The 71^stInternational PBF Course was held in Makepe Palace Hotel in Douala from 7 to 19 May 2018. Thirty-two participants attended the course with six facilitators and three dedicated staff at the Secretariat. Three participants were from the Central African Republic and twenty-nine from Cameroon. The average score of the 32 participants who took the final exam was 75% which is slightly higher than the previous test results of the PBF courses. Three participants were awarded the certificate of distinction.

Hereby the detailed course report rapport du cours.

Positive aspects of the course

The daily course evaluations by the participants were good. Also at the closing of the course, we received positive feedback from several participants on the content and methodology of the course.

The quality of the action plans was better compared to previous courses because there was more time for the participants to work on them supported by coaching by the facilitators during the late afternoons and evenings. In particular, the action plans of the Division of Cooperation (DCOOP), the General Inspectorate of Medical and Paramedical Services, the National Malaria Control Program, the Regional Funds for Health Promotion and the General Directorate of the Ministry of Health from the Central African Republic were of a high standard.

The Makepe Hotel was rated better by the participants compared to previous courses. The hotel has invested in improving the rooms and the conference center. Food services were considered satisfactorily.

Aspects of the course that require improvements

During the final evaluation of the course, 30% of participants said that “the objectives of the seminar were not related to their professional activities”. We did not really understand this feedback but it could be linked to the fact that some directorates and programs are not yet fully engaged in the PBF program.

The duration of the course was considered too short for 39% of the participants; which means that despite the extra Saturday it is still difficult to share the main elements of the course within 14 days.

There were printing errors in the course book whereby some lines at the bottom of the pages were not visible and some tables and figures were fussy.

General recommendations of the course participants to the Ministry of Health

• Restitution of the PBF course recommendations in the respective workplaces including in CAR (all participants);
• Start PBF contracts with the Directorates and Programmes, which are not yet enrolled (all participants)
• Introduce PBF in the course curriculum of medical training schools, nursing schools, ENAM, etc (all participants)
• Harmonize the tax laws for both public and private health facilities and create an equal playing field (DRFP with MINFI)
• Advocate with the Ministry for a more rational division of the health districts (DOSTS / DRSP / DMOs / CIS)
• Advocate that training schools select and train students to become health entrepreneurs capable of advancing PBF best practices and innovation (all participants)
• Integrate the PBF quality reviews and accreditation in the work of the Inspectorates of the Ministry of Health (IG with support PBF Unit)
• Disseminate the circular of October 2017 of the Ministers of Health and Finance circular on the financial management of health facilities in Cameroon and make sure the new procedures are implemented (IGSA / PBF Unit)
• Develop or update the current laws  and procedures of the Ministry of Health to support the PBF reforms (IGSA / DAJC / DCOOP)
• Review the community verification interviews by local NGOs and make sure that they abide by ethical standards such as confidentiality (PBF Unit, CDV Agencies, DOST)
• Put the municipalities under performance contracts to assist with the PBF community activities such as household visits (PBF Unit)
• Assure that there is sufficient funding for supplementary feeding indictors in the nutrition whereby health facilities buy the required inputs  (Directorate of Health Promotion)
• Add more information at the PBF / HMIS portal such as health facility revenues and number of qualified personnel (CDV Agencies, PBF Unit, CIS)
• Disseminate the national PBF manual towards all contracted structures (PBF Unit / Regional Directorates / DMOs)

Main recommendations of the 17 PBF course working groups

The 17 groups developed the following action plans to be executed upon their return to the respective organizations. They are summarized in the following paragraphs and details can be found in chapter 7 of this report.

Central African Republic- Directorate General Fight Against Specific Diseases

Problems :

• The predominant input approach of partner organizations is not cost-effective ;
• The quality of the different parallel interventions of programs and partners is inadequate;
• The government contribution to the PBF approach is not sufficient ;
• There is still a lack of partner support for the PBF approach.

