The last FBP course of 2019 took place in Cotonou from December 2 to 14, 2019 with 32 participants from six countries (Mali, Comoros, Gabon, Mali, Niger, DRC and CAR). Eight groups (three groups from CAR) developed excellent action plans, which, if they are implemented, will greatly advance PBF in the respective countries and sectors.

Here the detailed report of the course (rapport).

STATUS OF PBF IN THE COUNTRIES AND SECTORS WITH MAIN MESSAGES:

• In the CENTRAL AFRICAN REPUBLIC around 50% of the population is covered with PBF, and the government decided to roll out to 100% the reforms nationwide by the end of 2020 with funding from the government, the World Bank and the European Union. NGOs such as Premiere Urgence Internationale – which attended the Cotonou course – may also start playing an active role. In the DEMOCRATIC REPUBLIC OF CONGO, the PBF reforms are progressing well and 40% of the population is covered by PBF. The designs in CAR and DRC are relatively “pure” in terms of the application of the PBF best practices. However, the participants from these two countries in Cotonou also propose several improvements in the design.
• In the COMOROS, 50% of the country is covered with PBF and the country is proposing to scale up in 2021 towards a “purer” PBF design compared to the current one. The six participants in Cotonou in their action plan proposed several improvements in the design and will advocate for a larger ownership for PBF among key decision makers.
• In GABON, the planning for performance-based financing started in early 2017 with Gabonese funding, but implementation has not yet started. This may be due to a lack of clarity on the financial procedures and willingness by government to provide the funds. The Ministry of Finance in Gabon aims to launch a pilot PBF program and could also help the Ministry of Health to progress with PBF.
• MALI has experienced long delays in starting the scale up of PBF despite that two pilot projects have shown excellent results. Yet, the Mali government with support of the World Bank, the Dutch government and GFF now aim to start a large relatively “pure” PBF pilot in 2020 for 5.8 million people and a budget of $ 66 million for four years. A large team of 14 people from Mali was in Cotonou to improve the design of the program.
• NIGER also experienced long delays in starting the scaling up of PBF despite that the pilot project has shown excellent results. The reasons for the delays are: 1. A lack of ownership for PBF by the decision-makers. PBF remained in the “project mode”; 2. Delays in the effective integration of the National Technical PBF Unit in the Ministry of Health; 3. Errors in the design of the PBF program. The Niger participants in Cotonou aim to revive PBF with the start of a large pilot programme.
• In the Central African Republic, the MINISTRIES OF JUSTICE AND THE INTERIOR with support of Cordaid aim to launch a PBF program. Experience in other countries with PBF in these sectors such as in the DRC have shown good results.

A problem in many countries is that PBF budget lines are not effectively integrated in the government budget and Finance Law procedures.

There may be a lack of clarity regarding the financial and legal procedures required to disburse the government budget through performance payments directly towards peripheral providers and the population instead of through the classical complex input procedures

A further general problem is that in several countries some decision-makers are hesitant to transform the less-transparent input financing into results-based funding, which transmits money directly to providers and the population. The latter approach is more transparent and less likely to lead to corruption. The best way to remedy this is to offer performance contracts to the main actors and departments of the ministries of health and finance. This should enable them to obtain a competitive remuneration adequate to only defend the public interest instead of earning money through shady deals.

WHO ATTENDED THE PBF COURSE IN COTONOU AND THEIR RESULTS

The last PBF course of 2019 was held in Cotonou from December 2 to 14, 2019 with 32 participants from six countries: Mali (14x), Comoros (6x), RCA (4x), DRC (4x), Gabon (2x), and Niger (2x). There were also two other sectors present during the course: The Ministry of Finance of Gabon and the Ministries of Justice and Interior from the Central African Republic. This shows that PBF is not only a reform in the health sector.

Thirty-two participants did the posttest and the average score was 72% with an average progression compared to the pre-test of 28%. Seven participants obtained a certificate of distinction with a score of 87% or more for the final test. We congratulate the course group that none of the participants obtained a certificate of participation with a score of 50% or less.

