The 68th performance-based financing (PBF) course took place from Monday, March 5 to Saturday, March 17, 2018. Hereby the detailed course report.
The main objective of this course was to train in PBF all the remaining DMOs and Regional Delegation staff of the two English speaking North West and South West regions. This to assure that by the end of 2018 the scale-up of PBF in the two regions can be completed in all districts.
Fifty-one participants attended the PBF course in Douala, 50 from Cameroun and one from the USA. There were 27 DMOs from the North West, South West and Littoral regions. The participants from the North West and South West regional delegations and regional funds for health promotion were the second largest group. There were five participants from the central Ministry of Health and one from the World Bank. The participants were organized during the first day of the course into 13 sub-groups to work on their specific action plans.
Fifty-two participants (including one of the hostesses) conducted the final exam and the overall score was 78%, which was 5% higher compared to the average of 73% in the previous 2016 and 2017 PBF courses. Twelve participants obtained distinctions for the final exam with scores of 90% or more and one participant obtained 100%. This showed that the teaching methodology has been effective for this large group of participants but also that many participants had already previous experience with PBF.
The daily evaluations were above average and in particular, the methodology and the organization scored well. The final evaluation showed that for 85% of the participants the course answered their expectations. 80% of the participants thought that the time of the discussions was OK but some felt that the facilitation team did not allow enough space for alternative ideas and that the team insisted too much that PBF has become the chosen policy of the government. The content of the modules was considered good with an average score of 87%.
- Security issues have emerged in the NW and SW regions during the last year and these require attention. There is a need to combine the standard PBF emergency approach of paying for outputs + quality with a type of microcredit bank system or NGOs pre-financing to start infrastructure improvement, recruitment of qualified staff. The PBF payment cycle requires at least 2-3 months and this takes too long if we wish to provide immediate cash in case of any destruction or instability in health facility catchment areas.
- Inter-district equity. A particular attention should be paid to equity bonuses in the SW region in order to breach the wide gaps between poor and rich districts. The national level should engage in a new mapping to absorb non-viable districts to the viable districts without compromising the regulatory role of the state to provide health services to all the citizens.
- Transform the credit cards (“cartons”) budget lines of the MOH for the health district financing into PBF performance subsidies. The operational details of this mechanism still need to be studied and strengthened. For example, will the regional treasuries directly pay the health facilities and other PBF actors or can an arrangement be made that the financial PBF Unit forwards already paid invoices to the treasury for bulk reimbursement?
- From vertical to comprehensive programs. Use the PBF approach instead of mass campaign for the Neglected Tropical Diseases (Leishmaniosis, Helminths, Trachoma) and integrate mass treatment and prevention indicators in the minimum package of activities. For this purpose, a few SMART NTD indicators will need to be added to the Minimum Package of Activities. Immunization programs should also avoid mass campaigns but concentrate on the improvement of the standard immunization program.
- How to select the vulnerable. Proper criteria should be applied to the selection of the vulnerable instead of political criteria. The participants support the PBF approach of selecting the vulnerable by basically decentralizing the decision making power to identify the poor to the local health facilities with their communities. The centralized approach of identification of the poor is complex and full of potential pitfalls.
- Drugs monopolies. The regional funds should assist with the liberalization of the essential drugs market and face a more competitive environment with also other wholesalers allowed to sell drugs. Health facilities based on the circular of the Ministry of Health and Finance should be free to buy where they can find the best cost-quality drugs but from distributors that are accredited by the regulator. The regional delegations should play an active role in promoting distributors to invest in their regions and to assure the quality of the drugs through an accreditation system.
- Make the Contract Development and Verification Agencies more efficient. Restrictions placed by the CTN on coaching conducted by medical and community verificators should be lifted so that competent verificators may also be used for the coaching activities of the health facilities. They can thereby reduce the pressure on the CDVA manager and deputies.
- In-patients days. The numbers of days to be bought at the level of the health centers should be increased. The justification for the length of stay should be evaluated during the quality reviews ;
- Referral of the vulnerable. That a new indicator “referral for the vulnerable patients” should be added to the MPA indicator list, which is subsidized at 4-6 times the subsidy of fee-paying patients. This increase in subsidy should also take care of transport money for the vulnerable ;
- Training at the district level. Include training as an indicator to be bought by the PBF program from the District Management Teams.
- Training schools. Use objective criteria for the admission of new trainees to schools for medical and health personnel. This must include the development of quality standards for teaching staff of training schools for medical and health personnel and the objective selection of teachers by a committee. Start implementing PBF also for training schools.
The North West and South West regions should study the individual contract worker’ contracts from the Adamaoua Region. The contract should follow the labor code to protect the contract workers but also protect the health facility to be able to recruit and to lay off workers when they become redundant for example when revenues go down ;
- SW and NW CDVAs must recruit Quality Improvement Bonus experts (builders, architects, civil engineers) to ascertain the quality of investments (QIB) in infrastructure and equipment
- Urgently conduct the mapping and rationalization of the health facilities into units with good economies of scale (Minimum 5 000 – maximum 14 000 and rural district on average 8000 inhabitants and urban 12 0000 inhabitants). This to be done by the District Management Teams under the supervision of the DMOs.
- Health facilities and district authorities must open accounts with commercial banks and this should be used for all revenues including from cost sharing, donations, any government operational budget and the PBF subsidies (=basket account principle). This principle is supported by the circular letter of the MOH and the MOF of October 2017 ;
- There should be no accumulation of functions such as being the regulator and the provider at the same time. E.g. DMOs cumulating posts with also being the hospital CMO should be avoided ;
- Results of peer groups quality reviews of hospitals should also be communicated to the DMO of the district. DMOs can be observers of the peer group evaluations ;
- Employ qualified staff for community PBF activities including promotive, preventive and curative activities supported. This qualified staff should also be supported by community members.