The 94th FBP International Course was held from December 2 to 14, 2024, at the Atlantic Beach Hotel in Cotonou, bringing together 14 participants from five countries.
Here is the course report (rapport).
This 94th international course demonstrates that there is still a large demand for knowledge, skills and change of attitudes training in the context of the PBF reforms. This training can be done during international courses, but also during follow up national courses at central and peripheral levels. The successes recorded with the PBF reform in several countries, particularly also testified by the participants from Mali, have made it possible to improve the quality of services and to improve the access to the health services. In addition, the motivation and retention of staff, particularly in rural and unsafe areas, have improved.
This gives hope that PBF is the essential approach to achieve Universal Health Coverage.
1. Guinea
The Republic of Guinea has requested and obtained from the World Bank a financing agreement for the Strengthening of Health Services and Capacities PBF program in the health regions of Kindia and Kankan from 2018 to 2023.
The implementation of this pilot experience of FBR activities began in January 2021. Thus, after more than three years of implementation, progress related to the various activities, quarterly quantitative and qualitative verifications have been made at all levels in accordance with the provisions contained in the national PBF manual of the Ministry of Health.
However, the implementation of the new phase planned for the FBR in Guinea faces several conceptual and practical problems. This gives a feasibility score of only 36%. This needs to be resolved so that the program will become successful. It requires the design of the PBF program to integrate the standard PBF best practices and instruments. This includes more autonomy of the health facilities and making the output- and quality indicators SMART.
1.1 Problems identified
By participants implementing the Guinea PBF program.
- The national PBF Unit (CTN) lacks the staff and appropriate premises for its operations. The institutional set-up of the CTN is not clear, and the CTN does not have a performance contract.
- The cost of Contract Development and Verification Unit is very high, due to the non-existence of a performance contract. These Contract Development and Verification Units were also recruited from abroad instead of being under the cover of a Guinean organization with an already existing legal status.
- The Project Management Unit (UGP) of the World Bank and the national PBF Unit carry out the same activities, which creates conflicts on who is responsible for what.
- The health facilities must still request authorization from the regional directors to purchase their inputs such as essential drugs from other accredited suppliers than the central medical stores system instead of having free access.
- The PBF equity indicators are missing in the list of subsidized output indicators. The primary level- and hospital level package indicators are available, but there is an urgent need to update them to make them SMART. The list of indicators does not contain the Quality Improvement Bonus indicator for starting up funds and investments in infrastructure and equipment.
- Dysfunction between the implementing actors due to an unsuitable procedure manual
- The budget available for the PBF approach cannot cover the 4 regions (Kankan, Kindia, Labé and Faranah) for a period of five years.
- There is a need for advocacy to obtain an exemption that authorizes the health facilities to set their own user fee rates. This can be settled in the national PBF manual
- The district validation committee has a plethora of non-technical members (around 15), who will complicate the process.
1.2 Recommendations
- Allocate a PBF budget of at least USD 4 per inhabitant per year for the next 5 years, ⇒ review the project costing.
- Advocate for the inclusion of a budget line for the financing of PBF activities in the National Budget.
- Extend the implementation of results-based financing to other regions of the country.
- Create appropriate premises with furnishing for the national PBF Unit and assure the institutional for the adequate functioning of the national PBF Unit (CTN).
- Make the quantitative (output) and qualitative indicators SMART in accordance with the PBF guidelines such as those of countries such as Mali and the PBF course manual.
- Update the national PBF manual and management tools in accordance with the international PBF best practices and instruments.
- Grant exemptions to the health facilities in the PBF districts such as for : a. the free purchases of essential drugs and medical equipment from various approved distributors; b. autonomous personnel management and, c. free pricing of user fees
- Integrate the improved SMART PBF output indicators and equity indicators in the new version of the PBF manual into the DHIS2 for data collection, analysis and interpretation.
- Reduce the number of members at the district validation committee level to only technical staff (around 5–6 persons instead of 14+).
2 Mali
To address multiple health problems, Mali has embarked on the PBF reforms, which has undergone two pilot phases in the Koulikoro region.
The Mali PBF program has achieved very positive results during the last years, which is even more remarkable due to the political and security problems. One of the participants worked for the last 14 months in a district that applied for the first time all the PBF best practices and instruments, which he describes in the following paragraph.
We believe that more advocacy of this kind should be done so that available internal and external funds for health will be spent in the same manner and so that the PBF reforms can be scaled up nationally in Mali.
However, despite the good application of most PBF best practices and instruments, there are still some issues to be resolved.
2.1 Problems of the health system in Mali
- The central directorates of the Ministry of Health do not have a performance contract with the national PBF Unit (CTN) to ensure good regulation.
