PBF: the pitfall of relying on a single sponsor

29 Aug

Bruno Meessen reflects on the lessons from a recent regional workshop 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 concern.

The workshop in Livingstone, Zambia was a great opportunity to get a broader view on the development of PBF in Anglophone Africa. This nicely complemented the information I already had on the current situation in Francophone Africa. Although a rigorous mapping of PBF schemes in Africa still needs to be done (in fact, the PBF CoP offered to perform such a mapping as a wiki project already more than 2 years ago, so if you are a possible sponsor and willing to help, do not hesitate to contact us!), I realized that a worrying pattern is emerging: PBF is increasingly turning into a story of a single sponsor per country.

In a few countries (e.g. Rwanda and more recently Benin), PBF champions have been successful in building a broad and strong commitment among several funders of the health system. Yet, this is a minority. In many countries, PBF today is mainly a (strong) bilateral relationship between the government and one of its partners (often the World Bank, sometimes USAID or another bilateral aid agency).  Other donors are just watching things closely for now, it seems.

PBF sponsored by a single donor means at least two missed opportunities.

First, it creates a misinterpretation on what PBF really is about: from the outside, PBF is seen as a single project of that particular agency, whereas inside the agency, it is seen as an innovative approach to study. I repeat what I already wrote elsewhere: PBF ‘s ambition is to be an entry point to address several structural weaknesses constraining health systems in low-income countries, and in sub-Saharan Africa in particular. Such a reformist view has many implications. One of them is that one responsibility of PBF champions is to look for possible synergies with other efforts to strengthen the health system, as happened for example with selective free health care in Burundi or the Health Sector Services Fund in Kenya.

There is a second missed opportunity: the possibility to use the PBF approach as a virtual basket of funds. Indeed, PBF offers the possibility to any donor to obtain results in its areas of interest (geographical or programmatic ones) in a manner consistent with a national strategy. The main requirement is to accept a shift from an input-based approach to an output-based one. It is a concrete way to realize principles promoted by Sector Wide Approaches or even the Paris Declaration. Conversely, this indicates that PBF champions have to engage and collaborate with agencies involved in basket funding arrangements.

It is not yet clear what prevents so many donors from committing to the strategy in new ‘PBF countries’. Skepticism? Inadequacy of their aid instruments? Disinterest in structural changes in the operation of the health system? A lack of funds? A conflict of interest? A wait-and-see attitude? I suspect that this outcome is also partly the result of mistakes made by ‘PBF champions’.

In 2004-2005, PBF was still in its infancy as a policy; several of us spent time and energy to defend and explain the strategy inside our organizations (ministries, aid agencies, research institutes…) or to the outside world. Today, thanks to the financial support of Norway and the UK and via the World Bank, PBF is becoming mainstream all over Africa. Yet, if its full potential is to be achieved, more work needs to be done. Are we not making the mistake to ‘lazily’ rest on our laurels, i.e. this acquired funding? In fact, PBF needs more donors to join and more fundamentally, still has to access public funding in many countries – integration in public finance will indeed be the real litmus test for the full realization of any PBF pilot project.

As a community, we have to bring the ongoing pilot projects to success, but we should not diminish our efforts to advocate for the strategy. Let us not make the mistake to believe that conclusive evidence from the impact evaluations will naturally bring key actors to commit to PBF. The world is simply not that rational. Seizing the transformative power of PBF is a common responsibility for all of us: the World Bank, the implementing PBF agencies, but also individual experts.

The fact that participants to the Zambia workshop formulated the request to receive assistance for these advocacy efforts is a clear indication that this is a widely shared view.

 

4 Responses to “PBF: the pitfall of relying on a single sponsor”

  1. Gyuri Fritsche 30/08/2012 at 16:44 #

    This is an interesting blog and as a good blog it points at a glass partially filled with water. The situation is not so dire though. There are solid lessons learned and examples to follow in the scaling-up of PBF from two countries (Rwanda and Burundi). Both countries have about 10 different fund holders contributing to 30-40% of total PBF funding. One can argue that the overall majority of countries that start PBF pilots are in an early phase with a single financing source, however these pilots have as a purpose to test PBF approaches and to document their effects. If positive, such pilots can attract attention from other development partners. By the way: PBF pilots are certainly not ‘single sponsor’ type financing arrangements. In the case of the World Bank sponsored pilots, such funding is from IDA, leveraged by substantial funding through the health results innovation trust fund (HRITF) financed by Norway and the UK. IDA itself is a multi-source financing mechanism. Finally, such funding passes in the overall majority of cases through public financial management and therefore, are seen as financed by the Government, and Government owned.

  2. Bruno Meessen 20/09/2012 at 21:03 #

    Thanks Gyuri. I agree that the World Bank is closely working with ministries of finance and that government ownership is strong in most countries. However, I believe that we should better monitor how other external actors contribute to PBF or at least to its broad agenda. I am particularly concerned by the fact that in many countries, donors which fund vertical programs do not consider PBF. It seems unfair when one sees how much stress PBF puts on maternal and reproductive health indicators, for instance. Maybe is their money captured by programs which are sometimes ministries within the ministry of health? I do not know. I also see a gap between the “value for money” rhetoric and the practices. What are the actions actually taken by aid agencies to obtain “value for money”? Too much of aid money does not reach the population. There are real inefficiencies stemming from poor aid coordination. PBF is particularly effective in addressing these two problems. It would be a pity that we miss to address these challenges.

  3. Nicolas de Borman 16/10/2012 at 16:56 #

    I share Bruno’s concerns. A single donor makes PBF system vulnerable. In Rwanda and Burundi, the scaling up of PBF was a joint effort of the government, NGOs and multiple donors. It made the PBF dynamic strong, and owned by multiple partners. Unfortunately, in most of the other SSA countries, RBF is perceived as “the World Bank or USAID project”. PBF is not yet used to pool funding from different donors.

    So, what does it take to gain support form other donors? First it takes time. Getting the EC, UNICEF or the French on board is a matter of multiple years. Unfortunately, it often takes more time than the duration of the pilot project. Secondly, it requires to be open to other inputs from the very beginning, in order to build trust and ownership, and be open to their priorities. In that sense, the “we know it all” discourse is damaging. There is a need for a high quality policy dialogue that is not always taking place. It requires flexibility at both ends.

    As an anecdote, I remember discussing with an EC representative about the EC co-financing a World Bank funded PBF project. His answer was: How many times has the World Bank co-financed an EC funded PBF?

    In order to avoid that these multiple PBF projects populate the PBF cemetery soon, the government has to play a key role: (i) co-financing PBF in order to show that they are serious about it, (ii) defining a clear mid-term sector-wide health financing strategy that includes PBF, and (iii) conduct a dialogue to ensure that donors align on the health financing strategy.

    • Hugues Temple-Boyer 16/10/2012 at 17:17 #

      I personally think that the real question, is not how to make more donors interested in PBF, but how to make governments invest more in health and ultimately fund the PBF approach. However, we must also ask ourselves why governments are reluctant in taking over the responsability of running the PBF approach. Is it a problem of extra cost that it could represent? Or is it that the predictability of expenses is a bit hazardous given that the MoF cannot often allocate budgets for non predictable expenses? We must look at institutional challenges when talking about sustainability, and not sure that calling for more donors to come at the table will help governements taking their own responsibilities.

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