Recommendations for Nigeria, The Gambia, Ethiopia and Zambia

The 31 participants in Mombasa with the facilitation team

The 70thperformance-based financing (PBF) course took place from Monday, May 28 to Friday, June 8, 2018, in Mombasa, Kenya. Thirty-one participants attended the course: 16 participants from Nigeria, 6 from Zambia, 5 from Ethiopia, 3 from The Gambia and 1 from the USA.

Hereby the detailed course report.

The groups analyzed their health systems and produced detailed action plans on how to advance PBF in their respective countries, states, and regions. Thirty participants conducted the final exam and achieved an average score of 70%, including three distinctions.

The “Village 70” authorities consisted of the Village Chief, Dr. Abba Zakari UMAR; the Deputy Village Chief Mr. Mannix NGABWE; the Time Keeper Dr. Halima ABATE; and the tax collector Mrs. Makasa NONDE. The energizers were Mr. Ensa Jarju, Dr. Baba, Mrs. Sharon, Dr. Abubakar and  Dr. Tijjani. They actively supported the facilitation process and contributed to a congenial atmosphere while maintaining “order” in the village.

The daily evaluations resulted in scores which were comparable to previous English spoken courses. The final evaluation indicated that the participants felt the content of the course to relate well to their regular professional activities. The participants were also satisfied with the methodology and the organization. The contents of the course modules were appreciated with much higher scores compared to the previous courses. Some participants commented that facilitators should avoid dogmatism and acknowledge that context-specific issues are important. The issue of respect for country-specific characteristics is fully recognized. At the same time, we deem open and comparative debate in an international forum which stimulates some out-of-the-box thinking also a vital characteristic of the course.

The course was organized around a strong core of ‘developing individual and country action plans’. This conscious focus was started a few years ago and with each course, more attention is given to the action plans. We are planning to advance in this way of going about the course and deepen the quality of the individual or group action plans each time and building the 17-course modules around this core task.

Country recommendations of the May 2018 Mombasa course

Nigeria NPHCDA

The Nigeria government – with financial support from the World Bank – started its RBF program in 2011, with the aim to test the innovative RBF approach in response to the poor national health indicators. By the end of 2018, NSHIP is supposed to cover approximately 13 million inhabitants. The RBF approach has seen encouraging results in Nigeria. Yet there are a number of key concerns around the design and its sustainability.


  • The RBF approach, so far, has been almost entirely financed by the World Bank and this project funding will come to an end by 2020. The sustainability of the approach is, therefore, a challenge.
  • The PBF Unit is positioned outside the MOH hierarchy, which makes it difficult to make the PBF approach a sustainable health reform, with little MoH buy-in and an equally low interest in the hospital sector and Hospital Management Board agencies.
  • There is a lack of coordination with the WB supported Save One Million Lives initiative and the PBF program – also supported by the World Bank. They are both output-based but the SOML only puts the States under contract, while leaving it random how the Disbursement Linked Indicator targets should actually be met.
  • The impact study that began with a baseline in 2012 proposed a research arm of the program, which would simply give money to health facilities without conditions, the so-called DFF approach, for comparison. This created a range of problems in terms of transparency, contamination, and cross-over, which ‘spoiled’ that academic design. Firm conclusions are therefore hard to draw from the practical execution of this research.
  • The administrative costs of the PBF approach in Nigeria are too high with a multitude of actors; this while the regulatory and CDV agencies (in the NSHIP–AF states) are not yet under performance contracts;
  • Quality Improvement Bonuses are absent in the Nigeria design while this is a crucial design feature in other World Bank-supported countries to improve support rehabilitation, making available equipment and human resources as well as the restart health facilities affected by instability
  • In the current NSHIP and AF-NSHIP design, the SPHCDA has both a role as the regulator (responsible for the oversight for all primary facilities in a state), as well as being the unit that signs the purchase contracts with the health facilities (both primary and secondary). This is a confusion of roles, and in practice through its specific positioning in the NPHCDA and SPHCDAs, the PBF unit (called PIU in Nigeria) may not have the cloud it needs to coordinate the reform efforts.
  • Altogether, the feasibility scan score of most Nigerian teams scoring along the current design is only 60%, while 80% is the proposed minimum. Design improvements are therefore necessary.

