The scaling-up of PBF in Nigeria – Mombasa report

La version française du posting est aussi disponible sur ce site.

The next English PBF course is in Mombasa Monday, April 1 to Saturday 13, 2019.            The next French PBF course is in Cotonou Monday 3 to Saturday 15 December 2018

The 36 participants to the 74th PBF course with the First Lady of Kilifi County

The 74th performance-based financing (PBF) course took place from Monday, October 29th to Friday, November 9th, 2018, in Mombasa, Kenya. Thirty-six participants attended the course: 34 from Nigeria, 1 from Liberia, and 1 from Cameroon.

Hereby the full course report.

The Nigeria team consisted of nine participants from the Federal level (4 from the NPHCDA and 5 from the FMOH) and 25 persons from nine States (Bauchi 5x, Borno 3x Gombe 4x, Kaduna 3x, Kano 1x, Kebbi 1x, Ondo 2x, Sokoto 3x, and Taraba 3x. There was one Senior Health Expert from the World Bank, based in Liberia. There was one high-level Cameroon Inspector from the Ministry of Health. There were three participants from the private sector, carrying out CDV roles in Borno State.


The five authorities tasked to maintain order in village 74

The “Village 74” authorities consisted of the Village Chief, Munirat OGUNLAYI; the Deputy Village Chief Cyprian Akwo CHUO; the Internal Affairs Minister and Timekeeper Samira Abdullahi Mohammed; the Finance Minister Comfort Dave-Diamond and; the Minister of Energy Oluwatosin Kolade.

They actively supported the facilitation process and contributed to a congenial atmosphere.


Christian Habineza, an independent consultant from Rwanda; Godelieve van Heteren, senior health systems consultant for various agencies; Tom Njiri the logistics and events manager from Kenya; Robert Soeters, PhD, overall coordinator of the course; Jean Claude Taptue, Senior Health Expert of the World Bank; Fanen Verinumbe, PBF consultant of the National PHCDA in Nigeria and Ann Waimiru, a psychologist from Kenya.


Thirty-two participants conducted the final exam. The average test score result was 70% (comparable to previous courses) with four certificates of distinction and three certificates of attendance. This was the second course in the 4-star Traveler’s Hotel, which provided the professional and pleasant ambiance for a smooth and problem-free learning process at the beautiful North Coast of Mombasa.

The daily evaluations yielded scores which were slightly above the previous 23 English courses. Yet, 41% of the participants felt that they were not sufficiently informed about the course in advance and some would have wished to receive the course book earlier. 43% of the participants felt the course was too short. The French spoken courses have one more day and this reduces the time pressure. We will also add one day to the Mombasa course of April 2019. Some participants commented that they would prefer more adult learning methodologies. With the next course extending by a day, the facilitation team will also consider the further deepening of adult learning, group work, exercises, etc.

Most participants came from Nigeria so that we could concentrate during this course on the specific issues of Nigeria.


PBF in Nigeria started in 2011 with a small pilot covering one LGAs in the three States of Adamawa, Ondo, and Nasarawa. It was scaled up within the three States in 2014 and in 2017 the PBF approach expanded towards five additional States in the fragile and unstable North East of the country.


  • Social outing to Swahili ruins

    The maternal mortality rate is 821 deaths per 100.000 live births on average in the country but reaches the extremely high 1549 deaths per 100.000 live births in the North Eastern States. The main causes of maternal death are hemorrhage, sepsis, and unsafe abortions.

  • In 2017, malnutrition in Nigeria increased to 31,5% of children underweight, 43,6% stunted and 10,8% wasted.
  • Under-five mortality is 120 / 1000 live births. Vaccination DTP3 coverage in 2017 was between 30% and 40% – far below the Africa average.
  • The unmet demand for modern family planning methods is high with a couple protection rate in 2013 of 10%, while the total demand is estimated at 36%.


  • A range of causes lies at the root of the poor quality health services and inefficient use of public and private resources in Nigeria: 1. Central planning and financing of inputs;              2. The existence of multiple monopolistic distribution systems of government and partners; 3. Poor coordination with the private sector; 4. Lack of autonomy of health facilities and;     5. Highly centralized human resource policy.
  • Several vertical health programs of government and partners aim at similar objectives but which lack coordination. Thus resources are wasted and they give different orientations to health workers at the facility level.
  • The World Bank currently finances three large but conceptually opposing and ‘verticalized’ projects: 1. Safe One Millions Lives; 2. The NSHIP PBF program and; 3. The newly introduced nutrition program ANRiN. The course participants felt these programs should be better coordinated through a unified conceptual framework for implementation to attain positive reforms in Nigeria.
  • The current “carrot x stick” approach used in the NSHIP program as quality factoring is problematic, and from an international comparative perspective increasingly dis-advised. The main disadvantage of the ‘carrot x stick’ is that the revenues become unpredictable for the health facilities, demotivating staff when the cost of certain activities that must be fully reimbursed such as for persons living with HIV, tuberculosis and for immunization are not fully covered due to the punitive “stick”. Yet, certain quality problems are intrinsic to already existing baseline problems and despite sometimes good efforts to improve the services, the punitive stick may push the health facilities even deeper into problems. Supporting the vulnerable implies that there must be the full reimbursement of the cost. The carrot x stick approach has already led to the refusal of several health facilities to continue the PBF approach such as, prominently, in Borno state, a state which faces already enough challenges as it is. So in short, while we all agree that quality is of prime importance, the current incentive structure may not achieve the desired results.


