Final Report PBF course January 2025 in Lomé

The NEXT 96st PBF COURSE will be organized in COTONOU, June 2-14, 2015. Hereby the announcement (annonce) and the application form (fiche

The 95th FBP course was organized in Lomé, Togo, instead of Cotonou, Benin. Hereby the course report (rapport).

Beach near Lomé

The change of country was necessary to facilitate the presence of a delegation of 20 people from Niger with representatives from the central, regional and district levels. In addition, there were three participants from Mali from the district- and health center levels. Benin was represented by the Director of Health of the “Atlantique” Department in Benin.

During the post-test, there were four people with a distinction (90% or more) and eight with a merit “mention” of between 80 and 89%.

Examples of PBF successes – also in insecure areas

The participants of the 95th PBF course in Lomé

Different groups of participants in the last 5-10 PBF courses have shown extraordinary results of the PBF programs in several countries such as Mali, Mauritania, DRC, Burundi and CAR. Well-structured PBF programs produce cost-effective and high-quality results. “Well-structured” is defined as the PBF program having an above 80% feasibility score following 23 criteria and applying the PBF management instruments such as the business plans, indices management tool and the quality improvement bonuses. PBF also offers equity bonuses ranging from 10% to 80% on top of the payment for the output and quality indicators that benefit vulnerable regions, districts and health facilities.

Moreover, in PBF, the poorest 10-25% are exempted from paying for their care through a targeted free health care mechanism. Health facilities are reimbursed for this targeted free service, and the identification of the poorest is carried out by health facility staff with their local community. This targeted free health care approach is more realistic and avoids over-expenditure such as in insurance systems, and it is better verified than generalized free health care such as for example for children, or delivery care.

The main reason for the success, also in insecure areas, is that more than 70% of the PBF budget is transferred directly to the accounts of peripheral providers who decide autonomously what and where to buy their inputs. This instead of a hands-on system where central level authorities decide how to use the money.

Yet the very encouraging results reported for example from Mali and Mauritania are under-reported, under-published and therefore under-funded beyond what is justified.

These PBF innovations constitute the alternative for all sorts of more traditional initiatives such as generalized free health care, compulsory health insurance systems or the imposition of health care price ceilings by government.

The introduction of Quality Improvement Bonuses

Monument in central Lomé

A very important innovation in recent years has been the introduction of quality improvement bonuses (QIBs). This is an output indicator whose value is between 500 USD (primary level) and 2000 USD (hospital level or for regulatory organizations). The QIB subsidies are paid directly into the accounts of autonomous health facilities or regulatory organizations. This, only after the QIB achievements (together with the other output indicators) are verified by Contract Development and Verification Agencies. They verify the investments realized in infrastructure, means of transport, equipment, or emergency expenses. A convincing business plan can also serve as the trigger for the first QIB payment as a method for health facilities to start their first investments.

The QIBs accelerate the upgrading of health facilities or regulatory organizations. The rehabilitation or purchase of inputs is carried out by each autonomous peripheral actor, according to their needs. This is more cost-effective by a factor 4-10compared to the traditional centralized input approach.

The end of PBF in Cameroon and Benin

Coffee growing in Togo mountains near Ghana border

Policy choices led in 2022 and 2018 to the end of promising PBF programs in Cameroon and Benin. These policy decisions have now led to the degradation of both (2) health systems.

In Cameroon, the Minister of Health terminated PBF in 2022. When consulting the literature with impact evaluations, observational- or photo studies in Cameroon, most papers agree that there were important positive results on output, quality, motivation of staff [1]. One study concluded that “despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal) [2]. Yet, surprisingly, despite the academic evidence and the training of most key implementing agents, the political willingness to maintain the PBF successes remained problematic in Cameroon. In 2022, the Minister of Health declared that he “was not in favour of PBF,” without any other justification.

Since the end of PBF, patients in Cameroon have had to bear higher financial (often informal) costs, and the quality of care has deteriorated due to the abandonment of regular PBF quality reviews by district and regional authorities. In short, Cameroon has returned to the old weakly regulated input health system at very high cost for the population.

Cotonou statue of the Amazone lady warrier

In Benin, the government ended the PBF approach in 2017. PBF in Benin was not perfect, but had promising results. The main reasons for the shutdown were the lack of harmonization between partners and that the government would not agree to pay performance bonuses to staff and that it would assume that a fixed salary was enough for health workers to perform. After negotiation with the government, the World Bank replaced the PBF reforms with the “Pfor R- Program for Results” approach. This approach directly injects funds into the Ministry of Health budget based on national performance indicators.

However, several field visits since 2022, in health facilities and focus group discussions, show that the results of this centralized approach are difficult to verify and were not felt by the health facilities. However, with PBF this money would be injected directly into all health facilities, including peripheral health facilities with the indices management tool to calculate performance bonuses, which gives more motivation to staff and produces better results.

Thus, the health policy of the Ministry of Health of Benin has regressed towards inefficient distribution of inputs and centralized planning. For example, the famous Paou health centre, which has experienced many innovations, during 20 to 40 years, within the framework of the Bamako initiative and primary health care, suffered a fire in 2022. Yet, three (3) years later, it has not been rehabilitated due to inefficient procedures at the central level. Under the PBF approach with the QIB system described above, the rehabilitation would have been carried out autonomously by the health centre team in a few weeks or months.

