The challenges of implementing results-based financing health in Anglophone Africa

2 Jul

Bruno Meessen reports on a recent regional workshop organized by the World Bank on results-based financing for Anglophone African countries. In this first blog post, he identifies some reassuring facts and lessons. In a second blog post, he will come back on matters of concern.

Around 80 experts from 9 countries (Cameroon, Gambia, Kenya, Lesotho, Liberia, Sierra Leone, Tanzania, Zambia and  Zimbabwe) joined their forces in Livingstone (yes, next to Victoria Falls) for a 4-day workshop organized by the African Region of the World Bank and the World Bank Institute. The general theme of the event was “Challenges of implementing results-based financing health in Anglophone Africa.” As you may remember, a similar workshop  had been organized for Francophone African countries in December in Limbe (a town which, by the way, used to be called “Victoria” between 1858–1982. It  looks like Queen Victoria was popular among explorers and missionaries in the 19th century!).

The program covered most of the major issues faced by any country willing to adopt an RBF/PBF strategy: institutional arrangements, budgetary forecasts, operational challenges, ICT solutions for data management, the importance of pilot projects, institutional and financial sustainability, PBF & Universal Health Coverage , monitoring & evaluation, contractual options, procurement and financial procedures, etc.

Most participants were familiar with PBF and its key principles. The faculty team was also impressive. National experiences were the central topic of the workshop. Some countries like Zambia, Sierra Leone, Liberia and Zimbabwe are well advanced in their PBF policies. Others like Cameroon, Kenya or Tanzania are at the pilot stage. Gambia and Lesotho have yet to start their first pilot.

Lessons in terms of design

The workshop was rich in lessons. Here are a few that I would like to highlight.

First, one could observe a convergence in terms of design. This is particularly true for projects supported by the World Bank. Some schemes will probably need some corrections. In Zimbabwe for instance, the health staff is not allowed to earn some personal income from their performance (PBF revenue collected by the health facility has to be allocated to purchase of inputs). The current approach in Liberia is more a performance-based contracting experience than what we are used to call a PBF scheme in sub-Saharan Africa. While ‘contracting out’ could be necessary in a post-conflict setting, one should hope that donor countries will realize that contracting out districts to their national contractors has limits, especially in terms of maximizing resources for frontline services. The most efficient approach to transfer technical assistance to countries is a topic which deserves more attention. At another level, I was particularly interested in the case of Kenya: the pilot scheme there is building on the ‘Health Sector Services Fund’, an existing scheme which transfers public resources directly to the bank account of health facilities. This should allow us to see the added value of linking the payment to results (if any).

Lessons in terms of implementation

Many discussions in Livingstone were consistent with discussions we had elsewhere. For instance, the challenge of geography and distance to health facilities came back. This is obviously not a challenge specific to PBF. However, it is important to keep in mind that PBF was conceived and fine-tuned in one of the most dense regions of Africa (the Great Lakes Region). Obviously, distance between the population and the health facilities are much greater challenges in some other parts of Africa. This was already much-discussed fact in the 2012 joint Communities of Practice workshop of Bujumbura with delegations from vast countries like Chad or Niger. It is probable that we have not yet factored in this challenge in the PBF strategy. (1)

This is a not scoop, but as mentioned by many participants, context matters a lot. PBF has sometimes been promoted with too simple messages (e.g. the guidance that the right budget for a PBF scheme is 3$/year/inhabitant). In a country like Nigeria, where a midwife may get a salary of $500, the amount required to motivate the personnel to work more would have to be substantial. Similar problems may be faced by South Africa’s neighboring countries: the pays have to be attractive to dissuade staff to migrate. We need a technique (like discrete choice analysis? ) to better identify what amount is required for a PBF to succeed in motivating a health staff. (2)

In general, throughout the workshop, one could feel a very good understanding among participants of challenges faced by PBF at country level. The partnership with the World Bank seems also strong. This is reassuring. For instance, there is large consensus on both sides that PBF requires to be piloted before to be scaled up at national level (by ‘pilot project’, we mean : a small experiment in a couple of districts to adapt the strategy to the local context). I remember that it was not the case 2-3 years ago: some countries, but also some agencies and experts, believed that one had to seize the window of opportunity and go to scale from day 1.

Points for action

During the workshop, we also identified things which should be addressed at regional or even global level. A first one is certainly the need to be more systematic in the transfer of tools and methods for the monitoring of PBF schemes. A lot of emphasis has been put on impact evaluation, but probably not enough on more classical monitoring and evaluation.  Another one is to move away from regional workshops gathering… mainly us: technocrats from the aid sector and the government. PBF possibly has major transformative value for African societies. The strength to play forcefully requires that we engage much more with civil society, including the media and non-governmental organizations.


(1)    Yet, one lesson I learned from Cambodia is that once the economy takes off, road building and growing urbanization can be more effective than covering the whole country with health facilities.

(2)    Yet, these methods will have to factor in that PBF modifies not only the income but also the effort to exert and to some extent, the decision rights held by the staff.


3 Responses to “The challenges of implementing results-based financing health in Anglophone Africa”

  1. Ben Bellows 05/07/2012 at 15:41 #

    Your first endnote brings to mind a conversation at a conference in Delhi where an OBGYN from Cuernavaca thought that better roads in Mexico had a significant role in reducing maternal mortality by opening what were once remote areas. And the many small rural health posts, a legacy from a time without decent road access, were then sometimes obstacles for patients in distress.

  2. Dr Penn Amaah 31/05/2013 at 13:03 #

    Performance based financing could be a very good method of meeting a predetermined performance target as it considers inputs and outputs to have an impact on the outcome. The World Bank and IMF advocate for Out-put based aid and contracting. The understanding of this is very good at policy level. At the level of implementation and especially in Africa, we see different things happening. Recently in Cameroon, this approach was used to ensure community vaccination during the first part of the combined Nutrition Action Week (NAW) and Maternal and Child Health (MCH) week of 2013. This project being run by the Ministry of Public health (government of Cameroon) was 90% sponsored by the government of Cameroon and 10% by UNICEF. The project ran for five days. Although mebendazole, vitamin A and other material were received on the first day, we only received flyers, banners and t-shirts on the third day. Although the campaign came to and end, no pre-financing of transportation and communication was done. The words were, ”just try to use your own means” when the money comes, you shall have your payment. ”The government has allocated the money but it is taking time to be signed” said a supervisor supervising the Njikwa health district. Poor governance, slow bureaucracies and less importance (relatively) is attributed to health problems in these settings. With all these, you can paint the picture of using the not-enough-teams for sparsely populated health areas in which those involved in the campaign have to trek to climb hills and enter forests to meet their targets. Coupled to this, we witnessed a violation of the human rights of those involved in the campaign as they worked all-day-long and even under the rain to meet this objective. Imagine community recruited farmers abandoning their work to carry out a campaign for which they are not paid at the end. What becomes of their opinion when the campaign is to be carried out during the next upcoming campaign week? This and a lot more remain on the table. I think that if this was contracted to a third party, results could be a lot different. One of the difficulties/challenges of implementing Performance based financing in Anglophone Africa from this experience would be: following the guidelines strictly (contracting), doing away with the poor governance and complex bureaucracy and delivering collectibles in a timely manner.


  1. PBF: the pitfall of relying on a single sponsor « Performance Based Financing - 30/08/2012

    […] organized by the World Bank on results-based financing for Anglophone African countries. In a previous blog post, he identified several positive developments. In this second contribution, he shares a point of […]

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