Recommendations:

• Conduct a restitution and disseminate the Douala PBF training report;
• Organize a government seminar on PBF;
• Increase the state contribution for the PBF approach ;
• Transform existing state credits for the Directorates and Programs into PBF lines;
• Request technical assistance for harmonizing partner funding to strengthen the PBF approach;
• Develop a framework for harmonizing partner funding in support of the PBF approach.

Central African Republic – central hospitals

A study conducted by the World Bank in two central hospitals of Bangui in April 2018 showed that there is a weak autonomous management, an inefficiency of the use of the public resources and poor financial transparency marked by informal payments to staff instead of patients paying fees directly to the cashier of the hospital.

Recommendations:

• Create in the Finance Law a line for operating expenses of the central hospitals (CHUMED, Hôpital Amitié, Community Hospital, CNHUB etc. …). This should replace the already existing fixed budget lines. This budget could be transferred monthly to a commercial account of the hospital and to be autonomously managed through the quarterly business plans and the index tool.
• Create in the Finance Law a PBF budget line for the central hospitals. This line should be used on the basis of hospital outputs in terms of outputs and quality. Output indicators from central hospitals can be the same as the hospital indicators already with PBF performance contracts in the other regions.
• Formalize informal practices so that money enters the hospital’s cash register

General Inspectorate of Medical and Paramedical Services– Cameroun

Action plan

• Organize a feedback meeting on PBF in the Inspectorate, produce advocacy sheets explaining PBF best practices and equity ;
• Develop a business plan and contract with the Minister of Health after preparation and coaching by the PBF Unit ;
• Involve the inspectors in the quarterly evaluation missions of the PBF Unit to the regions and in particular to study and support the PBF accreditation system;
• Develop a strategic document explaining the PBF accreditation system for public and private health facilities ;
• Organize a brainstorming session on the procedures for the regularization of private and public health facilities in collaboration with technical services (PBF Unit, DOST, and DAJC);
• Make available information on the status of private and public health facilities.

Division of Cooperation (DCOOP)

The main mission of the DCOOP is the coaching of technical and financial partners,  domestic NGOs, local associations and civil society. There is a mismatch in the involvement of partners in the government’s vision in favor of PBF, which leads to the vertical and parallel approach of their efforts not strengthening the health system. Moreover, most partner interventions are characterized by the input approach that does not work well.

Action plan

• Map the partners of the Ministry of Health;
• Sensitize and engage with partners in favor of strengthening the health system through results-based approaches to reach universal health coverage in Cameroon ;
• Develop, disseminate and monitor the orientations and standards that govern the agreements with the different partner organizations.

Directorate for the Control of Diseases, Epidemics and Pandemics (DLMEP)

Action plan

• Inform the DLMEP staff on the PBF concept;
• Manage resources efficiently by identifying all partners and government directorates and programs involved;
• Assist with the definition of the PBF indicators ;
• Harmonize the data collection tools.

The Legal Affairs and Litigation Division

The signing of the financing agreement between the World Bank and the Government of Cameroon to finance the PBF approach highlights the need for a reform of the management process of the structures. It requires institutional reform, firstly through the amendment of the legal texts, and secondly through the enrichment of the legal instruments through the development of new financial management standards in accordance with the PBF approach.

Action plan

• Empower the health facilities and promote competition for contracts ;
• Identify the texts to be revised followed by the revision of the management texts of the health facilities;
• Organize a workshop for drafting the normative texts in these areas.

The Directorate of Health Promotion (DPS)

Cameroon’s population does have limited access to improved sanitation facilities and drinking water of good quality. Waste management remains a major public health problem.

The Directorate is in the process of signing its second PBF contract after the first contract, which was evaluated at 15%. This low score was caused by an insufficient budget for the realization of activities, the non-application of the index tool and there are big infrastructural problems.

DPS Action Plan

• Share the main messages of the PBF course to the entire management ;
• Develop a WASH standards document on hospital waste management, water purification and improved latrines ;
• Publicize normative documents at the Ministry of Health web portal ;
• Revise and test the composite WASH quality indicators to be applied during the household visits and integrate them in the PBF manual ;
• Define and adopt the individual evaluation criteria of the Directorate team ;
• Request quality improvement bonuses for future contracts and initiate infrastructural improvements to improve staff working conditions;
• Optimize the use of available financial means from partners and mobilize them to improve the quality of WASH interventions.

