{"id":4465,"date":"2020-01-08T20:36:41","date_gmt":"2020-01-08T19:36:41","guid":{"rendered":"http:\/\/www.sina-health.com\/?p=4465"},"modified":"2020-01-14T14:30:59","modified_gmt":"2020-01-14T13:30:59","slug":"recommendations-for-6-countries-from-the-82nd-pbf-course-in-cotonou","status":"publish","type":"post","link":"https:\/\/www.sina-health.com\/?p=4465","title":{"rendered":"Recommendations for 6 countries from the 82nd PBF course in Cotonou"},"content":{"rendered":"<p><\/p>\n<div id=\"attachment_4452\" style=\"width: 410px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Participants-2-1-e1578512333843.jpg\"><img aria-describedby=\"caption-attachment-4452\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4452 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Participants-2-1-e1578512333843.jpg\" alt=\"\" width=\"400\" height=\"250\" \/><\/a><p id=\"caption-attachment-4452\" class=\"wp-caption-text\"><span style=\"color: #000000;\">All participants successfully passed the post-test ! Congratulations<\/span><\/p><\/div>\n<p><span lang=\"EN-GB\" style=\"color: #000000;\">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.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>Here the detailed report of the course<\/strong><span style=\"color: #993300;\"><strong>\u00a0(<a style=\"color: #993300;\" href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/RapCoursPBF82CotonouV06012020.pdf\">rapport<\/a>).<\/strong><\/span><\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>STATUS OF PBF IN THE COUNTRIES AND SECTORS WITH MAIN MESSAGES:<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">In\u00a0the 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 \u2013 which attended the Cotonou course \u2013 may also start playing an active role. In the DEMOCRATIC REPUBLIC OF CONGO,\u00a0the PBF reforms are progressing well and 40% of the population is covered by PBF. The designs in CAR and DRC are relatively &#8220;pure&#8221; 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.<\/span><\/li>\n<li><span style=\"color: #000000;\">In the\u00a0<em>COMOROS<\/em>, 50% of the country is covered with PBF and the country is proposing to scale up in 2021 towards a \u201cpurer\u201d 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.<\/span><\/li>\n<li><span style=\"color: #000000;\">In\u00a0<em>GABON<\/em>, 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.<\/span><\/li>\n<li><span style=\"color: #000000;\"><em>MALI<\/em>\u00a0has 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 \u201cpure\u201d 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.<\/span><\/li>\n<li><span style=\"color: #000000;\"><em>NIGER<\/em><em>\u00a0also\u00a0<\/em>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 \u201cproject mode\u201d; 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.<\/span><\/li>\n<li><span style=\"color: #000000;\">In the Central African Republic, the\u00a0<em>MINISTRIES OF JUSTICE AND THE INTERIOR<\/em>\u00a0with 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.<\/span><\/li>\n<\/ul>\n<div id=\"attachment_4455\" style=\"width: 360px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Image-temple-des-pythons-e1578512371773.jpg\"><img aria-describedby=\"caption-attachment-4455\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4455 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Image-temple-des-pythons-e1578512371773.jpg\" alt=\"\" width=\"350\" height=\"215\" \/><\/a><p id=\"caption-attachment-4455\" class=\"wp-caption-text\">Image de temple de pitons de Ouidah<\/p><\/div>\n<p><span style=\"color: #000000;\">A problem in many countries is that PBF budget lines are not effectively integrated in the government budget and Finance Law procedures. <\/span><\/p>\n<p><span style=\"color: #000000;\">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<\/span><\/p>\n<p><span style=\"color: #000000;\">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.<\/span><\/p>\n<p><!--more--><\/p>\n<p><span style=\"color: #000000;\"><strong>WHO ATTENDED THE PBF COURSE IN COTONOU AND THEIR RESULTS<\/strong><\/span><\/p>\n<p><span style=\"color: #000000;\">The last PBF course of 2019 was held in Cotonou from December 2 to 14, 2019 with 32 participants from six countries: Mali (14x), Comoros (6x), RCA (4x), DRC (4x), Gabon (2x), and Niger (2x). There were also two other sectors present during the course: The Ministry of Finance of Gabon and the Ministries of Justice and Interior from the Central African Republic. This shows that PBF is not only a reform in the health sector.