National PBF scale-up in Cameroon – the 76th course

       We report on the PBF course, which took place in Douala from April 22 to May 4, 2019 with 58 participants from Cameroon. Hereby the detailed cours report (rapport du cours)

The 58 participants of the cours with national and regional authorities

This time there was a large delegation of 13 people from the Ministry of Finance with 8 financial controllers and 5 Treasurers General of Payments (TPG) from 6 regions. There were 8 economic and social advisors of the governors from 8 regions. The Ministry of Planning and the Department of Civil Registration (BUNEC) were represented and there were two independent participants. All other participants were from the health sector

The daily evaluations of the course showed an average score of 80%, which is 1 point higher than the average of the 44 previous French courses. The impact of the 76th PBF course was reflected in the good quality of the action plans proposed by the different groups and the general recommendations (see the rest of this report).

Fifty-nine participants (including one participant from BUNEC, who assisted as an observer) did the post-test and the average progression from the pre-test was 29%. The average post-test score was 68%, which is 4% lower than the 72% average of the last 20 courses. Nine participants obtained a certificate of distinction with a score of 87% or higher for the final course test. Six participants obtained a certificate of participation with scores of 50% or less.

The achievements of PBF in Cameroon

  • Towards the end of 2018, performance-based financing in Cameroon covered 78% of the population and it will reach 100% during 2019 ;
  • The liberalization of the pharmaceutical sector with the accreditation of pharmacies by the regulators has started to produce the results on improving the availability of medicines in certain regions such Littoral. This liberalization has also resulted in the increase of the health facility revenue rather than that these revenues benefit some monopolistic distributors. The health authorities in Littoral Region accredited 10 wholesale distributors in Douala and the other regions started the same accreditation process.
  • The contracting of the regional and district health authorities produces good results. It better focuses the authorities towards achieving their core activities such as quality control and accreditation of the health facilities and pharmacies. This for most authorities is a welcome move away from wasting their time on the inefficiencies that existed in the old system of input procedures without a clear vision or objectives ;
  • A health centre in the North region before PBF rehabilitation

    As an example of the positive effects of PBF for the availability of qualified staff in remote areas, Ngong and Guider health districts in the Northern Region reported an increase in the number of qualified personnel by 98% from 55 to 109 between 2017 and 2019. PBF has a positive impact on the migration of qualified personnel to vulnerable PBF health facilities.

  • Numerous PBF infrastructure improvements have been made as shown by the following images, pre- and post of Guider Health District in the Northern Region.

  • Rehabilitation with quality improvement bonus

    The PBF Program in Civil Administration (BUNEC) has been operational since the third quarter of 2018 in three Regions and the initial results are encouraging.

  • During the 76th PBF course there were 8 financial controllers and 5 Treasurers General of Payments. They produced an excellent action plan on the procedures for the timelypayment of the PBF funds by the Regions.

Summary of problems and recommendations

  1. Payment delays continue and the PBF budget 2019-2022

The main problem identified during the 76th PBF course is the continued delays of the PBF subsidy payments of up to six months. These delays were due in part to the non-implementation of the joint circular letter of MINSANTE-MINFI N ° 36-56 of 03 November 2017 setting the modalities for the management of financial resources of the PBF health facilities at the level of the financial bodies concerned such as the financial controllers and the TPGs. The delays had a very negative impact on the achievement of the indicators and on the use of the planned budget for the minimum and complementary health activities as well as for the district, regional and central health authorities of the MOH. In particular the low disbursement for the health packages resulted in the impression that a relatively high proportion of 34% was used for the expenditures of the Contract Development and Verification Agency. However the problem is not the high rate of spending for the CDV Agencies, but rather the low use of the health packages budget of only USD 1.17 per person per year in 2018 instead of at least USD 3.00.

