Implementation Research: Taking Results Based Financing from scheme to system Challenges of integrating an innovative health financing scheme into the health system: lessons from Performance-Based-Financing (PBF) in Cameroon (2006 - 2015) Research report Cameroon Isidore Sieleunou, Jean-Claude Taptue Fotso, Estelle Kouokam, Denise Magne Tamga, Habakkuk Azinyui Yumo, Anne-Marie Turcotte-Tremblay, Valéry Ridde
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Implementation Research: Taking Results Based Financing from scheme to system
Challenges of integrating an innovative health financing scheme into the
health system: lessons from Performance-Based-Financing (PBF) in
We would like to thank the Alliance for Health Policy and Systems Research for the funding
and the Institute of Tropical Medicine for the technical support for the implementation of this
project.
We are most grateful to Mr Enandjoum Bwanga, the National Coordinator of the Cameroon
Health Sector Support Investment Project, and Dr Paul Jacob Robyn, the World Bank’s Task
Team Leader in Yaoundé, for their kind support.
We also thank all the research assistants at R4D International, particularly Ajeh Rogers
Awoh, Mark Nbenwi, Blonde Ngo Mbo, Léonard Ndongo, Albert Le Grand Amba and
Marlène Tchoffo, for their great commitment for field activities for this study, and finally all
the key informants whose availability and candid insights made this research possible.
We are much indebted to many people who reviewed the first or second draft of this report
and provided valuable comments.
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Table of Contents
I. INTRODUCTION...................................................................................................................................... 10
II. BACKGROUND ....................................................................................................................................... 12
III. OBJECTIVES ............................................................................................................................................ 13
IV. METHODOLOGY ................................................................................................................................. 14
A. STUDY DESIGN .............................................................................................................................................. 14
B. CONCEPTUAL FRAMEWORKS ............................................................................................................................ 14
Description of how PBF developed over time ............................................................................................... 14
Analytical work ............................................................................................................................................. 15 Factors enabling or hindering the development of PBF program in Cameroon (agenda setting, formulation, and
implementation) ........................................................................................................................................................ 16 Assessing the transfer of the purchasing role from international NGOs to National agents in two regions (North-
West and South-West regions) .................................................................................................................................. 17 C. INSTRUMENTS, SAMPLE AND DATA COLLECTION ................................................................................................... 18
D. ADDRESSING VALIDITY AND RELIABILITY OF COLLECTED DATA ................................................................................ 19
E. DATA MANAGEMENT AND ANALYSIS.................................................................................................................. 20
F. ETHICAL CONSIDERATION ................................................................................................................................ 21
G. LIMITATIONS ................................................................................................................................................ 21
V. RESULTS ................................................................................................................................................. 22
A. PROGRESS OF THE PBF SCHEME ....................................................................................................................... 22
The CORDAID project (21) ............................................................................................................................ 22
The Ministry of Public Health’s project supported by the World Bank ......................................................... 24 a. History .................................................................................................................................................................... 24 b. Key features of the project .................................................................................................................................... 25 C. Coordination, monitoring and evaluation activities .............................................................................................. 25
Scaling-up process ........................................................................................................................................ 27 Population coverage .................................................................................................................................................. 27 Service coverage ........................................................................................................................................................ 27 Health system integration.......................................................................................................................................... 27 Country ownership .................................................................................................................................................... 27 Society, idea and knowledge ..................................................................................................................................... 28
VI. FACTORS ENABLING OR HINDERING THE DEVELOPMENT OF THE PBF PROGRAM .............................. 30
A. AGENDA SETTING ..................................................................................................................................... 30
Problem Stream ............................................................................................................................................ 30
Windows of opportunity ............................................................................................................................... 34
B. FORMULATION OF PBF CAMEROON ................................................................................................................. 35
Windows of opportunities ............................................................................................................................ 40
C. IMPLEMENTATION PBF CAMEROON ................................................................................................................. 40
Windows of opportunity ............................................................................................................................... 45
VII. TRANSFER OF THE PERFORMANCE PURCHASING AGENCY (PPA) ....................................................... 50
A. ENGAGING IN THE TRANSFER PROCESS ............................................................................................................... 50
B. ACTORS INVOLVED IN THE TRANSFER PROCESS .................................................................................................... 51
C. THE PURPOSES OF THE TRANSFER ..................................................................................................................... 51
D. THE SOURCES OF THE TRANSFER ....................................................................................................................... 53
E. THE DIFFERENT COMPONENTS OF TRANSFER ....................................................................................................... 53
F. FACTORS THAT FACILITATED THE TRANSFER ......................................................................................................... 54
G. FACTORS THAT HINDERED THE TRANSFER ........................................................................................................... 55
H. APPRECIATION OF THE TRANSFER...................................................................................................................... 58
VIII. CONCLUSION................................................................................................................................. 59
IX. LIST OF REFERENCES .............................................................................................................................. 60
During the workshop, a UNICEF expert gave a presentation on the malnutrition trends in
Cameroon. He pleaded the support of the PBF program for the inclusion of some malnutrition
indicators. Consequently, two indicators at MPA and two indicators at the CPA level were
retained.
