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

Hereby, the course report-b

Central African Republic Security and Justice Sector

• Providing security is a core function of the state and directly linked to its legitimacy. However, security state actors such as the national police can also be seen as a threat by citizens because of their behavior and way of operating.
• In CAR, despite all efforts, state security forces remain demotivated for various reasons: low salaries, insufficiently educated personnel, limited facilities & equipment, etc., and are therefore less dedicated to their jobs. This can lead, in some cases, to human rights violations, ineffective service delivery, and high levels of corruption. 

Recommendations

• CORDAID to visit authorities from the Ministry of Interior & Public Security to present PBF solutions to some of the problems. A PBF pilot could follow 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 a result of the war, quality reviews are not conducted regularly, and some health workers exploit this situation by buying medicines from unauthorized sources to increase their profits. The socio-political crisis has halted economic activity, leaving many people poor and forcing health workers into private practice, where they try to earn extra income to meet basic needs.
• Delays in subsidy payments further reduce staff motivation.
• Low-quality care is linked to the availability of counterfeit medicines in some health facilities.

Recommendations Regional Fund for Health Promotion North-West

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

Cameroon CDV Agency North-West – problems and recommendations

The indices tool has a high non-submission rate of 35% and 22% over two consecutive quarters. One reason for this poor performance is that, in practice, the deputy managers of the CDV Agencies conduct coaching activities at best once a year, or not at all, due to security concerns and because they do not reside in the district, unlike the verifiers. Yet, CDV Agency verifiers (alongside supervisors from district health authorities) are the closest actors to health facilities and the community. Verifiers visit health facilities monthly, allowing 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. Administer a post-test, and select officers who score above 80% for particular axes.
• For CDV verification officers, provide regular coaching, and invite the Manager or Deputy for risk-based coaching or coaching on pertinent issues like conflicts or adherence issues.
• CDVA verification officers should monitor progress in the indices tool submission rate and score.

Ethiopia – problems and recommendations

Ethiopia is Africa’s second-most populous country, 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 the fact that 1 in 3 children are chronically malnourished and that the MMR is high, at 412 per 100,000 live births.

Under the Health Sector Transformation Plan, the Federal Ministry of Health identifies Universal Health Coverage (UHC) as a key component, aiming to provide all essential health services to 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 has run a showcase PBF project since 2015 in Borena Zone, Oromia Region, serving 186,000 people with encouraging results, and now aims to expand the PBF program to 1-2 million people in Jimma Health Zone. However, Ethiopia has not yet adopted a full PBF strategy, and the priority is to engage, together with the World Bank, in collectively exploring the feasibility of results-based strategies in Ethiopia, in relation to the three directorates for this exercise.

Main problems

• The PBF feasibility score detailed on pages 78 and 79 of this report is 32-36%, far below the recommended standard of 80%. This means several design improvements are needed to better use PBF’s opportunities.
• Provider managers cannot influence cost-sharing tariffs; in our country context, the government has sole authority to set them.
• No freedom to buy drugs. Health facilities must submit priorities to the EPSA, but only when items are out of stock; the EPSA mandates facilities to buy inputs from private accredited distributors.
• Lack of autonomy: health facilities are not autonomous because the Health Care Financing strategy is not yet approved.

Recommendations

• 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 a total population of 94 million.
• The PBF budget should not fall below USD 4 per capita per year. The required budget for those regions would be USD 22.995.992 for the Special Support region, USD 141.868.004 for Oromia, and USD 13.735.966 for Addis Ababa.
• 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.

NIGERIA

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. Multiple monopolistic distribution systems by 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 lack coordination. As a result, resources are wasted, and health workers at the facility level receive different orientations.
• The World Bank currently finances three large but conceptually opposing and ‘verticalized’ projects: 1. Save One Million Lives; 2. The NSHIP PBF program; and 3. The newly introduced nutrition program ANRiN. Course participants felt these programs should be better coordinated through a unified conceptual framework to achieve 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 into 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, of which they are also signatories, and stop the practice of transferring revenues to a single treasury account.
• Rethink the single treasury account practice, under which health facilities must deposit their revenues with the treasury, to which they have little access. This is the opposite of giving health facilities more (financial) autonomy.

Change some features of the PBF design in Nigeria

• Domicile the PBF unit in the Federal and State Ministries of Health rather than in National and State Primary Health Care Agencies/Boards to improve coordination, include the hospital level, and ensure regulatory oversight for sustainability.
• 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.