Recommendations :

  • For a new States wishing to start PBF, an institutional set-up is proposed that can be found in the course report
  • The positioning of the PIU at both National and State level within the MOH at an appropriate level, e.g. under the PS;
  • Advocate for the CMVAs (CDV Agency) to take on the role of signing and coaching of the health facility contracts rather than the SPHCDA ;
  • Finalise proposal on Community PBF to ensure that other incentives exist for the community ;
  • Remove the Ward Development Committee (WDC) chairman (and another community representative) from the health facility bank account ;
  • Advocate with the World Bank to introduce the Quality Improvement Bonuses. The project documents may also emphasize that the health facilities can use other funds for infrastructure while the PBF subsidies should more focus on small rehabilitations, improving equipment and, in general, quality improvements.

Kano State – Nigeria

Kano State in the northern part of Nigeria has a population of 13.8 million. There is a concentration of private health facilities in the metropolitan areas. Despite years of government efforts and investments, the delivery of quality healthcare services remains a challenge: The infrastructure is poor. Many facilities do not have the required equipment or the drugs to deliver basic health services. Facilities face acute shortage of qualified manpower and funds are insufficient to cater for basic needs. Key impact indicators such as under-5 mortality assisted deliveries and family planning coverage is far below the national average. The health system has low responsiveness, is inefficient and inequitable. There are resource leakages, which are mostly associated with public health services.


  • Kano State proposes a new reform approach, which is Performance-based financing (PBF), starting in three LGAs covering 1 million people.
  • The aim is to meet the Sustainable Development Goals (SDG) whereby health facilities provide quality care. Both public and private will be contracted to target the population in a competitive manner. People entrusted with the responsibility in the health system should be held accountable for their performance and should work with contracts and be compensated on the basis of their performance.
  • The budget for the pilot should be around 4 million USD per capita per year.With the ongoing reform and strengthening of health services, the State has a unique opportunity to introduce and finance PBF through the Kano Health Trust Fund Law and through the Saving One Million Lives project.
  • The Kano State Contributory Health Care Management Agency is proposed to serve as the contract development and verification agency.
  • There exist in the State a pool of employable qualified health personnel, which the health facilities could employ through the PBF approach.
  • The institutional set up is shown in the report of the NPHCDA above. The PBF Unit will be situated at the State Ministry of Health with a State PBF Steering Committee and LGA validation committees.
  • The PBF best practices will be applied as much as possible with autonomous management, competition for contracts, public-private partnerships and equity instruments.
  • Other problems such as the obligation to bank money in the Treasury Single Account, the central Medical Stores monopoly and the procurement law for infrastructure needs to be analyzed and solutions found.

 Jigawa State – Nigeria

Health indices in Jigawa State are among the worst in the country due to low investment in the health sector, ineffective health systems as well as poor health-seeking behavior among the populace. Different health reform initiatives for the last 10 years have unfortunately been ineffective.

The State aims to implement PBF in response to these challenges.

Some key issues regarding the implementation of PBF

  • The Treasury Single Account principle does not allow health facilities to control their own funds, which poses a serious problem for autonomous financial management ;
  • Human resource management is too centrally controlled and there should be more autonomous management of human resource also for the contract staff ;
  • The procurement process for the inputs (drugs, consumable, equipment, etc.) are still based on central planning through the Central Medical Store. This creates frequent stock out problems and the wasteful use of public resources ;
  • The financing source for the PBF program has not yet been decided upon ;
  • There are few private health facilities in the State ;
  • The election process during 2019 may negatively influence the reforms.

Yet, there are also opportunities such as:

  • The existence of the PBF know-how in the country ;
  • The committed Commissioner of Health may also promote during the election process PBF as a solution on how to improve the health services.


  • The Jigawa State action plan will focus on the design of a Performance-based financing pilot in 3 large LGAs, Gwaram, Kafin Hausa and Babura, covering a population of about 1 million people representing nearly 20% of the state population.
  • The 1% consolidated revenue fund may be tapped into for funding PBF ;
  • The existence of the SOML funding that may be tapped, which could benefit future PBF funding ;
  • To conduct awareness creation meetings with various stake holders during the 3rdweek of June 2018
  • To conduct advocacy meeting with members of the state house of assembly 4thweek of June 2018
  • To conduct study tour with key stakeholders to Rwanda in July 2018.