<\/span><\/p>\n<div id=\"attachment_4449\" style=\"width: 360px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Sculpture-Vodoo-e1578512296808.jpg\"><img aria-describedby=\"caption-attachment-4449\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4449 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Sculpture-Vodoo-e1578512296808.jpg\" alt=\"\" width=\"350\" height=\"440\" \/><\/a><p id=\"caption-attachment-4449\" class=\"wp-caption-text\">Sculpture dans la ville de Ouidah<\/p><\/div>\n<p><span style=\"color: #000000;\">Thirty-two participants did the posttest and the average score was 72% with an average progression compared to the pre-test of 28%. Seven participants obtained a certificate of distinction with a score of 87% or more for the final test. We congratulate the course group that none of the participants obtained a certificate of participation with a score of 50% or less.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>For certificates of distinction, these are:<\/strong><\/span><\/p>\n<p><span style=\"color: #000000;\"><em>With 87% (4 mistakes out of 30)<\/em><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Dr. Johny IKWA, Coordinator of the EUP (ACV) of the Province of Tshuapa in the DRC<\/span><\/li>\n<li><span style=\"color: #000000;\">Dr. Abdallah AHMED, COMPASS Coordinator &#8211; World Bank funded project in Comoros<\/span><\/li>\n<li><span style=\"color: #000000;\">Dr. Mohamed DIAMALDINE, Regional Health Director of Moh\u00e9li in the Comoros<\/span><\/li>\n<li><span style=\"color: #000000;\">Mrs Dalla MAGASSOUBA from the Project Management Unit of the common basket funding in Mali<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\"><em>With 90% (3 mistakes out of 30)<\/em><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Dr. Fran\u00e7ois KANDU, Chief Doctor of the Budjala Health Zone in the DRC<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\"><em>With 93% (2 mistakes out of 30)<\/em><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Dr. Jean Marie MOKOLA, Coordinator of the EUP (CDV Agency) of the Province of Sud Ubangi in the DRC<\/span><\/li>\n<li><span style=\"color: #000000;\">Dr. Naye CAMARA, CANAM (Insurance Company) in Mali.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\"><strong>EVALUATION OF THE COTONOU COURSE BY THE PARTICIPANTS<\/strong><\/span><\/p>\n<div id=\"attachment_4458\" style=\"width: 360px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Autorit\u00e9s-de-village-82-e1578512425310.jpg\"><img aria-describedby=\"caption-attachment-4458\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4458 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Autorit\u00e9s-de-village-82-e1578512425310.jpg\" alt=\"\" width=\"350\" height=\"262\" \/><\/a><p id=\"caption-attachment-4458\" class=\"wp-caption-text\">The authorities of the village 82 in Cotonou.<\/p><\/div>\n<p><span style=\"color: #000000;\">The daily course evaluations had an average score of 81%, which is 2 points higher than the average of the 46 previous French-language courses. On the last day of the course the participants evaluated the course, which shows a satisfaction score of 91% for the preparation and the general impressions of the course. The organization was assessed as good except for the quality of the hotel. The hotel had a low score of 21% and food also scored low with 25%.<\/span><\/p>\n<p><span style=\"color: #000000;\">The open mindedness of the facilitators was evaluated at 93%. The majority of the modules were evaluated as satisfactory except for the module\u2019s economics (61%), the indices management tool (48%) and costing (44%). These last two modules did not have enough time.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>Recommendations concerning the course methodology:<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Review how to improve the modules on economics and health economics, indices management tool and costing so that they can be better understood by the participants;<\/span><\/li>\n<li><span style=\"color: #000000;\">Review how to further reduce the number of modules and materials to be dispensed in such a way that the other elements of the course will have more time;<\/span><\/li>\n<li><span style=\"color: #000000;\">The Hotel Atlantic Beach Benin was evaluated poorly. The proximity to the beach and the distance from the city centre of 5-7 kilometres makes its location very optimal so that participants can focus on the course instead of being distracted in the city centre. The Hotel is not very busy, some staff is not professional, and there are often problems with water and the internet. Food is sometimes insufficient. Yet, changing to a better hotel will also require the course fee to increase.