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.

Here is the course report (rapport)

This 94th international course shows strong demand for knowledge, skills, and change-of-attitude training in the context of PBF reforms. This training can be delivered during international courses and during follow-up national courses at central and peripheral levels. The successes recorded with PBF reform in several countries, particularly as testified by participants from Mali, have made it possible to improve service quality and access to health services. In addition, staff motivation and retention have improved, particularly in rural and unsafe areas.

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

1.           Guinea

The Republic of Guinea has requested and obtained from the World Bank a financing agreement for the Strengthening of Health Services and Capacities PBF program in the health regions of Kindia and Kankan from 2018 to 2023.

Implementation of this pilot FBR activity began in January 2021. Thus, after more than three years of implementation, progress on the various activities and quarterly quantitative and qualitative verifications has been made at all levels, in accordance with the provisions of the national PBF manual of the Ministry of Health.

However, implementing the new phase planned for the FBR in Guinea faces several conceptual and practical problems. This gives a feasibility score of only 36%. The program must resolve these issues to succeed. It requires designing the PBF program to integrate standard PBF best practices and instruments. This includes giving health facilities more autonomy and making output and quality indicators SMART.

1.1       Problems identified

By participants implementing the Guinea PBF program.

• The national PBF Unit (CTN) lacks the staff and appropriate premises for its operations. The CTN’s institutional setup is unclear, and it lacks a performance contract.
• The cost of the Contract Development and Verification Unit is very high because it lacks a performance contract. These Contract Development and Verification Units were also recruited from abroad instead of being under a Guinean organization with an existing legal status.
• The World Bank Project Management Unit (UGP) and the national PBF Unit carry out the same activities, creating confusion about who is responsible for what.
• Health facilities must still request authorization from regional directors to purchase inputs, such as essential drugs, from other accredited suppliers rather than the central medical stores system, instead of having free access.
• The PBF equity indicators are missing in the list of subsidized output indicators. The primary- and hospital-level package indicators are available, but they urgently need to be updated to make them SMART. The indicator list does not include the Quality Improvement Bonus indicator for starting up funds and investments in infrastructure and equipment.
• Dysfunction between the implementing actors due to an unsuitable procedure manual
• The budget available for the PBF approach cannot cover the 4 regions (Kankan, Kindia, Labé, and Faranah) for five years.
• Advocacy is needed to obtain an exemption authorizing health facilities to set their own user fee rates. This can be settled in the national PBF manual
• The district validation committee has many non-technical members (around 15), which will complicate the process.

1.2       Recommendations

• Allocate a PBF budget of at least USD 4 per inhabitant per year for the next 5 years, ⇒ review the project costing.
• Advocate for including a budget line to finance PBF activities in the National Budget.
• Extend results-based financing implementation to other regions of the country.
• Create appropriate premises with furnishing for the national PBF Unit and ensure the institutional framework for the adequate functioning of the national PBF Unit (CTN).
• Make the quantitative (output) and qualitative indicators SMART in accordance with PBF guidelines, such as those of Mali and the PBF course manual.
• Update the national PBF manual and management tools in accordance with the international PBF best practices and instruments.
• Grant exemptions to the health facilities in the PBF districts, such as for: a. the free purchase of essential drugs and medical equipment from various approved distributors; b. autonomous personnel management and c. free pricing of user fees
• Integrate the improved SMART PBF output indicators and equity indicators in the new version of the PBF manual into the DHIS2 for data collection, analysis, and interpretation.
• Reduce the number of members at the district validation committee level to only technical staff (around 5–6 persons instead of 14+).

  2         Mali

To address multiple health problems, Mali has embarked on the PBF reforms, which have undergone two pilot phases in the Koulikoro region.

The Mali PBF program has achieved very positive results in recent years, which is even more remarkable given the political and security challenges. One participant worked for the last 14 months in a district that applied, for the first time, all PBF best practices and instruments, which he describes in the following paragraph.

We believe more advocacy of this kind is needed so that available internal and external health funds are spent in the same manner and so that PBF reforms can be scaled up nationally in Mali.

However, despite the strong application of most PBF best practices and instruments, with a feasibility score of 84%, some issues remain unresolved.

