The NEXT 96st PBF COURSE will be organized in COTONOU, June 2-14, 2015. Hereby the announcement (annonce) and the application form (fiche) 

The 95th FBP course was organized in Lomé, Togo, instead of Cotonou, Benin. Hereby the course report (rapport).

The change of country was necessary to facilitate the presence of a delegation of 20 people from Niger with representatives from the central, regional and district levels. In addition, there were three participants from Mali from the district- and health center levels. Benin was represented by the Director of Health of the “Atlantique” Department in Benin.

During the post-test, there were four people with a distinction (90% or more) and eight with a merit “mention” of between 80 and 89%.

Examples of PBF successes – also in insecure areas

Different groups of participants in the last 5-10 PBF courses have shown extraordinary results of the PBF programs in several countries such as Mali, Mauritania, DRC, Burundi and CAR. Well-structured PBF programs produce cost-effective and high-quality results. “Well-structured” is defined as the PBF program having an above 80% feasibility score following 23 criteria and applying the PBF management instruments such as the business plans, indices management tool and the quality improvement bonuses. PBF also offers equity bonuses ranging from 10% to 80% on top of the payment for the output and quality indicators that benefit vulnerable regions, districts and health facilities.

Moreover, in PBF, the poorest 10-25% are exempted from paying for their care through a targeted free health care mechanism. Health facilities are reimbursed for this targeted free service, and the identification of the poorest is carried out by health facility staff with their local community. This targeted free health care approach is more realistic and avoids over-expenditure such as in insurance systems, and it is better verified than generalized free health care such as for example for children, or delivery care.

The main reason for the success, also in insecure areas, is that more than 70% of the PBF budget is transferred directly to the accounts of peripheral providers who decide autonomously what and where to buy their inputs. This instead of a hands-on system where central level authorities decide how to use the money.

Yet the very encouraging results reported for example from Mali and Mauritania are under-reported, under-published and therefore under-funded beyond what is justified.

These PBF innovations constitute the alternative for all sorts of more traditional initiatives such as generalized free health care, compulsory health insurance systems or the imposition of health care price ceilings by government.

The introduction of Quality Improvement Bonuses

A very important innovation in recent years has been the introduction of quality improvement bonuses (QIBs). This is an output indicator whose value is between 500 USD (primary level) and 2000 USD (hospital level or for regulatory organizations). The QIB subsidies are paid directly into the accounts of autonomous health facilities or regulatory organizations. This, only after the QIB achievements (together with the other output indicators) are verified by Contract Development and Verification Agencies. They verify the investments realized in infrastructure, means of transport, equipment, or emergency expenses. A convincing business plan can also serve as the trigger for the first QIB payment as a method for health facilities to start their first investments.

The QIBs accelerate the upgrading of health facilities or regulatory organizations. The rehabilitation or purchase of inputs is carried out by each autonomous peripheral actor, according to their needs. This is more cost-effective by a factor 4-10compared to the traditional centralized input approach.

The end of PBF in Cameroon and Benin

Policy choices led in 2022 and 2018 to the end of promising PBF programs in Cameroon and Benin. These policy decisions have now led to the degradation of both (2) health systems.

In Cameroon, the Minister of Health terminated PBF in 2022. When consulting the literature with impact evaluations, observational- or photo studies in Cameroon, most papers agree that there were important positive results on output, quality, motivation of staff [1]. One study concluded that “despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal) [2]. Yet, surprisingly, despite the academic evidence and the training of most key implementing agents, the political willingness to maintain the PBF successes remained problematic in Cameroon. In 2022, the Minister of Health declared that he “was not in favour of PBF,” without any other justification.

Since the end of PBF, patients in Cameroon have had to bear higher financial (often informal) costs, and the quality of care has deteriorated due to the abandonment of regular PBF quality reviews by district and regional authorities. In short, Cameroon has returned to the old weakly regulated input health system at very high cost for the population.