Discussions also focused on the difficulty in preparing the RFHP for the transfer to take over
the PPA.
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Scaling-up process
Based on the fact that the PBF program in Cameroon has moved from a pilot project to a
national scheme (though not covering all the regions) on one hand, and is currently attempting
to progress to a national policy with the integration of the scheme into the national health care
financing on other hand, we situated this scaling-up process in-between the adoption and the
institutionalisation phases.
The initial Cameroon Health Sector Support Investment Project was a five-year US$25
million project. The project underwent a restructuring on June 2011 and again in March 2014.
The project received an IDA Additional Financing of US$20 million to support the scale-up
of performance-based financing to additional target populations in the poorest regions of
Cameroon, and a US$20 million allocation from the Health Results Innovation Multi Donor
Trust Fund (HRITF) to be used in the initial project areas to scale-up the activities of the
project in the 26 districts currently implementing PBF by extending PBF to the impact
evaluation group facilities.
Population coverage
PBF was introduced in Cameroon by CORDAID in 2004 in the East region through the
RESSEC 1 project. It started in four Catholic health facilities in the Batouri Diocese, covering
an estimated population of 16,914 inhabitants. In 2008, Cordaid extended the PBF project in
24 catholic health facilities through the new RESSEC2 project, for a total population of 120
000 inhabitants. In 2011, the government PBF project started in 4 health district in the littoral
region. This project was progressively extended to the North-West region at the beginning of
year 2012 (4 health districts), to the South-West region 3 months later (4 health districts), and
to the East region 6 month later (all the 14 health districts of the region), for a total population
of 3 million inhabitants. The previous project supported by Cordaid in east region ended in
2010.
Service coverage
In 2004, Cordaid started its PBF project with 14 output indicators. The government project
started in 2011 with 23 MPA indicators and 24 CPA indicators. Five months later, these
indicators were reduced to 15 MPA and 16 CPA but was increased again to 23 MPA and 25
CPA 6 months later by the Ministry of Health. These indicators were used by all region until
June 2015. The revised process to introduce new indicators and community indicators for the
PBF community started in the 2015 and was still going on.
Health system integration
From the beginning of the project in the Littoral region, the government decided to use a
national structure to carry out the role of the performance purchasing Agency (PPA): the
Regional Funds for health promotion. In the three other regions (North-West, South West, and
East region), international organizations were recruited to play the PPA role during 3 years. In
late 2014 and beginning 2015, the PPA role was transferred from the international
organizations to the RFHP in the 3 above mentioned regions. In 2015, the RFHP was also
created in the 7 other regions in other to prepare the national scaling up of the PBF.
Country ownership
The government changed its legal framework in other to allow the RFHP to fully play its role
in the implementation of PBF and other health activities at the regional level. This new legal
framework provided them with managerial autonomy. A national PBF steering committee that
includes different ministerial departments and other ministries directly or indirectly involved
in the implementation of the PBF in Cameroon was created to guide the development of the
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program. In addition, the MoPH decided to create a PBF Technical Unit in 2014. As part of
the sustainability vision, the government invested Fcfa 670 million and its financial procedure
for the implementation of the PBF project in the littoral region during the year 2014.
