Ethiopia, Nigeria, Cameroon, CAR and the Netherlands? The 78th PBF course

Le résumé en français du rapport est présenté en bas

The next English-spoken PBF course will be in Mombasa ftom the 28th of October to the 9th of November, 2019.

This 78th performance-based financing (PBF) course took place from Monday, April 1st to Saturday, April 13th  2019, in Mombasa, Kenya. Twenty-six participants attended the course: 14 from Nigeria, 7 from Ethiopia, 2 from Cameroon and 2 from the Netherlands. 

Hereby the course report.

The Nigeria team consisted of fourteen participants, from the Ministries of Health in Adamawa, Borno, Kebbi, Kwara, Nasarawa, Ondo and Yobe States. The Ethiopia teams consisted of three participants from the Ministry of Health at federal level and four from a PBF pilot in Borona Zone in Oromia regionThe two participants from Cameroon were from the North West region. We welcomed one participant from CAR and two from The Netherlands – one working at CORDAID head office in The Hague, and the other a senior general practitioner in Holland.

The “Village 78” authorities consisted of the Village Chief, Dr. Omar IBRAHIM; the Deputy Village Chief, Flora KWIZERA; the time keeper, Buzinel Gudisa Mijena; the Finance Ministers, Kinyuy Margaret Gham and Kees Melcherts and the EnergizersBaba Laminu, Abubakar Abana and Mekdelawit Mengesha.

They actively supported the facilitation process and contributed to a congenial atmosphere while maintaining “order” in the village.

Evaluation of the course venue and the course

Twenty-six participants conducted the final exam. The average test score result was 67% with six certificates of distinction and six certificates of attendance.

This was the third course in the 4-star Traveller’s Hotel, which provided a professional and pleasant ambiance. This justified the higher full board tuition fee.

The daily evaluations yielded scores, which were with 85%, 1,6% above the previous 24 English courses and 6% above the previous French-spoken course. Methods and facilitation scored 87,5% (the same as the previous courses). Participation scored 87.2% (the same as the previous courses). Organization scored 86.6% (0,3% above the average of the previous courses). The subject of timekeeping scored 78,8% (6,2% above the average of the previous courses).

The final evaluation indicated that for 88% of the participants the content of the course related well to their regular professional activities. Yet, only 52% said that they were well-informed in advance about the course and some indicated that the course book should have been distributed 1-2 weeks in advance of the course. The fact that some participants’ names were only known a week before the commencement of the course contributed to this score. Participants were satisfied with the methodology and the organization. In October 2018 a large proportion of 43% of participants thought the course to be too short and nobody thought that the course was too long. This course we added one day (the Saturday) to the course duration and this worked better to reduce the time pressure to finalise the action plans as well as the course modules.


Central African Republic Security and Justice Sector

  • Providing security is one of the core functions of the state and directly linked to its legitimacy​. However, security state actors such as the national police can also be considered to be a threat by their citizens​ based on their behaviour and their way of operating.
  • In CAR, despite all efforts being made, state security forces are demotivated due to diverse reasons: low salaries, personnel not educated enough, limited facilities & equipment, etc and hence less dedicated to their jobs. This leads in some cases to violation of human rights and ineffectiveness in service delivery with a high level of corruption. 


  • CORDAID to visit authorities from the Ministry of Interior & Public Security for presenting PBF solutions to some of the problems. A PBF pilot could be considered following the standard approach of developing output-, quality- and geographic equity indicators. Lessons may be learned from a similar PBF approach in the Democratic Republic of Congo.

Cameroon RFHP North-West Region – problems and recommendations

  • As the result of the war, the quality reviews are not conducted regularly and some health workers abuse this situation to start buying medicines from unauthorized sources in order to increase their profits. The socio-political crisis has put a hold to economic activities rendering many people poor and forcing health workers into private practice where they try to make extra money to take care of their basic needs.
  • There are delays in payment of the subsidies and this further contributes to staff being not adequately motivated.
  • Low quality of care related to counterfeit medicines availability in some health facilities.

