PBF in seven Sahel countries, Rwanda and education

The 29 participants in Benin

We report on the PBF programs in seven Sahel countries and on the recent developments in Rwanda, which was the first country in Africa that started PBF in 2001 and scaled it up in 2005. We also report on PBF in the education sector in the Central African Republic.

This was the last of 10 PBF courses in 2018 organized by SINA Health with different partners. The Cotonou course took place from the 3rd to the 15th December 2018 with 29 participants from eight countries: Senegal (10x), Mauretania (5x), RCA (3x) Niger (3x), Chad (3x), Cameroon (3x) Mali (1x) and Rwanda (1x). The course was organized by BEST-SD in Benin with the assistance of BASP-96 from Burkina Faso.

The daily evaluations of the course averaged 82%, which is 3.5 points above the average of the 43 previous Francophone courses.  The impact of the 75th PBF course has been translated into a good quality of the action plans carried out by the groups of countries (see rapport final du cours).

Twenty-nine participants did the posttest and the average progress compared to the pre-test was 29%. The average score of the post-test was 74%. Eight participants obtained a certificate of distinction with a score of 87% or higher and two participants obtained a certificate of participation of 50% or lower.

Country recommendations

1. Mali

There were favorable results of two pilot RBF projects (2009-2011 and 2016-2017) in Mali after which the government decided to expand it in Mali. However, for this approach to be successful, it requires major reforms of the health system and the commitment of the highest authorities and partners.

The Benin Atlantic Ocean beach


  • The Malian participants in Cotonou will contact the 41 participants, who previously attended one of the PBF courses, and will organize a workshop to discuss the implementation of RBF. They propose to review the theories, best practices, and instruments currently being applied in Mali, also taking into account the lessons learned from the pilot projects in Mali ;
  • Develop, review and validate an action plan for the implementation of RBF in Mali;
  • Advocate with the government and the partners to make available an adequate budget for RBF of at least US $ 4 per person for the areas covered ;
  • Stimulate better coordination of the partners in the financing and implementation of RBF;
  • Advocate for more autonomous management of the health facilities ;
  • Revision of the texts for the community health facilities (CSCom) to better separate the functions of the health professionals who are responsible for the day-to-day management and the community owners who are responsible for monitoring and strategic decisions;
  • Assure the equitable distribution of primary and secondary FBR contracts to the government, private not-for-profit, and private for-profit health facilities;
  • Conduct a baseline study in each of the three RBF regions.

2. Chad

Chad has the following problems of their health system: 1. The national health budget has fallen sharply during the recent few years; 2. The public budget is used inefficiently as the result of centralized input policies; 3. There is a lack of integration and use of qualified personnel working in the (informal) private sector or who are unemployed; 4. Regulators at all levels of the health system do not perform their responsibilities adequately.

A pilot project has been implemented from 2001 to 2013 with such encouraging results that it justified the scaling up of PBF in Chad. The evaluation of the pilot showed significant improvements in the quality and utilization of health services as well as an increase in staff motivation.

Yet, it has been difficult to implement. To advance the scaling up, the course participants from Chad propose that the government should declare PBF their national reform approach. Yet the design should be improved because the participants gave the PBF purity score only 62%, which is below the minimum of 80%. They also identified a number of killing assumptions that should be addressed to increase the chance of success.

Exercising during the course

Recommendations Chad:

To the Government

  • Adopt the PBF reform approach as national policy ;
  • Put into place an improved PBF implementation framework ;
  • Contribute to the financing of PBF by transforming traditional government “input” budget lines into PBF lines ;
  • Rationalize the health facility catchment areas in units of on average 10.000 inhabitants ;
  • Break the monopolies on the distribution of essential drugs and other inputs.

To technical and financial partners

  • Adopt PBF as the preferred development approach ;
  • Support PBF by funding it ;
  • Provide technical assistance for PBF;
  • Support civil society to support the establishment of PBF.

3. Senegal

The analysis of the national FBR program in Senegal shows that there are many challenges despite the progress made. For this, the program needs to apply the best practices proposed in the context of performance-based financing. The implementation of the Cotonou action plan developed by the 10 participants from Senegal will be an important contribution to achieving the objectives set. The commitment of the different stakeholders will be a sine qua non for its realization.