 2.1 Problems of the health system in Mali

• The Ministry of Health’s central directorates do not have performance contracts with the national PBF Unit (CTN) to ensure effective regulation.
• The contracts are signed, on the one hand, between the Contract Development and Verification (CDV) Agencies, presidents of ASACOs, and the Technical Directors of the community health centers, and, on the other hand, between the CDV agencies and the owners of private structures, instead of being signed between the Contract and Verification Agencies and the Technical Directors.
• Private structures do not have the same chance as public structures to benefit from a main contract for implementing the FBR approach because of certain indicators.
• The absence of a direct financial contribution from the Malian government to the PBF basket makes the program unsustainable.

2.2 Recommendations

• Organize an exchange meeting with the Minister’s Office (Secretary General of the Ministry of Health) to facilitate establishing performance contracts between the National Technical PBF Unit (CTN) and the central directorates (DGS, ANAES).
• Ensure a State financial contribution of at least 20% of the PBF budget to ensure its sustainability.
• Advocate to the Minister of Health and Finance to transform government-delegated budget lines (crédits déléguées) for hospitals, other health facilities, and communities into a PBF government budget line. This will allow the change of input financing towards performance-based financing
• Promote the “bilateral” signature between the in-charge of the health facilities and the CDV agencies. This will promote autonomous and more efficient management.
• Extend the coverage of the PBF reforms at the national level.
• Advocate to the health commission of the National Transitional Council (CNT) for resource mobilization in favor of the FBP.
• Carry out action research at the operational level on FBR themes
• Organize a technical working group on PBF good practices with stakeholders (professional orders, FENASCOM, Association of liberals).

 3.     Chad

PBF pilot experiments began in Chad between 2011 and 2013, from 2017 to 2019, and from 2022 to December 2025. After one year of implementation, the latest project was extended to four other provinces, bringing the PBF to twelve provinces in 12 out of 23, covering 55% of the country’s population. The evaluation showed encouraging results, particularly in strengthening the pillars of the health system, motivating health workers, reducing cases of drug shortages, and improving the work environment.

The coordinators of two Contract Development and Verification Agencies attended the Cotonou course. They have achieved remarkable results, but changes in national-level management have endangered this progress, leading to non-payment of PBF subsidies and uncertainty about the program’s future. This is particularly damaging considering the political sensitivities in remote areas of the country.

  3.1 Problems of the Contract Development and Verification Agencies

• Recurring delays in subsidy payments.
• Complete renewal of the national PBF Technical Unit team (CTN) without skills transfer, leading to a system-wide malfunction.
• Delay in obtaining the authorization for expenditure (ANO) from the World Bank Project Implementation Unit for national PBF Unit activities, thus leading to non-compliance with the PBF payment cycle
• Provincial Pharmaceutical Agencies (PPA) are authorized to obtain supplies from a few private wholesalers. However, health facilities can obtain supplies only from the provincial pharmaceutical agencies. Thus, the PPA is a monopolist for the health facilities, leading to stock-outs and sometimes higher prices.
• Health facility managers are often transferred by the Ministry of Health, so they lack “ownership” and commitment to PBF reforms.
• Health Center Community Committees are not very functional, but they participate in the financial management of the health facilities because they co-sign the accounts. As a result, health facility funds are often blocked in the account instead of being used according to the PBF business plan and the PBF indices management tool.
• District authorities lack rigor in scoring composite indicators during quality reviews, so scores are systematically too high.

The score calculated from the 23 indicators of the PBF feasibility analysis is 64%, which is well below the feasibility threshold for a performance-based financing program.

  3.2     Recommendations

• Promote a free market for essential drugs so health facilities can access accredited pharmaceutical wholesalers.
• Encode private health facilities that do not have a code in the Health Management Information System
• Enforce the memorandum of understanding in the financing of the World Bank-financed PBF program in Chad
• Enforce the PBF manual – Chad
• Mobilize resources for scaling up PBF towards national level
• Diversify partners in the financing of the World Bank-financed PBF program
• Recruit other accountants to ensure the financial flow in the payment of subsidies by the Project Management Unit
• Limit the movement of local staff trained in PBF
• The World Bank to accelerate the process of obtaining the authorization for expenditure.
• Comply with the PBF Manual.

 4.       Burundi – Education

The overall situation of the Education Ministry’s schools in Burundi reflects the country’s demographic context, with a very high birth rate that also influences the school-age population. This has repercussions on the required budget, infrastructure, teachers, teaching and pedagogical materials, etc.

The development and implementation of the FBP education project in Burundi started in Bubanza, from 2014 to 2016. From 2020 to 2021 and to today, the project has been implemented in Muramvya province in the center of the country, with financial support from the NGO Cordaid. Expertise France is starting an FBP project in Bujumbura City Hall from the 2024-2025 school year.

