Start: 2011
Phase: Pilot started in 2011, and the national rollout started in 2015. It stopped in 2017. Efforts to restart PBF are ongoing.
Coverage Estimate: 100% => 0%
Feasibility of design before 2017: Modest 62%
Previously supported by: MOH; WB; Belgium Technical Cooperation, AEDES; USAID; GF; Local Firms
Description:
Benin piloted the PBF approach between 2010 and 2017. This initiative aimed to accelerate progress toward the Millennium Development Goals. Several partners (the World Bank, the Global Fund, Enabel, and GAVI) decided to harmonize the management of their resources supporting the strengthening of Benin’s health system, formalizing this commitment by signing the Compact in November 2010. Gradually, the whole country was covered by PBF during a few years.
Yet, in 2017, the new President abruptly ended the PBF reforms. Indeed, PBF in Benin was not perfect, but it had promising results. The main reasons for the shutdown were the lack of harmonization between partners, the government’s refusal to pay performance bonuses to staff, and the assumption that a fixed salary was enough for health workers to perform.
From 2017 onwards, the government then introduced the ARCH obligatory health insurance system. As described by Ghammou, J; Bourgeois, M; et al. (2025) in Afrique Contemporaine, the ARCH program is unknown to beneficiaries and lacks sufficient financing. An interviewed patient with an insurance card was refused treatment three times because hospital staff could not treat him because the ARCH program failed to reimburse the treatment. The ARCH program has a top-down approach from the Presidency and did not consider the opinions of local experts and stakeholders.
Moreover, from our experience in Burkina Faso, we learned that targeting vulnerabilities through the Single Social Register (RSU) is extremely bureaucratic and inefficient. That is why, in PBF, we decentralize the responsibility for targeting the vulnerable to the health facility level.
After negotiations with the government, the World Bank replaced the PBF reforms with the “PforR – Program for Results” approach. This approach directly injects funds into the Ministry of Health budget based on national performance indicators.
Several field visits to health facilities since 2022 and focus group discussions show that the results of the centralized government ARCH and P4P World Bank approaches are difficult to verify and have not been felt at the facility level. However, under PBF, this money would be injected directly into all health facilities, including peripheral ones, using the indices management tool to calculate performance bonuses, which motivates staff and produces better results.
Thus, Benin’s Ministry of Health policy has regressed toward inefficient input distribution and centralized planning with a non-functional obligatory health insurance system. For example, the famous UNICEF-supported Paou health center, which has experienced many innovations over 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 and the decentralized quality improvement bonus system, which provides a bonus of between USD 750 and USD 5000 after the achievement of each stage of the rehabilitation or the purchase of equipment, means of transport, etc the health center team would have carried out the rehabilitation autonomously within a few weeks or months.