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\"><strong>THE SIX PBF COURSES OF 2019 IN MOMBASA, DOUALA AND COTONOU<\/strong><\/span><\/p>\n<p><span style=\"color: #000000;\">This report is the last of 6 courses that were organized in 2019 by SINA Health, the Regional Fund for Health Promotion in Littoral, and BEST-SD in respectively Mombasa, Douala and in Cotonou. In total we welcomed 248 participants from 17 countries in three French-spoken and three English-spoken courses. The main contributors to the courses came from Cameroun (116x), Nigeria (33x), Liberia (15x), Mali (14x), Central African Republic (14x), Burundi (9x) and Ethiopia (7x). From the other 8 countries there were between 1 and 4 participants. There were 65 female participants (26,2%), which is a too small proportion.<\/span><\/p>\n<p><span style=\"color: #000000;\">The average score for the post-test of the courses was 69% and the average progress compared to the pre-test was 23%. 21 participants obtained a certificate of participation (8,5%), while 32 obtained a distinction (12,9%).<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>SUMMARY AND RECOMMENDATIONS OF EACH GROUP IN COTONOU <\/strong><\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>1.\u00a0<\/strong><\/span><strong style=\"color: #000000; font-size: 1rem;\">DRC<\/strong><\/p>\n<div id=\"attachment_4450\" style=\"width: 360px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Presentation-du-poster-e1578512306279.jpg\"><img aria-describedby=\"caption-attachment-4450\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4450 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Presentation-du-poster-e1578512306279.jpg\" alt=\"\" width=\"350\" height=\"428\" \/><\/a><p id=\"caption-attachment-4450\" class=\"wp-caption-text\">Presentation of the DRC action plan.<\/p><\/div>\n<p><span style=\"color: #000000;\">PBF in the DRC covers 30 million inhabitants and has been developed over the past 15 years. Overall, it has become one of the \u201cpurest\u201d PBF interventions in terms of following its best practices and theories.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>The problems of the PBF program are:<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Contracts are signed between three or four parties instead of between two. The CDV Agencies do not only sign health facility contracts with their in-charges, but at the same time with the district authorities and the president of the health committees;<\/span><\/li>\n<li><span style=\"color: #000000;\">Absence of subcontracts between the main health centre contract holder and health posts and private structures in the catchment area. This means that these non-contracted health facilities remain outside the control of the regulatory authorities;<\/span><\/li>\n<li><span style=\"color: #000000;\">The (private) health facilities, which do not have contracts with the CDV Agencies or main contract holders are likely to provide poor quality care and to use poor quality cheaper or even expired medicines to compensate for the unfair competition with those health facilities with PBF contracts;<\/span><\/li>\n<li><span style=\"color: #000000;\">Application of flat fee payments during visits to health facilities instead of variable fees based on drugs and services consumed. This leads to an inadequate cost recovery for essential drugs, consumables, etc, the use of poor-quality medicines, and demotivation of health workers;<\/span><\/li>\n<li><span style=\"color: #000000;\">Several reference health centres, which serve the population with a hospital package, are not recognized by the Ministry;<\/span><\/li>\n<li><span style=\"color: #000000;\">Absence of contracts between the Ministry of Health and the Provincial Health Inspectorate;<\/span><\/li>\n<li><span style=\"color: #000000;\">Absence of contracts between the health centres and their health committees;<\/span><\/li>\n<li><span style=\"color: #000000;\">The current PBF budget is around $ 3.00, which is less than the recommended $ 4.00 per person per year;<\/span><\/li>\n<li><span style=\"color: #000000;\">Government funding for PBF is too low, only around 10% compared to 90% for external financing;<\/span><\/li>\n<li><span style=\"color: #000000;\">Existence of an essential drugs supply monopoly by the Provincial Distribution Centres and the supply by other partners of drugs in the form of inputs;<\/span><\/li>\n<li><span style=\"color: #000000;\">The quality improvement bonuses are only granted once at the start of the project instead of it being regular investments to improve infrastructure, equipment and, human resources;<\/span><\/li>\n<li><span style=\"color: #000000;\">The health facilities are not authorized to recruit or dismiss their staff.