The last 92nd international PBF course took place at Benin Atlantic Beach Hotel in Cotonou, with 32 participants from three countries. Here the final report of the course (rapport final).
The 16 participants from Mali were the largest group, including nine from the contract, development, and verification agency (CDV) Koulikoro, three District Medical Officers, three providers and one from the University. Among the 10 participants from Guinea-Bissau, there were two from the World Bank Project Implementation Unit and eight from the Ministry of Health. Benin was represented by five persons from the accounting firm COFIMA, and one person from MSV (Médecins sans Vacances).
Thirty-two participants took the post-test, and the average score was 71%, which meant an average improvement of 25% compared to the pre-test (46%). Nine participants earned a Certificate of Distinction with a score of 90% or higher on the course post-test. In addition, we congratulate Ms. Armelle Carine GABA, who obtained 100% for the final test.
This course was very well evaluated by the participants with the daily and final scores higher than previous French-speaking courses. This is probably linked to the fact that the majoirty of the participants self-financed their stay. The Benin Atlantic Beach Hotel was, this time, also better prepared to receive the participants compared to previoous courses.
This course was also historic in the PBF community, because we welcomed the 3000th participant since the first course in 2007. This was Jessica Vanessa da CUNHA, the social expert from the Bank’s Project Coordination Unit World in Guinea-Bissau.Recommendations from participants and summary of group action plans
- Performance-based financing (PBF) is an (health) systems reform approach, particularly in health, and that it aims at quality, efficiency and equity.
- The urgent need for countries to converge towards the more cost-effective PBF approach and;
- The resources of our countries are very limited and the need to have efficient use of those resources.
We arrived at the following analysis, proposals, and recommendations:
1. Republic of Mali
Mali has an area of 1.2 million km² with 20 million inhabitants and an annual per capita income of only 770 USD. Health coverage and the quality of care are low, and care is often administered by unqualified staff.
Decades of implementation of several reforms have not significantly improved impact indicators such as crude mortality, maternal mortality and infant and child mortality.
Health system problems in Mali
Insufficient health personnel and an inadequacy in the geographical distribution of human resources. The contribution of the private sector to improving health outcomes remains limited due to the government’s preference to assist the public sector. The performance of the national public pharmaceutical supply system is suboptimal. National public health spending ($7 per capita) represents less than 1% of GDP. Prepayment systems are still fragmented and only cover around 13% of the population. Mali has on average only six qualified personnel per 10,000 inhabitants (the WHO standard is 23).
This situation is aggravated by the political-security crisis with persistent insecurity making it difficult to focus on health services in certain regions of the country (especially the north and center).
Performance-based financing (PFB) reform in Mali
To deal with these problems, Mali embarked on the PBF reforms, which underwent two pilot phases in the Koulikoro region. The budget planned for the component “Strengthening Health Service Delivery (RPSS) 2020-2024 through performance-based financing” is USD 66.4 million (IDA USD 34 million and USD 3 million from the GFF and USD 29.4 million from the Netherlands).
The following successes of the PBF reform were observed: i. improving the quality of services; ii an increase in key service delivery indicators; iii staff motivation was improved and; iv their retention in rural posts. A new phase of the PBF begins in June 2024 and the group from Mali is proposing to intensively advocate to the authorities and its partners to continue with the PBF as the preferred strategy.
In the point of view of the Malian participants, there is no plan B for the PBF approach.
This is to achieve Universal Health Coverage, or even the Sustainable Development Goals.
More specifically, the Malian group proposes to the Ministry of Health and Social Development and the CTN :
- Extend the implementation of the PBF across the entire nation.
- Advocate with the Minister of Health and Social Development, the Minister of Economy and Finance and with the Health Commission of the National Transition Council (CNT) for the contribution of the State towards financing PBF with the aim to ensure its sustainability.
- In particular; i. A financial contribution from the State of 20% to the total expenditure of the PBF program; ii. Advocate with the Minister of Economy and Finance for the transformation of certain government budget lines (such as the delegated credits, infrastructure) towards PBF subsidies for the health facilities and iii. Advocate with the health commission of the National Transition Council for the mobilization of resources for the implementation of a national PBF program.
- Promote competition between public and private health facilities and give more opportunities to the private sector to obtain (PBF) contracts.
- Make performance contracts with the central directorates of the Ministry of Health and Social Development.
- Reduce the number of output indicators from 51 to less than 40 in accordance with PBF best practices.
- Adapt the ratio of the verification officers per main health facility contract holder to international standards (1 medical verifier for 15; and 1 community verifier for 30 health facilities).
- Recruit infrastructure verification officers in the new PBF project (1 per 500,000 inhabitants covered by the PBF).
- Revise the national PBF manual so that the above recommendations can be implemented.