Society, idea and knowledge
Several evaluations have been done since the beginning of the PBF in 2004. These include for
instance the baseline study in December 2010 and the mid-term evaluation in March 2013 in
the littoral region. Baseline evaluation in East, North-West and South-West regions was
carried on in 2012, and the endline took place in June 2015. Many staff at operational and at
central level were trained in PBF during several international 2-weeks courses.
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Figure 2: Timeline
Introduction of PBF in 3 Catholic health facilities of the Batouri Diocese, funded by CORDAID (RESSEC 1 Project )
Population coverage
Extension of the project in 24 health facilities in the East region with CORDAID financing support (RESSEC2 project)
Starting the PBF Project in 4 health districts of the Littoral Region with the World Bank support
Contract signed between MoH and AEDES to implement a PBF pilot project in 4 health Districts in the North West Region and 4 Health Districts in the South West Region
with the World Bank supportContract signed between the Ministry of Public Health and the CORDAID NGO to implement a PBF pilot project in
all the 14 HDs in the East Region with the World Bank support
Decision to extend the PBF to 15 health districts of Adamawa, North and Far North Regions with the World
Bank support
Starting of the PBF Project with 14 MPA indicators in the Catholic health facilities of the Batouri Diocese (RESSEC 1
Project )Service coverage
Starting of the PBF Project with 23 MPA and 22 CPA indicators in the Littoral Region
1st revision of the indicators
Review and adoption of a new list of indicators
Starting of the PBF Project with 23 MPA and 22 CPA indicators including 2 relating to community PBF in the
East Region
Discussion to add community PBF in the Littoral, North-west and South-west
Health system integration
Signing of the subsidiary agreement between MoH and the Littoral RFHP f
or the implementation of the PBF Project
UNICEF shows interest to join the PBF program
Creation of RFHP in 6 other regions
Transfer of PPA from AEDES to the South West and the North-West RFHP
Signing of the loan agreement between the government of Cameroon and the WB for the implementation of a
PBF project
The Board of Directors approved the 5 years PBF
Adoption of the 2007/2008 Law reforming public financing in Cameroon
Country Ownership
Signing of the loan agreement between the State of Cameroon and the World Bank
Signing of a 2nd loan agreement between the State of Cameroon and the WB
Official launching of the PBF project in the North & South west region
Creating a national PBF committee
Setting up of the regional PBF committees
Decision of the MoH to create a PBF Technical Unit
Funding of the PBF project in
the Littoral Region with state resources
6-month extension of the CORDAID contract in the East Region to allow
the transfer of the PPA
MoU between the Government and the North-West & South-west RFHP
RESSEC 1 Project evaluationSociety, idea and Knowledge
Evaluation of the project operationalization conditions
PBF training for the East, Littoral, North-West and South-West regions staff during an international
2-weeks course
Baseline study of thePBF project
in the Littoral region
Baseline study of the PBF project
in the East, North-west and South-west regions
Development of the procedure manuals of the North & South West
Development of the Cameroon PBF portal web
Mid-term evaluation of the PBF project
in Cameroon
Mid-term evaluation of the PBF project in the Littoral Region
Endline study of the PBF project in the East, North-west and South-west regions
VI. FACTORS ENABLING OR HINDERING THE DEVELOPMENT OF THE
PBF PROGRAM
For the remaining part of this report, we will focus on the Cameroon Government-World
Bank PBF program – referred to as the PBF program. We decided to exclude the pilot
CORDAID project because it was limited in size and activities.
The development of the PBF took place in an environment where an organizational culture, a
mode of functioning and the actors’ own logic already existed. These factors sometimes
played as obstacles and other times as drivers to the development of the PBF program. The
development of the program can be divided in three phases based on Ridde's conceptual
framework, an extended version of the Kingdon model, namely agenda setting, formulation
and implementation. For each phase, we focused on the actors, on the context, and to some
extent on the effects.