For certificates of distinction, these are:

With 87% (4 mistakes out of 30)

• Dr. Johny IKWA, Coordinator of the EUP (ACV) of the Province of Tshuapa in the DRC
• Dr. Abdallah AHMED, COMPASS Coordinator – World Bank funded project in Comoros
• Dr. Mohamed DIAMALDINE, Regional Health Director of Mohéli in the Comoros
• Mrs Dalla MAGASSOUBA from the Project Management Unit of the common basket funding in Mali

With 90% (3 mistakes out of 30)

• Dr. François KANDU, Chief Doctor of the Budjala Health Zone in the DRC

With 93% (2 mistakes out of 30)

• Dr. Jean Marie MOKOLA, Coordinator of the EUP (CDV Agency) of the Province of Sud Ubangi in the DRC
• Dr. Naye CAMARA, CANAM (Insurance Company) in Mali.

EVALUATION OF THE COTONOU COURSE BY THE PARTICIPANTS

The daily course evaluations had an average score of 81%, which is 2 points higher than the average of the 46 previous French-language courses. On the last day of the course the participants evaluated the course, which shows a satisfaction score of 91% for the preparation and the general impressions of the course. The organization was assessed as good except for the quality of the hotel. The hotel had a low score of 21% and food also scored low with 25%.

The open mindedness of the facilitators was evaluated at 93%. The majority of the modules were evaluated as satisfactory except for the module’s economics (61%), the indices management tool (48%) and costing (44%). These last two modules did not have enough time.

Recommendations concerning the course methodology:

• Review how to improve the modules on economics and health economics, indices management tool and costing so that they can be better understood by the participants;
• Review how to further reduce the number of modules and materials to be dispensed in such a way that the other elements of the course will have more time;
• The Hotel Atlantic Beach Benin was evaluated poorly. The proximity to the beach and the distance from the city centre of 5-7 kilometres makes its location very optimal so that participants can focus on the course instead of being distracted in the city centre. The Hotel is not very busy, some staff is not professional, and there are often problems with water and the internet. Food is sometimes insufficient. Yet, changing to a better hotel will also require the course fee to increase.

THE SIX PBF COURSES OF 2019 IN MOMBASA, DOUALA AND COTONOU

This report is the last of 6 courses that were organized in 2019 by SINA Health, the Regional Fund for Health Promotion in Littoral, and BEST-SD in respectively Mombasa, Douala and in Cotonou. In total we welcomed 248 participants from 17 countries in three French-spoken and three English-spoken courses. The main contributors to the courses came from Cameroun (116x), Nigeria (33x), Liberia (15x), Mali (14x), Central African Republic (14x), Burundi (9x) and Ethiopia (7x). From the other 8 countries there were between 1 and 4 participants. There were 65 female participants (26,2%), which is a too small proportion.

The average score for the post-test of the courses was 69% and the average progress compared to the pre-test was 23%. 21 participants obtained a certificate of participation (8,5%), while 32 obtained a distinction (12,9%).

SUMMARY AND RECOMMENDATIONS OF EACH GROUP IN COTONOU

1. DRC

PBF in the DRC covers 30 million inhabitants and has been developed over the past 15 years. Overall, it has become one of the “purest” PBF interventions in terms of following its best practices and theories.

The problems of the PBF program are:

• Contracts are signed between three or four parties instead of between two. The CDV Agencies do not only sign health facility contracts with their in-charges, but at the same time with the district authorities and the president of the health committees;
• Absence of subcontracts between the main health centre contract holder and health posts and private structures in the catchment area. This means that these non-contracted health facilities remain outside the control of the regulatory authorities;
• The (private) health facilities, which do not have contracts with the CDV Agencies or main contract holders are likely to provide poor quality care and to use poor quality cheaper or even expired medicines to compensate for the unfair competition with those health facilities with PBF contracts;
• Application of flat fee payments during visits to health facilities instead of variable fees based on drugs and services consumed. This leads to an inadequate cost recovery for essential drugs, consumables, etc, the use of poor-quality medicines, and demotivation of health workers;
• Several reference health centres, which serve the population with a hospital package, are not recognized by the Ministry;
• Absence of contracts between the Ministry of Health and the Provincial Health Inspectorate;
• Absence of contracts between the health centres and their health committees;
• The current PBF budget is around $ 3.00, which is less than the recommended $ 4.00 per person per year;
• Government funding for PBF is too low, only around 10% compared to 90% for external financing;
• Existence of an essential drugs supply monopoly by the Provincial Distribution Centres and the supply by other partners of drugs in the form of inputs;
• The quality improvement bonuses are only granted once at the start of the project instead of it being regular investments to improve infrastructure, equipment and, human resources;
• The health facilities are not authorized to recruit or dismiss their staff.

