PBF in Mauretania, Togo, Djibouti, CAR and Guinea

The 33 participants of the PBF course in Cotonou

The 69th PBF course took place in Cotonou from 18 to 30 January 2018 with 33 participants from Djibouti (12x), Togo (11x), Mauretania (7x), CAR (2x), and Guinea Conakry (1).

The impact of the 69th PBF course has been translated into the good quality of the action plans produced by the country groups. The course facilitation team is experienced because they come from several countries (DRC, Benin, Burkina Faso, Netherlands) and also work in several countries. In addition, the CAR and Guinea Conakry delegations came with practical experiences on PBF from their countries. This helped other participants to better understand the realities and experiences of PBF around the world.

Five participants obtained a certificate of distinction with a score of 90% or higher for the end-of-training test. They were three from Mauretania, one from Togo and one from Guinea :

Summary of the recommendations of each country


Participants at the door of no return in Ouidah

The Togo government believes that PBF is an alternative for ensuring good quality of health service, efficient use of its resources, and financial access to care for the most vulnerable. The Cotonou group did an analysis of the feasibility score for the introduction of PBF in Togo and this showed a potential score of 92%. This encouraging score can be achieved if the action plan of the participants in Cotonou is implemented. This proposed the following derogations:

  • Health facility managers should have the right to recruit and dismiss contract workers and have the right to refer non-performing civil servants back to the administration ;
  • Authorize health facilities to set their cost recovery tariffs.
  • Allow the health facilities to purchase inputs such as essential drugs from multiple distributors operating in competition.

Moreover, the team recommends to develop and sign performance contracts (using standard output and quality indicators) with the Directorates of the Ministry of Health and to transform existing government input budget lines into PBF performance subsidy budget lines.

The implementation of the PBF pilot is proposed to be done at the regional level with at least a target population of one million inhabitants for good economics of scale. For the first year, it is proposed to invest at least 3.5 million US dollars and increase the funding in the second year to 7 million US dollars. A baseline household operational survey with a control area is proposed to measure the effect of PBF

Action Plan:

  • Submit the Cotonou report to the Ministry of Health authorities and partner organizations, who financed the delegation’s participation in the course ;
  • Organize a feedback session with the Ministry of Economy and Finance (MEF) and the Minister of Health and Social Welfare ;
  • Contribute to the finalization of the PBF programme such as the costing, mapping of the pilot area and determine the duration of the pilot phase ;
  • Implement the PBF pilot programme.


Beach in Ouidah, Benin

Djibouti is a desert country with a population of about 870,000 and an area of 23,000 km2. The majority of the population lives in the city of Djibouti but the country has also a large number of refugees from the neighboring countries Ethiopia, Yemen, and Somalia.

To help remove bottlenecks in the health system, the 2013-2017 National Health Development Plan recommends the use of contracting. The Ministry of Health of Djibouti and the World Bank have agreed on a performance-based financing (PBF) strategy since 2011. The initial $ 7 million project was completed in 2013 with an additional grant of $ 7 million to cover the period from 2014 to 2018.

The strengths of FBP during the 2011-2018 program are the following.

  • Rehabilitation of health centers and the purchase of medical equipment ;
  • Introduction of the indices management tool (but only for the PBF subsidies) ;
  • Raising the quality of the health services ;
  • Improving the quality of the HMIS such as the completion of the registers, the monitoring sheets, etc.

However, the FBP program in Djibouti is not pure, and the feasibility score according to the Djiboutian group in Cotonou is only 16%.

The main problems identified are as follows :

  • The Djibouti PBF project budget is estimated at only US $ 3.5 per capita/year;
  • There is no government financial contribution yet to the PBF programme ;
  • The Departments of the Ministry of Health are not under performance contracts ;
  • The number of indicators at primary and hospital levels were set at below 20, while according to international standards this should be between 25 and 35 ;
  • The rationalization of the health catchment areas is not yet implemented (between 6000 to 14 000 inhabitants for the primary level with main and secondary contract holders) ;
  • Health facility revenues from cost sharing are not used at the point of collection. Instead, the Financial Department of the Ministry of Health collects at the end of each month the revenue from the facilities ;
  • There is no independent contracting and verification agency yet. The National Health Insurance Company (CNSS) already contracts health facilities and it makes sense to create a CDV Agency under the umbrella of the CNSS ;
  • The indices management tool is used by the health facilities to calculate staff performance bonuses, but only for the PBF subsidies instead of all revenues such as proposed by the PBF best practices ;
  • The Central Medical Stores (CAMME) monopolizes the market for essential drugs and other inputs. This creates frequent stock-outs and hinders access to quality care.


  • Advocate with the Government of Djibouti to initiate a new phase of the PBF programme taking into account the improvements in the design proposed by the Cotonou group. The current PBF feasibility score is only 16%, so several important improvements need to be made in the design ;
  • Advocate for government also to financially contribute towards the PBF programme ;
  • Revise the institutional set up according to PBF standards ;
  • Review the indicators for the primary and hospital health packages ;
  • Allow more autonomy for the health facilities ;
  • Conduct the mapping of health facilities and rationalize the health catchment areas according to the PBF standards ;
  • Put the directorates of the MOH under PBF performance contract ;
  • Promote competition by accrediting other input distribution structures.


Role play during course

Mauritania is a Sahelian country in West Africa with about 4 million inhabitants.

