The PBF scheme was introduced nationwide in April 2011, following a year of Free Health Care (FHC). The FHC Initiative tackled the issue of user fees in accessing ser- vices, however, evidence emerged that supply (provision of health care services) did not cope with the increased demand (more users wanting to access services). In an attempt to increase the quality as well as efficiency of service delivery and also tackling informal fees at facility level, the PBF scheme was introduced at all 1200 PHUs with six quantity indicators addressing Reproductive and Child Health (RCH) and 10 quality indicators. A year later the two national referral hospitals for RCH, Ola During Children Hospital and Princess Christian Maternity Hospi- tal were added to the scheme. They are evaluated based on quality criteria.
The scheme is managed by the PBF Technical Team, sup- ported by the Health Financing Unit of the Ministry of Health and Sanitation. The verification teams in the dis- tricts are led by the District Health Management Teams and supervision and verification is done jointly with the local councils. Central level is verifying the two hospitals of the scheme.

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This article focuses on the financial sustainability of the strategy linking performance-based financing (PBF) and free health care (FHC), which has been implemented nationwide in Burundi since 2010. It concentrates on the financial re- sources invested by the government and its technical and financial partners. It seeks to establish whether government resources alone can guarantee the financial sustainability of PBF-FHC or whether other inputs are required.
This article first defines the concept of financial sustainability used in the context of PBF-FHC. It subsequently analyzes financial sustainability based on three indicators: (i) the reliability and stability of financing; (ii) the availability and ade- quacy of both current and long-term financing; and, (iii) the appropriate and timely allocation of resources by the gov- ernment.
Through the establishment of a budget line dedicated to PBF-FHC, the government contributes to the reliability and stability of financing. This is further compounded by its formal commitment to provide PBF-FHC with an annual alloca- tion representing 1.4 percent of its general budget. Analyzes show that this government contribution remained sta- bled; it even exceeded the annual rate of 1.4 percent between 2010 and 2013.
Despite encouraging results, PBF-FHC is faced with an important financial gap which cannot currently be bridged by the government or TFPs. In addition, health facilities are faced with cash shortages – placing them at risk of stock outs of both drugs and other inputs – caused by important reimbursement delays.
Finally, this article examines the approaches recommended to address financial sustainability in the context of PBF- FHC, namely: (i) the reduction of PBF-FHC implementation costs; (ii) the mobilization of government and TFPs re- sources; (iii) guaranteed regular payment of health facilities’ invoices; and (iv) the integration of PBF-FHC in the nation- al health financing strategy, which seeks to increase efficiency by integrating different health financing mechanisms.

The main conclusion of this analysis is that although government involvement and financing are requisite, they are not sufficient to guarantee the financial sustainability of PBF-FHC in Burundi.

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