The 95th FBP course was organized in Lomé, Togo, instead of Cotonou, Benin. Hereby the course report (rapport).
Beach near Lomé
The change of country was necessary to accommodate a delegation of 20 people from Niger, including representatives from the central, regional, and district levels. In addition, three participants from Mali attended from the district and health center levels. Benin was represented by the Director of Health of the “Atlantique” Department.
During the post-test, four people earned a distinction (90% or more) and eight earned a merit “mention” of between 80 and 89%.
Examples of PBF successes – also in insecure areas
The participants of the 95th PBF course in Lomé
Different groups of participants in the last 5-10 PBF courses have shown extraordinary results from PBF programs in several countries, including Mali, Mauritania, DRC, Burundi, and CAR. Well-structured PBF programs produce cost-effective and high-quality results. “Well-structured” means a PBF program has an above-80 % feasibility score across 23 criteria and uses PBF management instruments such as business plans, an indices management tool, and quality improvement bonuses. PBF also offers equity bonuses ranging from 10% to 80% on top of payment for output and quality indicators, benefiting vulnerable regions, districts, and health facilities.
Moreover, under PBF, the poorest 10-25% are exempt from paying for care through a targeted free health care mechanism. Health facilities are reimbursed for this targeted free service, and health facility staff, with their local community, identify the poorest. This targeted free health care approach is more realistic and avoids overspending, as in insurance systems, and it is better verified than generalized free health care, such as for children or delivery care.
The main reason for its success, even in insecure areas, is that more than 70% of the PBF budget is transferred directly to peripheral providers’ accounts, who decide autonomously what and where to buy their inputs. This is 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 offer an alternative to more traditional initiatives such as generalized free health care, compulsory health insurance systems, or government-imposed health care price ceilings.
The introduction of Quality Improvement Bonuses
Monument in central Lomé
A very important innovation in recent years has been the introduction of quality improvement bonuses (QIBs). This output indicator ranges from 500 USD (primary level) to 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 happens only after Contract Development and Verification Agencies verify QIB achievements (along with other output indicators). They verify investments in infrastructure, transport, equipment, or emergency expenses. A convincing business plan can also trigger the first QIB payment, helping health facilities start their first investments.
The QIBs accelerate the upgrading of health facilities or regulatory organizations. Each autonomous peripheral actor carries out rehabilitation or purchases inputs based on its needs. This is 4-10 times more cost-effective than the traditional centralized input approach.
The end of PBF in Cameroon and Benin
Coffee growing in Togo mountains near Ghana border
Policy choices in 2022 and 2018 ended 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, including impact evaluations and observational or photo studies in Cameroon, most papers agree that PBF produced important positive results in output, quality, and staff motivation [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, despite the academic evidence and the training of most key implementing agents, political willingness to sustain PBF’s successes remained problematic in Cameroon. In 2022, the Minister of Health declared that he “was not in favor of PBF,” without any other justification.
Since the end of PBF, patients in Cameroon have had to bear higher financial (often informal) costs, and care quality has deteriorated because district and regional authorities abandoned regular PBF quality reviews. In short, Cameroon has returned to the old, weakly regulated input health system at a very high cost to the population.
Cotonou statue of the Amazone lady warrior
In Benin, the government ended the PBF approach in 2017. PBF in Benin was not perfect, but it had promising results. The main reasons for the shutdown were the lack of harmonization between partners, the government’s refusal to pay performance bonuses to staff, and the assumption 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 to health facilities since 2022 and focus group discussions show that the results of this centralized approach are difficult to verify and have not been felt at the facility level. However, under PBF, this money would be injected directly into all health facilities, including peripheral ones, using an index-based management tool to calculate performance bonuses, which motivates staff and produces better results.
Thus, the Ministry of Health’s health policy in Benin has regressed toward inefficient input distribution and centralized planning. For example, the famous Paou health center, which has experienced many innovations over 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 and the QIB system described above, the health center team would have carried out the rehabilitation autonomously within a few weeks or months.