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\"><strong>Recommendations<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Advocacy for the mobilization and allocation of resources in the health sector by setting specific taxes earmarked for PBF;<\/span><\/li>\n<li><span style=\"color: #000000;\">Advocacy for the granting of quality improvement bonuses to the health facilities;<\/span><\/li>\n<li><span style=\"color: #000000;\">To accredit wholesale distributors of drugs in each province;<\/span><\/li>\n<li><span style=\"color: #000000;\">Guarantee the availability and effectiveness of pharmacists at the provincial level to conduct the regulatory accreditation system for pharmacies;<\/span><\/li>\n<li><span style=\"color: #000000;\">Respect the principle of the signing of contracts with only two signatories;<\/span><\/li>\n<li><span style=\"color: #000000;\">Sign the contract between the CDV Agencies and reference hospitals;<\/span><\/li>\n<li><span style=\"color: #000000;\">Proceed to the signing of sub-contracts between health centres and viable private structures and health posts.<\/span><\/li>\n<\/ul>\n<p><strong style=\"color: #000000; font-size: 1rem;\">2. \u00a0Union of Comoros<\/strong><\/p>\n<p><span style=\"color: #000000;\">The Union of the Comoros has an estimated population of 742,000. The reproductive health indicators have seen positive developments in recent years. The maternal mortality rate went from 517 cases in 1996 to 172 deaths per 100,000 live births in 2012. However, the health system in Comoros has still several problems such as poor-quality health services, inequitable access, low motivation of staff and the centralized purchasing of resources. In addition, the health budget is highly dependent on external donors. Many already poor households are experiencing worsening poverty due to direct payments for their health services.<\/span><\/p>\n<p><span style=\"color: #000000;\">A PBF project was set up in 2011 with the support of the French Development Agency (AFD) and which has shown promising results. With the support of the World Bank, the country plans to extend this experience to other structures not covered until the end of 2020 with the AFD approach, but from 2021, the country will test the &#8220;pure&#8221; PBF approach.<\/span><\/p>\n<p><span style=\"color: #000000;\">The team from the Comoros in Cotonou noted that to benefit more from the PBF system, more PBF best practices must be respected. The feasibility score that analyzes the &#8220;purity of the PBF system&#8221; was only 28%. The main problems are the absence of the government budget in the program, the insufficient appropriation of the program by the Ministry and the lack of autonomy of the structures. The PBF project has not yet integrated the technical instruments and remuneration for the quality of care.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>Recommendations<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Restitution of the PBF training at national and island level with the authorities, other sectors, and partners;<\/span><\/li>\n<li><span style=\"color: #000000;\">Introduction of an information- and advocacy note in the Council of Ministers;<\/span><\/li>\n<li><span style=\"color: #000000;\">Development of a PBF communication plan for all stakeholders including partners;<\/span><\/li>\n<li><span style=\"color: #000000;\">Organization of advocacy and training meetings on PBF at all levels<\/span><\/li>\n<li><span style=\"color: #000000;\">Revision of the PBF manual;<\/span><\/li>\n<li><span style=\"color: #000000;\">Advocacy for the inclusion of a PBF budget line in the Finance Law of the government budget;<\/span><\/li>\n<li><span style=\"color: #000000;\">Advocacy for a derogation of the law, which ensures the autonomy of management of pilot PBF health facilities.<\/span><\/li>\n<\/ul>\n<p><strong style=\"color: #000000; font-size: 1rem;\">3. \u00a0Gabon<\/strong><\/p>\n<div id=\"attachment_4456\" style=\"width: 310px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Eglise-Catholique-de-Ouidah-e1578512396241.jpg\"><img aria-describedby=\"caption-attachment-4456\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4456 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Eglise-Catholique-de-Ouidah-e1578512396241.jpg\" alt=\"\" width=\"300\" height=\"459\" \/><\/a><p id=\"caption-attachment-4456\" class=\"wp-caption-text\">The church in Ouidah, opposite the vodou temple<\/p><\/div>\n<p><span style=\"color: #000000;\">The need to strengthen governance and the search for an efficient and effective public administration have led Gabon to undertake reforms based on results-based budgeting. Since 2015, the Gabon budget has gone from the input mode to the budget programming mode.<\/span><\/p>\n<p><span style=\"color: #000000;\">However, the reality is that the state budget is still executed in the input mode and not on paying for performance for already achieved results. In addition, we note the absence of a process, the financial procedures and the legal framework, which makes it possible to pay for performance.