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) and 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 Nigerian government has embraced the Universal Health Coverage agenda, and the current challenge at all levels, state and federal, is to develop a sustainable proposition for health systems strengthening and health financing that leads to UHC. The federal and state governments are exploring various financing modalities. They are looking at how, for instance, a Basic Health Care Provision Fund, as a percentage of consolidated oil revenues, could contribute to domestic health financing, i.e., primary health care. Other large schemes, funded by loans and grants from external partners such as the Save a One Million Lives program, also factor into the equation. The new state and federal governments, which will take office by the end of May 2019, will have to focus on further integration and domestic management of the health system, making the next 18 months a crucial policy period in Nigerian health politics. Various Nigerian states represented at the April 2019 course sent senior SOML staff to explore PBF for this debate on integration and UHC. Several of the States present were also involved in implementing the NSHIP program and the RBF program in Nigeria, and expressed interest in introducing further RBF/PBF elements into state 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

Advocate and discuss with the Hon. Commissioner of Health the future architecture and financing of the PBF program. Issues to be discussed are:

• Rearrange the State architecture by establishing a Technical Coordination Unit in the MOH for basket funding.
• Coordinate state activities that currently run in parallel but could be integrated into the PBF program, such as SOML and other partners.
• Advocate and lobby the State Government to increase and release budgetary allocation for health funding.

Recommendations for 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 policymakers on PBF, traditional institutions, faith-based organizations, community-based organizations, civil society organizations, and professional bodies sensitization.
• Scaling up PBF in other currently non-contracted health facilities across the state
• Make free MNCH services into high-quality, subsidized, user-fee-paid services

Recommendations Kebbi State

• Advocate with policymakers for the PBF program as a reform strategy, and explain how it differs from previous reform approaches that did not achieve the desired objectives, such as Alma Ata primary health care and the Bamako Initiative.
• Prepare a Memo to the National Council on Health to advocate for a 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 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 on the verge of implementation, with the PBF program to achieve individual programs’ goals and ensure sustainability. The two programs can go hand in hand with support from Government, SOML, and donors
• SOML may shoulder responsibility for conducting study tours to some states that are already implementing the PBF program.
• Since some State policymakers may consider the PBF setup complex, there is a need to innovate by designating KECHES as the CDV agency so it can, backed by law, initiate performance payments instead of input payments, breaking monopolies held by 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 from remitting their cost recovery revenues to 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 per capita expenditure per year, using the state expenditure on health, has consistently been below $3. Therefore, the State budget must make funds available to cover 20% of the project. User fees will also be introduced for cost recovery purposes and to allow managers to handle cash.
• The SOML unit can be given responsibility for functioning as the PBF unit; therefore, it 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
• The State Supported Health Insurance Agency will establish a Contract Development and Verification Agency.
• The payment unit may be established within the SMOH.
• Laws impeding the implementation will be set aside, and a pilot will be in 3 LGAs.

Recommendations Nasarawa State

• Nasarawa 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, 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 the population.

Recommendations for Ondo State

• Institution of PBF in the Ministry of Health.
• Scale up PBF to all health facilities.
• Definition of roles and responsibilities
• 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 the populace about PBF.

Recommendations for Yobe State

• Stakeholders’ sensitization on PBF
• Advocacy to policymakers on PBF
• Sensitization of traditional institutions, faith-based organizations, community-based organizations, civil society organizations, and professional bodies
• Scaling up PBF in other non-contracted health facilities across the state
• Make Free MNCH services high-quality, subsidized, 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 become too expensive, leaving little room for other spending. This full-coverage situation is now under threat because many GPs in remote areas are retiring. Young doctors are often unwilling to work in those areas. Therefore, there is a need to stimulate starting GPs to work in those areas.

Recommendations Netherlands – General Practitioner

• Mobilize all actors by engaging the public and sensitizing GPs to take responsibility and aim to cover the whole country, including remote or vulnerable urban areas.
• Use the geographic equity bonus and investment bonus to encourage GPs to start practice in named areas. There is already a system in which 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 Zeeland during the summer.
• 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, representatives of the dominant health insurance company in that area, and negotiate this with the MoH
• Seek approval from the Ministry of Finance to increase the macro budget spent on primary care.
• Seek cooperation with the local health insurance company. The insurance company has a legal duty to ensure sufficient health care in its respective areas.

Adjust the existing postal code pricing system. The local health insurance company and, sometimes, local authorities such as councils and provincial administrations can pay an additional investment bonus.