Zamfara State – Nigeria

Zamfara State is located in north-western Nigeria and has a population of 4.8 million.


  • The health system in the State is fragmented ;
  • Health facility autonomy is limited without competition in the procurement of essential drugs ;
  • There are few adequately skilled human resource ;
  • There is an unacceptable high level of maternal, neonatal and child mortality ;
  • There is limited health funding, poor utilization of services, and the centralization of health care services.


  • The State Ministry of Health proposes to initiate Performance-based financing(PBF). The approach will be bottom up and will be piloted in three Local Government Areas across the state (one per senatorial zone) and cover a population of about one million people ;
  • The current feasibility scan score is only 44% and the team proposes to discuss the change issues at several levels with the aim to improve the design of the PBF approach including from where to source the funds ;
  • An ambitious action plan has been presented in the detailed report.

Yobe State – Nigeria

Yobe is in the North Eastern part of Nigeria with 3.4 million people and 17 LGAs. 80% are poor subsistence farmers and the literacy level is 35%. On average, a woman gives birth to 7 children within her reproductive life span. The median age at first marriage is 16.3 years accounting for the high rates of teenage pregnancy and associated health problems. Yobe State has unacceptable health indices with an MMR of 1200 / 100,000. The contraceptive prevalence rate is only 3%.

Yobe started in 2017 with PBF and this will be scaled up in 2018 to 10 LGAs. However, there are design problems and the feasibility score is only 64%.


  • There is only USD 3 per capita per year for the PBF program in the State. This needs to be around USD 6 per capita per year if the program wishes to successfully face the problems due to political instability, dilapidated infrastructure, the absence of equipment and the very poor population.
  • The SOML DLI approach is not linked to the PBF program so that it is problematic for the State to achieve the DLI targets.
  • The regulatory institutions are not yet under performance contracts ;
  • There are no Quality Improvement Bonuses.


  • Establish PBF unit under the Office of the Hon Commissioner and establish a PBF coordinating unit in the office of the PS to sign a contract with the Directorates ;
  • Create a legal and policy frameworks for provider autonomy to hire and fire staff ;
  • Decentralise the procurement of supplies by the health facilities from distributors operating in competition ;
  • Revise the business plans to include the Quality Improvement Bonuses ;
  • Review the law to allow the government to directly fund private and public health facilities on the basis of PBF principles and best practices ;
  • Sensitize the decision makers to mobilize PBF resources.


The Ministry of Health of Zambia has been engaged in RBF for several years, but no national PBF unit has yet been established. There are four RBF projects financed by the World Bank, USAID, DFID and SIDA that are managed under 4 different departments. This is posing a challenge with regard to coordination and resource optimization.

This may change since the Government at the beginning of 2018 announced the shift in their approach from INPUT based planning towards OUTPUT based planning. It is on this basis that the Zambia team proposes to lobby for the integration and establishment of a professional PBF Unit directly under the Permanent Secretary so that there will be a better coordination of the different vertical RBF programs.

Action points

  • Debriefing of the NTLP and Partners in the concepts of PBF
  • Debriefing the Permanent Secretary (PS) on the concept of PBF
  • Training of CHWs
  • The signing of contracts between District Health Offices and health facilities and hospitals
  • The signing of contracts between health facilities and community-based organizations.

The Gambia

The Gambia is a small country on the West coast of Africa with a population of 1.9 million. The Maternal Mortality Rate is high with 433 / 100,000 and the contraceptive prevalence rate is 9%. The total fertility rate is also high at 5.6. Wasting and stunting but at the same time, overweight problems are public health concerns.

Since 2014, The Gambia started a PBF pilot financed by the World Bank and currently covers 40% of the population. It is being implemented in 5 of the 7 health regions of the country, all of which are in rural areas.