A. Agenda setting
The data revealed that the PBF program emerged in the agenda of policy makers following
the coupling of the problems stream (i.e., weak health outcomes, especially for maternal and
child health, and inefficiency regarding financial resources) and the orientations stream (i.e.,
national mandates to improve population health, with an important reform of the health sector
to achieve the health-related MDGs). This coupling was initiated by the actors from the
World Bank in cooperation with a network of policy makers (i.e., political entrepreneurs)
from the Ministry of Public Health.
Problem Stream
The problems regarding the poor maternal and child health outcomes had been recognized by
the state before the 2000s. Approximately ten years ago, Cameroon was confronted with high
rates of maternal and child mortality. The rates increased from 454 deaths per 100 000 live
births in 1996 to 669 deaths per 100 000 live births in 2004 (35). In 2005, the former Ministry
of Health, Mr. Urbain Olanguena Awono, acknowledged that the maternal mortality rate was
unacceptable and that it was necessary for the government of Cameroon to react by drawing
up its action plan based on the principles of Equity, Social Justice and National Solidarity
(72).
We traced back around the end of the 1990s an important event that contributed to
understanding the issue of poor maternal health outcomes as an important problem. During
the National Symposium on the Reproductive health held in Yaoundé from the 14th to the
17th December 1999, many national experts and policy makers expressed their concerns
regarding the worsening of maternal and child outcomes. This lead the country to define eight
priorities sectors taking into account its own national specificities (73).
The publication of a report (74) by the World Bank in June 2003 drew consideration for this
issue. It advocated that the time had come to pay greater attention to the poor maternal and
child health status. In fact, the publication of the report titled “Cameroon country status
report: Reversing the Decline in Health Outcomes", was a key element that supported the
recognition of the poor health status as a real problem that deserved an attention. The
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importance of this report was highlighted during our interviews and respondents indicated that
this was a very important document that largely influenced the comprehension of the health
sectors' problems in the context of Cameroon.
"There was stagnation, ok, the government was aware of the poor health indicators. Health
indicators had been stagnating in the country especially getting toward reaching the
millennium development goals. Reaching the millennium development goals, it's hell,
especially in maternal and child health. Emm, Cameroon has over the years had an increase
in the mortality rate which is a problem [ok]. Infants and maternal mortality rates have been
on the rise [ok]" NI_Policy maker4
"Maternal mortality was just climbing. It caused a bit a shame for the country to see a critical
situation like that. In fact, the State started from the year 2000 to try to find solution for the
unacceptable poor condition of maternal and child health" NI_Implementer1
"OK. Uh there was a report on the health system - Country study support - that the Bank
released; the Bank makes the sectoral report and must do every five years for each sector. It's
more or less a descriptive analysis of the sector, what are the weaknesses, strengths,
challenges, etc. and there was one that was made in 2003-4 something like that, that was not
very good. But this report guided the CMU -the Country Management Unit- of IDA grant
financing source for financing the health sector" NB_Partner1
The report revealed a difficult paradox to interpret: the disconnection between socioeconomic
indicators and those of health. Indeed, the results of this study showed that health indicators
were not proportionate with the level of wealth of the countries, measured by gross domestic
product (GDP). Above all, it was striking to notice that some countries (e.g. Lesotho ) with
socioeconomic levels well below that of Cameroon had much better health outcomes. There
were allocative efficiency issues, in that, the majority of public funds for health care were
allocated to the central and provincial levels of the health care system, and peripheral level
with the greatest need were receiving the least funds.
