The 77th performance-based financing (PBF) course took place from Monday, May 13 to Saturday May 25, 2019. Hereby the course report.
The course welcomed a mixed group of 51 participants from the Ministry of Health, the Ministry of Finance, the National Civil Status Registration Office, the Ministry of Economy, Planning & Regional Development, and the Governors’ office of the West Region. All participants conducted the final exam. The overall score of the final test was 70% and eight participants obtained distinctions for their final exam with scores of 87% or more.
The status of PBF in Cameroon
By the end of 2019, 100% of the Cameroun population will be covered by performance-based financing and will be 10th low or middle income country to achieve this. 100% of the 2.7 million town of Douala is now under PBF with 80-90% of the contracts given to the private sector.
It took Cameroon 13 years to achieve national coverage in 2019, starting with a small pilot in the East region in 2006, and scaling up in 2011 to four regions. Yet, the changes required to apply the reforms are challenging. The circular written by the Ministers of Health and Finance in November 2017 with the orientation to strictly apply the PBF best practices, has not yet been fully implemented. This due to lack of understanding by important stakeholders. It is also difficult for some to leave their comfort zones towards becoming change agents. Thus, it was imperative to organise in April and May 2019 two courses for in total 110 senior participants from the central level and all the ten regions.
A particularity of this 77thcourse was that it was simultaneously presented in English and French. This required the full harmonization of the course materials. The large number of participants and the presence of five ministries required a very disciplined course methodology in which the village authorities approach played a crucial role. The methodology became more participatory during this course whereby we reworked the PowerPoint presentations in such a manner that we first presented questions to the participants, which they answered before giving in animation mode the answers. This worked out well. Despite that the course has extended from 12 to 13 days in 2017, the course was still considered short by 38% of the participants. For next courses we may reduce the number of modules so that we only present the most essential aspects and instruments of PBF and concentrate on the main messages only.
1. Problems with payment and procedures
The main problem in Cameroon is the delay in the payments by government of the PBF subsidies since October 2018. It has put into danger the success of the PBF reforms. This delay is due to several problems. Some are not related to the PBF program such as the overspending of government funds so that credit for all government expenses was blocked by IMF. Yet, other problems were related to the nature of the PBF payment procedures, which are performance-based instead of input-based and which requires another type of verification, validation and audit. This change in paradigm and procedures are not well understood by crucial stakeholders in the payment system such as those responsible for the budgeting at the Ministry of Health and the Ministry of Finance levels, the parliamentary approval and those responsible for the payments at the regional level such as the regional Treasurer Paymaster Generals, the Regional Finance Controllers and the key staff in the Governors’ offices.
The two PBF courses therefore welcomed in total 21 participants from the Ministry of Finance, three finance experts from the Ministry of Health, two representatives from the Ministry of Economy & Planning and Regional Administration and 11 representatives of the Governor’s office from all regions. They assisted in their action plans to develop and explain the steps and procedures required for the prompt payment of the PBF subsidies to all PBF stakeholders. This report presents their findings and proposals.
2. Costing of the PBF minimum budget 2020-2022 of USD 4-5 per capita per year
During the courses, the facilitation team also assisted in the costing for the implementation of the national PBF programme 2020-2022 and proposed USD 4,16 for 2020, USD 4,62 for 2021 and USD 5,17 for 2022. This costing wasfor about 80% included in the three-year budget proposal of the Ministry of Health during the pre-budget conference that took place from 28 to 30 May in Yaoundé. It still needs to be evaluated by the Ministry of Finance before it goes to parliament for approval. We request all those concerned to protect this minimum PBF budget, still increase it so that the full PBF program can be carried out.
3. The opportunities to transform more input lines of the government budget into PBF
The analysis of the ministry of health budget shows that several budget lines are candidates to be transformed into performance budget lines. There are several candidates such as :
- Public Investment Budget (BIP). For example, it proposes to build health centers with the very cumbersome central construction approach. Studies in Burundi and DRC showed that transforming this into PBF quality improvement bonuses, would render this budget 10 (ten) times more efficient. This budget alone could already cover almost 100% of the PBF budget ;
- Biens et services– It contains several sub-budget lines candidate for transformation into PBF;
- FINEX (financement de l’extérieur).It requires partners to align with the national health policy of PBF as the strategy towards Universal Health Coverage.
4. Collaboration with partners in Cameroon concerning PBF
Course participants in their action plans flagged several problems related to partners continuing their input policies whereby they potentially work against the PBF reforms. We mention the case of input-oriented community programs whereby unskilled community health workers are also given curative tasks. Another problem is the dumping of medicines in the market which impedes the emergence of Cameroonian pharmaceutical distributors accredited by the government. The input policies also forego the possibility to create economic multiplier effects and to strengthen the resilience of the health system. Yet, it appears that some partners such as GAVI positively consider aligning their strategy to the national policy.
