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.