Hereby the report and recommendations of the last PBF course of 2016 that took place in Mombasa, Kenya from the 28th of November to the 9th of December. Throughout the two weeks of the course and after, the country teams engaged in drafting and improving their action plans on how to implement and advance PBF in their countries.

There were 17 participants from Nigeria, three from Cameroon, two from Zimbabwe and one from The Gambia and one from Kenya.

The “village 56” chief, Dr Celestino BASERA together with his deputy, timekeeper and tax collector, actively supported the facilitation process and contributed to a congenial atmosphere and towards maintaining “order” in the village.

New approaches for future PBF courses

• The PBF course content and program materials have expanded considerably. Our aim during the last years to fully cover all modules during the 12-days course has become unrealistic. Another factor is that the starting levels of each participant is different; some are novice in PBF while other’s have already PBF knowledge and come to the course with specific objectives.
• During the September 2016 PBF course in Douala and Mombasa we piloted for the first time a modular approach whereby we presented during one day two different modules at the same time in two conference halls. The overall impression was positive and the conclusion is that we must further expand the modular approach.
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  The Sunday outing to the waterfall of life

  For the 2017 courses, SINA Health will therefore start to develop differentiated course provision: (i) Basic in-country courses with modular approaches during the first and the second week and zooming in on the particularities of the country; (ii) Basic international courses with modular approaches during the first and the second week and; (iii) Modular, advanced courses of one week.

• In the basic courses, the introduction modules 1,2 and 3 as well as (health) economics and PBF theories remain for all groups. Also, the conflict resolution and the feasibility scan will remain for all course participants. Each participant will continue to develop their personal action plan.
• We will further develop the usage of ‘take-home’ messages at the beginning of each module.
• These changes will require to adapt the exam for each of the groups. We will format the certificate to indicate at which level each participant has conducted the course.

Recommendations of the Mombasa participants

Nigeria general

The World Bank is currently funding large PBF pilots in three States (Adamawa, Nasarawa and Ondo) until 2018, and additional funding for the extension of PBF to five North-Eastern States (Borno, Yobe, Gombe, Bauchi, Taraba State). It is important in Nigeria to move beyond the ‘pilot’ or ‘project’ phase of the current PBF programs towards a reform approach which is part of the health system. The Federal Ministry of Health should also adopt a more central role in the PBF reforms.

Adamawa State Recommendations

• PBF should be scaled up PBF as soon as possible in the remaining 10 LGAs of the State, now still under the control study Decentralized Facility Financing (DFF).
• The Local Government Area (LGA) PHC Authority and Health Management Boards (HMB) should be reimbursed based on output performance indicators, with considerations for quantity, quality and equity.
• Routine integrated supportive supervision (ISS) and PBF quality evaluations of health facilities should be combined and for this an integrated PBF quality checklist should be used.
• There is a need to advocate for funds coming to the health sector through PBF mechanisms. This may include the Saving One Million Lives (SMOL PforR) program as well as the state’s health budget. With these measures, the PBF budget should meet the standard of USD 4 per capita per year.
• Funds currently used to centrally purchase drugs at the state level for secondary health facilities, through the essential drugs program should be converted to PBF subsidies. Drugs should be obtained through competitive procurement by the health facilities themselves.
• Donor agencies, such as UNICEF should instead of providing inputs such as drugs, subsidise already existing or additional PBF indicators, which may interest them.
• Payments of bonuses should be based on new, differentiated indices management tools for the different stakeholders.

Nasarawa State Recommendations

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  Shimba Hills

  To abolish the existing DFF system and scale up PBF to all LGAs;

• To have the State government take up full ownership and also for the funding of PBF. A series of advocacy visits to state policy makers and traditional rulers is planned by the State PHCDA for the first quarter, 2017;
• To give equity bonuses for hard-to-reach LGAs and health facilities;
• To step up computerization and internet connectivity in LGAs and health facilities;
• To engage in stronger advocacy and awareness raising amid religious and community leaders for Family Planning and immunization issues.