The main challenges of the health system

  • Funding: insufficient allocations to the needs and inefficiency in the use of existing public resources ;
  • Poor quality of care and competence of human resources ;
  • Poor distribution of qualified human resources, but there is no shortage in the total number of professionals (doctors, nurses, midwives) ;
  • Poor staff motivation ;
  • Very low basic salaries and ineffective management of bonuses and allowances;
  • Insufficient mechanisms to measure the satisfaction of the population and to ensure social marketing ;
  • Lack of an equipment maintenance strategy ;
  • There are geographic and financial equity issues with an inverted financial pyramid, which does not inject enough money into the periphery and primary level of the health system ;
  • Quantitative and qualitative insufficiency of essential drugs created by the CAMEC monopoly ;
  • A poorly functioning health management information system ;
  • The problem of harmonizing the demand component of the WB-financed project managed by another sector, with the supply component managed by the Ministry of Health.

The feasibility score for the current FBP program is 52% and this leads to the following recommendations:

  • Adopt the institutional proposed set-up (see in the French text);
  • Establish CDV Agencies in both regions. Analyze the best legal framework for these CDV agencies such as through umbrella contracts with the Regional Council. Yet, the PBF unit and the WB may wish to retain the right of non-objection for crucial staff recruitments ;
  • Introduction of equity bonuses to compensate for vulnerabilities at the regional level, at the health facility level, and for vulnerable people ;
  • Propose legal derogations for : a. Setting autonomously user fee tariffs at health facilities ; b. Allow health facilities to use their own cost-sharing revenues and to use a commercial bank account instead of the public treasury; c. Health facilities should be allowed to recruit human resources with direct contracts and allow facilities to send non-performing civil servants back to the Ministry in case of problems; d. Allow facility managers to have the right to purchase their inputs from distributors operating in competition, which are accredited by the regulator.
  • Conducting a baseline household and quality study, which establishes priorities and measures progress;
  • Introduce the community PBF indicator “two annual household visits according to the protocol” in the primary package ;
  • Map and rationalize the health catchment areas and the establishment of primary and secondary contracts ;
  • Train the PBF actors including the regional CDV agency teams.


Community fishing at the Benin beach

CAR, with a population of 4.7 million, is in a political crisis since 2012. Life expectancy in CAR in 2015 was 54 for women and 51 for men and the maternal mortality rate is high with 882 per 100,000 live births. The child mortality rate is also high at 130.1 per 1000 births.

The Central African Republic started with the introduction of a free care policy in 2012 following the crises with mixed results. The performance-based financing approach was launched in 2016 by the government with the aim of improving the health system, especially the quality of care with the direct support of the World Bank and the European Union. The first results of the PBF approach in CAR during the first 18 months of implementation are favorable. It covers in 2018 about 50% of the country and the goal is to increase the coverage to 100% by the end of 2019. There are still several challenges to achieving Universal Health Coverage, including the harmonization of technical and financial partners by supporting the national policy on performance.


  • Insecurity and lack of access to remote health facilities ;
  • Inadequate capacity of local staff due to limited schooling, which makes it even difficult to develop good business plans ;
  • Non-existence or poor-performing health facility committees ;
  • Delay in the payment of PBF subsidies;
  • Incomplete care for the vulnerable.


  • Hold meetings with MINUSCA and local authorities on security to better support and protect health facilities in insecure areas ;
  • Organize strategic meetings with the main actors ;
  • Conduct the mapping of accessible areas where the CDV Agencies and health facility staff can meet to conduct verification in safe areas ;
  • Increase the number of field visits for coaching ;
  • Further, support the recruitment process of qualified staff for the health facilities ;
  • Review the living conditions of the staff and develop strategies to support staff such as through improved housing ;
  • Assure with the in-charge of the health facilities the timely payment of the salaries and bonuses. Experiment with innovative approaches such as to use Mobile Money accounts for staff ;
  • Increase the ceiling for vulnerable patients to be exempted.


Rainy season in Benin

The country has a total area of 246,000 km² with a population estimated at 11.3 million inhabitants. 65% of the population live in the rural areas. The health status of the Guinean population is characterized by high mortality and morbidity related to preventable diseases. A central problem is a monopoly and the weak financial and logistical capacity of the central purchasing office.

Among the priority interventions of the PNDS 2015-2024, PBF is identified as an approach to improve the overall performance of the health system towards achieving the Universal Health Coverage in by 2024. The Ministry of Health, with the support of technical and financial partners, launched a performance-based financing pilot project the health district of Mamou from 2016 onwards.

The group of participants from Guinea who attended Course 65 of January 2018 in Cotonou identified several potential strengths of the PBF in Guinea including the political will and the interest of partners in PBF.

They also identified the following  weaknesses of the health system :

  • Poor geographic accessibility;
  • Poor quality supply of health services ;
  • Uneven distribution of human resources between urban and rural areas ;
  • Poor accessibility of the population to quality drugs as the result of the Central Medical Stores monopoly to purchase inputs and the development of the parallel informal market for medicines ;
  • The regulatory function is inadequate ;
  • Inadequate public, private and faith-based partnerships and lack of government support to the private sector;
  • High administrative costs :
  • Inadequate financial government contribution towards the PBF program ;
  • Centralized recruitment of public health facility staff ;

The feasibility score is 40% and the following action plan is proposed:

  • Advocate with the government for financial participation in implementing the PBF program ;
  • Discuss and negotiate with government and partners to include more criteria of PBF purity and reach at least an 80% score for the feasibility scan ;
  • Set up the National Technical PBF Unit ;
  • Allow PBF health facilities to purchase their inputs (drugs/equipment) and manage autonomously human resources (hiring and firing) and to set cost-sharing tariffs ;
  • Negotiate and sign performance contracts with the regulatory authorities at all levels ;
  • Conduct the mapping and rationalization of the primary and hospital health catchment areas by the District Health Management Team ;
  • Set up the District Validation Committee Teams ;
  • Continue the PBF programme in the 19 health facilities of Mamou District ;
  • Review the PBF manual and improve the indicator packages of output and quality for the primary and hospital levels, community NGOs, regional health departments and district health departments.
Print Friendly, PDF & Email