"The infant mortality rate was very high compared to some countries in the same or even
lower level of wealth as Cameroon. And we also know that many women and children were
dying due to the lack of adequate care" NC_Policymaker2
"..... we were trying to figure out a paradox in this country. If you look at the health indicators
for Cameroon, look at the basic indicators and you look at the socioeconomic status of
Cameroon on the other axis, there was a complete disconnect. Cameroon was a bit of an
outlier. It wasn't attaining its potential" NB_Partner3
The data analysis also revealed two other political/strategic disconnections: the highly
centralized management of the health system and a real disjunction in health program
implementation between the peripheral and the central level. Indeed, it was striking to see that
at the central level, high-level discussions were taking place, but that nothing concrete was
translating to the operational level. In this regard, one respondent confided that:
"The one thing that always struck me was the level of sophistication and the quality of the
policy debates and policy discussions. And then, when you look at the implementation on the
ground -and I visited many hospitals and health centers and so forth-, there was a disconnect
again" NB_Partner3
The publication of the World Bank report provided evidence on the state of health outcomes
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and health financing, and raised awareness on the situation. As a result, the decision-making
level conceptualized the lack of a suitable health financing policy to produce good outcomes
as an important issue (in the problem stream) that was to be addressed by the government.
Orientation stream
Within the orientation stream of the Cameroon PBF program, a series of background
mandates and reforms allowed the introduction and adoption of the program.
First of all, most of the key informants evoked primarily, the close deadline to the MDGs and
the government priority to achieve these MDGs. Despite huge investments in health by many
funders, the health indicators in Cameroon were stagnating especially in the domain of mother
and child health. There was therefore a need for an innovative approach that could improve
the health of the population.
“I think that the main idea for the World Bank was that already so many years, so many
donors put so much money in the health system and, despite all that, the changes are not that
big, eg the mother and child mortality rate which even went worst here in Cameroon”
NB_Partner3
"I had an opportunity to go to Sierra Leone where I represented Cameroon in a meeting on
the MDGs uh ... so we were about twenty-five, fifteen countries and realized that those who
had started with the PBF had quickly improved their MDGs " NC_Policy maker3
Secondly, the fight against corruption came in as a mandate of high priority for the
government. Indeed, in the late 90s, the ranking of Transparency International reported twice
that Cameroon had the greatest perceived corruption index (75).
"My recollection is that there were frustrations that were very typical of Cameroon eh,
corruption, mismanagement, etc" NB_Partner2
"So much money has been pumped into the system through GAVI, through the Global Fund,
through bilateral partners, through WHO, UNICEF. A lot of money went into that sector. I
can tell you that the per capita health financing in Cameroon, I think it was around or more
than $ 60! But it still gave nothing! The indicators ... if you see Cameroon's MDG eh!
Maternal mortality keeps increasing. Governance was not at the top." NI_Implementer10
In 2004, the government launched the Sparrowhawk operation1 in order to put the
management of public funds in order. On October 5th
, 2004 at Monatélé, the Cameroonian
President firmly stressed in an election campaign speech that the fight against corruption will
be a priority for his government if he is re-elected. After his re-election, actions were taken to
fulfil this promises.
In 2005, the Cameroonian President declared: "... I have given instructions to the Government
to put the battle up a notch ... We cannot fight against poverty by letting people divert public
funds". (76)
Then in 2006, following Cameroon’s achievement of the completion point of the heavily
indebted poor country initiative (HIPC), it gives a measure of its determination to improve the
governance of the country, by intensifying and densifying the tone of his speech: "those who
1 Name given to the vast judicial operation for the fight against corruption in Cameroon
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have enriched themselves at the expense of the public fortune must disgorge ... white collar
offenders had better watch out" (76)
In this context, any initiative or program that supported the fight against corruption tented to
be well received. For example, there was the creation of the National Anti-Corruption
Commission in 2006 (NACC).
"In short, there's been some reluctance and I think the results show ... anyway ... There has
been commitment from the government that made it such that from the prime minister down to
the Ministry of Public Health, it had to advance. What must be said is that our presentation
aimed at framing the PBF to show that it could be used for the fight against corruption and
for efficient financial management of the health system’s resources. So there was commitment
from the State, the government through the Minister of Health, the first minister, to implement
this project ..." NC_Policy maker3
The political changes, including the cabinet reshuffle in December 2007, let to a new Minister
of Public Health in an environment where the government was committed to the fight against
corruption and for which several senior officials including several ministers (for example the
former ministers of public health and finance) and directors general suspected of
embezzlement and illegal enrichment were prosecuted, gave an additional impetus to the
reflections. In the following months, officials with great political and technical reputation, as
well as considerable experience, were appointed at the administrative inspection services of
the Ministry of Public Health, with a mandate to instil reforms that were underway in the
health system. One of these officials was given, later on, the coordination of the PBF project
management unit at the time of its implementation. Endorsement of the PBF program by the
newly appointed Ministry of Public Health was then fundamental to push the policy into the
agenda setting.