Recommendations Senegal

  • Align Senegal’s RBF approach with international RBF best practices ;
  • Identify and implement the main mechanisms to make RBF sustainable in Senegal ;
  • Promote that health facilities have access for their essential drugs needs to distributors operating in competition ;
  • Integrate the Universal Health Coverage Agency (ACMU) and the Ministry of Health’s internal inspection into the RBF system to make them responsible for verification and verification;
  • Harmonize the interventions of the RBR-NP and CAEP for a better rationalization of the resources.

4. Niger

The Ladies of the course

Niger has implemented two pilots PBF projects: One in the health district of Boboye in 2015 and another in the Tillabéri region in 2017. The favorable results justified the scaling up by the government with financial and technical support committed by the World Bank. The feasibility score, conducted by the three participants from Niger, based on 23 purity criteria, was 68%. In addition, they identified two killing assumptions that should be solved for PBF to be successful: 1. The negative effects of the single treasury account system that makes implementing PBF impossible and; 2. The existence of a monopoly for the purchase of medicines and other inputs.

Recommendations Niger

  • Make the national PBF unit operational and link it directly to the office of Secretary-General ;
  • Develop performance contracts with the central and regional Ministry of Health departments ;
  • Define the procedures for recruiting the Regional Contract Development and Verification Agencies. This can be through an international tender, or by identifying a local organization with an already existing legal status. The disadvantages of recruiting an organization after an international tender is that: 1. It lasts at least a year; 2. It is not a sustainable solution and ; 3. It is more expensive. To the contrary, identifying an already existing organization will not have these disadvantages but the contract should be made very SMART of what is being expected to prevent negative interference by local leaders.
  • Advocate with the Minister of Public Health for the allocation of the World Bank’s total health budget for performance-based funding approach instead of mixing it with other input components. Experience shows that a mixed approach does not work and creates confusion among the implementing agents.
  • Empower the organizations with PBF contracts by allowing them to open their accounts at commercial banks and to use the funds autonomously.
  • Develop performance contracts with all stakeholders (primary health facilities, hospitals, regulators) in the PBF regions.

5. Cameroun

In 2017 the Ministry of Health decided to extend the PBF approach to the three remaining regions of Central, South, and West. The national coverage of the PBF approach by the end of 2018 was around 70%. PBF contracts were developed and signed between the PBF Unit and Ministry of Health central directorates and programs, including with the Central Inspectorates.

The Cameroun team in Cotonou conducted the PBF feasibility scan and came to the score of 84%. Yet, they also identified the following main challenges:

  • A relative monopoly of Central Medical Stores remains in place despite the ministerial decision authorizing the PBF health facilities to procure drugs from private distributors. They are only allowed to do so after a period of seven days when the health facilities fail to obtain drugs through Central Medical Stores ;
  • The centralized management and posting of civil servants to health facilities is inefficient and creates enormous distribution problems in particular in disfavor of rural areas.

Recommendations Cameroun 

  • For the district of Cité Verte in the capital Yaoundé, the course participant proposes to 1. Map and rationalize the health catchment areas in units of on average 10,000 inhabitants; 2. Establish a communication, education and information plan for district actors and; 3. Restitute the main PBF messages with all actors of the district.
  • For the national blood transfusion program, the participant proposes to 1. Introduce the PBF approach in the management of blood transfusion centers; 2. Review PBF management options for the future Blood Transfusion Center and 3. Introduce competition between autonomous Regional Blood Transfusion Centers instead of applying centralized planning from Yaoundé.
  • The representative of the General Inspectorate of Administrative Services developed the following action plan: 1. Advocate for free competition between distributors of medicines and consumables; 2. Monitor the implementation of the ministerial decision on drug supply with providers and wholesalers in relation to the relevant structures; 3. Produce a quarterly report to the Minister of Public Health on the status of PBF implementation (coverage, challenges, and recommendations) in particular in 1st and 2nd category hospitals.

6. Mauretania

The village 75 authorities

The FBP program in Mauritania is in its start-up phase in two regions covering 600,000 inhabitants. However, greater FBP coverage with also a district of the capital Nouakchott would be desirable to achieve better economies of scale and to be more representative with a rural and urban mix.

