The 80^th international PBF course organised by SINA health in Mombasa-Kenya in November 2019, welcomed 37 participants from Nigeria 19; Liberia 16; South Sudan 1; and CAR 1. Most were from the health sector. Hereby the detailed course report.

This course was evaluated by the participants as one of the best since 2007. The criteria methods and facilitation, participation and organisation scored very well with averages of respectively 95% 93%, and 94%. The final evaluation indicated that for 100% of the participants the content of the course related well to their professional activities and that the methodology of the course was excellent. Yet, 50% of the course participants also commented that the course was too short.

NIGERIA

With respect to the PBF experiences in Nigeria, the seven States present in Mombasa were mixed. Four states (Bauchi, Borno, Gombe and Ondo) are in the current NSHIP PBF program, but funds will run out by 2020. Three states (Kaduna, Niger and Rivers) wish to set up a PBF systems with their own funding from the start. So, the Nigerian PBF system is at a cross roads.

The States present in Mombasa all share similar challenges in their (pre-PBF) health systems. There are insufficient and poorly distributed human resources, inefficient input systems with frequent stock-outs, dilapidated infrastructure, poor quality services, and the verticalization of programmes. Some State representatives describe their current health system as being in a “state of emergency”.

The course participants agreed, that the World-Bank supported NSHIP program PBF pilots in the states – implemented since 2011 – have produced very good results. As a result, there is the growing consensus that PBF should become the preferred reform approach to achieve Universal Health Coverage in Nigeria. The delegations in Mombasa indicated they wish that PBF moves forward towards a sustainable systems approach.

Different World Bank approaches have tested different strategies in Nigeria, but this also created problems in the process.

(i) The Save One Million Lives (SOML) programme is basically a contract mechanism between the Federal and the State level, without applying PBF best practices at the Local Government Authority – and health facility levels. It therefore became seen as an input project and States used the SOML money in the “business as usual” manner. Its evaluation in 2019 was not favourable.

(ii) The decentralised facility financing (DFF) approach was a research idea to finance the control LGAs that were compared with the PBF LGAs but without any verification. This DFF approach had no checks and balances and lacked transparency and it should never have been proposed in the first place. Since 2014, several groups attending the PBF courses in Mombasa proposed to change this DFF approach towards PBF, but these recommendations were ignored for years. DFF created contradictions and may even have contributed to less transparent systems.

(iii) In addition, the Bank also developed a Nutrition programme (ANRIN), which has not been harmonised with the PBF reforms. It is unfortunate if this large program would not benefit from the advantages of the decentralised performance approach. It should advocate the local purchasing of supplementary feeding by the health facilities and their communities instead of this being done through centralized input financing. This nutrition program, if it applies the PBF principles, has the potential to create enormous economic multiplier effects.

GENERAL RECOMMENDATIONS FOR NIGERIA

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      The PBF course village authorities

  It is desirable to scale up PBF towards 100% coverage in the States. This in order to create good economies of scale and to allow for the harmonisation of the health system following the common-sense PBF principles of autonomy, public-private partnerships, competition for contracts and transparency.

• Depending on the ambitions of each State, the PBF budget may range from USD 4.00 per capita per year up till USD 7-12 if a larger number of activities is foreseen. This may contain more free health care, include the supplementary feeding nutrition program, or include the non-communicable diseases. Equally, an increase of the per capita budget is required when infrastructure is dilapidated or if the State has a large proportion of internally displaced persons or refugees.
• Yet, for the PBF reforms to be successful, it will be necessary how to deal with the interests vested in the current input schemes of infrastructure, drugs, and equipment. This requires a constructive dialogue with the parties concerned about how to move from input financing towards performance financing of health systems
• All States in Mombasa stress the need for advocacy through exchanges with the decision-makers, meetings, State Health Summits, through conducting study visits or by following PBF courses.
• Embed the State PBF Unit within the State Ministries of Health. This to obtain access to the decision-making authorities and funding streams.
• In order to expand the current performance-based financing design it is recommended to develop performance contracts with all agencies and directors under the ministry of health and its agencies.
• Consider to embed the CDV Agencies within the Contributory Health (Insurance) Scheme (CHS). The CHS already has a legal status and federal backing and it is better positioned to generate domestic funds. Yet, CHS as a stand-alone intervention has several design problems and inefficiencies.
• At State level, the State Ministries of Health should mobilize domestic resources to create new PBF budget lines including from the input-oriented capital investment, State Trust Funds, donors’ resources as well as existing budget streams of PBF, insurance and SPHCDA.
• The World Bank is advised to harmonize its different projects such as NSHIP, SOML, DFF and ANRiN.
• Several States also expressed the need to review the existing Laws in such a manner that they allow the PBF best practices to be applied and in particular autonomous health facility management, and targeted free health care with user fee payments.
• The generalized free health ‘policy’ should be replaced with sound quality-driven health-financing approach with targeted free health care.
• Include PBF in the medical and nursing schools’ curriculum.

