.
CHANGES IN TRAINING METHODOLOGY
During the last 10 years of PBF courses, the aim has always been to cover all course book modules in the 12 or 13 days of the course. This has become increasingly difficult to achieve because of the many new developments and instruments that were developed. As a result, the course book also expanded from an 80-page manual into a 260-page handbook with 17 modules.
We, therefore, propose the following changes in the course methodology:
- Reduce the course messages towards the essential ideas only of each module and make them simple to understand. This process is a work in progress because the lessons learned, new developments and opportunities in PBF are so fast that it requires continuous editing of the course materials.
- Reduce the time spent on plenary sessions and allow more time for the facilitation team to assist the different groups and individuals to develop their specific actions plans.
- Review the participants’ views and expectations on PBF by asking each participant on arrival to answer a pre-course questionnaire. Some are novices in PBF, who have come to learn but need first to understand and accept the PBF change issues. Others already have PBF knowledge or were recently recruited for a job in PBF. They do not need to be convinced about the change issues but wish to learn specific PBF knowledge and skills.
- Conduct a pre-test on the PBF knowledge of each participant. The outcome influences in how far the course should concentrate on the PBF basics or to fast-track towards the “how” of PBF and focus more on the instruments such as the output indicators, the indices management tool, the costing, and the contracting process with the different stakeholders.
- Organise national PBF courses (about 50% of all courses) with a specifically selected group of participants for example from the central regulatory level, hospital managers, regional or district regulators and/or CDV Agency staff. In such courses, we usually concentrate on developing SMART action plans for each stakeholder present.
- Better coordinate the debates also by making use of the “village” approach whereby the participants also become part of the facilitation team and influence the content and methodology. During the PBF course in the Central African Republic, the participants facilitated the debate instead of the facilitation team.