5. Which type of emergency response strategy to apply?
The North West Region team wrote an excellent action plan (see paragraph 1.3.4 and 7.4) in which they argue that the PBF equity instruments should be applied to the fullest with the liberal use of the quality improvement bonus payments. Yet, the timely payment of invoices is paramount, and we propose to develop procedures so that the USD 36 million emergency support from the World Bank should be positioned in such a manner that it can carry out immediate payment after receiving the invoices from the district validation committees. The PBF emergency approach is more promising than the traditional humanitarian emergency response strategy. The latter is dominated by international NGOs, it has such as in the NW and SW regions a poor geographic coverage and they weaken the health system by dumping medicines and taking over management responsibilities instead of strengthening it.
6. Several regions still have problems to access essential drugs and other inputs
Several regions such as the Centre, West and in particular the South still report problems with stock outs of drugs in the health facilities due to monopolistic practices of CENAME, some Regional Funds of Health Promotion and religious essential drugs distributors, which oblige their members only to buy from them. Not all regional Delegations of Health have yet accredited and assured the presence of several wholesale distributors in their respective regions. To the contrary, the Littoral Regional Delegation of Public Health has accredited 16 wholesale organizations. The experience in Littoral region shows that stock outs have become rare. Another recommendation of the course participants is that accredited distributors in one region should also have national accreditation so that neighboring regions can benefit. This is important for the West and South regions Moreover, in the NW and SW regions due to the security challenges it is easier for some health facilities to obtain their inputs from neighboring regions than from Bamenda or Buea.
7. Rationalisation of health district and health facility catchment areas
The District Medical Officers, who attended the PBF courses, propose that there is a need to rationalise the size of the health districts. There are rural districts with less than 20.000 inhabitants while other urban districts have more than 800.000 inhabitants. This leads to very poor economies of scale at both extremes and there is need to merge or to split the districts so that the average population is between the minimum of 100.000 and the maximum of 350.000.
The same applies for mapping and rationalisation of the health facility catchment areas, which is not yet completed. Yet, for this clear orientations have been given in the PBF national manual and during the courses.
8. Continue the advocacy and expansion of PBF
- Strengthen lobbying so that the instructions for the implementation of the PBF come from the Presidency of the Republic ;
- Make the PBF mechanism a Law ;
- Implement the PBF within the MINFI so that each level obtains performance contracts.
9. The Ministry of Economy, Planning & Regional Development (MINEPAT)
- Review the terms of the financing contracts and advocate with the technical and financial partners to use their resources to purchase results instead of buying inputs such as drugs, food, etc.
- Apply the greater efficiency of locally buying inputs instead of that partners such as UNICEF continue ordering plumpynuts (mostly peanut-based) from outside Cameroon. Review the strategic options to stimulate the private sector to establish local production units and thus to create markets to respond to the demand of the health facilities for supplementary feeding. For example, the Far North region having serious malnutrition problems is at the same time a promising production area for food.
- The creation of production units to satisfy the demand for supplementary feeding will also create economic multiplier effects at the grassroots level with economic growth and the creation of employment
- Organise short seminars, for the decision makers of the technical working groups.
10. National Civil Status Registration Office (BUNEC)
In total seven participants from BUNEC attended the two courses (2 from the central level and 5 from the regional level). The results of the PBF programme to strengthen the civil registration offices in Adamawa and Littoral regions are promising.
Yet, there are still problems to be solved :
- Free civil status registration for the population is not realistic given that the government only provides a small budget for these activities. It would also be erroneous to assume that partner organizations such as the World Bank will continuously finance this activity. Moreover, there already exists a vibrant informal civil registration market, but which is uncontrolled and people are paying more than if there would be a well-implemented official user fee regime.
- A cost-recovery scheme with an equity mechanism for indigenous persons would be justified.
- Review the targets for the civil registration activities (birth-, marriage- and death registration) because the current targets seem to be erroneous.
11. Review the solidarity fund payments by the Ministry of Health
The 10% tax on health facility revenues towards the solidarity fund has the perverse effect of health facilities hiding their revenues in order to avoid this tax. These funds could be better used by the health facilities themselves so that the intended objectives of the solidarity fund can be achieved. There is no convincing reason why the Ministry of Health with its 301 billion FCFA budget for 2020 needs to tax health facilities. The MOH should do the opposite, and instead of taxing health facilities assure that more money from the national budget is injected into the peripheral health facilities and communities. This to encourage quality services and better access for the vulnerable. Taxing the health facilities means taxing the population and the largest proportion of the MOH budget is already spent at the central level and this is what PBF aims to change. As alternative for taxing the periphery, the Ministry should accelerate to develop performance contracts with the regulators at all levels including the Directorates and Programs of the central MOH.
