The 58th International PBF Course was held at Makèpe Palace Hotel in Douala from 6 to 17 March, 2017.

Hereby the course report.

Forty-seven participants took part in this course with six facilitators and three staff dedicated to the Secretariat. Thirty-six participants were from Cameroon, three from Central African Republic, two from Burkina Faso, two from Côte d’Ivoire, 1 from Republic Congo, 1 from Democratic Republic of Congo, 1 from Chad and 1 from Switzerland.

In general, the international PBF course in Douala was a success. 88% of the participants said that the course met their expectations and 91% of them appreciated the teaching materials. The reception by the facilitation team was appreciated by 89% of the participants. The action plans of the 14 working groups were generally of high quality compared to previous courses. Yet, the number of modules and exercises to be shared has increased sharply in recent years and, as a result, 42% of participants said the time for the course was too short. The course facilitation will also have to make difficult choices on which modules to share with each individual participant and how to organise this modular approach adapted to the needs of each participant.

The general recommendations of the course

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  Sunset during the social event in Limbe

  Cameroun: Assure the regular payments of PBF invoices by the national PBF Unit. Payment delays are often between 6 and 12 months, which have put at risk the progress of the PBF program and has frustrated all actors, but especially those who depend for a large extent on the PBF subsidies such as the regulatory authorities and the CDV Agencies. At health facility level, this also applies for those activities that are offered free-of-charge to the population such as the support for the vulnerable, home visits, tuberculosis treatment and family planning services. Performance contracts with the national PBF Unit may solve these delays and this should already start in April 2017. New delays in the payment schedule most have consequences for the variable part of their remuneration. The directorates of the MOH should also be put under performance contracts starting from the 1^st of April in at least one directorate.

• Improve the economies of scale of the operations of the district health management teams. Districts should be rationalised into health district units covering around 150,000 people. This implies cutting certain large health districts such as Deïdo in Douala with a population of 800,000 into at least three new health districts. Other districts should be given a principal contract whereby they supervise those districts, which have less than 40,000 population. In the small districts, the medical doctor may concentrate on the hospital activities and leave the regulatory role to another medical doctor operating from another larger health district. All this also to avoid conflicts of interest.
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  Happy moments after obtaining the course certificate

  Set up urgently the CDV Agency for the Central Region with a technically well-equipped team recruited on the basis of competence and competition. In the legal sense, the CDV Agency should be under the umbrella of the Regional Fund for Health Promotion, but it should have a large degree of autonomy to avoid any potential conflicts of interest with the RFHP and notably concerning the distribution of drugs.

• Encourage Regions and CDV Agencies to make the most effective use of their PBF action research budget. Research topics should be identified and discussed during district validation meetings. The research budget should be made available to any actor capable of conducting quality research and could include health facility staff, regulators, members of public health schools. Moreover, it is encouraged that regions seek collaboration with international research institutes to further enhance the quality of their action research.
• Ensure the autonomy of the PBF health facilities by applying derogations for: (a) Authorizing health facilities to open separate commercial bank accounts, which they also control; (b) Applying the market price for the purchase of inputs instead of the higher mercurial prices and; (c) Authorizing health facilities to purchase their inputs from accredited distributors operating in competition.
• Encourage the quick introduction PBF in the Education sector in Cameroon and support the action plan of the Education sector group in Douala.
• Several country teams in the course (Burkina Faso, Chad, CAR (Bekou Fund), DRC, the Republic of Congo and Ivory Coast) propose that the design of their PBF interventions should improve and include more PBF best practices. Details can be found in the follwong paragraphs.