In Benin, the government ended the PBF approach in 2017. PBF in Benin was not perfect, but had promising results. The main reasons for the shutdown were the lack of harmonization between partners and that the government would not agree to pay performance bonuses to staff and that it would assume that a fixed salary was enough for health workers to perform. After negotiation with the government, the World Bank replaced the PBF reforms with the “Pfor R- Program for Results” approach. This approach directly injects funds into the Ministry of Health budget based on national performance indicators.

However, several field visits since 2022, in health facilities and focus group discussions, show that the results of this centralized approach are difficult to verify and were not felt by the health facilities. However, with PBF this money would be injected directly into all health facilities, including peripheral health facilities with the indices management tool to calculate performance bonuses, which gives more motivation to staff and produces better results.

Thus, the health policy of the Ministry of Health of Benin has regressed towards inefficient distribution of inputs and centralized planning. For example, the famous Paou health centre, which has experienced many innovations, during 20 to 40 years, within the framework of the Bamako initiative and primary health care, suffered a fire in 2022. Yet, three (3) years later, it has not been rehabilitated due to inefficient procedures at the central level. Under the PBF approach with the QIB system described above, the rehabilitation would have been carried out autonomously by the health centre team in a few weeks or months.

[1] We consulted 14 papers on PBF in Cameroon in February 2025 of which the World Bank Impact evaluation is the most important (Cameroon Performance-Based Financing Impact Evaluation Report 2017). The impact study results were positive, despite that the authors acknowledge that the study design may have contributed to problems of contamination bias between PBF health centres and control group health centres.

[2] Nkangu, M 2023 An in-depth qualitative study of health care providers’ experiences of performance-based financing program as a nation-wide adopted policy in Cameroon: A principal-agent perspective.

Niger

Niger, a Sahelian country in West Africa, is marked by significant challenges in public health. It has some of the lowest health indicators in the world, which calls for urgent reforms in the health sector. Faced with this situation, Performance-Based Financing (PBF) reforms are emerging as a promising approach to improve the efficiency and quality of health services. A first PBF project was launched in the Boboye Health District in 2018 with moderate favorable results. It should be noted that the project was imperfect and did not apply the majority of PBF best practices. However, in view of these promising results, the Ministry of Public Health intends to implement this approach in the Zinder and Maradi regions with financial support from the World Bank through the LAFIA IYALI project.

1. Feasibility of the current PBF program in Niger

The Niger participants to the course compared the PBF program in Niger with the 23 feasibility criteria of best practices that are identified in the PBF course book.

They found a feasibility score of 40% which demonstrates that there are still serious problems with the institutional set-up and application of PBF best practices in Niger. Efforts should be made to increase this score to 80%.

Among the 23 criteria there are also some killing assumptions that need to be addressed. The most important challenge is that the PBF budget per capita per year is too small. The PBF budget, which is planned for more than 10 million people is $ 0.59 per capita per year instead of $ 4.00. Other quite serious problems are the monopolized distribution of medicines and the non-authorization of the sale of medicines by the health facilities at primary level.

The recruitment of the ACV took a long time (about 3 years) leading to a delay in the disbursement of the PBF component.

2. Recommendations of the participants from Niger

• Place the national PBF Unit (CTN) at a higher level directly under the Secretary General to monitor and support the reforms of the entire health system instead of under the Directorate of Studies and Programming.
• Narrow the gap in the PBF budget for the beneficiary population from USD 0.57 to USD 4.00 per capita per year. This means either reducing the number of beneficiary districts or significantly increasing the PBF budget.
• Grant special exemptions to the health facilities of the two (2) regions for the efficient implementation of the PBF approach. These include :
  • Grant autonomy to the services providers, including the right to purchase drugs and other inputs directly from multiple accredited distributors, and allow health facilities to sell drugs so that they can increase their revenues.
  • Apply the targeted PBF free health services for vulnerable patients instead of generalized free services for children, delivery care, etc.
  • Do not discriminate against the private sector to obtain contracts with the CDV Agencies.
  • Map and divide the health care catchment areas into units of an average of between 6,000 and 12,000 beneficiary inhabitants.
  • Revise the Niger PBF national manual. First within a small committee and then with the participation of all stakeholders to ensure that PBF best practices are respected. The feasibility score should become at least 80%.
  • Put the Regional Contract Development and Verification Agencies with their district branches into operation as quickly as possible.
  • Set up mini labs at regional and district levels for quality control of medicines from accredited distributors operating in competition.
  • Sign performance contracts with the Directorates and Programs of the Ministry of Public Health.
  • Integrate all levels of health facilities, public, private and religious into the PBF system.
  • Clarify the operational and contractual links of the national PBF Unit (CTN) with the National Institute of Health Insurance (INAM) and the regional CDV Agencies.
  • Train key stakeholders at the central level including ministry authorities.