Recommendations

• Advocacy for the mobilization and allocation of resources in the health sector by setting specific taxes earmarked for PBF;
• Advocacy for the granting of quality improvement bonuses to the health facilities;
• To accredit wholesale distributors of drugs in each province;
• Guarantee the availability and effectiveness of pharmacists at the provincial level to conduct the regulatory accreditation system for pharmacies;
• Respect the principle of the signing of contracts with only two signatories;
• Sign the contract between the CDV Agencies and reference hospitals;
• Proceed to the signing of sub-contracts between health centres and viable private structures and health posts.

2.  Union of Comoros

The Union of the Comoros has an estimated population of 742,000. The reproductive health indicators have seen positive developments in recent years. The maternal mortality rate went from 517 cases in 1996 to 172 deaths per 100,000 live births in 2012. However, the health system in Comoros has still several problems such as poor-quality health services, inequitable access, low motivation of staff and the centralized purchasing of resources. In addition, the health budget is highly dependent on external donors. Many already poor households are experiencing worsening poverty due to direct payments for their health services.

A PBF project was set up in 2011 with the support of the French Development Agency (AFD) and which has shown promising results. With the support of the World Bank, the country plans to extend this experience to other structures not covered until the end of 2020 with the AFD approach, but from 2021, the country will test the “pure” PBF approach.

The team from the Comoros in Cotonou noted that to benefit more from the PBF system, more PBF best practices must be respected. The feasibility score that analyzes the “purity of the PBF system” was only 28%. The main problems are the absence of the government budget in the program, the insufficient appropriation of the program by the Ministry and the lack of autonomy of the structures. The PBF project has not yet integrated the technical instruments and remuneration for the quality of care.

Recommendations

• Restitution of the PBF training at national and island level with the authorities, other sectors, and partners;
• Introduction of an information- and advocacy note in the Council of Ministers;
• Development of a PBF communication plan for all stakeholders including partners;
• Organization of advocacy and training meetings on PBF at all levels
• Revision of the PBF manual;
• Advocacy for the inclusion of a PBF budget line in the Finance Law of the government budget;
• Advocacy for a derogation of the law, which ensures the autonomy of management of pilot PBF health facilities.

3.  Gabon

The need to strengthen governance and the search for an efficient and effective public administration have led Gabon to undertake reforms based on results-based budgeting. Since 2015, the Gabon budget has gone from the input mode to the budget programming mode.

However, the reality is that the state budget is still executed in the input mode and not on paying for performance for already achieved results. In addition, we note the absence of a process, the financial procedures and the legal framework, which makes it possible to pay for performance.

The PBF reform approach is a good solution to pay directly for performance. It allows a better allocation of state resources to the different sectoral administrations and saves money because PBF does not require an increase in the existing input budgets. The idea is first to use the already available budget more efficiently. In addition, it helps to better motivate agents based on their results.

Finally, greater accountability of operational units and decentralization of resource management will generate a multiplier effect capable of boosting the local economy.

Recommendations

• Understand why the PBF payments have not yet started within the Ministry of Health;
• Apply the PBF reforms within the Ministry of Budget and Finance;
• Establish the PBF implementing agencies such as the Steering Committee, the national PBF Unit, the regulators at all levels, the Contract Development and Verification Agency;
• Invite PBF experts to raise awareness of advantages if the PBF reform, conduct training workshop for PBF actors, establish a work schedule;
• Creation of PBF budget lines in the government budget, with the elimination of non-performing “input” budget lines and the creation of PBF budget lines;
• Creation of a special account from the budget support with the aim to benefit the various “autonomous” entities of the Ministry of Finance.

4.  Mali

Mali has an estimated population of 20.3 million inhabitants. With an annual per capita income of around USD 770 in 2017, Mali belongs to the group of the 25 poorest countries in the world. Employees and civil servants in the formal sector are covered by a compulsory health insurance scheme administered by a public semi-autonomous insurance agency. The government supports free health care plans (subsidized) by subsidizing specific services (for example, caesarean section, treatment of malaria, HIV-AIDS, etc.). The government and the majority of partners support “input” funding. The quality of care is low due to the lack of human resources, who are poorly motivated, the lack of equipment and poor infrastructure and the frequent shortages of drugs. This is compounded by the persistent insecurity in Mali.