SPECIFIC RECOMMENDATIONS AT STATE LEVEL

1. BAUCHI STATE

Bauchi State has 7,2 million population and is part of the World Bank-supported NSHIP PBF program since 2017. Currently, approximately 60% of the population is covered with PBF. This program, during its short existence, produced exciting results and the State wishes to expand PBF and make it sustainable. Yet, so far, the State has not used its own funds for the implementation of PBF.

For this, the State should mobilise various sources of local funding and scale up PBF State-wide. It should include performance contracts with all agencies and directors under the Ministry of Health and its agencies. Finally, it is desirable to integrate the PBF operations within the Bauchi State Health Contributory Health (insurance) scheme.

2. BORNO STATE

Borno State in the North-East of the country has 6,3 million inhabitants with 27 LGAs. Since 2009, Borno State has been suffering from insurgencies that created huge internal population movements. The results of the PBF program that started in 2017, in two pilot LGAs have been very promising. Hence, after NSHIP ends in 2020, the state wishes to continue PBF in two major LGAs, which host a total of 1,7 million persons with many IDPs. The team proposes to conduct a realistic costing for the PBF program and to unlock input-financing from domestic and external resources into output financing at USD 5 per capita per year.

3. GOMBE STATE

Gombe State has a population of 3,6 million. Only 3.5% of the 2019 state budget was allocated to health. Gombe has successfully implemented PBF in 6 of the 11 LGAs. However, the NSHIP PBF program will end in 2020 and Gombe State wishes to sustain the PBF program through state financing. The state Government should sustain and scale up the NSHIP program to the remaining five Local Government Areas of the state. This requires to establish a basket fund to coordinate donor funds in the state by organizing engagement meetings with Ministries of Finance, Budget and planning, Health, SPHCDA and office of the state accountant general, and representatives of donor agencies. The State House of Assembly should also pass a bill establishing the State Contributory Health Scheme in line with the principles of performance-based financing.

4. ONDO STATE

Ondo State has a population of 5.1 million with 18 LGAs. Ondo State was among the three initial PBF pilot states of NSHIP since 2011, scaling up to 9 LGAs in 2014 while the remaining 9 LGAs were operating under the research design of Decentralized Facility Financing (DFF). Results were good, but NSHIP financing will run out by June 2020.

The State has not prepared a sustainability plan from the outset of the project. There may be reluctance among key decision makers to abandon the less transparent input-financing system over which the decision makers have a lot of power. Moreover, the general free health care policy in the State makes it difficult to provide quality services and to prevent stock-outs of essential drugs and other inputs.

The Ondo participant will conduct advocacy with State government officials and World Bank representatives to advance PBF during the planned high-level summit on the future of PBF. There is also a need to merge the PBF best practices with the health insurance CHS system. Scaling up the PBF approach to 100% of the State is desirable and this requires pooling the different sources of funds towards PBF.

5. KADUNA STATE

Kaduna State is located in the North-West of Nigeria. The problems of the health systems are the same as described in the general Nigeria section above and with the insufficiently-resourced generalized free health care policy. The State has not yet started PBF, but there is a strong political will at the highest levels to explore the potential of PBF. It remains to be seen in how far there will be opposition from those decision-makers, who may also have interests to maintain their decision-power over the input resources. The Kaduna team will draft an information Memo for the Commissioner of Health to present at the State Council meeting. There is a need to analyse which funds are available in Kaduna for PBF and which can be used for a pilot in 3 LGAs. Technical support may be required to design and implement the Kaduna State PBF reforms.

6. NIGER STATE

Niger State has a highly dispersed population of 6.1 million. The health sector is critical to Niger State development, and is a priority of the present administration. Health indicators are poor and geographical access, workforce productivity and the service quality pose profound challenges.

The Niger participant proposes a PBF pilot in three LGAs. In preparation, it may be necessary to organize a study tour to States already implementing PBF. A realistic costing of above $ 4-6 per capita per year should be done with the available finds so that a well-designed PBF pilot can be implemented. This is expected to produce convincing results visible for the population and decision makers. This should be the best advocacy tool so that the State will in the future transform already existing input budget lines into PBF budget lines.

7. RIVERS STATE

Rivers State is located in the oil-rich Niger delta region with Port Harcourt as its capital. While the State’s economy is still largely dependent on oil, the declining oil price and ongoing security challenges has caused a steady economic decline. The quality of the health services is so poor that it is difficult to achieve UHC without major reforms. The PBF approach is likely to be the best strategy. The participant proposes to raise awareness and advocate to start PBF in Rivers State at the next State Steering Committee. She will also prepare a briefing document on PBF principles and best practices.

LIBERIA

The Liberia health system is heavily donor-dependent since the start of the civil war in 1989 and the outbreak of the Ebola Virus Diseases (EVD) in 2015. Yet, this donor support is phasing out. The economy has also slowed down. Deep reforms are needed to make more efficient use of the scarce public resources.