- Advocate to the departments of Higher Education and Research, and National Education to integrate the PBF into the training curricula of doctors and paramedics.
- Advocate with the Regional Health Directorates of Koulikoro and Ségou, that the CDV Agency in Koulikoro and its branch in Ségou to include the two health centers from the university campuses (Kabala and Ségou) under PBF contracts.
- Advocate with the national PBF Unit and the MESRS for the formalization of an operational framework for action research and dissemination of study results.
- Crete binominal contracts whereby only the Technical Director of the Health Facilities (DTC) sign contracts with the CDV Agency instead of also the President of the ASACO.
- Make the separation of functions effective at the community health centre (CSCom) level and confer the daily management autonomy to the medical in charge of the health facility.
2. Republic of Guinea-Bissau
In 2022, the country’s population was estimated at 2.1 million inhabitants, with an annual growth rate of 2.2%. In 2019, the life expectancy at birth was 59.4 years. In 2018, approximately 35.7% of the population lived in urban areas and 64.3% in rural areas.
Administratively, the country is divided into eight regions. The westernmost regions are the most populated. Religious diversity is significant, notably with animist, Muslim, and Catholic religions. In ethnic terms, although there are between 10 and 30 ethnic groups, over 85% of the population belongs to one of the five ethnic groups. The official language is Portuguese, but Creole is the most widespread language of oral communication.
- Unequal distribution of human resources due to several causes such as the poor working conditions in rural areas.
- Lack of the clear definition of tasks and obligations of health professionals and the treatment protocols for illnesses.
- Inadequate investments in health infrastructure.
- Lack of autonomy in the management of health facilities regarding the hiring and firing of human resources.
- Advocacy with the government representatives for the preparation and implementation of a PBF pilot project covering approximately 1 million people (= 50% of the population) with an emphasis of rural areas, but also with a smaller proportion of urban population.
- The per capita PBF budget should be at least $4 per person per year.
- Advocate with the government to contribute to the national PBF program at least 20% of the required PBF budget.
- Jointly analyze the budget proposal with the financial director of the Ministry of Health, with the aim of transforming some ministry of Health budget lines into PBF budget lines.
- Propose to the ministry a mission to exchange experiences with countries that have already implemented PBF, to identify best practices in PBF and learn from their successes and mistakes.
- During the initial implementation phase of the pilot project, create a Contract Development and Verification Agency (ACV in French). This agency should be contracted to work within an already existing health insurance agency in the country. This to avoid lengthy contracting procedures but also to avoid overlapping institutions.
- Appoint officially the already existing national PBF Unit (CTN in French).
- Organize a PBF course in Portuguese and train particularly the national PBF Unit members.
- Develop the Guinea Bissau PBF manual.
- Implement PBF best practices.
COFIMA, is an accounting firm, which conducts various activities including the audit of development projects. As such, several missions were carried out by COFIMA and counter-verification missions. Furthermore, COFIMA has carried out verification missions on behalf of several donors for projects/programs implemented under the Performance Based Contracting (PBC) format, which is similar to the PBF approach.
- Advocate for the rapid return of the PBF approach to Benin.
- Implement, in conjunction with health/education NGOs, PBF in its pure form in at least one department in Benin.
- Map the countries where PBF is implemented and financed by technical and financial partners or governments.
- Associate the COFIMA audit firm with CDV teams during verification missions.
3.2. Doctors without Holidays
Médecins Sans Vacances (MSV) is a Belgian NGO active in 5 African countries (Benin, Burkina-Faso, Burundi, DRC, Rwanda). One of the objectives of the MSV is to fully strengthen the capacities of partner hospitals, so that they can deliver better quality patient-centered medical care. MSV applies a strategic planning approach and each collaboration with a partner begins with an in-depth analysis of local needs and capacities. This analysis is then translated into a Capacity Building Path (TRC) of 3 to 5 years, which is renewable. In Benin, Médecins Sans Vacances collaborates with seven (07) partner hospitals.
The main problems are that the strategy has not changed much during the different phases of the TRC and that there is no correlation of resource allocation linked to the performance of the partner hospitals.
Make hospitals understand that it is no longer a question of obtaining fixed resources in terms of subsidies/support from MSV but that that resources will be given based on the performance of the health facilities.
There are several options:
- Establish a Quality Improvement Bonus (BAQ in French) mechanism during 3 Capacity Building Path (TRC in French). One cycle lasts 3 years. A first Capacity Building Path of three years, and then a second were completed and from the third TRC onwards, we will add the PBF Quality Improvement Bonus mechanism.
Correlate MSV support to the performance of the partner hospitals. The annual hospital support budget will therefore be used to allocate the subsidy each quarter according to the quantity and quality performance assessment.