[1] We consulted 14 papers on PBF in Cameroon in February 2025 of which the World Bank Impact evaluation is the most important (Cameroon Performance-Based Financing Impact Evaluation Report 2017). The impact study results were positive, despite that the authors acknowledge that the study design may have contributed to problems of contamination bias between PBF health centres and control group health centres.

[2] Nkangu, M 2023 An in-depth qualitative study of health care providers’ experiences of performance-based financing program as a nation-wide adopted policy in Cameroon: A principal-agent perspective.

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Report of the 94th PBF course in Cotonou December 2024

The 94th FBP International Course was held from December 2 to 14, 2024, at the Atlantic Beach Hotel in Cotonou, bringing together 14 participants from five countries.

The 14 participants of the PBF course with the facilitation team

Here is the course report (rapport).

This 94th international course demonstrates that there is still a large demand for knowledge, skills and change of attitudes training in the context of the PBF reforms. This training can be done during international courses, but also during follow up national courses at central and peripheral levels. The successes recorded with the PBF reform in several countries, particularly also testified by the participants from Mali, have made it possible to improve the quality of services and to improve the access to the health services. In addition, the motivation and retention of staff, particularly in rural and unsafe areas, have improved.

This gives hope that PBF is the essential approach to achieve Universal Health Coverage. Continue reading

Report of the 93nd PBF course in Cotonou and announcement 95th course January

The 42 participants of the PBF course.

The 93rd international FBP course, the first course of which started in 2007, was held from April 29 to May 11, 2024, at the Atlantic Beach Hotel in Cotonou bringing together 42 participants from three countries.

Hereby the course report. (rapport)

The next PBF course in Lomé (Togo) will be organized from January 13th until the 25th 2025. Hereby the announcement (annonce).

This international course demonstrates that there is again a growing demand for skills building in international PBF and for other continuing courses organized at the national level. The successes recorded as part of the PBF reforms in the countries concerned, particularly in Mali, have made it possible to improve the quality of services and increase the main indicators of service provision. In addition, staff motivation and retention, particularly in rural areas, have improved.

This gives hope that PBF is the essential approach to achieve Universal Health Coverage.

The positive results of the PBF reforms in Mali, which correctly applies best practices and instruments, show that combining direct financial support based on performance with autonomous management of health facilities is the solution for efficient and high-quality health services, at primary, secondary and tertiary levels.

PBF is also believed to be experiencing a revival in several countries after the slowdown caused by COVID-19. This includes the potential of PBF to improve the efficiency of tertiary hospitals which often experience terrible inefficiency in the use of state resources, and which often results in an unregulated privatization through informal services provided by government health workers.

In addition, the PBF addresses the problem of shortage of qualified health personnel in remote and war-affected areas. This effectiveness of the PBF in stabilizing the health sectors (and potentially also education and other sectors) contributes to reducing social tensions. For future compulsory insurance systems, we believe that PBF could also solve the challenges of quality control, strict verification and cost control. The creation of contracting and verification agencies under the aegis of the CANAM compulsory insurance system in Mali shows good prospects. Continue reading

Final report of the 92nd PBF course of 27 November to 9 December 2023 in Cotonou, Benin

The next 93rd PBF course will be organized in Cotonou from April 22 to May 4, 2024. Here the course announcement (annonce cours 93) and course registration form (fiche d’inscription 93)

The last 92nd international PBF course took place at Benin Atlantic Beach Hotel in Cotonou, with 32 participants from three countries. Here the final report of the course (rapport final).

The 32 participants from Mali, Guinea-Bissau and Benin

The 16 participants from Mali were the largest group, including nine from the contract, development, and verification agency (CDV) Koulikoro, three District Medical Officers, three providers and one from the University. Among the 10 participants from Guinea-Bissau, there were two from the World Bank Project Implementation Unit and eight from the Ministry of Health. Benin was represented by five persons from the accounting firm COFIMA, and one person from MSV (Médecins sans Vacances).

Thirty-two participants took the post-test, and the average score was 71%, which meant an average improvement of 25% compared to the pre-test (46%). Nine participants earned a Certificate of Distinction with a score of 90% or higher on the course post-test. In addition, we congratulate Ms. Armelle Carine GABA, who obtained 100% for the final test.

Acrobats during the closing ceremony

This course was very well evaluated by the participants with the daily and final scores higher than previous French-speaking courses. This is probably linked to the fact that the majoirty of the participants self-financed their stay. The Benin Atlantic Beach Hotel was, this time, also better prepared to receive the participants compared to previoous courses.

This course was also historic in the PBF community, because we welcomed the 3000th participant since the first course in 2007. This was Jessica Vanessa da CUNHA, the social expert from the Bank’s Project Coordination Unit World in Guinea-Bissau. Continue reading

The report of the 91st PBF course – organised in Benin

We have organized the first standard PBF course in 2023 in Cotonou, Benin. This was an open PBF course, the 91st since 2007 and the 16th in Benin.

It was organized between the 6th and the 18th of February, 2023. There were 18 participants from Tchad (15 x), Mali (2 x) and Benin (1 x).

Hereby the report of the course rapport du cours.

This course was well rated by the participants, with daily and final scores between 8 and 20 percent higher than previous French courses. This was probably because this group had only 18 participants, which facilitated the adult learning process whereby all participants could contribute to the discussions. The Benin Atlantic Beach Hotel was this time better prepared to host the participants compared to the December 2022 course.

The next 92nd open PBF course will take place from October 30th to November 10th, 2023 in Cotonou.

SUMMARY OF COURSE FINDINGS

Recommendations participants read on February 18 at the Closing Ceremony Continue reading