Recommendations Regional Fund for Health Promotion North-West

  • Health facility managers should be guided by the professional code of ethics. To stimulate this, the regulator should conduct regular quality reviews and provide feedback to staff from the community verification interviews.
  • Ensure that the personal needs and motivation are not neglected. This can be achieved through the more regular payment of the subsidies and by the regular coaching on financial management whereby enough reserves are set aside for the rainy days.
  • The Regional Delegation of Public Health should regularly update the list of accredited sources of drug procurement. They and the district health authorities should also make surprise visits to these sources for drug quality control. Samples of their product could equally be collected for quality control.
  • Health-facility managers should supervise the pharmacies regularly and to ensure that perpetrators of parallel sales of drugs are identified and punished. This is done by using the indices tool through performance bonuses in which a higher weight is given to the non-private sale bonus.
  • To the consumers, to ensure that they receive receipts upon consumption of services especially drug sales.
  • The government should ensure that subsidies are promptly paid in order to maintain a level of quality in Health Facilities.

Cameroon CDV Agency North-West – problems and recommendations

There is a high rate of non-submission of the indices tool of 35% and 22% consecutively for two quarters. One of the reasons for this poor performance is that the deputy managers of the CDV Agencies in practice conduct their coaching activities at best once per year or not at all due to the security reasons and the fact that they do not reside in the district such as the verifiers. Yet, the CDV Agency verifiers (with the supervisors of the district health authorities) are the closest actors for the health facilities and the community. The verifiers visit the health facilities on a monthly basis, which provides them with the possibility for regular interactions. It also provides the possibility to coach on the indices management tool.

Recommendations CDV Agencies in Cameroon

  • To the national PBF technical unit, to amend the clause which indicates that only coaching done by the Manager or Deputy Manager is payable
  • To the CDVA Manager, organize training for CDV verification officers on the indices tool and on coaching skills. A post-test should then be administered and officers who scored above 80% should be selected for particular axes.
  • To the CDV verification officers regular coaching should be done and the Manager or Deputy should be invited for risk-based coaching or coaching on pertinent issues like conflicts or adherence issues.
  • The CDVA verification officers should monitor the progress in indices tool submission rate and score.

Ethiopia – problems and recommendations

Ethiopia is the second most populated country in Africa with 102 million inhabitants. Health service delivery and indicators in Ethiopia have been improving over the last 25 years. Yet there are still important caveats such as that 1 in 3 children are chronically malnourished and that the MMR is high with 412 per 100,000 live birth.

The Federal Ministry of Health under the Health Sector Transformation Plan addresses Universal Health Coverage (UHC) as a key component, aiming at coverage for all essential health services, for everyone without financial hardship. As part of this overall strategy, Performance-based financing (PBF) is mentioned in the HSTP chapter on efficiency and in the draft Health Financing Policy.Cordaid carried out a showcase PBF project since 2015 in Borena Zone in Oromia Region for a population of 186,000 with encouraging results and now aims to expand the PBF program to a larger population of between 1 and 2 million people in Jimma health zone. Yet,Ethiopia as a country is not yet engaged in a full PBF strategy and the first priority is to engage together with World Bank in the collective exploration of feasibility of results-based strategies in Ethiopia in relation with the three directorates to this collective exercise.

Recommendations Ethiopia

  • To map and compare the current system of Ethiopia with a system informed by PBF and results-based strategies
  • Design a national PBF proposal on a potential pilot, with a target population selected from Addis Ababa (Urban) 3,433,999, Somali (Special support region) 5,748,998 and Oromia (Rural) 35,467,001 from total population 94 million. We consider that PBF budget should not be below 4 USD per capita. The needed budget for those regions would then amount to USD 22.995.992 for the Special Support region, for Oromia USD 141.868.004 and for Addis Ababa USD 13.735.966.
  • For the Jimma pilot supported by the Oromia Regional Health Bureau and FMOH, with support from the Dutch government and Cordaid: revisit the current design, based on PBF best practices.


General observations

  • 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.