Maternal mortality is extremely high with 1072 death per 100,000 live births. Human resource management is compromised and the country uses inefficient input supply chains.

As has been shown in the different PBF, P4P or strategic purchasing programs in Liberia during the last 8 years, these performance systems can assist in addressing these inadequacies. Yet in order to tap its full potential, it requires a deeper structural reform of the current PBF designs and the harmonization by government and the Ministry of Health of the approaches of the different donors.

RECOMMENDATIONS FOR LIBERIA

• Advocate with technicians and policy makers in the Ministry of Health and the Ministry of Finance for full-scale harmonized output-based financing (or strategic purchasing);
• Ensure that the PBF approach is incorporated into the current draft health strategy;
• Harmonize Liberia’s different performance-based schemes into one national PBF scheme;
• Transform the current financing system of generalized free health care towards targeted free health care system and make quality care and efficiency the main objectives;
• Revise the institutional setup of the PBF program;
• Move the PBF Unit under the Office of the Minister for better coordination, and which will allow to contract all departments;
• Introduce the geographic equity bonus system with the aim to support rural services and to promote staff retention in remote health facilities;
• Identify a national institution to play the role of Contract Development and Verification (CDV) Agency. Possibly, this could be the already existing Governance Commission.
• Establish County and in some large districts, district level CDV branches of the national CDV Agency;
• The CDV agency should contract health facilities based on their performance and not on their status of being public, private or religious structures;
• Conduct the mapping and rationalization of the catchment areas based on national standards of between 5.000 and 14.000 population;
• Establish County validation committees consisting of the County Health representatives, the CDV Agency and service providers;
• Health facilities should establish their cost-sharing tariffs together with their communities;
• Introduce quality improvement bonuses and integrating them in the standard output indicator list;
• Introduce need-based action research with budgetary allocations in the performance contracts at the central level and at the peripheral level managed by the CDV agencies;

CENTRAL AFRICAN REPUBLIC – EDUCATION

The education sector in CAR faces severe problems. The population has a low level of schooling, there is inadequate funding, there are inefficient input strategies and there is an extreme shortage of skilled teachers. The school infrastructure is mostly dilapidated and there is a shortage of text books.

PBF pilots in education started in CAR in 2009 by Cordaid. The results were convincing. It is estimated that a fully-fledged PBF reform in all primary schools in CAR would only cost around USD 20-25 million per year. The Ministry of Education wishes to adopt and finance performance-based financing, but this has not yet materialized. Therefore, Cordaid continues to finance PBF in one of the districts – Nana Mambéré – as a continued pilot and advocacy tool. In this action plan we propose how to improve this initiative and to further promote the PBF approach.

RECOMMENDATIONS for PBF in EDUCATION

• Advocate with the Ministry of Education to find funding for the PBF reforms. The World Bank is the most likely organisation that may respond favourably. Moreover, input lines in the government budget for the education sector should be reviewed with the aim to transform them into PBF budget lines.
• Review the “general” free education policy, and advocate for “targeted” free education, whereby parents with resources contribute and thereby enhance the quality of the education. This should also lead to more efficient use of resources and to better motivated teachers.
• A costing for 60,000 pupils of $ 20 per capita per pupil requires USD 1.2 million, while so far only USD 850.000 is available. So, there is a need to reduce the number of pupils, which benefit from the Cordaid PBF program or search for additional funding.
• Move towards the separation of functions (Cordaid is currently plays the role of fundholder, verification and does the quality checks) by including local education authorities and by enhancing the role of the national PBF education unit in the MOE.
• Apply the indices management tool to enhance transparency at schools and to better monitor financial processes including the performance bonuses to motivate teachers.

SOUTH SUDAN

Decades of war and tribal violence have rendered a large part of the population very poor. Health indicators and service delivery are deeply challenged. The health system is mainly financed by donors, but they apply the inefficient input- and “zero cash” system at health facility level that complicates the development of sustainable health facilities.

In this context, Cordaid is contemplating a PBF pilot in Torit County, for a population of 120.000 people, with one hospital and the primary level health facilities. The conditions in Torit are favourable due to a relatively good accessibility of the health facilities, and a relatively well-developed local economy compared to other Counties in the country.

The Mombasa participant will debrief the Cordaid Office in Juba and present the Mombasa action plan with the aim to start a PBF pilot program in Torit county. This could be followed by meetings with the National government and the Torit County health authorities to discuss the possibility of piloting a PBF program in 50% of Torit County with 120.000 inhabitants. The pilot should also conduct research by comparing the results in the PBF health facilities with the other 50% of the County. This requires a feasibility study at National and Torit County level, comparing the baseline situation in both the PBF and the Pool fund health facilities. This PBF pilot may than evaluate after 2 years the results with the control health facilities with the standard Trust Fund approach. There may be a need to solicit the support of public health- and PBF expert(s) to develop the PBF pilot.