Human Resources Directorate

The Human Resources Department of the Ministry of Public Health manages a workforce of 51,000 civil servants spread over the country.

Problems

• Accumulation and loss of personnel records ;
• Poor reception of personnel visiting the Directorate ;
• Centralization of personnel management.

Action plan

• Conduct a baseline study for the implementation of the PBF concept and facilitate the definition of human resource indicators.
• Develop the procedures manual on how to process personnel cases by indicating the time limits for each case. This manual will also specify the circuit of the files in order to reduce losses ;
• Decentralize the mechanisms for personnel management through the transfer of skills from the Human Resources Department to the Regional Delegations of Public Health.
• The central level should play more the role of regulator. Thus, at the end of each quarter, a national HRD team should conduct working visits to the regional delegations based on well-defined indicators.
• Define human resource standards for the health facilities based on the mapping of the existing ones. This to improve the allocation of human resources according to the needs of each region, district, and health facility.

The PLMI

The National Multisectoral Program for the Fight Against Maternal, Neonatal and Infant-Juvenile Mortality (PLMI) has as its main mission the implementation of the Government’s policy regarding the reduction of mortality. It is a program that is led at the technical level by the Ministry of Health assisted by the Ministry for the Promotion of Women and the Family. The PLMI far from being an actor of implementation must rather ensure the efficient implementation of activities at all levels (central, regional and operational).

The problems

• The health situation of mothers, newborns, and children remains a concern in Cameroon despite several interventions undertaken to date.
• The PLMI is not very efficient in its mission especially with regard to the coordination of the different actors. This leads to a waste of resources, the parallel application of programs and partner efforts. The concentration on targeted interventions should be a more effective to use resources.

Action plan

• Restitution of the findings, analysis, and recommendations of the PBF course to the PLMI team ;
• Advocate for the mobilization of funds and resources for the LMMNI.

National Malaria Control Program (PNLP)

Malaria remains a problem in Cameroon. In 2017, it was responsible for 24% of outpatient consultations and 44% of hospitalizations. It is responsible for 21% of deaths among children under 5 (PNLP Report 2017). In response to this global problem, WHO has initiated the Roll Back Malaria (RBM) initiative.

Action plan

• Develop the new PNLP plan and implementation guide.
• Strengthen social marketing for use of malaria services (use of bed nets, sanitation, use of health facility services at the first symptoms of disease)
• Pay subsidies to health facilities so that they can buy inputs and treat children under 5 free of charge. In addition, PBF quality indicators should assure the availability of antimalarial inputs in health facilities.
• Break the monopoly of the CENAME and open the market for competition.
• Map and stimulate wholesale and retail pharmacies as well as laboratories to make available good quality essential drugs inputs at a lower cost.
• CHWs should no longer conduct curative activities. Their work should mainly focus on home visits, educational talks and referrals to health facilities.

Directorate of Family Health

Problems

• Maternal, child and adolescent health indicators in Cameroon remain a concern ;
• Inefficient allocation of parallel budget lines imposed by government directorates and programs as well as partner organizations ;
• Poor regulation and coordination of interventions by different partners.

Action Plan

• Provide feedback about the PBF course to the family health team;
• Review the output and quality indicators of the minimum and hospital package of activities in the existing evaluation questionnaires;
• Develop standard standardized supervision tools for regions.

Health Information Unit

Over the last five years, the Ministry and its partners have embarked on profound reforms of the National Health Information System (NHIS) with the aim of correcting the dysfunctions caused by the multitude of tools and databases developed by vertical systems.

