The 33 participants of the course.

The first PBF course in Chad took place in the “Centre Etoile” in Ndjamena, with 33 participants coming from the central directorates of the MOH (12x), from the Inter-ministerial Coordination Unit for Universal Health Coverage (5x), INSEED (3x), Project Coordination Unit (UCP) Redisse (5x) and two national NGOs (2x). Representatives of the Ministry of Finance and Budget (5x) and the Ministry of Planning (1x) were also present.

31 participants took the post-test, and four participants obtained a certificate of distinction with a score of 80% or more for the final test of the course, which were Mr. ASSEMAL Alfred, Responsible for monitoring and evaluation of UCP REDISSE; Dr SODJE Hinberka, from the NGO Alerte Santé ; Mr. GOUH PINABEY Nathaniel, from INSEED; Dr NEHOULNE Gaston, from the MSPSN.

The PBF programme 2022-2025 in Chad and its preparations

The results of previous PBF programs showed improvements in some indicators such as for assisted deliveries, children fully immunised and the quality of care. The government of Chad and the World Bank agreed in 2021 on a new project called the “Health System Performance Strengthening Project” (PRPSS), which will cover all districts in eight provinces. The duration of the project is 4 years. The population covered is 6.7 million inhabitants out of 13.2 million inhabitants of the country, or about 51% of the total population. The amount of funding is $ 106.5 million over 4 years.

Preparatory activities are underway, namely the establishment of the PBF Unit (CTN-FBP in French) and the Contract Development and Verification Agencies (ACV in French). The effective start is scheduled for January 2022. For the preparation of the program, the government organises five international PBF courses. These courses are also used for the training of national facilitators, who will then train the different actors of health facilities, provincial and district regulatory authorities as well as other key actors.

Achievements of the PBF program in Chad

• The PBF program is relatively pure in terms of applying the PBF best practices.
• There is willingness adopt the PBF reforms within the government and among development partners.
• Nine working groups developed excellent action plans during the PBF course which, if implemented, will greatly improve the health system in Chad.

Problems identified by participants concerning the PBF pogram

• Health facilities have insufficient infrastructure and equipment
• A study of 17 tracer products showed that on average, a health facility has 7 of the 17 products => availability rate 44%. This is caused by the “input” financing approach with centralized purchasing of inputs for the health system. The consequence is an inefficient distribution of equipment and drugs with an unused surplus in some HFs, and a shortage in other HFs.
• Some policymakers may be reluctant to accept the change from central “input” financing towards direct results-based financing of the health facilities because they may lose certain benefits linked to input financing
• The members of the Health Committees in Chad play a very important role in the day-to-day management of the health facilities including the signing of contracts and bank checks. However, in PBF best practice, the day-to-day management should be done by the permanent members of the HFs (in-charge with his team) This to avoid late payments and the risk that Health Committee members only sign when they receive “something” in return.
• The performance contracts in Chad are signed by several actors instead of just two. This poses problems because with three or more signatories it is no longer clear who is responsible, which can create confusion.
• Poor management of human resources and the presence of unqualified staff. There is an unequitable distribution of health workers in rural and urban health facilities. Waek knowledge and skills of health staff
• There are not yet PBF budget lines in the Finance Law. This may be caused by a lack of clarity regarding the financial and legal procedures required to disburse the government budget through payments directly to peripheral providers and to the population.
• The functioning of the current HMIS is not optimal at all levels of the health pyramid.
• In the previous PBF pilot program, paper invoices for all HFs in the country were centralized at Ndjamena level.

The 33 participants of the PBF course

Recommendations

• Make wider use of the quality improvement bonuses to correct the problems related to poor infrastructure and the lack of equipment
• Allow the health facilities in the 8 PBF provinces to buy essential drugs, consumables and equipment from accredited distributors operating in competition
• Authorize the Central Pharmaceutical Agency to supply drugs to private health facilities.
• Offer performance contracts to all units and departments of the ministries of health and finance, which allows them to obtain competitive remuneration.
• Most participants (79%) said it would be better if the day-to-day management will be done by permanent HF managers, including the signing of bank checks, and managing drugs. However, they also proposed to get the opinions of the participants of the next course who are closer to the field.
• Performance contracts should be signed between two entities (= binomes). Thus, for Chad, it is proposed that the HF contracts be signed between the Head of the Health Center (RCS) and the CDV (ACV) coordinator.
• Advocate at Ministry of Civil Servants and the Ministry of Finance and Budget to decentralize human resources management, supporting according to the regulations in force and increase the PBF subsidies for the decentralized recruitment of contractual staff.
• On the job training and supportive supervision
• Study the possibility of transforming the government budget lines “crédits délégués” into “PBF” budget lines.
• Advocate for the operationalization of DHIS2
• Archive the paper PBF HF invoices at decentralized level. This recommendation means that HFs and the CDV Agency (ACV) each file copies of the PBF invoices. The CDV Agency also maintains the data in an EXCEL file and enters the data into DHIS2.

All participants successfully passed the post-test ! Congratulations

The last FBP course of 2019 took place in Cotonou from December 2 to 14, 2019 with 32 participants from six countries (Mali, Comoros, Gabon, Mali, Niger, DRC and CAR). Eight groups (three groups from CAR) developed excellent action plans, which, if they are implemented, will greatly advance PBF in the respective countries and sectors.