The PBF program

To cope with these problems, Mali has embarked on PBF reforms with two pilot projects in the Koulikoro region, which produced encouraging results. A new PBF phase is being prepared to start in 2020 with a budget of US $ 66.4 million supported by World Bank, the Dutch government and GFF in four regions with a total target population of 5.8 million.

The score of the feasibility scan applied by the Mali group in Cotonou is 84%. The main problems are: 1. The current budget is $ 2.8 per person per year, which is too low compared to the desired $ 4.00; 2. The State contribution to the FBR is zero; 3. Several parties sign FBR contracts, which creates transparency problems because it is no longer clear who is responsible for which activity.

Recommendations

• Advocate with the authorities for the mobilization of additional resources;
• Make the institutional framework functional (Steering Committee, CTN and ACV);
• Continue training actors through the organization of an FBR course in Bamako;
• Develop a roadmap with the actors for the resolution of the identified problems.

5.  Niger

This Sahelo Saharan country has in 2018 a population of around 22 million. There are several problems of the health system: 1. Poor quality of services; 2. Great dependence on unqualified community health workers; 3. Inequitable use of human, financial resources and inputs by region and; 4. Several free health care schemes without reliable financial reimbursement such as for children between 0 and 5 years, delivery care, family planning, etc.

Niger started a Performance Based Financing (PBF) pilot scheme in 2015 with funding from the World Bank. It was considered a success because it improved the availability of drugs, the hygiene in health facilities, it improved the technical quality, and there were rehabilitations of the infrastructure and the strengthening of the motorcycle park. After the evaluation of the pilot phase, the scaling up was supposed to take place in 2016. Unfortunately, this was not implemented.

Another problem is that the feasibility score of the PBF program, carried out by the two participants from Niger in Cotonou, is only 18%. It will therefore be necessary to improve the design of the PBF program.

Recommendations

• Advocate to increase the PBF program budget of the partners (World Bank and others) to at least US $ 4 per inhabitant per year. The 6 districts in the four regions of Dosso, Maradi, Tahoua, Zinder have a population of 3.2 million and this means that a total PBF budget of 24.5 billion CFA francs is required for four years. Tillabéry is already financed by the partner KFW for an amount of 18.2 billion FCFA, but this intervention is not “pure” PBF and mixed with input elements so that it is less efficient;
• Advocate for a derogation / revision of the legal texts so that health facilities can obtain essential drugs and other inputs from several wholesalers / pharmaceutical distributors operating in competition. This also requires to strengthen the national accreditation system to assure quality drugs. 
• Advocate for the separation of functions between the CDV agency and the payment agency (case of the CDV Agency of the Tillabéry Region) through the identification of a new independent payment agency;
• Conduct the restitution of the course action plan and advocate to energize the national PBF Unit, to write the RBF action plan, to organize a PBF course.
• Sensitize decision makers that the introduction of PBF is a more realistic towards UHC, Health Insurance and targeted free health care.
• Establish a Task Force made up of national resource persons to support the RBF program;
• Develop a new version of the national PBF manual that includes community RBF.

Central African Republic – Security and Justice sector

There have been several politico-military crises for the past years in CAR and, as a result, the country is listed in the Human Development Index at 188th out of 189. Widespread impunity is a major factor in the resurgence of armed conflicts. However, a peace agreement in February 2019 gives hope for improving security and justice in the country. In this context, it is crucial that the population has access to justice and this needs to be reinforced.

That said, security actors such as the national police have an aging workforce, they lack equipment and do not receive adequate (re)-training. The government is absent in certain parts of the country. In addition, the Ministry of Justice and the Magistrates lack independence from the Executive. There is also weak autonomy of management in police stations, the gendarmerie, the penitentiary services, and the courts.

The PBF program is a promising solution to support government structures at the local level such as police stations and prison services, courts and tribunals by offering them performance contracts. After the baseline study a pilot project will be developed to take place in Bangui. The objective is to solve the problems that are faced by police stations, local prisons, local courts and tribunals and to make them more professional, independent and autonomous.