The recommendations from the 14 working groups

Burkina Faso

• Strengthen the institutional set-up of the national Technical RBF unit and enhance closer collaboration with the other directorates in the MOH;
• Promote market competition for the distribution of inputs in RBF health facilities => (a) Identify and select wholesalers; (c) Disseminate Derogation Notes and the List of Wholesalers; (c) Conduct briefings with concerned stakeholders;
• Make health facilities more autonomous in decision-making, personnel management, resource management and procurement: => (a) Conduct awareness-raising activities on the benefits of health facility autonomy within the MOH (DES, DGS, SG, MS); (b) Advocate with the Prime Minister for a special autonomous status of FBR health facilities; (c) Prepare a draft note for the derogations;
• Assure adequate financial resources for the implementation of a combined program package of free health care and FBR => (a) Conduct meetings to advocate the pooling of resources for free health care and RBF with the argument that this will enhance a more efficient use of limited public resources; (b) Develop a memorandum for the pooling of free health care and RBF; (c) Hold a meeting to harmonize FBR and free health care tools.
• Conduct a combined free health care / RBF costing => Sensitize the Ministry and the partners for the importance of a pooled budget for the cash payments for results of the health facilities.

Education sector

The education sector faces problems in terms of equity (regional disparities, low student retention), quality (insufficient teachers, poor infrastructure, low pupil achievement and a lack of textbooks) and governance (misuse of resources).

Recommendations

• Organize a PBF course specifically for the education sector;
• Ensure the training of actors at all levels and conduct exchange visits;
• Set up the National Technical Unit PBF (NTC-PBF) for the education sector;
• Contract regional CDV Agencies for the PBF education programme;
• Advocate for the transformation of the traditional Ministry of Education input budget towards cash payments based on results;
• Advocate for adequate funding of PBF (around $ 20 per pupil per year);
• Begin preparing for the pilot phase, taking into account PBF best practices and lessons learned from the pilot.

Littoral Region – Cameroun

Currently 23% of the population in Littoral region (=850,000 inhabitants) is covered by PBF. During 2017, the PBF program will expand towards four additional districts.

Recommendations

For the Ministry of Public Health

• Transform the vertical input budget lines towards horizontal PBF financing of health package indicators at primary and hospital level;
• Decentralize the recruitment of staff towards the health facility level;
• The Deïdo District in Douala town has 800,000 people and requires more qualified staff (public health doctors) for the effective coverage of all 300 HF;
• Government should allow that public health facilities can make infrastructure investments above FCFA 5 million.

At the ACV Littoral / DRSP Littoral

• The regulatory activities in Yabassi health district (which has a population of less than 20,000) should be done by the DHMT of one of the neighbouring health districts.

North-West Region – Cameroun

The North-West Region has 1.8 million inhabitants and 19 health districts of which 4 districts (600,000 people) are under PBF. During 2017, four more districts will start PBF and this will make the total population under PBF 1.2 million.

The non-PBF districts face several problems such as poor health indicators, poor motivation of staff and the inadequate number of human resources, inadequate funding, inefficient use of public funds, input policy and, as a consequence, poor quality of services.

Recommendations:

• Conduct meetings with town halls, churches, tontines and local media;
• Brief staff on PBF theories and best practices;
• Identify all legal and illegal FOSAs and obtain basic health facility data
• Update the populations of responsibility of the health facilities.

South-West Region – Cameroun

PBF started in the South-West region in April 2012 in 4 health districts. Scaling up of PBF will take place in 2017 in five new health districts. The problems in South-West Region are similar as in other regions and PBF can solve these problems through: (a) Direct allocation of resources at the operational health facility level; (b) Inject cash locally to create multiplier effects for boosting the economy, and generating taxes for the State.

Recommendations:

• Linguistic differences should be taken into account when organizing international training courses.
• The Regional Delegate and the Administrator of the Regional Fund, should encourage health facilities to autonomously procure their inputs from different distributors and not only from the RFHP;
• Health facilities in the PBF districts should be allowed to open separate commercial bank accounts (and not at the treasury) so that health facilities can better respond to their needs;
• Map the health facilities and districts according to the PBF standards;
• Advocacy for autonomy of health facilities;

Centre Region

The government made the decision to launch PBF during 2017 also in the Centre region.

Recommendations:

• Set up as soon as possible the CDV Agency for the Centre Region under the juridical coverage of the Regional Fund for Health Promotion Fund. It must be ensured that the team will be recruited on the basis of competence and in a competitive manner;
• Start the mapping and rationalisation of health districts into health facility catchment areas of around 8-10,000 inhabitants with principal and secondary PBF contracts;
• Establish a plan for communication, education and information on PBF and develop spots and slogans.

