The NEXT 97th PBF COURSE will be organized in COTONOU, November 17-19th, 2025. Hereby the announcement  (annonce) and the application form (fiche inscription) 

The 96th international course, held from June 30 to July 12 in Cotonou, was a success, with 37 participants from six countries. The largest group was from Mauritania (18), followed by Guinea-Bissau (7), Madagascar (5), Mali (4), Benin (1), and the DRC (1).

The course differed from previous ones in that the facilitation team provided early feedback on the groups’ action plans from the very beginning. This enabled the groups to modify and improve the quality of their action plans up to four or five times.

Hereby the full course report (rapport).

The 37 participants of the Cotonou course with the facilitation team

This was the third PBF course, held in seven months (December 2024, January 2025, and July 2025), which indicates that the PBF reforms are again attracting a growing interest in the ten African countries in attendance at the courses. This is also due to the hard work of several African experts and consultants of the World Bank and Cordaid, as well as the Dutch Embassy in Bamako. There were 75 participants in the three courses, and PBF is again seen as a credible, if not the best, approach to achieving universal health coverage. We estimate that currently fifteen countries in Africa implement PBF, including around five in the education sector.

1 Guinea-Bissau

Guinea-Bissau is in the PBF start-up phase. It is essential to establish the PBF National Technical Unit (CTN) directly under the Secretary General, with a strong coordinator who is familiar with PBF, who is a leader, along with 1-2 PBF experts. Continue reading →

Mali demonstrates that some past academic criticisms of PBF were wrong

We report the success achieved in Mali with an almost “pure” PBF approach (feasibility score of 92%). Mali demonstrated, for the first time, unambiguously, that when the standard six PBF equity instruments are applied correctly, the results are very significant for vulnerable people and areas, including those affected by political insecurity.

The PBF program in Mali provided care (including consultations, admissions, deliveries, and surgeries) to 460,000 vulnerable patients over four years, 7 to 8 times more than the project had anticipated. The PBF equity approach includes targeted free care for vulnerable populations (25% of all patients) and geographic equity bonuses for districts and health facilities.

The regional Contracting and Verification Agencies are integrated into the already existing Mandatory Health Insurance (CANAM) structure. PBF strengthened the health system with an administrative cost of only 15% for the regional Contracting Development and Verification Agencies. The project demonstrated a significantly higher cost-benefit ratio than initially anticipated. The decentralized quality improvement bonuses of between USD 1000 and 5000 showed remarkable results that enabled health facilities and regulatory authorities to invest in rehabilitation, equipment, transportation, and the recruitment of qualified personnel.

The above findings are demonstrated in several published articles (Bagayoko et al, 2025[1]) (Bagayoko et al, 2025[2]) and the World Bank’s final report on the “Accelerating Progress Towards Universal Health Coverage (PACSU) Project 2019-2024” (World Bank, 2025[3]).

Two critical conditions for success in Mali were: a. The regular payment of the PBF subsidies, and b. The selection of vulnerable groups was carried out by health facilities with their communities, rather than through a centralized, complex, and costly identification of vulnerable groups.

These two conditions were not met in other countries, notably the PBF programs in Burkina Faso (2013-2018) and Benin (2013-2018). In Cameroon (2012-2022), there were significant delays of up to a year in subsidy payments, so that the staff of health facilities stopped assisting vulnerable patients free of charge due to the lack of funds.

Thus, according to the PBF best practices and the failure to implement the PBF equity instruments and regular payments, it was conceptually also impossible to achieve good results for the poorest in these countries.

However, despite these conceptual and practical flaws, some academic authors have used these examples to demonstrate in their view that PBF is not a good approach for equity, that PBF weakens the health system, and is inefficient (Paul E, Ridde V, et al 2018^[4], Turcotte, Ridde, et al 2018[5]). The example of Mali now demonstrates that the above arguments and conclusions were flawed. Unfortunately, this led many decision-makers to mistakenly perceive PBF as an ineffective approach. The Mali case, in our opinion, corrects this misconception.

We also recommend that the actors involved in the Mali programme conduct a quantitative and qualitative intervention-control study. This investigation aims to further examine the effects of the PBF programme on effectiveness, efficiency, quality, and output results, with a particular focus on the vulnerable.

[1] Bagayoko, M., Diabaté, M., Tamga, D., & Keita, Y. (2025). Strengthening Equity in Access to Basic Health Care for Indigents via PBF : Selected Key Results in Koulikoro Region, Mali. SAS Journal of Medicine, 11(05), 530‑537. https://doi.org/10.36347/sasjm.2025.v11i05.026

[2] Bagayoko, M., Diabate, M., & Tamga, D. (2025). The Granting of Special Quality Improvement Bonuses is an Efficient Means of Correcting Inequities and Accelerating Health Coverage in Mali’s Results-Based Financing Model. SAS J Med, 5, 526‑529.

[3] Implementation Completion Report Mali – Accelerating Progress Towards Universal Health Coverage February 2025, World Bank

[4] Paul E, Ridde V, et al Performance-based financing in low-income and middle-income countries. Isn’t it time for a rethink BMJ Global Health https://doi.org/10.1136/bmjgh-2017-000664

[5] Turcotte-Tremblay, Ridde V et al. The unintended consequences of combining equity measures with performance-based financing in Burkina Faso International Journal for Equity in Health (2018) 17:109 https://doi.org/10.1186/s12939-018-0780-6

The NEXT 96st PBF COURSE will be organized in COTONOU, June 30 to July 12, 2025. 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.

Continue reading →

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 →

The 42 participants of the PBF course.

The 93^rd 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 →