Here the detailed report of the course (rapport).

STATUS OF PBF IN THE COUNTRIES AND SECTORS WITH MAIN MESSAGES:

• In the CENTRAL AFRICAN REPUBLIC around 50% of the population is covered with PBF, and the government decided to roll out to 100% the reforms nationwide by the end of 2020 with funding from the government, the World Bank and the European Union. NGOs such as Premiere Urgence Internationale – which attended the Cotonou course – may also start playing an active role. In the DEMOCRATIC REPUBLIC OF CONGO, the PBF reforms are progressing well and 40% of the population is covered by PBF. The designs in CAR and DRC are relatively “pure” in terms of the application of the PBF best practices. However, the participants from these two countries in Cotonou also propose several improvements in the design.
• In the COMOROS, 50% of the country is covered with PBF and the country is proposing to scale up in 2021 towards a “purer” PBF design compared to the current one. The six participants in Cotonou in their action plan proposed several improvements in the design and will advocate for a larger ownership for PBF among key decision makers.
• In GABON, the planning for performance-based financing started in early 2017 with Gabonese funding, but implementation has not yet started. This may be due to a lack of clarity on the financial procedures and willingness by government to provide the funds. The Ministry of Finance in Gabon aims to launch a pilot PBF program and could also help the Ministry of Health to progress with PBF.
• MALI has experienced long delays in starting the scale up of PBF despite that two pilot projects have shown excellent results. Yet, the Mali government with support of the World Bank, the Dutch government and GFF now aim to start a large relatively “pure” PBF pilot in 2020 for 5.8 million people and a budget of $ 66 million for four years. A large team of 14 people from Mali was in Cotonou to improve the design of the program.
• NIGER also experienced long delays in starting the scaling up of PBF despite that the pilot project has shown excellent results. The reasons for the delays are: 1. A lack of ownership for PBF by the decision-makers. PBF remained in the “project mode”; 2. Delays in the effective integration of the National Technical PBF Unit in the Ministry of Health; 3. Errors in the design of the PBF program. The Niger participants in Cotonou aim to revive PBF with the start of a large pilot programme.
• In the Central African Republic, the MINISTRIES OF JUSTICE AND THE INTERIOR with support of Cordaid aim to launch a PBF program. Experience in other countries with PBF in these sectors such as in the DRC have shown good results.

Image de temple de pitons de Ouidah

A problem in many countries is that PBF budget lines are not effectively integrated in the government budget and Finance Law procedures.

There may be a lack of clarity regarding the financial and legal procedures required to disburse the government budget through performance payments directly towards peripheral providers and the population instead of through the classical complex input procedures

A further general problem is that in several countries some decision-makers are hesitant to transform the less-transparent input financing into results-based funding, which transmits money directly to providers and the population. The latter approach is more transparent and less likely to lead to corruption. The best way to remedy this is to offer performance contracts to the main actors and departments of the ministries of health and finance. This should enable them to obtain a competitive remuneration adequate to only defend the public interest instead of earning money through shady deals.

Continue reading →

The 80^th international PBF course organised by SINA health in Mombasa-Kenya in November 2019, welcomed 37 participants from Nigeria 19; Liberia 16; South Sudan 1; and CAR 1. Most were from the health sector. Hereby the detailed course report.

This course was evaluated by the participants as one of the best since 2007. The criteria methods and facilitation, participation and organisation scored very well with averages of respectively 95% 93%, and 94%. The final evaluation indicated that for 100% of the participants the content of the course related well to their professional activities and that the methodology of the course was excellent. Yet, 50% of the course participants also commented that the course was too short. Continue reading →

The 39 participants to the PBF course in Cotonou

The 80th FBP course took place in Cotonou from June 17 to 29, 2019 with 39 participants with 10 countries represented. Hereby the detailed course report.

MAIN MESSAGES

• We report that in Burundi, Gabon, Mauritania, Ivory Coast, Cameroun, the Democratic Republic of Congo and the Central African Republic performance-based financing is advancing well.
• Yet, delays of subsidy payments in Cameroon caused by factors not related to PBF has created serious problems.
• There are prolonged delays in the scale up of PBF in Guinea Conakry and Madagascar and efforts to restart PBF in Benin have not yet been successful.
• Yet, overall, when reviewing the results from these 10 countries, the balance is positive. Lessons learned are becoming available both from positive experiences but also from mistakes made.

The PBF course was successful in exchanging the above experiences and all the participants from in total 11 groups developed excellent action plans that are likely to advance PBF in the 10 countries represented. Continue reading →

The 77th performance-based financing (PBF) course took place from Monday, May 13 to Saturday May 25, 2019.  Hereby the course report. 

                    The 51 participants of the 77th PBF course

The course welcomed a mixed group of 51 participants from the Ministry of Health, the Ministry of Finance, the National Civil Status Registration Office, the Ministry of Economy, Planning & Regional Development, and the Governors’ office of the West Region. All participants conducted the final exam. The overall score of the final test was 70% and eight participants obtained distinctions for their final exam with scores of 87% or more.

The status of PBF in Cameroon

By the end of 2019, 100% of the Cameroun population will be covered by performance-based financing and will be 10^th low or middle income country to achieve this. 100% of the 2.7 million town of Douala is now under PBF with 80-90% of the contracts given to the private sector. Continue reading →