<\/span><\/p>\n<p><span style=\"color: #000000;\">The PBF reform approach is a good solution to pay directly for performance. It allows a better allocation of state resources to the different sectoral administrations and saves money because PBF does not require an increase in the existing input budgets. The idea is first to use the already available budget more efficiently. In addition, it helps to better motivate agents based on their results.<\/span><\/p>\n<p><span style=\"color: #000000;\">Finally, greater accountability of operational units and decentralization of resource management will generate a multiplier effect capable of boosting the local economy.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>Recommendations<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Understand why the PBF payments have not yet started within the Ministry of Health;<\/span><\/li>\n<li><span style=\"color: #000000;\">Apply the PBF reforms within the Ministry of Budget and Finance;<\/span><\/li>\n<li><span style=\"color: #000000;\">Establish the PBF implementing agencies such as the Steering Committee, the national PBF Unit, the regulators at all levels, the Contract Development and Verification Agency;<\/span><\/li>\n<li><span style=\"color: #000000;\">Invite PBF experts to raise awareness of advantages if the PBF reform, conduct training workshop for PBF actors, establish a work schedule;<\/span><\/li>\n<li><span style=\"color: #000000;\">Creation of PBF budget lines in the government budget, with the elimination of non-performing &#8220;input&#8221; budget lines and the creation of PBF budget lines;<\/span><\/li>\n<li><span style=\"color: #000000;\">Creation of a special account from the budget support with the aim to benefit the various &#8220;autonomous&#8221; entities of the Ministry of Finance.<\/span><\/li>\n<\/ul>\n<p><strong style=\"color: #000000; font-size: 1rem;\">4. \u00a0Mali<\/strong><\/p>\n<div id=\"attachment_4457\" style=\"width: 360px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Bebe-PBF-du-cours-e1578512408325.jpg\"><img aria-describedby=\"caption-attachment-4457\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4457 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Bebe-PBF-du-cours-e1578512408325.jpg\" alt=\"\" width=\"350\" height=\"467\" \/><\/a><p id=\"caption-attachment-4457\" class=\"wp-caption-text\">Baby PBF from Mali in Cotonou<\/p><\/div>\n<p><span style=\"color: #000000;\">Mali has an estimated population of 20.3 million inhabitants. With an annual per capita income of around USD 770 in 2017, Mali belongs to the group of the 25 poorest countries in the world. Employees and civil servants in the formal sector are covered by a compulsory health insurance scheme administered by a public semi-autonomous insurance agency. The government supports free health care plans (subsidized) by subsidizing specific services (for example, caesarean section, treatment of malaria, HIV-AIDS, etc.). The government and the majority of partners support \u201cinput\u201d funding. The quality of care is low due to the lack of human resources, who are poorly motivated, the lack of equipment and poor infrastructure and the frequent shortages of drugs. This is compounded by the persistent insecurity in Mali.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>The PBF program<\/strong><\/span><\/p>\n<p><span style=\"color: #000000;\">To cope with these problems, Mali has embarked on PBF reforms with two pilot projects in the Koulikoro region, which produced encouraging results. A new PBF phase is being prepared to start in 2020 with a budget of US $ 66.4 million supported by World Bank, the Dutch government and GFF in four regions with a total target population of 5.8 million.<\/span><\/p>\n<p><span style=\"color: #000000;\">The score of the feasibility scan applied by the Mali group in Cotonou is 84%. The main problems are: 1. The current budget is $ 2.8 per person per year, which is too low compared to the desired $ 4.00; 2. The State contribution to the FBR is zero; 3. Several parties sign FBR contracts, which creates transparency problems because it is no longer clear who is responsible for which activity.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>Recommendations<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Advocate with the authorities for the mobilization of additional resources;<\/span><\/li>\n<li><span style=\"color: #000000;\">Make the institutional framework functional (Steering Committee, CTN and ACV);<\/span><\/li>\n<li><span style=\"color: #000000;\">Continue training actors through the organization of an FBR course in Bamako;<\/span><\/li>\n<li><span style=\"color: #000000;\">Develop a roadmap with the actors for the resolution of the identified problems.