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Last May 11th, in Clermont-Ferrand, the "Panel discussion on Performance-based Financing in sub-Saharan Africa : Challenges and Risks" took place.

Speakers: Petra Vergeer (World Bank), Agnes Soucat (AfDB), Nicolas de Borman (AEDES), Olivier Basenya (MoH Burundi).
Chair: Bruno Meessen (ITM).


The panelists started the discussion by identifying some of the risks of PBF.

Many of them pointed at the potential for over-reporting and data falsification that demand a strong verification system and arrangements that reduce conflict of interests. The WB is now looking specifically to this question, basing on experiences in both in low income and in middle and high income countries. Indeed, gaming can me discovered but it's difficult to sanction effectively. Verification is also a challenge towards social accountability. The verification process should move away from being technocratic and involve much more the community and reflect its needs, through democratic participation and voice.

Another issue that was highlighted is that of crowding-out of some activities and overlooking indicators that are not included in the list of those remunerated. This problem is not a major concern when schemes include the whole health system, while it is a problem when the schemes focus on vertical activities (AIDS, maternal health, etc.).

Also, quality and the measure of it has been reported as a concern, in particular in hospital settings. Bruno underlined how we must be careful about not to overstretch the concept of PBF. Quality of care can be partially measured and improved through PBF scheme, but it's important to realize that it is not possible to measure complex tasks and create behavioural changes only using PBF. We have to be creative and adaptive and think of different tools. As Louis Rusa noted, improving quality would require going to the very heart of health staff and its behaviour. This is not possible. While PBF can create conditions (availability of inputs, awareness of the importance of quality, etc.) so that quality will follow, it cannot enforce the dimensions of quality in its entireness.

In general, there is a risk that some actors would try to use PBF to fix problems, too many problems at once. Olivier Basenya mentioned how he observes such misunderstanding in Burundi regarding hospitals. From his experience, Oivier thinks that there is also an issue of potential negative unintended effects of PBF, such as inequitable distribution of resources (which may stem from the unequal capacity of health facilities to seize opportunities offered by PBF). By being proactive, it is possible to prevent risks. For instance, in Burundi, there is a payment formula which advantages health centres in remote areas.

Agnes Soucat pointed out to three risks:

  • (1) the confusion between PBF schemes funding institutions and funding salaries. If we look at all the available evidence there is clear proof that funding institutions (for example, through fee-for-service FFS systems) is conductive to increased production of health services.
  • On the contrary, the effectiveness of paying individual is much more debated and there is no evidence in the literature, especially in health were tasks are executed by teams.
  • (2) the second risk is to consider PBF as a quick fix. What works in PBF is the injection of a culture of openness, accountability, results, evaluation. Implementing PBF schemes is much more about this than about the narrow interpretation of PBF. It is about the forest, not the tree.
  • (3) thirdly, there is a risk of viewing the existing experiences as an unquestionable model, without looking at the history of how they emerged. In Rwanda, many decisions taken to design the PBF scheme (both in its operational and institutional arrangement) were opportunistic and dictated by a specific context and needs. Each country should not clone the same approach, but should have an in- depth discussion about the issues to address and the design of the scheme. Enough attention has to be paid to the analysis of the causal chain.

* The importance of the adaptation to the context and a larger view of PBF schemes as complex health financing strategies was followed up in the discussion. Peter Bob Peerenboom gave the example of the question of how much funds should be injected through PBF. The US$ 2-3 amount applied in the Great Lakes countries is not a "gold standard". Of course, countries where the funding per capita is much higher (such as
Cameroon) should make different choices. He stressed that in each country, a diagnosis of the local problems and opportunities has to be made. Friedeger Stierle said that PBF should not be seen as a stand- alone scheme; we should avoid multiplication of many parallel schemes.
PBF invites us to pay more attention to the purchasing function within the health system.

* In this sense, Kenneth Leonard noted that the current success of the strategy could potentially represent one of its biggest risks. Other countries may begin to "copy/paste" the approach of successful ones with no adaptation, and this will be a recipe for failure. PBF is an innovative strategy, which requires innovation and creativity in finding new solutions both by government and donors at central level, as well as by providers at facility level. Therefore, it is important that people keep innovating and being creative about what works and what does not work in specific contexts. Indeed, Agnes said, the PBF "fashion" cannot overshadow the reality of contexts. In some contexts, PBF may simply not be the right solution.

Bruno then invited the panel to share their views on challenges of PBF schemes. Many of those challenges were identified by the panelists and during the discussion.

Petra reported her experience of some countries that are novel to PBF schemes and yet they think of implementing them at national level from day 1. These countries have to be advised about slowing down the process, create pilot schemes, monitor and evaluate them well and learn from the experience.

Nicolas reported that in some countries, the implementation of PBF schemes happened in "vertical" way, because actors (both within governments and donors) have agenda that require quick implementation.
Donors want to implement quickly because they want to fix their failing projects. Also, PBF experts are sometimes loud advocate of PBF schemes and create a sort of dichotomy about PBF and the rest of the health system strengthening process. On the contrary, PBF is an entry point for reforming health systems. We need to develop policy dialogue and alliances; radicalism and polarization creates antagonism.
In DRC, for example, the discussion today is whether yes/no to scale up PBF at national level, while the real issue is to reorganize the health system in order for it to be efficient and equitable. The PBF community needs to adopt less prescriptive approaches. The challenge is to look at the global picture of the health system. We must avoid the 'tunnel view'.

Even in countries where pilots have been in place, the scaling up at national level is not simple. Oliver recalled the difficult process of discussions and negotiations that took place in Burundi. It is important to allow sufficient time for this dialogue to create institutional arrangements that are agreed and appropriated. When they are many different pilot schemes, harmonization is a challenge. Serge Mayaka noted that this is maybe even more challenging in vast countries, such as the DRC.

Olivier sees also a challenge at the level of the health information system. How to find synergies and avoid duplication and overburden health facilities with data reporting? Agnès noted that there is a rapid development of ICT in Africa such as electronic patient files; this is an opportunity, but also it is challenging, as it poses the risk of multiplication of concurrent systems.

Another challenge is to access public finance, which represent a new issue in many donor-dependent countries and poses a challenge for health cadres have to learn lessons rapidly.

In summary, the chair concluded that PBF is a major challenge. We need to take a long term view and be aware of problems, challenges and the issue of path dependency, and always be looking at health system strengthening in a holistic way. The process is dynamic, and needs to be so, in a very honest way, highlighting risks and challenges and pointing out to the lessons learned.