  • There is a need to speed up the payment of primary level and hospital level invoices as well as the better use of the quality improvement bonuses to address the problems of health facilities such as staff shortages, obsolete infrastructure, lack of equipment, negative effects of the instability in the country increasing the number of very poor people and the need to respond to the refugee and internally displaced persons crisis ;
  • There is a need to increase the subsidies to respond to new vision of the Ministry of Health and their partners. This also because in December 2018, the government with the support of partners increased the number of indicators (or activities) at the primary level from 34 to 40 and integrated new indicators for Civil Registration and nutrition.
  • The most conservative overall costing of PBF in Cameroon shows that PBF spending in 2019 will be around USD 3.50 per person per year, but that it will increase in 2020 to USD 4.00 and in 2021 and 2022 to USD 5.00.
  • In the absence of the (political) willingness to increase the budget available for PBF to USD 5.00 per year per person there are some scenarios 1. Cancel a number of indicators; 2. Cancel all support for the vulnerable in the community and especially in unstable areas (which is expensive); 3. Cancel the quality improvement bonuses for the rehabilitation and support to qualified personnel in the country’s remote areas; 4. Cancel the full PBF coverage to all Regions in Cameroon.
  • The above choices must be made by the country’s politicians and not by the costing experts of the Ministry. Unfortunately, there seems not to exist a plan B to return to the previous input financing policy with its complex and non-transparent procedures. The input approach, according to the WHO estimate, costs around USD 80 per person per year, which is about 16 times more than what PBF asks for. This scenario seems even more gloomy. If the government wishes to continue with the inefficiencies of the monopolistic distribution of inputs as well as the non-involvement of the private sector this will further aggravate the situation.
  • So, the question that arises is to what extent the government and partners have the political will to move forward with the rational and more efficient PBF approach in a difficult environment with limited budgets. If the answer is “no”, we must fear for the evolution of the health system in Cameroon, which will also have political and social consequences.
  • The World Bank budget alone cannot finance PBF in Cameroon and filling the gap must mainly come from the government (and other partners). So we propose to continue the transformation of the existing budget lines of the Finance Law into PBF budget lines in such a way that the PBF budget reaches at least USD 5.00 per person per year from 2021 onwards. An analyses of the budget of the Ministry of Health demonstrates that money for the PBF exists if only 20-25% of the total budget could be transformed into PBF, RBF or strategic purchase performance financing.
  1. Advocacy with the government for PBF and the increase of the PBF budget
  • The 76th PBF course village chief

    Advocate for the Ministry of Finance to introduce into the Circular bearing the instructions on the implementation of the Finance Laws, all provisions facilitating the implementation of PBF for fiscal years 2020, onwards.

  • Increase the proportion of the budget allocated to performance-based financing in the budget of the MOH => 1. Identify the budget lines that can be transformed into PBF lines; 2. Codification of the resources allocated for the local recruitment of staff by the health facilities in PBF subsidies
  • Increase the number of participants of the heads of other Ministries such as MINEPAT, MINFI, MINCOSUPE and MINMAP in charge of budgeting for PBF International courses in 2019.
  • Plan a symposium or a two-day conference in Yaoundé to bring together senior officials from these ministries, especially the budget preparation team, highlighting the benefits of PBF and illustrating it through the results achieved to date in the field of health. This because the participation of a 14-day training may be difficult for senior officials.
  • Put under performance contracts the actors of the Ministry of Finance, including the financial controllers and the Treasurers General Payment.
  • Integrate experts from the Ministry of Finance (financial controllers and Treasurers General of Payments) into the group of facilitators of the PBF courses – the first course starts on May 13. This for them to better explain the logic of the PBF financial procedures and thus to prevent delays in the PBF payments as well as with the aim to transform other budget lines into PBF.
  • Make a plea to the Government so that the resources transferred to the communes are allocated directly to the health facilities in the form of QIBs as of the budget year 2020.
  • Advocate with partners to contribute technically and financially towards the government’s national PBF policy. The Directorate of Cooperation (DCOOP) of the MOH should develop a brochure on the government’s PBF reform and invite all partners to offer assistance in the logic of buying results instead of providing inputs. In this booklet it is necessary to explain the best PBF practices, what are the results already achieved and how the partners can intervene by avoiding support in which reinforces the monopolies and the allocative, technical and administrative inefficiencies.
  1. Training of health facility staff in financial procedures
  • Train health facility staff in the management of human resources or encourage them to recruit financial administrators in the health facilities ;
  • Improve the monthly application of the indices management tool and review the indicators for the quality score of the indices management tool
  • Invite the health facilities to systematically affiliate the locally recruited staff into the National Social Security Fund, and ensure that their social security contributions are regularly paid;
  • Grant health facilities not only quality improvement bonuses at the start of the program but make them available continuously so that new challenges can be faced. This should be done on the basis of convincing business-plans.
  1. The budget and the efficiencies of the Regional CDV Agencies 
  • The good moments of the course