Ondo State Recommendations

• Immediate upgrade of all health facilities implementing DFF to PBF
• To stimulate autonomous health facility management including the setting of tariffs
• National PBF regulators should review the frequency of Integrated Supportive Supervision. This to ensure the efficient utilization of available resources.
• Change the perception among key stakeholders that PBF is a “project” that will end once the World Bank stops its financing. Advocate that PBF principles are institutionalized in the conduct of government affairs and enhance thereby the ownership and sustainability of PBF.
• Introduce performance contract between Hospital Management Board and HMB officials.

Kenya Options program in Bungoma County

A comparison of the PBF intervention in Kenya with the recommended PBF best practises reveals that there is need to address several design problems:

• To advocate for a larger list of PBF indicators;
• To advocate at the county level for facilities to have autonomy as per the PBF best practise;
• To advocate to decentralize medical supplies and the facilities to be allowed to purchase input based on need and from different sources. Purchasing decisions on inputs should be made at health facility level and not at county level;
• To build capacity of the county health executive arms on PBF;
• To advocate for the need of CDV agency at the county levels (could Options play a role in this?);
• To advocate for change in the funding structure to conform to 4 USD per capita per year;

Cameroun

In general, the country is facing a number of problems: (1) Shortages and poor motivation of human resources; (2) Difficult geographical access in rural areas; (3) Financial access problems and high out-of-pocket payment for health; (4) Poverty and inequalities; (5) Maternal mortality has increased from 430 maternal deaths / 100.000 live births in 1998 to 669 in 2010 and 782 in 2011; (6) Adult HIV prevalence rate in 2015 was 4.5% and there is little respect of HIV testing protocols.

PBF programs have been implemented in four regions in Cameroun since about 5 years. Currently PBF upscaling takes place in the three Northern Regions towards 45% of the country by the end of 2017 and towards and 100% by 2020.

Two members of the Cameroon team in Mombasa came from the tertiary gynaecological-obstetrics and paediatrics hospital (HGOPY) in Yaoundé. The hospital started its unique PBF program in April 2015 despite a large number of challenges: (1) No PBF budget due to the fact that PBF has not yet been introduced in the Centre Region. (2) Limited administrative and financial autonomy; (3) Large, chronic debt; (4) High input prices above market equilibrium prices due to cumbersome public administrative procedures.

Recommendations HGOPY hospital:

• Negotiate mechanisms for hospital debt relief
• Government should reserve in 2017 part of their contribution for PBF for the 3^rd and 4^th referral hospitals;
• Make a catchment area plan for all 3^rd and 4^th level referral hospitals in Cameroun
• Use for the 3^rd and 4^th level referral hospitals the same PBF indicators as the 2^nd level referral hospitals,
• Negotiate for HGOPY to obtain inputs from the free market instead of following the cumbersome public sector procedures, which increase the price.
• HGOPY should sign in 2017 a contract with CDV agency of the Centre Region
• Review and further develop the internal contracting method of HGOPY between the General Directorate and the 14 departments

The Gambia

The government pilots Performance-Based Financing as an approach to health services reform. PBF is currently being implemented in 5 of the 7 health regions all of which are in the rural areas. The total number of health facilities under PBF contract are 37.

The feasibility scan score is 46%, which implies that several PBF principles are not applied in The Gambia. There is a need to gradually implement these in order to increase the possibility of positive effects. There has been an effort to establish a PBF Unit in the Ministry. However, this Unit has not been adequately staffed. The functionality of this Unit is crucial in the implementation of the project and ensuring the buy-in by the MOHSW so that they adopt PBF as a national health reform strategy. To ensure that this is achieved, there is need for advocacy for the staffing of this unit with the necessary personnel.

Zimbabwe

Zimbabwe has adopted PBF as health systems approach since 2011 with encouraging results. The government therefore decided to scale up PBF from 18 districts in 2011 to all 60 rural districts in 2014. The Zimbabwe team in Mombasa was tasked to develop recommendations for the consolidation of the PBF approach in Zimbabwe and look into possibilities of buy-in by other technical and financial partners such as notably the Global Fund.

Recommendations:

• Review the PBF implementation arrangements by introducing the National AIDS Agency as CDV Agency at provincial and district level;
• Include PBF contracts also with the regulatory levels;
• Establish a PBF unit within the Ministry;
• Expand the scope of the PBF packages by adding more indicators;
• Mobilise more resources for PBF;
• Increase the involvement of the private sector in the health system;
• Increase the competition in the distribution of health commodities.