<\/span><\/li>\n<\/ul>\n<p><strong style=\"color: #000000; font-size: 1rem;\">5. \u00a0Niger<\/strong><\/p>\n<p><span style=\"color: #000000;\">This Sahelo Saharan country has in 2018 a population of around 22 million. There are several problems of the health system: 1. Poor quality of services; 2. Great dependence on unqualified community health workers; 3. Inequitable use of human, financial resources and inputs by region and; 4. Several free health care schemes without reliable financial reimbursement such as for children between 0 and 5 years, delivery care, family planning, etc.<\/span><\/p>\n<p><span style=\"color: #000000;\">Niger started a Performance Based Financing (PBF) pilot scheme in 2015 with funding from the World Bank. It was considered a success because it improved the availability of drugs, the hygiene in health facilities, it improved the technical quality, and there were rehabilitations of the infrastructure and the strengthening of the motorcycle park. After the evaluation of the pilot phase, the scaling up was supposed to take place in 2016. Unfortunately, this was not implemented.<\/span><\/p>\n<p><span style=\"color: #000000;\">Another problem is that the feasibility score of the PBF program, carried out by the two participants from Niger in Cotonou, is only 18%. It will therefore be necessary to improve the design of the PBF program.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>Recommendations<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Advocate to increase the PBF program budget of the partners (World Bank and others) to at least US $ 4 per inhabitant per year. The 6 districts in the four regions of Dosso, Maradi, Tahoua, Zinder have a population of 3.2 million and this means that a total PBF budget of 24.5 billion CFA francs is required for four years. Tillab\u00e9ry is already financed by the partner KFW for an amount of 18.2 billion FCFA, but this intervention is not &#8220;pure&#8221; PBF and mixed with input elements so that it is less efficient;<\/span><\/li>\n<li><span style=\"color: #000000;\">Advocate for a derogation \/ revision of the legal texts so that health facilities can obtain essential drugs and other inputs from several wholesalers \/ pharmaceutical distributors operating in competition. This also requires to strengthen the national accreditation system to assure quality drugs.\u00a0<\/span><\/li>\n<li><span style=\"color: #000000;\">Advocate for the separation of functions between the CDV agency and the payment agency (case of the CDV Agency of the Tillab\u00e9ry Region) through the identification of a new independent payment agency;<\/span><\/li>\n<li><span style=\"color: #000000;\">Conduct the restitution of the course action plan and advocate to energize the national PBF Unit, to write the RBF action plan, to organize a PBF course.<\/span><\/li>\n<li><span style=\"color: #000000;\">Sensitize decision makers that the introduction of PBF is a more realistic towards UHC, Health Insurance and targeted free health care.<\/span><\/li>\n<li><span style=\"color: #000000;\">Establish a Task Force made up of national resource persons to support the RBF program;<\/span><\/li>\n<li><span style=\"color: #000000;\">Develop a new version of the national PBF manual that includes community RBF.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\"><strong>Central African Republic &#8211; Security and Justice sector<\/strong><\/span><\/p>\n<div id=\"attachment_4448\" style=\"width: 360px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Vodou-e1578512280409.jpg\"><img aria-describedby=\"caption-attachment-4448\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4448 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Vodou-e1578512280409.jpg\" alt=\"\" width=\"350\" height=\"465\" \/><\/a><p id=\"caption-attachment-4448\" class=\"wp-caption-text\">Poster in Ouidah<\/p><\/div>\n<p><span style=\"color: #000000;\">There have been several politico-military crises for the past years in CAR and, as a result, the country is listed in the Human Development Index at 188th out of 189. Widespread impunity is a major factor in the resurgence of armed conflicts. However, a peace agreement in February 2019 gives hope for improving security and justice in the country. In this context, it is crucial that the population has access to justice and this needs to be reinforced.<\/span><\/p>\n<p><span style=\"color: #000000;\">That said, security actors such as the national police have an aging workforce, they lack equipment and do not receive adequate (re)-training. The government is absent in certain parts of the country. In addition, the Ministry of Justice and the Magistrates lack independence from the Executive. There is also weak autonomy of management in police stations, the gendarmerie, the penitentiary services, and the courts.