Recommendations

• Write the terms of reference for the recruitment of a Technical Assistance team to carry out the baseline study for the PBF reforms in the security and justice sector. The experts must have the competence to develop quantitative and qualitative indicators, and have a good command of the Central African judicial system.
• Organize with the Technical Assistance team a restitution of the results in a workshop;
• Formulate the PBF security and justice program in CAR by the respective Ministries with support from CORDAID and the Technical Assistance team.

7.  Central African Republic: NGO Première Urgence Internationale

The Ministry of Health in CAR is facing major challenges to deliver health services. The government has chosen PBF as the approach to reform the health services and to define the roles of the different stakeholders. The government and donors such as the World Bank aim to set up the PBF as the path to Universal Health Coverage, but other donors and certain NGOs still support the input paradigm and general free health services. The latter is also cemented in a presidential decree.

The NGO Première Urgence Internationale has worked in CAR for several years and has also worked in several other African countries, but, so far, mainly supported the input logic. According to the evaluation of the Bekou project in 2018, the European Union proposed that for the new phase of the health project to integrate the lessons learned by the PBF in the areas supported by the World Bank. This under the leadership of the Ministry of Health

The PBF feasibility scan carried out by the participant of the NGO Première Urgence Internationale in Cotonou showed a score of 56%. This means that it is necessary to align the planned intervention in Bangui with the PBF best practices. This should lead to with the aim a feasibility score of 80% or more. The four-year budget of $ 12.5 per person per year available gives the opportunity to formulate an excellent PBF program in the city of Bangui.

This requires the following measures:

• Advocate with the hierarchy of the NGO Première Urgence Internationale and the Bekou project to accept the changes necessary to harmonize the intervention with the PBF best practices;
• Prepare a PowerPoint presentation, which summarizes the training in Cotonou;
• Prepare the meeting with the hierarchy of Première Urgence and Bekou;
• Advocate and obtain authorization to change the content of the intervention;
• Discuss the changes with the CTN-PBF coordinator of the CAR.
• Once the above proposals for a “purer” PBF approach are accepted by the hierarchy, the following activities and changes can be implemented
• Include private and faith-based health facilities in the PBF program instead of only contracting public structures;
• Include community PBF indicators in the proposal, such as the home visits following a protocol;
• Integrate the Complementary Activities Package (hospitals) into the PBF intervention and include the 5 Bangui hospitals in the PBF intervention, which in practice are urban district hospitals;
• Reduce the number of “input” budget lines of the Bekou program and transform them into PBF subsidy lines;
• Conduct a new costing, which include the above changes.

Central African Republic: Inspectorate General of the MOH

 The objectives of the Inspectorate General of the MOH for PBF are:

• Contribute to improving the quality, efficiency and equity of public, private and faith-based health structures.
• Inspect and control the activities and the compliance with standards of the different PBF stakeholders such as the PBF Unit, the regulatory structures at different levels, the CDV Agencies, the service providers, the local NGO, and the pharmaceutical wholesalers.
• Perform the counter-verification of the accreditation of the PBF health facilities.

The experience of implementing results-based funding since 2010 (by Cordaid and another project funded by the World Bank) has generated very useful lessons in the CAR. The Government views results-based financing, which is at the heart of World Bank support, as a crucial tool for establishing a culture of accountability.

The two General Inspectors took part in the 82nd PBF course organized in December 2019 in Cotonou. During this training, they identified the following weaknesses to be corrected to ensure the successful continuation of the program:

• Low contribution of the Government in financing the PBF program;
• Limited involvement of central level actors in the management of PBF;
• Persistence of the monopoly on the purchase of drugs and other inputs;
• Centralized definition of cost recovery tariffs instead of decentralized decision by health facilities;
• Limited autonomy in recruiting and dismissing government staff.

 Recommendations

• Advocate with the government to encourage competition in the market for essential drugs and other inputs;
• Stimulate the installation of wholesale distributors of drugs operating in competition within the country;
• Grant a larger autonomy to health facility managers for the decentralized management of human resources (recruitment and dismissal), the supply of drugs and the setting of cost-recovery tariffs;
• Implement the contracting process of actors and regulators at the central level (directorates, and other services of the ministry);
• Advocacy with the Minister of Finance and Budget for the effective disbursement of the PBF budget lines in the 2020 Finance Law.