Hôpital Gynéco Obstétrique et Pédiatrique de Yaoundé

HGOPY Hospital had a structural financial deficit since its construction and was unable to pay taxes and all its bills. The main reason was that the payroll was too high. Some categories of staff are plethoric and there are a multitude of fixed allowances (which are far above the basic salaries). This situation is caused by the semi-autonomous public status of the hospital in which management has limited and there are cumbersome public procurement procedures. There is no threat of bankruptcy that obliges the hospital in case of structural loss to close its doors. Thus, there is no strong incentive for management and staff to change their inefficient manner of working. There is not yet a good separation of functions between the regulator, the CDV Agency, the payer and the provider. There is no external PBF financing due to the lack of a CDV Agency in the Central Region. Yet, since the introduction of PBF in 2015 there were important improvements in reducing the debts and improving output and quality.

Recommendations:

• Establishment of a CDV Agency in the Central Region that will solve the problem of separation of functions (regulator, CDV, payer);
• Empower HGOPY in the management of its human and financial resources;
• Train all concerned personnel in the use of the indices management tool.

Ivory Coast

Ivory Coast is located in West Africa with a population of 24 million and a GDP of 1,244 USD. The national PBF strategy was developed in 2013 with a feasibility score of 70%, meaning that there from the start there still were design imperfections. The introduction of PBF has two phases: (1) A two-year pilot project (2016-2018) with 19 health districts; (2) Scaling up from 2018 onwards in 15 health districts on the basis of the results of the first phase.

Recommendations:

Making the PBF program purer. This implies:

• Liberalize the purchase and distribution of medicines and other inputs and promote competition to assure the availability of these products in health facilities;
• Empower health facilities in the management of their human, material and financial resources;
• Include private and faith-based health structures in the pilot PBF programme;
• Initiate Community PBF by introducing community indicators during the pilot phase of the programme.

 The Democratic Republic of Congo – Tshuapa Province

The province of Tshuapa is one of the 26 provinces in the DRC and is located 1200 km north-east of Kinshasa. The province has a population of 2.4 million and has a low population density. A PBF program was launched in 2013 by a program financed by the World Bank, which was made purer in 2016 during its second phase. The feasibility scan core for the PBF program in Tshuapa province is 56%. Hence, there is stil a need to improve the set-up of the PBF program to reach the desired 80%.

Recommendations:

• Increase the PBF budget from $ 3 to $ 4 per person per year;
• Reduce the administrative cost to 30%;
• Increase the national health budget from 4% to 15% and its disbursement rate to 100%;
• Promote a common basket for various sources of health financing that includes government and partner funds;
• Reverse the financial pyramid from the central level towards the intermediate and peripherals;
• Accelerate the process of the retrocession of a portion of the provincial wood harvesting tax towards increasing the provincial health budget;
• Eliminate all monopolies in the acquisition of drugs and allow health facilities to purchase their input from different accredited distributors operation in competition;
• Expand contracts towards also private health facilities.

Tchad

The first pilot phase of results-based financing (RBF) financed by the World Bank took place during 18-month between 2011 and 2012. The Swiss Cooperation entrusted the Swiss TPH-CSSI Consortium from 2015 onwards with the implementation of the “Support Project for the Chad, Yao and Danamadji Health Districts” (PADS), which cover 290,000 inhabitants. The budget for the Performance Purchase Component is USD 2.03 per person per year.

Recommendations:

• Insufficient budget for PBF (<$ 4 per capita per year) => Consider increasing the budget for the RBF component of the programme;
• Include the following indictors in the PBF package: (a) community-based PBF indicators with CHWs; (b) the management of spontaneous post-abortion care; (c) bonuses for Traditional Birth Attendants, when they refer patients to the health facility; (d) nutrition indicators;
• For equity purposes, address the regional and district vulnerabilities and include in the package targeted free health care indicators for vulnerable individuals;
• Diversify the sources of drug supplies => (a) Advocate with the MOH and partners for a waiver to allow health facilities to purchase their inputs instead of centralised drug purchasing; (b) Identify the sources of medicines and understand their functioning (vertical programs, private and public providers);
• Separate the functions of contracting and payment. The authorities do not a priori refuse the separation of functions => Outsource project verification functions and satisfaction surveys; Outsource the payment function. The project executed by TPH-CSSI Switzerland would retain the functions of contracting, at least initially;
• Reduce the multiplicity of contracts and PBF approaches in the Danamadji health district => Advocate with PNLP, CIDR and Care for a single health district funding framework;
• Funding currently in the form of inputs could be used for performance payments;
• An equity fund could be allocated through the Objective and Means Contracts based on current practices through the Health Committees (COGES).