- The contracts are signed on the one hand between the Contract Development and Verification (CDV) Agencies, presidents of ASACOs and the Technical Directors of the community health centres, and on the other hand between the CDV agencies and the owners of private structures instead of being signed between the Contract and Verification Agencies and the Technical Directors.
- Private structures do not have the same chance as public structures to benefit from a main contract for the implementation of the FBR approach because of certain indicators.
- The absence of direct financial contribution from the Malian government to the PBF basket, which does not allow the program to be sustainable.
2.2 Recommendations
- Organize an exchange meeting with the Minister’s Office (Secretary General of the ministry of Health) to facilitate the establishment of performance contracts between the National Technical PBF Unit (CTN) and the central directorates (DGS, ANAES).
- Ensure a financial contribution from the State of at least 20% to the PBF budget to ensure its sustainability and sustainability.
- Advocate to the Minister of Health and Finance for the transformation of government delegated budget lines (crédits déléguées) for hospitals, other health facilities and communities towards a PBF government budget line. This will allow the change of input financing towards performance-based financing
- Promote the “bilateral” signature between the in-charge of the health facilities with the CDV agencies. This to promote the autonomous and more efficient management.
- Extend the coverage of the PBF reforms at the national level.
- Advocate to the health commission of the National Transitional Council (CNT) for the mobilization of resources in favour of the FBP.
- Carry out action research at the operational level on FBR themes
- Organize a technical working group on PBF good practices with stakeholders (professional orders, FENASCOM, Association of liberals).
3. Chad
PBF pilot experiments began in Chad between 2011 and 2013, from 2017 to 2019 and from 2022 to December 2025. After one year of implementation, the latest project was extended to four other provinces, bringing the PBF to twelve provinces in 12 out of 23 covering 55% of the country’s population. The evaluation showed encouraging results, particularly in strengthening the pillars of the health system, motivating health workers, reducing cases of drug shortages and improving the work environment.
The coordinators of two Contract Development and Verification Agencies we present during the Cotonou course. They have achieved remarkable results, but all this has been endangered by some changes in the management at national level, leading to the non-payment of the PBF subsidies and even unclearness about the future of the program. This is particularly damaging considering the political sensitivities in remote areas of the country.
3.1 Problems of the Contract Development and Verification Agencies
- Recurring delays in the payment of subsidies.
- Complete renewal of the national PBF Technical Unit team (CTN) without transfer of skills leading to a malfunction of the entire system.
- Delay in obtaining the authorization for expenditure (ANO) from the World Bank Project Implementation Unit for national PBF Unit activities, thus leading to non-compliance with the PBF payment cycle
- Provincial Pharmaceutical Agencies (PPA) are authorized to obtain supplies from a few private wholesalers. However, the health facilities can only obtain supplies from the provincial pharmaceutical agencies. Thus, the PPA is a monopolist for the health facilities leading to stock-outs and sometimes higher prices.
- Health facility managers are often transferred by the Ministry of Health so that they lack the “ownership” and commitment towards the PBF reforms.
- Health Centre Community Committees are not very functional, but they participate in the financial management of the health facilities because they are the co-signatories of the accounts. The result is that health facility money is often blocked in the account instead of being used according to the planning of the PBF business plan and the application of the PBF indices management tool.
- A lack of rigor in the scores of composite indicators during the quality reviews by the district authorities so that the scores are systematically too high.
The score calculated from the 23 indicators of the PBF feasibility analysis is 64%, which is well below the feasibility threshold for a performance-based financing program.
3.2 Recommendations
- Promote the free market in the supply of essential drugs so that health facilities have access to accredited pharmaceutical wholesalers.
- Encode private health facilities that do not have a code in the Health Management Information System
- Enforce the memorandum of understanding in the financing of the World Bank financed PBF program in Chad
- Enforce the PBF manual – Chad
- Mobilize resources for scaling up PBF towards national level
- Diversify partners in the financing of the World Bank financed PBF program
- Recruit other accountants to ensure the financial flow in the payment of subsidies by the Project Management Unit
- Limit the movement of local staff trained in PBF
- The World Bank to accelerate the process of obtaining the authorization for expenditure.
- Comply with the PBF Manual.
4. Burundi – Education
The overall situation of the schools of the Education Ministry in Burundi reflects the demographic context of the country with a very high birth rate which also influences the school-age population. This has repercussions on required budget, infrastructure, teachers, teaching and pedagogical materials, etc.
