We have organized the first standard PBF course in 2023 in Cotonou, Benin. This was an open PBF course, the 91st since 2007 and the 16th in Benin.

It was organized between the 6th and the 18th of February, 2023. There were 18 participants from Tchad (15 x), Mali (2 x) and Benin (1 x).

Hereby the report of the course rapport du cours.

This course was well rated by the participants, with daily and final scores between 8 and 20 percent higher than previous French courses. This was probably because this group had only 18 participants, which facilitated the adult learning process whereby all participants could contribute to the discussions. The Benin Atlantic Beach Hotel was this time better prepared to host the participants compared to the December 2022 course.

The next 92nd open PBF course will take place from October 30th to November 10th, 2023 in Cotonou.

SUMMARY OF COURSE FINDINGS

Recommendations participants read on February 18 at the Closing Ceremony

Considering that:

• PBF is a systems reform approach, well-tested in the health sector, and which focuses on the quality of health services, efficient delivery of services and equitable distribution of resources to support the vulnerable ;
• There is an urgent need for all actors to converge towards the PBF approach and ;
• The resources of our countries are very limited and the need to have an efficient use.

We, participants of the 91^st course on PBF held in Cotonou, Benin from 06 to 18 February 2023, recommend the following :

To the participants

• Popularize and promote the PBF approach, as a systems reform approach, particularly in the health sector ;
• Put in your daily practices in the various positions of responsibility the PBF approach ;
• Make the necessary pleas to allow the good implementation of PBF.

To the facilitators

• Integrate other sectors such as education and administration into future PBF courses ;
• Continue to train actors at various levels and countries and set up a pool of PBF trainers in the different countries.

To policy makers

• Facilitate the implementation of the 11 PBF best practices ;
• Implement PBF in other sectors such as Education, Administration, Finance, etc. ;
• Ensure that the current health financing system is reformed.

Context and problem analysis in Chad

The Chadian population was estimated in 2022 at around 16 million inhabitants in a territory of 1,284,000 km². Most of the population lives in rural areas because the rate of urbanization is with 24.4% low compared to other African countries. The population lives far from health centres, which makes referral to hospitals difficult, especially during the rainy season.

The national economy in 2022 evolves in an environment marked by various macroeconomic shocks linked to the Covid-19 pandemic, insecurity, and politico-military unrest. This situation has disrupted the budgetary programming and allocations, which has been redirected towards taking charge of the security expenses.

The health system in Chad has several problems such as the low number of human resources in rural areas, the dilapidated infrastructure, the monopoly of the state central medical stores which creates frequent stock out. The financing of Chad’s health system is based on direct cost recovery from the population, delegated credits from the State and support from the technical and financial partners working in the health sector. This system encounters numerous difficulties and is not very efficient with insufficient resources, loss of resources, inequity of the delegated credits, slowness in the financial flows, poor coordination of partner interventions, etc.).

All these factors contribute to one of the highest maternal mortality rate in the world of 1140 per 100,000 live births (2017 according to the World Bank database).

Performance-based financing system is a systems reform approach with the focus on results defined as the quantity and quality of outputs and the inclusion of vulnerable (poor) people. This implies that the health facilities are like autonomous organizations that make a profit for the benefit of public health objectives and their personnel.

Currently, the PBF system is financed by the World Bank from external resources, but the program is spearheaded by the Ministry of Public Health. Government financial participation in this program requires the reorientation and reorganization of the functioning of regulatory structures and decision-makers.

Recommendations from the Cotonou course groups from Chad

The current financing system in Chad does not allow the Ministry of Finance to ensure transparency and traceability of the use of funds injected into the budget of the Ministry of Health. This is the consequence of their non-involvement in the implementation of the PBF system and it requires the close collaboration between the technical services of the Ministry of Finance and those of the Ministry of Health to promote the implementation of the PBF program.

For the year 2023, the Ministry of Finance and Budget plans to put in place the rigorous management of funding mechanisms as it requires concrete results through performance contracts, the obligation of accountability and the improvement of the productivity of the public administration and in particular in the health- and education sector.

Ultimately, it will be a question of having a new public service management model based on results indicators and the efficient management of public resources and an improvement in the quality of public expenditure.

Recommendations

• Identify PBF budget lines ;
• Identify current amounts by structure ;
• Put the budget allocations by beneficiary structure in the provinces ;
• Inform the beneficiaries of the credits ;
• Determine the overall funding allocated by the government to the PBF program ;
• Advocate with the authorities by showing them the effectiveness and efficiency of the PBF system.

Mali – Ministry of Health and Social Development (MSDS)

• Scale up the PBF program throughout the national territory ;
• Advocate with the Ministry of Health, the Ministry of Economy and Finance and the health commission of the National Council of the Transition (CNT) for the mobilization of resources for the implementation of PBF ;
• Continue the training of the different stakeholders ;
• Speed up the finalization of the national PBF sustainability strategy ;
• Promote the signing of binary contracts between CDV agencies and the health facilities or other actors ;
• Organize a study trip for a practical understanding of the implementation of PBF ;
• Integrate vaccination campaigns against COVID-19 into the package of activities of health facilities that implement PBF.

Benin

Despite the ambitions of the policies and the support of technical and financial partners, Benin’s health system remains very inefficient, the abandonment of PBF will have led to the resumption of old systems with the corollary of a regression of the achievements of PBF. However, there is still a political will to do well even if from our point of view and in view of our current knowledge of PBF, the best approach remains and remains PBF.