<\/span><\/p>\n<p><span style=\"color: #000000;\">The PBF program is a promising solution to support government structures at the local level such as police stations and prison services, courts and tribunals by offering them performance contracts. After the baseline study a pilot project will be developed to take place in Bangui. The objective is to solve the problems that are faced by police stations, local prisons, local courts and tribunals and to make them more professional, independent and autonomous.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>Recommendations<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Write the terms of reference for the recruitment of a Technical Assistance team to carry out the baseline study for the PBF reforms in the security and justice sector. The experts must have the competence to develop quantitative and qualitative indicators, and have a good command of the Central African judicial system.<\/span><\/li>\n<li><span style=\"color: #000000;\">Organize with the Technical Assistance team a restitution of the results in a workshop;<\/span><\/li>\n<li><span style=\"color: #000000;\">Formulate the PBF security and justice program in CAR by the respective Ministries with support from CORDAID and the Technical Assistance team.<\/span><\/li>\n<\/ul>\n<p><strong style=\"color: #000000; font-size: 1rem;\">7. \u00a0Central African Republic: NGO Premi\u00e8re Urgence Internationale<\/strong><\/p>\n<div id=\"attachment_4451\" style=\"width: 360px\" class=\"wp-caption alignright\"><a href=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Participants-concentr\u00e9s-e1578512321378.jpg\"><img aria-describedby=\"caption-attachment-4451\" decoding=\"async\" loading=\"lazy\" class=\"wp-image-4451 size-full\" src=\"http:\/\/www.sina-health.com\/wp-content\/uploads\/Participants-concentr\u00e9s-e1578512321378.jpg\" alt=\"\" width=\"350\" height=\"294\" \/><\/a><p id=\"caption-attachment-4451\" class=\"wp-caption-text\"><span style=\"color: #000000;\"> Participants concentrate on role-play.<\/span><\/p><\/div>\n<p><span style=\"color: #000000;\">The Ministry of Health in CAR is facing major challenges to deliver health services. The government has chosen PBF as the approach to reform the health services and to define the roles of the different stakeholders. The government and donors such as the World Bank aim to set up the PBF as the path to Universal Health Coverage, but other donors and certain NGOs still support the input paradigm and general free health services. The latter is also cemented in a presidential decree.<\/span><\/p>\n<p><span style=\"color: #000000;\">The NGO Premi\u00e8re Urgence Internationale has worked in CAR for several years and has also worked in several other African countries, but, so far, mainly supported the input logic. According to the evaluation of the Bekou project in 2018, the European Union proposed that for the new phase of the health project to integrate the lessons learned by the PBF in the areas supported by the World Bank. This under the leadership of the Ministry of Health<\/span><\/p>\n<p><span style=\"color: #000000;\">The PBF feasibility scan carried out by the participant of the NGO Premi\u00e8re Urgence Internationale in Cotonou showed a score of 56%. This means that it is necessary to align the planned intervention in Bangui with the PBF best practices. This should lead to with the aim a feasibility score of 80% or more. The four-year budget of $ 12.5 per person per year available gives the opportunity to formulate an excellent PBF program in the city of Bangui.<\/span><\/p>\n<p><span style=\"color: #000000;\"><strong>This requires the following measures:<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Advocate with the hierarchy of the NGO Premi\u00e8re Urgence Internationale and the Bekou project to accept the changes necessary to harmonize the intervention with the PBF best practices;<\/span><\/li>\n<li><span style=\"color: #000000;\">Prepare a PowerPoint presentation, which summarizes the training in Cotonou;<\/span><\/li>\n<li><span style=\"color: #000000;\">Prepare the meeting with the hierarchy of Premi\u00e8re Urgence and Bekou;<\/span><\/li>\n<li><span style=\"color: #000000;\">Advocate and obtain authorization to change the content of the intervention;<\/span><\/li>\n<li><span style=\"color: #000000;\">Discuss the changes with the CTN-PBF coordinator of the CAR.