  • The current PBF set-up does not yet promote full sustainability and buy-in by the Ministry of Health.
  • Health facilities in the urban areas are not included and neither are private and faith-based health facilities.
  • Based on the report of the NaNA coordinator who attended the PBF course in 2016, the Mid Term Review of early 2018, and the report of the group that came to the June 2018 Mombasa course, it is clear that there is a need to make the PBF health reform approach more sustainable by bringing the PBF Unit within the MOH.
  • The MoHSW is both the Regulator and the CDV, which is not recommended for transparency reasons ;
  • NaNA also doubles its role as a fund-holder and CDV, which is not recommended for transparency reasons ;
  • There is dual contracting of the Regional Health Department by both the NaNA and the MoHSW.
  • Health facility business plans are reviewed by three institutions: a. The Region; b. the PHC Unit in the MoHSW an; c. the NaNA project staff. This confuses the facility staff and it leads to delays in the negotiations and signing of the contracts.
  • Health facility user fees are paid into a central account of the Treasury Department instead of into a commercial bank account of the health facilities
  • There are too few indicators both for the primary (15) and the hospital level (6), while at least 25 for each level is recommended.


  • Promote the buy-in from the MoHSW for PBF and develop a strategy on how the PBF approach may be institutionalized through a PBF Unit in the MoHSW, autonomous CDV Agencies and QIB Officers – For the detailed set-up see the detailed course report
  • Ask the National Nutrition Agency for their support to engage with the senior management of the ministry of health ;
  • Increase the scope of complementary health indicators in the primary and hospital packages ;
  • Reduce the verification costs for community RBF ;
  • Introduce the contracting of the regulator at all levels for the implementation of activities ;
  • Allowing health facility managers to use the funds generated from user fees for the improvement of the quality of services.
  • Strengthen health facility autonomy through the application of the business plans and the indices management tool.


Ethiopia is the second most populated country in Africa with 102 million. Health service delivery and indicators in Ethiopia have been improving over the last 25 years. Yet there are still important caveats such as that 1 in 3 children are chronically malnourished and that the MMR is still high with 412 per 100,000 live birth. The health services challenges are also unequal with pastoral areas of the country particularly lagging behind and healthcare provision remains basic and in many cases, the services are of poor quality.

Therefore, the next phase of improvement will require more investments if the country wishes to go beyond the basic level primary care, largely provided by community-based health extension workers, to having fully functional primary health facilities and hospitals with skilled health care providers equipped to handle life-threatening conditions, and having an effective referral mechanism.

The Federal Ministry of Health under the Health Sector Transformation Plan addresses Universal Health Coverage (UHC) as a key component, aiming at coverage for all essential health services, for everyone without financial hardship. As part of this overall strategy, the Performance-based financing (PBF) approach was adopted as a strategy to ensure quality improvement.

Why applying PBF in Ethiopia?

Cordaid carried out a PBF pilot in 2015 in Borena Zone in Oromia Region for a population of 186,000 with encouraging results. In the PBF approach, there are several angles of improving quality of the services while there are also several equity instruments that can be applied if the resources are made available. Yet, in PBF efficiency is also crucial with the aim to make better use of scarce public resources through competitive contracting, accreditation of health facilities and pharmacies, public-private partnerships and creating a group spirit in health facilities by sharing profits in the form of performance bonuses. HMIS also improves by a robust PBF verification and validation system. Performance contracts are introduced also for the regulatory authorities at all levels and for the CDV Agencies and Community Based Organisations.


The institutional design of the Cordaid PBF pilot is still project-based and does not yet propose a set-up, which involves the government institutions as well as the national health insurance company.


  • Establish a PBF unit within the Federal Ministry of Health to oversee the overall implementation process of PBF initiatives in Ethiopia. For the set-up see the course report.
  • For scale up and to link PBF with the health sector transformation plan of the country, further evidence is needed. This may become a joint responsibility between the Oromia Regional Health Bureau, the Borena Zonal Health Department and the District (Woreda), and the Health Offices of Borena. The rollout is intended to include 9 districts to cover a population of around 581,000 ;
  • The Oromia Regional Health bureau must approve the scale-up financed by Cordaid and the Dutch embassy ;
  • The new scaled-up project include a zonal validation committee  ;
  • The Payment Agency for the PBF project is the Addis Abeba office of Cordaid only during this pilot phase of the project. Once PBF in the future may become national policy, other payment agencies should also start playing this role ;
  • The Zonal Contract Development and Verification Agency may be played by the Cordaid sub-office in Yabello town but in the (close) future this role may be transferred to the Ethiopian Health Insurance Agency (EHIA).
  • The action plan of the Mombasa group includes several workshops to advance the scale up, conducting exposure visits and training of frontline champions in PBF.
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