  • “Destressing” after one week of hard work at the Swahili ruins

    Change the current input financing toward performance contracting ;

  • Break the monopolies of the drugs management agencies and allow facilities to buy their inputs from accredited distributors operating in competition ;
  • Inject more funds directly in the health facilities and allow them more decision power on the use of public funds instead of leaving the decision powers to central administrators ;
  • Provide more autonomy for health facilities for human resource management and the setting of user fees ;
  • Collaborate more closely with the private sector and offer them contracts as equals to government health facilities, under similar quality regimes ;
  • Allow health facilities to open their own bank accounts to which they are also signatories and stop the practice whereby revenues must be transferred to the single treasury account.


  • Domicile the PBF unit at the Federal and State Ministries of Health rather than in National and State Primary Health Care Agencies/Boards for better coordination, the inclusion of the hospital level and for the regulatory stakeholders to ensure sustainability.
  • Introduce the carrot + carrot approach instead of the current carrot x stick approach in terms of the incentive payments, but at the same time promote quality by applying sticks such as delaying signing contract for those health facilities that do not make progress ;
  • Encourage all wards, LGAs and States to conduct the complete mapping and rationalization of health facilities so that on average one principal contract holder covers around 10.000 inhabitants at primary level and around 100-200.000 people at the hospital level ;
  • Increase the per capita direct PBF subsidies and investment units from the current $ 1 per person per year to $ 2,50 – $3,00;
  • Introduce LGA validation committees in which the LGA health authorities together with the LGA CDV staff discuss the invoices based on the verified data, solve problems, discuss the patient satisfaction surveys and the consequences of these data for the renewal of contracts ;
  • Review the roles of the Contract Management and Verification Agencies(CMVA) and the Independent Verification Agencies(IVA) ;
  • Modify existing laws so that: 1. Health facilities retain and use their cost recovery revenues in PBF dedicated accounts; 2. The managers of the facilities are the signatories of these accounts ; 3. Facility managers can choose their supplies from any accredited supplier.


  • Poster presentation of action plans

    Better document the encouraging results of PBF in some high-performing States such as Adamawa – where PBF has existed since 2011 – and Gombe State which only started in 2017, but is showing promising signs of improvement, so that they can be used for advocacy purposes ;

  • Present these results during the National Council of Health (NCH), the National Planning Commission (NPC) ;
  • Encourage State authorities to make PBF the preferred reform approach to achieve Universal Health Coverage;
  • Integrate the different vertical programs into one harmonized health strategy following the PBF best practices approach;


Borno is the epicenter of the conflict in NE Nigeria with the Boko Haram insurgency. Due to displacements, the population is highly mobile and there is insecurity across vast areas in the state with vandalized health structures. 15% of the population is not accessible at all for health workers. The PBF program so far only signed 108 or 27%  of the contracts on a total of 399 desired contracts (this ratio excludes the inaccessible areas).

Due to concerns about gaming, whereby false data were produced, the PBF program decided to switch from the carrot + carrot approach towards the carrot x stick approach. This lead to frustrations among health facility staff and several health facilities have since refused to sign contracts. The highly dynamic population and the insecurity in the state make patients reluctant to give their true addresses, which makes verification an even larger challenge and applying punitive sticks under such circumstances may be counterproductive. Another demotivating factor is that the PBF program suffers from long payment cycles, which is particularly damaging in the unstable environment of Borno State.


  • The hippos of Haller’s Park in Mombasa

    Change the payment cycle to monthly reimbursements instead of three monthly ;

  • Integrate all vertical programs at the state primary health care development agency and the state ministry of health into one basket of results-based payments.
  • The specific circumstances in Borno State make it important to conduct intense action research of the best approach towards the emergency PBF approach. Any action researcher with a promising study protocol should be encouraged with PBF performance financing to conduct studies.


  • Adopt the PBF approach as health system strengthening strategy in Gombe State ;
  • Create a PBF unit at the highest level possible within the State MoH so that the hospitals and the regulators can also be included in the PBF reforms ;
  • Create a State budget line in 2019 for PBF and use already existing external partner resources. For example, 40% of the SOML funds should be channeled towards a pure PBF approach ;
  • Request the State to finance PBF in two additional LGA’s from 2019 onwards ;
  • Advocate for the integration of the vertical programs into one single program using the PBF approach to maximize the opportunities and improve efficiency.


  • Advocate with the government on the need to expand PBF implementation to all health facilities and consider addressing the problems identified in the PBF feasibility scan (see the detailed report)
  • Support the Ministry of Health to commence full implementation of primary PBF in 3 counties ;
  • Continue to be a PBF advocate within and outside the World Bank.


  • The pleasant learning environment at the Indian Ocean

    Accelerate the scale-up of the PBF health reforms from the current 65% to 100% of the population.

  • Transform the input financing strategies of several (partner) programs into the PBF output and quality-based payment approach ;
  • Expand the national PBF unit at the level of Ministry of Public Health so that they can better play their coordinating role in Cameroon ;
  • Start human resource policy reforms that allow for more autonomy for health service providers ;
  • Increase the capacity of the central Ministry of Health members by sending them to PBF course.
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