[1] We reviewed 14 papers on PBF in Cameroon in February 2025, and the World Bank Impact evaluation is the most important (Cameroon Performance-Based Financing Impact Evaluation Report 2017). The impact study results were positive, although the authors acknowledge that the study design may have contributed to problems of contamination bias between PBF health centers and control group health centers.
[2] Nkangu, M. 2023. An in-depth qualitative study of health care providers’ experiences of performance-based financing program as a nationwide adopted policy in Cameroon: A principal-agent perspective.
Niger
Niger, a Sahelian country in West Africa, faces significant public health challenges. It has some of the lowest health indicators in the world, which calls for urgent reforms in the health sector. In response, 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 moderately favorable results. The project was imperfect and did not apply most PBF best practices. However, given 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
Niger participants in the course compared the PBF program in Niger with the 23 feasibility criteria of best practices identified in the PBF course book.
They found a feasibility score of 40%, showing that serious problems remain with the institutional set-up and application of PBF best practices in Niger. Efforts should be made to increase this score to 80%.
Sunset over the Sahara desert
Among the 23 criteria, some assumptions need to be addressed. The most important challenge is that the PBF budget per capita per year is too small. The PBF budget, planned for more than 10 million people, is $0.59 per capita per year instead of $4.00. Other serious problems include the monopolized distribution of medicines and the non-authorization of medicine sales by primary-level health facilities.
Recruiting the ACV took a long time (about 3 years), delaying 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 reforms across the entire health system instead of under the Directorate of Studies and Programming.
- Narrow the PBF budget gap 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 health facilities in the two (2) regions to implement the PBF approach efficiently. These include :
- Grant autonomy to service providers, including the right to purchase drugs and other inputs directly from multiple accredited distributors, and allow health facilities to sell drugs to increase revenue.
- 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 when awarding contracts to CDV Agencies.
- Map and divide the health care catchment areas into units with an average of 6,000 to 12,000 beneficiary inhabitants.
- Revise the Niger PBF national manual. First, within a small committee, then with the participation of all stakeholders, to ensure PBF best practices are respected. The feasibility score should be 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 to quality-control 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 between the national PBF Unit (CTN), 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 to scale up PBF reforms nationwide. This is also because differences between regions with and without PBF have become significant in service availability, health workers, and quality of care. This creates serious equity problems between the regions.
1. Challenges of the PBF reforms in Mali
However, despite PBF’s positive results in Mali, challenges remain.
- The Malian government’s lack of direct financial contribution to the PBF basket risks compromising the program’s sustainability and making it appear as an initiative supported only by technical and financial partners.
- Not all central directorates of the Ministry of Health have performance contracts with the CTN, which also threatens the sustainability of PBF in Mali.
- Currently, the CDV Agencies sign tripartite contracts with the presidents of ASACOs and the heads 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 implementing 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 for subcontractors and support the development of their contracts.
- Organize training by the District Medical Office of Djenné for health facility managers and their health committees on the PBF manual.
Benin
Benin experimented with PBF between 2010 and 2017. This aimed to accelerate achievement of the Millennium Development Goals, and several partners (World Bank, Global Fund, Enabel, and Gavi) decided to harmonize resource management to support strengthening Benin’s health system, framing this commitment by signing the Compact in November 2010.
The government ended PBF in 2017 because of: a. difficulties integrating and appropriating 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 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) or the lessons learned from it.
From our point of view, difficult working conditions and the diminishing purchasing power of health sector workers lead to demotivation and a drop in the performance of health facilities. Given 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 people to analyze the context, highlight the positive and negative aspects, and conduct a comparative study of health facility performance during the PBF period and afterward.
- Start a research initiative in the health catchment area of Abomey Calavi SO-Ava, introducing performance bonuses in health facilities. This would be another element to strengthen the case for resuming PBF after the end of the current World Bank-financed centralized Performance for Results (PforR) approach.
- Make the case to senior officials in the Ministry of Health, the Presidency, and donors for reintroducing FBR in Benin at the end of PforR.
- Develop the PBF with private health facilities as well.