4.1      Analysis of problems/challenges

• Low funding of the education sector, especially in PBF
• ​​Burundi’s basic schools face a low retention rate (10% in cycles 1 to 3 in 2023)

4.2     Main recommendations

• Increase the budget allocated for primary education by diversifying funding sources (development partners, investment, contributions by well-organized communities, etc.).
• Transform existing input budget lines from the Ministry of Education into government PBF budget lines.
• Establish regulatory bodies to scale up PBF.
• Review existing indicators to make them SMART.
• Carry out a new costing taking into consideration that the budget per primary school child increases by a factor 3-4.
• Revise the PBF Manual with the involvement of all stakeholders and respecting the PBF approach.
• Update the mapping of schools to be put under PBF.
• Limit the movements of local staff trained in PBF.
• Promote teaching quality through quality reviews based on a harmonized national quality composite indicator list.

5.          Benin

Benin experimented with PBF between 2012 and 2018 and set up a countrywide PBF program, financed by the World Bank, the Global Fund, and Belgian cooperation. Difficulties in integrating and adopting different approaches at the Ministry of Health level, a lack of harmonization among partners, and the absence of a competitive environment for access to inputs led the government to end the program.

Benin’s current health sector reforms to achieve UHC do not capitalize on the experience of the PBF program between 2012 and 2018 or the lessons learned from it.

The Pahou health center was integrated into the PBF between 2012 and 2018, and the following achievements were mentioned by the staff:

• More financial autonomy for the health center managers, who could make spending decisions to buy drugs and equipment and to carry out rehabilitations.
• Increased money directly available (from PBF subsidies and user fees) at the health facility level to recruit staff and make investments.

5.1.       Specific observations in the Pahou CS after the closure of the PBF program

During the visit to the center on December 5, 2024, the following observations were made:

• Dilapidated infrastructure. A fire hit the Center in 2021. Three years after this fire, the staff did not obtain any funds to carry out the rehabilitation. However, with the PBF approach, the center could have been rehabilitated through its own user-fee revenues, PBF subsidies, the PBF Quality Improvement Bonus (QIB or BAQ in French), or additional direct government cash funding.
• Lack of external revenues such as PBF subsidies or other subsidies from the state or partners.
• Lack of management autonomy for the center manager to take initiatives and resolve problems such as recruiting qualified contract staff, rehabilitating the center, and purchasing equipment
• Lack of financial management autonomy by the health facility management. The authorizing officer for expenditure is not the health facility manager but the District Medical Officer of Ouidah District, who also serves as the regulator. This also creates a conflict of interest between the provider and the regulator.
• The Pahou District Health Center, like all centers in the country, depends on the central “input” distribution system for inputs, with no choice.
• Health facility managers are not authorized to spend cash.

In view of these findings, staff in the discussions expressed a wish to reintroduce best PBF practices in health facilities. Hence, the following recommendations.

 5.2      Recommendations

Relaunch the PBF program in Benin, considering the following:

• Draw on PBF best practices to introduce more autonomous management of this health center on an experimental basis. This would make it possible to deal with the above-observed problems.
• Learn from the mistakes made during the first PBF phase in Benin between 2012 and 2018 and draw all possible lessons.
• Consider the innovations and improvements that have taken place in other countries during the last 10 years, such as Rwanda, Burundi, Mali, the DRC, and Mauritania.

Thus, in the preparatory phase, we propose the following:

• Conduct two studies on the quality of care by master’s students at the ISRP, comparing the PBF implementation period with the current period at the Pahou health center.
• Advocate for the relaunch of PBF in Benin based on the PBF best practices known in other African countries, with a more prominent coordinating role of the Ministry of Health and with a national approach based on the PBF best practices such as more autonomy of health facilities, free access to distributors operating in competition for inputs such as essential drugs and the involvement of the private sector, especially in (semi) urban areas.
• Develop a PBF project based on the results of the studies carried out => where, who, what, when, budget (financing to be sought where)?
• Advocate with the Ministries of Education for the introduction of PBF teaching in the training curricula of students in schools and universities, particularly in medical schools and at the Regional Institute of Public Health (IRSP);
• Introduce basic notions of performance-based financing into the training curricula of the IRSP and medical schools.
• Train Master’s students in public health in PBF, since most are managers, authorities, and service providers in Benin and other countries in the sub-region.