Recommendations Cameroun 67th french PBF course

The 61 participants of the Doula PBF course

The 67th International PBF Course took place at Makepe Palace Hotel in Douala from 12 to 24 February 2018. Sixty-one participants took part in this course with six facilitators and three dedicated staff at the Secretariat. All participants were from Cameroon. The average score of the 61 participants who did the final test was 75%, which was slightly above the test scores of the last two years. Seven participants obtained a distinction with a score of 90% or more.

The course report (rapport du cours) can be downloaded from this site.

The positive aspects of the international PBF course in Douala

  • 92% of the participants said that “the objectives of the course were related to my professional activities”.
  • The duration of the course was considered satisfactory by 78%. This is a sharp increase compared to the March 2017 PBF course in Douala, which ended Friday instead of on Saturday.
  • The course book was considered good. This was the result of an intense editing of the French and the better harmonization between the book and PowerPoint slides.
  • The rooms and the internet at the Makepe Hotel have improved.
  • The course was attended by six Regional Health Delegates and 29 District Chief Medical Officers from seven regions, and we believe that all these health authorities have understood the rationale for the PBF and that they are ready to start or to improve the implementation of PBF in their various regions.

 The challenges during the PBF course

  • Traditional dancing in Cameroun

    The group was very large with 61 people, but this did not influence negatively the test scores, which were higher than the average of the previous PBF courses.

  • Makepe Palace Hotel was not appreciated by the participants and the conference room is not good for a group of 61. The Hotel at times also failed to provide a sufficient amount of food for the participants.
  • The time for the discussions was not considered sufficient for some participants. To the contrary, other participants said that the moderators gave too much time for discussions. They observed that the discussions were not always useful because they would rather learn what is PBF instead of to question the PBF approach.
  • The modules microeconomics and health economics were considered difficult and only 51% of participants were satisfied with these modules.
  • The relatively low score of 65% for the module on regulation is not well understood by the facilitation team because this module received sufficient time during the course. Also, the relatively low score of appreciation for the community PBF module with only 59 % is not well understood.

 Problems identified by course participants concerning PBF in Cameroun

  • The late payments of invoices by the PAISS project / national PBF Unit of the invoices of the different PBF actors were also not solved during 2017 after 5 years of attempts. PAISS developed a complex payment system that never worked well and this damaged the progress of the PBF program in Cameroon.
  • The PBF program has insufficient capacity especially in public health (analysis of data) as well as in health economics (to plan and conduct the costing) that allows for a correct planning of the expenses at the national level as well as at the level of the regions.
  • As recommended in the previous PBF courses of 2017, the PBF Unit signed the first performance contract with the Secretary-General for the 4th Trimester of 2017, but there was no evaluation yet. In addition, the profiles and attributions of all national PBF Unit staff have not yet been clearly defined and the mechanisms for paying the staff bonuses through the indices management tool are not yet applied.
  • Some districts still have an excessively large population of more than 250,000 inhabitants while other districts have a too small population of less than 75,000 to sometimes as low as 20,000. There are still many health facilities that cover either a too large population of 14,000 or more or a population of less than 5,000.
  • There is not yet a protocol at the level of the PBF portal to respond to the increase proposed by the district validation committee in the case of a high number of vulnerable people in a health facilities where the ceiling is increased from 10% to 25%, 50% or even 100% if there are  high proportion of minorities (Baka), internally displaced persons or refugees from neighboring countries.
  • The mechanism for submitting invoices to the portal for District Management Health Team and Regional Public Health Delegations is not yet functional.
  • It is unclear whether health facilities are allowed to keep a savings sub-account linked to their main current account
  • The procedures to follow for the health facilities which have accounts in microbanks are not yet clear. PBF money must first be transferred by the national PBF unit to Major Banks at the Regional level, which have “mother” accounts that in turn must forward this money to the microcredit bank accounts of the health facilities. This necessitates informing the health facility managers so that they can trace the money and collect it.
  • The rules for the recovery of health facilities in war zones, which require urgent support or repairs with the Quality Improvement Bonuses, are not yet clear.
  • The national hard copy PBF manual signed by the Minister is not yet printed and distributed to the PBF stakeholders.
  • The question of who are the signatories of the bank account of health facilities still poses problems. Members of the community are sometimes still signatories and this, in general, creates a lot of problems. It is, therefore, necessary to professionalize the financial management of health facilities and the principal contract holders must have at least two qualified staff, who are also the signatories of the account.
  • For many participants in the course, community PBF still only means supporting Community Health Workers. This is wrong because the PBF proposes that community work should also be done by the qualified staff of the Health Centers and in particular also for the Home Visits. They can be joined by community members, which is beneficial because they know better the community. This can indeed be a Community Health worker but also someone from the Commune, the Church or a qualified volunteer in urban areas. Unqualified Community Health Workers should not be involved in the distribution of drugs to avoid quackery. Instead, PBF proposes to promote the professionalism of medical acts.

Recommendations and solutions proposed

  • Limbe beach

    The following changes were made to solve the chronic payment delays of the PAISS project: 1. Integration of the PAISS team into a new national PBF Unit under one coordinator. This Unit has four subunits with unit managers and five cross-cutting units ; 2. There is a manager for the Payment Unit of the national PBF unit for the payment of the invoices ; 3. Since January 2018, invoices of the health facilities and other PBF actors are submitted online through the PBF Portal; 4. Validation of invoices is done by the District Validation Committee, chaired by the District Medical Officer and no longer by the PAISS project; 5. The confirmation of the data submitted to the portal must be done by a public health expert of the national PBF Unit ; 6. Payment of invoices will be done online to the commercial bank accounts of health facilities, CDV agencies, and regulators at all levels.

  • The above improvements materialize with the opening of new premises for the national PBF Unit in Yaoundé with 24 rooms and several meetings rooms.
  • Clearly identify the roles and responsibilities of all employees of the PBF Unit.
  • Improve the economies of scale of the health map by rationalizing the target populations of the districts as well as of the health facility catchment areas. This requires dividing the health districts into units of about 150,000 population and for example to divide very large health districts like Deïdo in Douala with a population of 800,000 in three. At the same time, it is proposed to give some districts major contracts that supervise the small districts For example, in districts with a small population, the medical doctor might focus on the hospital’s work and not on regulation to avoid conflicts of interest.
  • Include the signing of performance contracts with Health Districts as output indicator for the Regional Health Delegations ;
  • Urgently set up CDV Agencies for the Central, South and West Regions.
  • Encourage CDV Agencies to use their action research budget as efficiently as possible. Research topics should be discussed during the district validation meetings. The work should not be restricted to CDV Agency staff but should be used for any actors best capable of doing quality research (health facility staff, regulators, members of public health schools). The regions may also seek collaboration with international research institutes.
  • Strengthen the autonomous management of health facilities. This means: (a) Authorizing health facilities to open separate commercial bank accounts ; (b) Applying the market price for the purchase of inputs and no longer the higher mercurial prices, and; (c) Allow the PBF health facilities to purchase their inputs from accredited distributors operating in competition. The above points for autonomous management were formalized by a Circular of the Minister Health together with the Minister of Finance.
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