Problems

• The reporting of health data through the Dhis2 platform is not yet complete ;
• Inadequate analysis of the available data ;
• The mapping of health catchment areas is not yet up-to-date in the context of the work done to rationalize catchment areas for PBF contracts ;
• Vertical information systems from partners remain inflexible and do not yet harmonize their data collection with the Dhis2 platform

Action Plan HMIS

• Update the format of the Monthly Activity Reports taking into account household visit indicators ;
• Update the health map with respect to the rationalization implemented by the PBF program ;
• Train the staff in charge of the collection and electronic transmission of Dhis2 data ;
• Train the health facility managers in the analysis of the Dhis2 data for decision making ;
• Advocate with the partner vertical programs for the integration of their data requirements in Dhis 2.

Regional Fund for Health Promotion – North

Problems

• Lack of knowledge of the PBF reforms by the staff of the regional fund ;
• Stock-outs in the supply of essential drugs as the result of the monopoly policy of the regional fund supplying the health facilities and the monopoly of the CENAME to the regional fund.

Action plan

• Brief the collaborators on the importance of the relationship between the Regional Find and the CDV Agency ;
• Review the status of regional drug stocks in health facilities ;
• Negotiate with each health facility a plan to clear their debts ;
• Establish a commission to review the regional fund procedures manual and adapt it where necessary to adopt the PBF best practices ;
• Implement the PBF in the National System of Medicines ;
• Advocate with the partners to integrate their activities for greater efficiency.

Regional Fund for Health Promotion – West

During 2018, the West Region initiated the Regional Fund for Health Promotion. The region has a population of 847,000 with 20 health districts of which five were selected to start PBF during 2018. Yet, there is not a CDV Agency in the West Region.

Action Plan

• Conduct a feedback meeting with colleagues of the regional fund ;
• Make a follow-up on the signing process of a Memorandum of Understanding with the Ministry of Health;
• Make a follow-up for the application of the Minister’s circular to accelerate the liberalization of the pharmaceutical market in the Region ;
• Make the West CDV Agency operational as soon as possible.

UNFPA

The main interventions of the UNFPA in Cameroon are geared towards the better management of specific pathologies through capacity building, support for reproductive health inputs, equipment for maternity wards and the strengthening of the technical platform in health facilities. Priority interventions are family planning, essential neonatal emergency obstetric care, adolescent and adolescent reproductive health, gender-based violence, research, repair of obstetric fistulas, and maternal death review.

UNFPA injects thousands of dollars annually into support for different implementing partners across the country. Despite this support, the results are not very satisfactory.

Action plan

• Negotiate partnership agreements with DCOOP and the PBF Unit for the purchase of clearly defined indicators using the PBF approach ;
• Purchase specific UNFPA indicators not yet purchased by other sources such as the government and the World Bank ;
• Support the PBF Unit and the technical directorates with a UNFPA PBF expert with good reproductive health experience and with clear terms of reference ;
• Solve infrastructure- and equipment needs through the mechanism Quality Improvement Bonuses (BAQ).

The Evangelical Lutheran Church of Cameroon (OSEELC)

The OSEELC is composed of 4 hospitals and 19 health centers in 3 regions of Cameroon and has more than 500 employees. There is a large degree of centralization of power at the level of the OSEELC Church, which limits the autonomy of its health facilities.

Action plan

• Discuss the PBF course action plan with the Church Executive Office and Church Board members ;
• Start a process of decentralization of power towards more autonomy of health facilities ;
• Conduct a financial hospital audit with the aim that health facilities must balance their income and expenditures followed by the implementation of the recommendations ;
• Restructure the staffing patterns ;
• Improve the quality of care in the health facilities with the aim to be accredited by the PBF system ;
• Bring more efficiency in the management of the health facilities and ensure good governance.

Adamaoua and North Region CDV Agencies

The Contract Development and Verification  Agencies of the Adamaoua Region (1.2 million) and the North Region (2.7 million) were created in June and July 2016. In 2018, all the districts and health facilities in the two regions are covered by the PBF program.

Problems

• The list of accredited pharmaceutical wholesalers for the distribution of medicines is still not available in the Adamaoua Region ;
• The rationalization of the health facility catchment areas is not yet effective in some health districts in the North Region.

Action plan

• Approach the Regional Delegate to make available to all actors the list of approved pharmaceutical wholesalers ;
• Approach the Health Districts to update the health map according to PBF standards.