Encourage reforms in Nigeria – based on the PBF best practices

  • Change the current input financing towards 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.
  • Rethink the single treasury account practice whereby health facilities must deposit their revenues at the treasury to which they have little access. This is the opposite of providing more (financial) autonomy to health facilities.

Change some features of the PBF design in Nigeria

  • 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.
  • Modify existing lawsso 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.

Recommendations concerning the advocacy for PBF in Nigeria

  • 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;

Political update

After the February 2019 presidential elections, Nigeria is currently establishing its federal and state governments for the coming years. The Universal Health Coverage agenda has been embraced by the Nigerian government, and the current challenge in all states and at federal level is to come up with a sustainable proposition for health systems strengthening and health financing to lead to UHC. Federal government and state governments are looking into the various financing modalities. They are looking in how for instance a Basic Health Care Provision Fund – as a percentage of the consolidated oil revenues, could contribute to domestic health financing, i.e. of primary health care. Other large schemes, based on loans and grants from external partners such as the Save a One Million Lives program also form part of the equation. The new state and federal governments which will take office by the end of May 2019 will all have to turn to further integration and domestic management of the health system, which will turn the next 18 months into a crucial policy period in Nigerian health politics. Various Nigerian states represented in the April 2019 course had sent senior SOML staff to engage in the exploration of PBF for this debate of integration and UHC. Several of the States present were also involved in implementing the NSHIP program, the RBF program in Nigeria, and expressed an interest in introducing further RBF/PBF elements in the states’ policies.

Below follow the individual states recommendations, which all seem to revolve around further integration and taking domestic control of the agenda.

Recommendations Adamawa State

Advocacy and discussion with the Hon. Commissioner of Health on the future architecture and financing of PBF program. Issues to be discussed are:

  • Rearranging the State architecture by having a Technical Coordination unit in the MOH for basket funding.
  • Coordinate activities in the state which now run in parallel but which could be integrated into the PBF program, such as SOML and other partners.
  • Advocacy and lobby with the State Government to increase and release budgetary allocation for health funding.

Recommendations Borno State

  • Integration of state financial resources for funding the PBF program
  • Analysis of the available funds and the population that can be covered by PBF
  • To propose an institutional set-up on how the system could operate under PBF
  • Stakeholders’ sensitization on PBF
  • Advocacy to policy makers on PBF, traditional institutions, faith-based organisations, community based organisations, civil society organisations and professional bodies sensitization.
  • Scaling up PBF in other the currently non-contracted health facilities across the state
  • Make free MNCH services to high quality subsidised user fee paid services

Recommendations Kebbi State

  • Advocate with policy makers on the need to accept the PBF programme as reform strategy and explain the difference with previous reform approaches that have not achieved the desired objectives such as the Alma Ata primary health care and the Bamako Initiative.
  • Prepare a Memo to the National Council on Health to advocate for National Policy on PBF which all states are obliged to implement
  • Group all programs such as the Primary Health Care Under One Roof (PHCUR) and the KECHES under the ‘ONE’ State Steering Committee and Technical Consultative Group in the Office of the Permanent Secretary.
  • Engage consultants when necessary to support the feasibility study and the implementation of PBF with support from the SOML
  • Calculate and propose to the government a PBF budget of more than 20%to reduce donor dependency in order to achieve $4-$6 per capita for the catchment population of the State
  • Integrate all vertical programs such as KECHES which is just at the verge of implementation and marry it with the PBF programme in order to achieve individual programs goals and ensure sustainability. The two programmes can go hands in hands with support from Government, SOML and donors
  • The SOML may shoulder the responsibility for the conduct of study tours to some states that are already implementing the PBF programme.
  • Since the PBF set-up may be considered to be complex by some State policy makers there is need to create an innovation to consider KECHES as the CDV agency and being backed by law, it can initiate the payment of performance instead of for inputs, the breaking of the monopolies for the pharmaceutical suppliers. Authorities may also not feel threatened by the separation of the functions of provision, regulation and contract development & verification
  • Pilot PBF in selected LGAs of the state using SOML funds;
  • Advocate to the Ministry of Budget and Economic Planning and the Ministry of Finance to exempt the health care facilities in 5 pilot LGAs under the PBF approach to remit their cost recovery revenues from going into the treasury single account but into the health facility bank account on which the facility operators are signatories.