12. Assuring that the procedures are in place to promptly pay the PBF subsidies.
The following table presents the steps with deadlines from the budget preparation until the payments of the invoices. All concerned actors should closely monitor the steps and deadlines of this process. It is also proposed by the course participants to develop a financial manual for PBF implementation actors in addition to the PBF circular of November 2017 and what was already written in the PBF manual of Cameroun.
|Acteurs||Actions à mener||Comment||Délais|
|CTN||– Costing Initial du budget de l’Année au niveau PMA, PCA, ECD, Délégation, ACV, Directions Centrales, CTN||– La CTN prépare l’outil costing sur base des exigences de activités prévues et les évaluations et revues réalisées de terrain||Avril|
|DRFP – avec CTN||– Costing des ressources à allouer aux structures de santé (prestataires, régulateurs, ACV, ASLO) pour le système de santé par l’approche financement basé sur la performance.
– Les ressources allouées par le mécanisme PBF couvre les quatre programmes du Minsanté selon les niveaux de pyramide sanitaire.
|– La DRSP organise un atelier est de rencontres de concertation avec les acteurs (CTN, DEP)
– Cette activité entre dans le contrat de performance de DRFP
|Mai – Juin|
|DRFP||– Analyse de l’Enveloppe Budgétaire officiellement alloué au Minsanté suivi par l’Arbitrage pour finaliser le budget alloué aux structures par le mécanisme PBF.
– Finalité : Le montant des ressources selon l’approche PBF est connu et arrêté
|– CTN assiste aux rencontres de l’analyse et de l’arbitrage
– Introduire dans la Circulaire de l’Exécution du Budget, le principe de dotation annuel unique des ressources des structures sanitaires qui seront allouées à travers l’approche PBF
|Assemblée nationale||– Vote la Loi de Finances dans laquelle se trouve le Budget||– Session budgétaire de novembre||Novembre|
|DRFP||– Suivre au niveau de Direction Général de Budget de MINFI que la dotation des ressources aux structures de santé selon l’approche PBF est fait en délégation automatique, annuel et unique auprès des contrôleurs financiers régionaux||– Rencontre avec les sectorielles santé à la Direction Générale de Budget pour s’assurer que la dotation de ces ressources est fait de manière automatique, annuel et unique||Novembre -Décembre|
Financier – Action 1
|– Télécharger le Budget à partir d’une clé USB de la Direction Général de Budget dans PROBMIS.
– Imprimer les autorisations de dépense (cartons)
– Distribuer les autorisations de dépense (cartons) et les carnets de bons de commande (cela explique le titre) à la DRSP
|– Application informatique PROBMIS ;||Au plus tard le 15 Janvier de l’année N|
|DRSP – Action 1||– Le Délégué envoie le projet de décision de déblocage unique pour toute la dotation annuelle régionale au Gouverneur ;||– Dès la réception du carton venant du contrôleur financier||48h (17 Janvier de l’année N) ;|
|Gouverneur Action 1||– Le gouverneur reçoit le projet de décision de la DRSP, le mets en forme et l’envoie au Contrôleur de Finance pour le Visa Budgétaire||– Dès la réception du projet venant de la DRSP||48 h (19 janvier de l’année N|
Financier – Action 2
|– Le contrôleur régional appose le Visa Budgétaire sur le Projet de décision qu’il a reçu du Gouverneur||– Dès la réception du projet venant du projet de décision venant du Gouverneur||48h (21 Janvier année N) ;|
|– Le gouverneur signe la décision de déblocage de la totalité de la dotation régionale et la renvoie au Délégué Régionale de la Santé Publique||– Dès la réception du projet venant du contrôleur régional||48h (23 Janvier, année N)|
|– Le Délégué engage et ordonnance la totalité de la dotation régionale et transmet le dossier au contrôleur régional de finance||– Par un bon de commande dès la réception de la décision de déblocage venant du Gouverneur||48h (25 janvier année N)|
Financier – Action 3
|– Le contrôleur financier régional traite et transmet la dépense au TPG||– Il utilise l’application PROBMIS dès réception du bon de commande engagé||48h (27 janv. année N)|
|– Le TPG traite la dépense et procède à la mise de la somme totale dans un compte de dépôt, et ouvre un registre de suivi||– Il utilise l’application informatique CADRE.||48h (29 janv. année N);|
|– Le TPG procède au paiement dès réception des justificatifs (factures des comité de validation des districts)||– Il utilise l’application informatique SYSTAC et ses délais sont les suivants : Le 2 de chaque mois pour le PMA-PCA et le M pour les DS et la DRSP).||24h après PEC (29 janv. N)
Financier – Action 4
|– Traitement et transmission de la dépense au TPG||– Fichier PROBMIS et Dossiers physiques
– dès réception du bon de commande engagé
|48h (25 janv.N)|