<\/span><\/li>\n<li><span style=\"color: #000000;\">Once the above proposals for a \u201cpurer\u201d PBF approach are accepted by the hierarchy, the following activities and changes can be implemented<\/span><\/li>\n<li><span style=\"color: #000000;\">Include private and faith-based health facilities in the PBF program instead of only contracting public structures;<\/span><\/li>\n<li><span style=\"color: #000000;\">Include community PBF indicators in the proposal, such as the home visits following a protocol;<\/span><\/li>\n<li><span style=\"color: #000000;\">Integrate the Complementary Activities Package (hospitals) into the PBF intervention and include the 5 Bangui hospitals in the PBF intervention, which in practice are urban district hospitals;<\/span><\/li>\n<li><span style=\"color: #000000;\">Reduce the number of \u201cinput\u201d budget lines of the Bekou program and transform them into PBF subsidy lines;<\/span><\/li>\n<li><span style=\"color: #000000;\">Conduct a new costing, which include the above changes.<\/span><\/li>\n<\/ul>\n<p><strong style=\"color: #000000; font-size: 1rem;\">Central African Republic: Inspectorate General of the MOH<\/strong><\/p>\n<p><span style=\"color: #000000;\"><strong>\u00a0<\/strong><\/span><span style=\"color: #000000;\"><strong>The objectives of the Inspectorate General of the MOH for PBF are:<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Contribute to improving the quality, efficiency and equity of public, private and faith-based health structures.<\/span><\/li>\n<li><span style=\"color: #000000;\">Inspect and control the activities and the compliance with standards of the different PBF stakeholders such as the PBF Unit, the regulatory structures at different levels, the CDV Agencies, the service providers, the local NGO, and the pharmaceutical wholesalers.<\/span><\/li>\n<li><span style=\"color: #000000;\">Perform the counter-verification of the accreditation of the PBF health facilities.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\">The experience of implementing results-based funding since 2010 (by Cordaid and another project funded by the World Bank) has generated very useful lessons in the CAR. The Government views results-based financing, which is at the heart of World Bank support, as a crucial tool for establishing a culture of accountability.<\/span><\/p>\n<p><span style=\"color: #000000;\">The two General Inspectors took part in the 82nd PBF course organized in December 2019 in Cotonou. During this training, they identified the following weaknesses to be corrected to ensure the successful continuation of the program:<\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Low contribution of the Government in financing the PBF program;<\/span><\/li>\n<li><span style=\"color: #000000;\">Limited involvement of central level actors in the management of PBF;<\/span><\/li>\n<li><span style=\"color: #000000;\">Persistence of the monopoly on the purchase of drugs and other inputs;<\/span><\/li>\n<li><span style=\"color: #000000;\">Centralized definition of cost recovery tariffs instead of decentralized decision by health facilities;<\/span><\/li>\n<li><span style=\"color: #000000;\">Limited autonomy in recruiting and dismissing government staff.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000;\"><strong>\u00a0<\/strong><\/span><span style=\"color: #000000;\"><strong>Recommendations<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"color: #000000;\">Advocate with the government to encourage competition in the market for essential drugs and other inputs;<\/span><\/li>\n<li><span style=\"color: #000000;\">Stimulate the installation of wholesale distributors of drugs operating in competition within the country;<\/span><\/li>\n<li><span style=\"color: #000000;\">Grant a larger autonomy to health facility managers for the decentralized management of human resources (recruitment and dismissal), the supply of drugs and the setting of cost-recovery tariffs;<\/span><\/li>\n<li><span style=\"color: #000000;\">Implement the contracting process of actors and regulators at the central level (directorates, and other services of the ministry);<\/span><\/li>\n<li><span style=\"color: #000000;\">Advocacy with the Minister of Finance and Budget for the effective disbursement of the PBF budget lines in the 2020 Finance Law.\u00a0<\/span><\/li>\n<\/ul>\n<p><\/p>","protected":false},"excerpt":{"rendered":"<p>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. [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_mi_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[1],"tags":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/posts\/4465"}],"collection":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=4465"}],"version-history":[{"count":37,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/posts\/4465\/revisions"}],"predecessor-version":[{"id":4731,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/posts\/4465\/revisions\/4731"}],"wp:attachment":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=4465"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=4465"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=4465"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}