    The CDV Agencies in 2018 spent USD 0.65 per person per year. This amount seems efficient compared to other countries such as CAR, which have expenditures above USD 1.40.

  • The activities of the CDV Agencies have increased in 2018 with the introduction of new indicators. In addition, the follow-up of the quality improvement bonuses was insufficient. Therefore, there is only a limited scope for reducing the funding for the CDV Agencies and this is also not desired. Further reducing the CDV agency budget may create a lack of transparency in producing the PBF invoices. Cheating with invoices was observed in Nigeria and the DRC as the result of a verification system that was not robust enough.
  • However, some efficiencies could be achieved with the coaching activity that could be done by CDV Agency medical verification officers instead of by the managers. The advantage is that the verification officers already live in the district, which reduces the per diem and the cost of transportation. This change also requires the recruitment of medical verification officers with the ability to coach.
  1. Mapping and rationalization of the health facility and district catchment areas
  • Encourage the district management teams to carry out the annual mapping and rationalization of the health catchment areas. The main contractors should serve on average 10,000 people (8,000 for rural areas and 12,000 for urban areas) Each main contractor may have several secondary contractors. They are encouraged to select those clinics and health posts that provide good quality and which have the ambition to make available quality health packages. This process should also gradually allow the disappearance of below standard public an private health facilities.
  • The central level Directorate of the MOH should take into account and support the redistricting done by the district and regional health authorities instead of wishing to stick to their power that this is only their responsibility.
  1. Essential drugs and the recruitment of qualified staff

In some regions the problem of stock outs of essential drugs and other inputs such as equipment and consumables continues due to the still existing monopolies of the RFHP, CENAME (especially in the Southern and Centre Region) as well as the monopolies created by churches and plantations.

  • Advocate at all levels to liberalize the pharmaceutical market and avoid any form of monopoly.
  • Harmonize the list of wholesale distributors accredited by the regional health authorities at national level by the Directorate of Pharmacies of the MOH and inform all health facilities on this list through the Regional Delegations of Public Health. This harmonization should facilitate that health facilities in the border areas between the regions also use the accredited distributors from neighboring regions.

There is progress with the recruitment of qualified staff in the PBF health facilities, but especially in remote areas the coverage of qualified personnel remains insufficient.

  • Continue with the recruitment of qualified personnel with the aim to reach 1 qualified staff per 1000 habitants for the primary level as well as for the hospital level ;
  • Increase the PBF budget to stimulate the recruitment of qualified contract workers in the health facilities in rural and disadvantaged areas.
  1. Civil Administration- BUNEC
  • The financing of the civil administration offices in Cameroon is insufficient, in particular because the Law prescribes that these services should be free of charge
  • This results in lack of staff motivation and high costs for the population through the generally accepted informal payments for the birth certificates, etc. It also leads to the poor quality of the services offered by the unpaid civil administration officers.
  1. Regional and district level
  • The PBF course secretariat

    Increase the PBF budget for the regional and district health authorities by continuing to replace old earmarked funds (or “cartons”). The authorities should focus in particular on the accreditation of pharmacies and health facilities as well as the mapping and rationalization of health areas, training activities, and organizing action research.

  • Transfer the budget for action research related to PBF budget from the CDV Agencies towards the regional health authorities
  • Consider the creation, at the regional level, of a committee to supervise and monitor the PBF activities ;
  • Put under performance contract the Services of the Governors involved in the elaboration of the regulatory acts for the procedures to provide funds for the health facilities, once the Regional Financial Controller has prepared the Act. This must be done with great speed in order to respect the deadlines set for the successful settlement of payment procedures.

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