The development and implementation of the FBP education project in Burundi started in Bubanza, from 2014 to 2016. From 2020-2021 to today, the project is implemented in Muramvya province in the centre of the country with the financial support of the NGO Cordaid. Expertise France is starting an FBP project in Bujumbura City Hall from the 2024-2025 school year.
4.1 Analysis of problems/challenges
- Low funding of the education sector, especially in PBF
- Burundi’s basic school faces a low retention rate (10% in cycles 1 to 3 in 2023)
4.2 Main recommendations
- Increase the budget allocated for education at primary level by diversifying funding sources (development partners, investment, contribution by the well-organized community, etc.).
- Transform existing input budget lines form the Ministry of Education into government PBF budget lines.
- Set up regulatory bodies for scaling up PBF.
- Review the existing indicators so that they become SMART.
- Carry out a new costing taking into consideration that the budget per primary school child increases by a factor 3-4.
- Revise the PBF Manual with the involvement of all stakeholders and respecting the PBF approach.
- Update the mapping of schools to be put under PBF.
- Limit the movements of local staff trained in PBF.
- Promote the quality of teaching through quality review and based on a harmonized national quality composite indicator list.
5. Benin
Benin experimented with PBF between 2012 and 2018 and set up a PBF program covering the whole country financed by the World Bank, Global Fund and Belgium Cooperation. The difficulties related to the integration and appropriation of the different approach at the level of the Ministry of Health, the lack of harmonization between partners and the non-existence of a competitive environment for access to inputs led to the decision for the government to end it.
The current reforms undertaken in the health sector in Benin to achieve UHC do not capitalize on the experience of the PBF program between 2012 and 2018 and the lessons learned from it.
The Pahou health centre was integrated into the PBF between 2012 and 2018, and the following achievements were mentioned by the staff:
- More financial autonomy for the health centre managers, who could make spending decisions to buy drugs, and equipment and to carry out rehabilitations.
- Increase in the money directly available (from PBF subsidies and user fees) at health facility level to recruit staff and investments.
5.1. Specific observations in the Pahou CS after the closure of the PBF program
During the visit to the centre on December 5, 2024, the following observations were made:
- A dilapidated infrastructure. A fire hit the Centre in 2021. Three years after this fire, the staff did not obtain any funds to carry out the rehabilitation. However, with the PBF approach, the centre could have been rehabilitated with its own user fee revenues, with PBF subsidies, with the PBF Quality Improvement Bonus (QIB or BAQ in French) – or additional government direct cash funding.
- Lack of external revenues such as PBF subsidies or other subsidies from the state or partners.
- Lack of management autonomy of the centre manager to take initiatives and resolve problems such as recruiting qualified contract staff, rehabilitating the centre and purchasing equipment
- Lack of financial management autonomy by the health facility management. The authorizing officer of expenditure is not carried out by the health facility manager but by the Direct Medical Officer of Ouidah District, who also plays the role of regulator. Besides being ineffective, this also creates a conflict of interest between the provider and the regulator.
- The Pahou district health centre, like all centres in the country, depends on the central “input” distribution systems for inputs without any choice.
- Health facility managers are not authorized to spend cash.
In view of these findings, the staff in the discussions expressed their wish for the reintroduction of best PBF practices in health facilities. Hence the following recommendations.
5.2 Recommendations
Relaunch the PBF program in Benin, considering the following:
- Drawing inspiration from the PBF best practices to introduce more autonomous management of this health centre on an experimental basis. This would make it possible to deal with the above observed problems.
- Learn from the mistakes made during the first PBF phase between 2012 and 2018 in Benin and draw all possible lessons.
- Consider the innovations and improvements that have taken place in other countries during the last 10 years such as in Rwanda, Burundi, Mali, the DRC and Mauritania.
Thus, in the preparatory phase, we propose the following:
- Conduct two studies on the quality of care by master’s students at the ISRP comparing the period of implementation of the PBF approach and the current one in the Pahou health centre.
- Advocate to relaunch of PBF in Benin based on the PBF best practices known in other African countries with a more prominent coordinating role of the Ministry of Health and with a national approach based on the PBF best practices such as more autonomy of health facilities free access to distributors operating in competition for inputs such as essential drugs and the involvement of the private sector especially in (semi) urban areas.
- Develop a PBF project based on the results of the studies carried out => where, who, what, when, budget (financing to be sought where)?
- Advocate with the Ministries of Education for the introduction of PBF teaching in the training curricula of students in schools and universities, particularly in medical schools and at the Regional Institute of Public Health (IRSP);
- Introduce into the training curriculum of the IRSP and medical schools, the basic notions on performance-based financing.
- Train Master students in public health in PBF since most of them are managers and authorities, service providers in Benin and other countries in the sub-region.