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.
