Midline Qualitative Study Findings Report Cameroon PBF Impact Evaluation

Summary

Cameroon is currently implementing a large-scale impact evaluation to investigate the effects of Performance-based Financing on health outcomes within the specific country context of Cameroon. While the impact evaluation is based largely on quantitative analysis using baseline and endline surveys, the impact evaluation team proposed to introduce a qualitative component to the overall evaluation to probe deeper for explanations or explore specific issues that are relevant to the piloting of PBF in Cameroon. The roles of qualitative research imbedded within a PBF impact evaluation are numerous: (i) to determine the set of issues that are relevant to the specific country context; (ii) to construct relevant quantitative measures; (iii) to explore relevant issues in greater levels of depth and detail; (iv) to understand the role of place, time, practices and processes; and (v) to enhance interpretation of quantitative results.

The PBF Cameroon midline qualitative study was focused upon two primary objectives:

1. Experiences in the piloting of PBF at the central, regional and district level: perspectives of decision-makers, policymakers, and providers.
2. Experiential elements of health service delivery at the operational level: perspectives of community leaders and members

The midline qualitative data collection aimed to answer two separate but complementary sets of research questions that addressed the learning objectives of the study:

1. What has been the experience of piloting performance-based financing at various administrative and operational levels of the health system in Cameroon?
2. What has been the experience of health service delivery for health workers and
community members during the first two years of performance-based financing?

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Burundi: Questions on the Financial Sustainability of Performance-Based Financing and Free Health Care

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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The PBF Handbook: Designing and Implementing Effective Performance-Based Financing Programs

PERFORMANCE-BASED FINANCING (PBF) is a powerful means of increasing the quality and quantity of health services by providing incentives to suppliers to improve performance and achieve results. In support of the Millennium Development Goals, PEPFAR, the Global Health Initiative (GHI), and other important health initiatives, PBF can increase the use and quality of health services, stabilize or decrease the costs of these services, help use limited resources effectively, and improve staff motivation and morale, a proven incentive for staff retention.
In today’s dynamic development environment¬—with government institutions and local civil society organizations providing health services, the growth of complex multi-sectoral partnerships, the decentralization of public health functions, and country ownership of health and other services¬¬¬—organizations and countries throughout the world are increasingly using PBF to help make improvements in health and development. PBF links an organization’s funding to its achievement of agreed-upon targets and may include bonuses if the organization exceeds those targets.
This PBF handbook has been designed for use by both program design officers at US Government (USG) agencies at the central and country levels as well as for PBF implementers at national and local levels. It is our hope that presenting this comprehensive overview of PBF from both the funders’ and the implementers’ perspectives will help to facilitate the design, implementation, and evaluation of PBF programs that enhance service delivery and create positive health outcomes.

AIDSTAR Two Project

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