Recommendations Mauretania

  • Advocate that the government declares the RBF approach to become the main reform strategy of the health system in Mauretania ;
  • Propose that the Regional Council should play the role of a board, which meets, for example, four times a year. On the other hand, the day-to-day management of the contracting and the verification of the project should be the responsibility of the Regional Verification Teams and have its own contract with the national PBF unit;
  • Sign performance contracts with the Inspectorate General of Health and the Directorate of Pharmacies and Laboratories ;
  • Conduct during the pilot phase peer group evaluations of the PBF regional hospitals paired with other regional hospitals not yet implementing PBF  ;
  • Advocate for a waiver to break the monopoly for inputs in the pilot area ;
  • Advocate for a waiver for the autonomous management of the health facilities in the pilot area ;
  • Advocate for a waiver to allow health facilities to use autonomously all their revenues at the point of collection and thereby solve the problems with the single treasury account ;
  • Instruct the District Health Management Teams of the two pilot regions to update the division of the health areas;
  • Accelerate the contracting of the Regional Verification Teams by signing contracts between the Secretary-General and the Regional Verification Teams in both regions (premises, offices, equipment, logistics, operation …).

7. Rwanda

Rwanda in 2001 was the first country in Africa to pilot PBF and scaled it up nationwide in 2006. The results were very favorable and especially for the quality of care. The results were also published in several scientific articles. Other strengths were the harmonization of PBF with Obligatory Health Insurance and that the government pays 60% of the PBF budget. For many years, Rwanda was the PBF flagship country in Africa and several countries studied their case and visited the country.

However, despite these advances in the PBF approach, improvements are needed to benefit from the innovations in other countries in recent years. One way to analyze these innovations is by applying the 23 purity criteria and the course participant from Rwanda scored 60%.

Recommendations Rwanda:

  • Review the PBF system in Rwanda and adapt it to become more in line with international best practices and innovations.
  • Increase the PBF budget from the current USD 2 per capita per year to USD 5. This can be done first of all by transforming inefficient government input budget lines (= in-kind financing) into output- or PBF funding. Studies showed that US $ 4 invested in inputs equals US $ 1 invested in PBF. Moreover, partner funds can also be used more efficiently by transforming input budget lines into PBF lines;
  • Promote free competition whereby health facilities area lowed to purchase their medicines, equipment, and other medical consumables from different distributing operating in competition;
  • Make health facilities more autonomous for the recruitment, application of sanctions and even dismissal staff in case of need;
  • Introduce the PBF system also among private (for profit) health facilities in order to benefit from their comparative advantages. The government should therefore also develop contracts and pay PBF subsidies to private health facilities with the aims to achieve government objectives and to improve their quality of care.

8. Education in the Central African Republic

CAR’s education system has been paralyzed during the past two decades due to recurrent political and military crises. School indicators are poor with the primary school enrollment rate for girls of only 55% and 71% for boys. Cordaid introduced PBF in the education sector since 2008 and this has produced good results. The government declared PBF as their national policy. Yet despite this political will, the funding of around USD 20 million per year to cover the entire country has not yet been mobilized.

Since 2017, Cordaid has also tested two PBF approaches: 1. One for a stable zone (Nana Mambéré) where “pure” PBF is applied and; 2. Another for a non-stable area (Ouham Pendé) where a mixed approach is applied of PBF with inputs.

The PBF purity score produced by the CAR participants Cotonou for their education program is 48%.

Recommendations CAR education

To the government

  • Increase the number of student teachers in training institutes ;
  • Open PBF lines in the government budget for the schools and increase the amount ;
  • Provide opportunities for private partners to establish teacher training institutes and support them in the same way as public schools;
  • Apply a more equitable distribution of qualified teachers in schools nationwide ;
  • Update the general mapping of schools, especially at the primary level.

To those actors, who implement the PBF approach

  • Give basic knowledge to all field managers regarding PBF ;
  • Give autonomy to the community for the realization of construction activities at the local level.

At schools

  • Establish transparent management by using the indices management tool for the mobilization and motivation of the teachers ;
  • Adopt new rules for financial management also of the resources generated by the schools.
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