Recommendations Kwara State

  • Better coordination of all partners activities
  • The expenditure per capita per year using the state expenditure on health has been consistently below $ 3. Therefore, funds for PBF will have to be made available in the State’s budget to fund 20% of the project. User fees will also be introduced for cost recovery purposes and to allow managers handle cash.
  • The SOML unit can be given the responsibility to function as the PBF unit, hence, will be domiciled within the office of the Permanent Secretary. This will address issues around signing performance contracts with other directorates – the unit has the requisite experience
  • The PBF unit will come up with output, quality and composite indicators in answer to the state’s needs, and as recommended by PBF best practices
  • A Contract Development and Verification Agency will be established in the State Supported Health Insurance Agency.
  • The payment unit may be established within the SMOH.
  • Laws impeding the implementation will be set aside and pilot will be in 3 LGAs.

Recommendations Nasarawa State

  • Nasarawa’s State Government should scale up PBF in the health sector with the SMoH as the regulatory body and the State Health Insurance Program as the CDV Agency.
  • A sustainable PBF financing should be planned for the 361 PBF health facilities that lose their NSHIP financing in 2020
  • Allocate 70% of the State health budget towards the PBF system of financing directly the health facilities for their performance
  • Definition of roles and responsibilities of actors at all levels such as identified in the institutional set-up below
  • Advocacy to the relevant stakeholders for making the PBF program in Nasarawa sustainable
  • Sensitization and dissemination meetings to keep the stakeholders well informed.
  • Awareness creation among population.

Recommendations Ondo State

  • Institution of PBF in the Ministry of Health.
  • Scaling up of PBF to all the health facilities.
  • Definition of roles and responsibility
  • Institution of PBF in the Health Insurance Program
  • Advocacy to the relevant stakeholders
  • Sensitization and dissemination meetings to keep the stakeholders well informed.
  • Awareness creation among populace about PBF.

Recommendations for Yobe State

  • Stakeholders’ sensitization on PBF
  • Advocacy to policy makers on PBF
  • Sensitization of traditional institutions, faith-based organisations, community based organisations, civil society organisations and professional bodies
  • Scaling up PBF in other non-contracted health facilities across the state
  • Make Free MNCH services to high quality subsidised user fee paid services.

The Netherlands – General Practice

The Netherlands is one of the richest countries in the world. Health care is well organized. Expenditure per capita is close to € 4.000. Health care depends heavily on primary care. It makes the system affordable and sustainable. Without primary care patients would have to go straight to the hospitals. With huge costs as a result. With people already spending 15% of their net income on health, the system would get too expensive with no room for other expenditures. This situation of full coverage is now under threat because of the retirement of a large number of GP’s in remote areas. Young doctors tend not to be willing to work in those areas. Therefore there is a need to stimulate starting GPs to work in those areas.

Recommendations Netherlands – General Practitioner

  • Awaken all actors, by mobilizing the public and sensitizing GP’s to take their responsibility and aim to cover the whole country including the remote or vulnerable urban areas.
  • Use the geographically equity bonus and investment bonus to stimulate GP’s to start their practice in named areas. There is already a system whereby the regular, quarterly payments are increased in so called poor, city areas. On top of that we can use other incentives. E.g. recently provincial authorities in Zeeland have provided so called summer houses to attract doctors to work in summertime in Zeeland.
  • Pass a motion in the national assembly of general practitioners to extend the system to more areas.
  • Work out the height of the extra payment by the union and representatives from the designated areas; GP’s, council members, representative of the dominant health insurance company in that area, and negotiate this with the MoH
  • Seek approval from the Ministry of Finance, for a raise in the macro budget spent on primary care.
  • Seek corporation with the local health insurance company. The insurance company is having a duty by law to insure sufficient health care in their respective areas.

Make adjustments to the existing system of postal code pricing. An additional investment bonus can be paid by the local health insurance company and sometimes local authorities such as counsels and provincial administration. 

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