The 75th International PBF Course took place from 8 to 20 October 2018 in Kinshasa in the Democratic Republic of Congo, bringing together 60 participants from the central level.
Hereby the report of the course (rapport)
The health status of the population in DRC is not well. Maternal mortality and malnutrition rates are high. There are multiple problems in reproductive health such as complications and consequences of early and unwanted pregnancies. It is further aggravated by the occurrence of pregnancies that are too close together due to the low contraceptive prevalence of 8%. There is still no convincing strategy for involving the private sector in the health system.
The government and partners until recently have opted for the centralized planning of drugs and other inputs through public monopolies such as the National Drug System and Regional Distribution Centers. Many partners use the Regional Distribution Centers for their inputs or they import them through parallel logistic organizations. As a result, several studies (and confirmed by participants of the Kinshasa PBF course) found multiple and chronic stock-outs of essential drugs and other inputs in health facilities. This also leads to an unregulated pharmaceutical market that endangers the lives of patients.
During the last years, partners and the government mobilized billions of dollars but applied mainly the centralized purchase of inputs instead of investing the funds through strategic purchasing of services directly from health facilities and the community. This has blocked during decades the possibility of creating economic multiplier effects and thereby creating hundreds of thousands of jobs for health workers (who are currently unemployed), by creating opportunities for local businesses (construction, furniture, and equipment, agriculture …), and by stimulating the creation of Congolese industries to provide supplementary food, mosquito nets and other inputs. The centralized input policy could also not solve the problem of poor quality care in health facilities.
Faced with this alarming situation, the government made a strategic choice in 2016 for the “performance-based financing” reform approach, which has already produced good results, which were published in scientific journals, in pilot projects such as in the province of South Kivu since 2005. There does not seem to be a plan B outside the PBF approach because the existing paradigms have not worked and PBF applies common-sense strategies such as the decentralization of the decision-making level to local actors, good governance measures through the separation of functions, the improvements of public-private partnership as well as to break all forms of harmful monopolies in the supply and distribution of inputs.
The National Technical PBF Unit team was selected through a competitive manner based on their profiles and PBF field experiences The PBF Unit proposed strategies to support the Health Districts affected by the Ebola epidemic in 2018 and started PBF for 3 million inhabitants of Kinshasa through performance contracts mainly with private providers. Up to the end of 2018, around 13 million inhabitants benefit in DRC from the PBF reforms and the government aims to gradually scale up nationwide.
To move forward, there is the need to increase the critical mass of PBF experts. Thus, the government decided first to train central level decision makers and professionals. The training began on October 5 and 6 with a two-day workshop for 20 departmental directors from the Ministry of Health. This workshop was followed by a 14-day PBF course, from 8 to 20 October 2018, attended by 60 participants mainly from the central level, including three representatives of the partners and a representative of the Ministry of Labor and Social Protection. Further training is planned for the provincial level and the Contract Development and Verification Agencies in January 2019.
The impact of the RBF course was reflected in the good quality of the groups’ action plans. The average posttest score was 72%. This means a 32% improvement over the pre-test, which scored 40%. Seven participants obtained a distinction for their final test with a score of 87% or more. Facilitation, participation, and timekeeping were rated as satisfactory by the participants with scores of 93%, 94%, and 92%, respectively. On the other hand, the Nganda Training Center was not up to par and there were frequent problems with electricity and the sound system, the water supply was irregular and the quality of the rooms was poor.
The final evaluation of the course by the participants showed that the preparation of the course was good. The course duration was considered OK by 81% and the methodology was good. Yet, time for exercises and discussions was considered too short. In general, the contents of the course were highly appreciated, but the time for the indices management tool exercise and for the health economics module was too short for some participants.
- ThePBF subsidies for the health facilities in 2017 were too low at USD 1.08 per person per year. Also, the expenditures for the verification of results at USD 0.53 for the CDV Agencies were too low. It is desirable to increase the subsidies and expenditures towards respectively USD 2-3 per person per year for the health facilities and USD 1 for the verification of results through the CDV Agencies, Provincial Health Directorates, District Health authorities, and the Inspectorates for the counter verification. ;
- Continue to change the “input” paradigm(which means the centralized purchase of inputs) towards the “output” or “performance” paradigm(which means to contract, verify and pay for results).
- Inject at least 70% of the government and partner budget lines directly into the decentralized structures (health centers, hospitals, and communities) through performance contracts. This approach is more efficient due to the better knowledge of those working at the grassroots level on their real needs. It also creates economic multiplier effects with economic growth and the creation of the employment.
- The problems of malnutrition in the DRC are complex and do not only affect young children but also adults, especially pregnant and lactating women. The consequences are that it jeopardizes the future of the country. These problems are related to an inadequate supply of nutritional inputs through a. Lack of a nutritional supplement production industry for children; b. Non-integration of nutrition products in the list of essential medicines and c.; Continuation of the monopoly of distribution of inputs and nutrition supplements by the CDRs and parallel partners distribution systems. Thus, we propose a. Decentralized purchase of nutrition inputs by the health facilities; b. Integrate therapeutic foods into the list of essential medicines; c. Integrate the curative indicators for malnutrition at the primary and hospital level health packages; d. Stimulate the creation of a private industry for the production of therapeutic foods and complementary foods for the feeding of children; e. Stimulate the community capacity for the manufacturing of food from local cereals ;
- The existence of parallel quality assurance tools within the Ministry of Health such as the quality assessment tools of the integrated quality approach (DQI) and the PBF quality review tool used by the PBF Unit. The harmonization is important to prevent using different tools in the same health facilities and health districts.
- Many health facilities provide an incomplete set of activities at the primary and hospital level. In addition, the primary and the hospital level health packages should be reviewed and expanded to cover all key main curative, public health and preventive activities ;
The classical community participation approach has so far mainly focused on voluntary community workers and health committees. The results have been disappointing. Thus, it is necessary to introduce the community PBF approach with incentives for community indicators such as home visits, monitoring of the drop-outs, identification of the vulnerable and malnourished, etc. ;
- Institutional setup. The PBF Unit is currently attached to the Directorate of Studies and Planning (DEP). This limits their capacity to coordinate with the other central level directorates and programs. We, therefore, suggest integrating the PBF Unit and the internal Contract Unit inside the cabinet of the Secretary-General. An analysis should still be done on how to operate the Contract Unit and its relationship with the PBF Unit.
- Other major recommendations for the institutional set-up are : a. The involvement of the central level and provincial level Inspectorates in the counter-verification of results; b. The establishment of the Health District Validation Committees; c. Introduce the monthly verification of outputs instead of each three months and base the verification team at district level instead of at inter-district or provincial level ;
- Establish the exemptions from certain laws that allows applying the PBF best practices such as the promotion of competition for the supply and distribution of medicines ;
- The government should explain to partners that the PBF approach is the chosen reform approach and ask them to align with this strategic decision. Partners should support the strategic purchasing of outputs and performance instead of providing inputs ;
- The government should transform the classical “input” budget lines into PBF performance budget lines for the purchase of results ;
- All Directorates, Cells, Programs or Partners present at the PBF course should share and discuss the main recommendations with their colleagues ;
- The government should put into place more equitable mechanisms to improve the distribution of human resources ;
- Advocate for the integration of PBF also in other sectors such as education, labor and social welfare, water and sanitation ;
- The government should avoid imposing price ceilings on the pretext of responding to social concerns related to the impoverishment of the population ;
- Stop the system of health authorities asking money (taxes) from health facilities ;
- Address the problems of confidentiality in health facilities, including for young adults.