Adamaoua Region

The Adamaoua region is one of the largest regions of Cameroon with 1.2 million inhabitants and 9 health districts. PBF started in two pilot districts since 2016, but the scale up to cover all districts of the Region is planned by the end of 2017.

The Adamaoua region is experiencing similar problems as the other regions of Cameroon, but adds cultural problems, the lack of good roads, a high rate of HIV, a very poor quality of care and, as a result, very poor reproductive health indicators. The feasibility score in the non-PBF districts is only 60% due to problems with central purchasing of inputs, the lack of autonomy of health facilities and problems related to generalised free provision of certain activities. These problems need to be addressed before starting the scale up.

Recommendations:

• Increase the attendance of health facilities by patients through: (a) Advocacy with authorities, traditional leaders and religious leaders; (b) Stimulate demand by the use of social marketing PBF community indicators; (c) Encourage with incentives traditional birth attendants to motivate women to attend health facilities and; (d) Better ensure the quality standards at health facility level;
• Advocate for greater autonomy of HF;
• Recruit staff by the health facilities instead of through centralised recruitment;
• Improve the hygiene especially in hospitals.

Central African Republic

CAR has about 4.5 million inhabitants on an area of ​​623,000 km². Confronted with the recurring military-political crises since the end of 2012, the health system in CAR has been dysfunctional with declining health indicators.

Recommendations:

Make the EU-funded Bekou project more PBF pure and similar to the government PBF pilot programme financed by the World Bank. More specifically:

• For the National PBF Technical Unit: (a) Review the responsibilities of the community; (b) Introduce the indicators: “Investment Units” and “home visit following a protocol” ; (c) Separate the payment function from the contracting and verification function;
• For the CDV / CORDAID: (a) Apply the binary signatures of contracts; (b) Establish the district validation committee in the Bekou project zone; (c) Strengthen the coaching of the health facilities and (d) Develop the PBF community indicators of social marketing;
• For the regulators: (a) Change all input support for health facilities such as for drugs into cash payments based on performance; (b) Allow health facilities to recruit qualified staff by a demand-driven system and using investment units; (c) Include the inspection of retail pharmacies in the PBF districts by the regulatory authorities at regional and district levels.

Central level MOH – Cameroun

The national PBF Unit within the MOH was created in 2015 with the following missions: (a) Technical monitoring of the implementation of PBF activities; (b) The development of action plans and; (c) Follow-up and coordination meetings. The national PBF Unit will also start signing performance contracts with the directorates and services within the Ministry of Health. Since 2016, the General Secretariat of MINSANTE coordinates and supervises the activities between the CTN – PBF and the technical departments of the ministry.

Recommendations:

• Develop PBF contract with the ministerial departments;
• Sensitize managers of the MOH on the importance of the new PBF managerial approach, and in particular on the need for the establishment of a legal and institutional framework;
• Organize workshops for central level officials and train them in the PBF concept so that they take ownership;
• Continue advocacy for PBF with the technical and financial partners.

IRESCO

A CDV Agency was set up by the Regional Fund to start PBF in Adamaoua region but at the same time the national NGO, IRESCO, was contracted for counter-verification services and quality assurance services. However, the cooperation between the CDV Agency of Adamaoua and IRESCO has not been good.

Recommendations:

• The national PBF units is requested to solve the coordination problems between Adamaoua CDV Agency and IRESCO by better outlining their terms of reference and responsibilities.
• For the regional health authorities to carry out its role of the evaluation and accreditation of the pharmaceutical wholesalers in the region => (a) Evaluation of the wholesalers twice per year; (b) Establishment of the list of approved suppliers; (c) Dissemination of the list of approved wholesalers in the region.