Mali

The Mali PBF program has achieved very positive results in recent years, which is even more remarkable given the political and security challenges. Stronger advocacy is justified to ensure that internal and external health funds become available for the PBF approach.

In addition, it is desirable that the PBF reforms will be scaled up nationwide. This also because the differences between the regions with or without PBF have become very significant in terms of availability of services, health workers and the quality of care. This creates serious equity problems between the regions.

1.Challenges of the PBF reforms in Mali

However, despite the positive results of PBF in Mali, there are still challenges to address.

• The absence of direct financial contribution from the Malian government to the PBF basket risks compromising the sustainability of the program and making it appear as an initiative supported only by technical and financial partners.
• The central directorates of the Ministry of Health do not all have performance contracts with the CTN, which can also constitute a danger for the sustainability of PBF in Mali.
• Currently, the CDV Agencies sign tripartite contracts with the presidents of ASACOs and the head of Community Health Centers, instead of signing bilateral contracts only between the CDV Agencies and the heads of the service providers.
• Private structures do not have the same opportunity as public structures to benefit from a main contract for the implementation of the PBF approach.

2. Recommendations

• Advocate with the Ministries of Health and Finance to transform certain lines of the State budget such as the delegated credits to health facilities and subsidies granted to communes into PBF budget lines in the Finance Law.
• Establish performance contracts between the national PBF Unit (CTN) and the central directorates.
• Stimulate competition between public and private structures to obtain main contracts.
• Promote the bilateral signature between the Technical Directors of primary health facilities and the CDV Agencies for autonomous and more efficient management.
• Ensure supervision/coaching by the District Medical Officer of Djenné and Bougouni of the subcontractors and ensure the development of their contracts.
• Organize training by the District Medical Office of Djenné of health facility managers and their health committees on the PBF manual.

Benin

Benin experimented with PBF between 2010 and 2017. This was to accelerate the achievement of the Millennium Development Goals, and several partners (World Bank, Global Fund, Enabel and GAVI) decided to harmonize the management of their resources to support the Strengthening of Benin’s Health System and framed this desire by signing the Compact in November 2010.

The government ended PBF in 2017 as a result of :  a. Difficulties related to the integration and appropriation of the approach at the Ministry of Health level; b. The lack of harmonization between the technical and financial partners; c. The lack of a competitive environment to purchase to inputs and ; d. The government’s belief that a fixed salary would be sufficient to motivate health personnel. The reforms undertaken in the health sector since 2017 do not capitalize on the experience of the PBF (2012 – 2017) as well as the lessons learned from the latter.

From our point of view, the difficult working conditions, the diminishing purchasing power of health sector workers, in fact lead to demotivation and a drop in the performance of health facilities. Faced with this, the PBF approach of generating additional variable financial bonuses, seems to us to be the only alternative that can remotivate staff and consequently boost performance.

The problem is therefore to study the ways and means to put an improved FBR approach back on track in Benin with sufficient resources and the involvement of the private health sector.

1. Recommendations

• Form a team of 3 to 4 persons to analyze the context and highlight the positive and negative aspects and carry out a comparative study of the performance of health facilities during the PBF period and afterwards.
• Start a research initiative in the health catchment area of Abomey Calavi SO-Ava, with the introduction of performance bonuses in health facilities. This would be one more element to make a good case for the resumption of PBF after the end of the current World Bank financed centralized Performance for Results (PforR) approach.
• Make a case to senior officials of the Ministry of Health, the Presidency and donors for the reintroduction of FBR in Benin at the end of the PforR.
• Develop the PBF also with private health facilities.