"It was also a political commitment, the personal commitment of the Minister of Health was a
necessary condition" NI_Implementer1
"So I think that, in all fairness, the Ministry of Public Health was very inspired and motivated,
you know, to do something in this area. I think we have to give them credit" NB_Partner3
All political discourse was converging towards greater accountability to the population, and
also to a more efficient health system.
The changes in the orientation stream supported the emergence of a policy initiative (politics)
that favoured the introduction of new political ideas (policies) on PBF.
Policy entrepreneurs
The data suggests that it is the World Bank that carried the idea of developing PBF. The PBF
program in Cameroon included several prominent policy entrepreneurs who played important
roles in agenda-setting, as emphasized by the Kingdon model. These included officials from
the World Bank and the Ministry of Health.
Some senior officials from the World Bank were working on both the situation in Rwanda and
in Cameroon. They saw, through the early and encouraging results from Rwanda (77), an
opportunity to introduce the same strategy in Cameroon. Therefore, these players from the
World Bank initiated a policy dialogue with decision makers from the Ministry of Public
Public Health, through meetings and presentations of evidence from Rwanda, to consider how
Cameroon could adopt such an approach.
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"And then working on Cameroon, you know, I began... and I think once I did a presentation
you know at the Ministry of Public Health in Yaoundé about the Rwanda experience, and
there were various other things that the World Bank was recognizing is part of this global
movement. So when we put the health project together, we thought that this, you know, testing
out this approach will be really a good thing in the Cameroonian context" NB_Partner3
Although there were recognised problems, as mentioned above, as well as policies mandates /
directives, the PBF program was not on the agenda of policy makers until the end of 2007,
when the World Bank initiated and supported the participation of a delegation of officials
from Cameroon’s Ministry of Public Health in a PBF study tour in Rwanda. Thanks to
promising results that were showcased during the study tour, these officials, who can be seen
as political entrepreneurs, came back very motivated and acted as catalysts for change. They
succeeded in coupling the two streams of problems and policies.
"Already when we came back I think in 2007 from Rwanda, we made a presentation to all the
officials in the Ministry. What they said was that we were enthusiastic and that it was not sure
that what Rwanda was doing would succeed in Cameroon" NB_Policy maker3
The network of experts from the World Bank and officials from the MoPH played a crucial
role to persuade, through lobbying, the government to consider the PBF as a program of high
priority and importance. These policy entrepreneurs used evidence from Rwanda to claim that
the current health financing mechanism in place was not effective. They tried to convince
high-level authorities at both the Ministry of Health and the Ministry of Finance. These
people, who were determined to place PBF on the agenda of policy makers, had good
communication, lobbying and networking skills and also had important political connections.
They used their skills to persuade all influential officials to join the development of the PBF
program. The presence of political entrepreneurs was an important factor in opening windows
of opportunity towards political innovation by linking the three streams of problems,
orientation and solutions.
Windows of opportunity
A series of meetings and international workshops contributed to push PBF in the agenda. The
adoption of the PBF program coincided with the reform of public finance laws. Largely
driven by the government, the reform was a public symbol of the presidents' commitment to
transparency. This was marked by a shift from an input-based budget to a results-based
budget. Some players recognized this as an element that weighed considerably for the
emergence of the PBF approach in Cameroon.
"Public finances were governed by the law of 1962 that evolved, and then in 2007, there is the
2007/2008 law of December 26th
, 2007 that reforms public finances in Cameroon, changing
the budget from a means-based to a results-based budget " NC_Policy maker1
The idea was also fertilized by the context of institutional reforms within the health system,
with the adoption of the sector wide approach (SWAP), where we also noted the involvement
of high-level players. There was the implementation of a health sector support investment
project (HSSIP), under the SWAP. This opened a window of opportunity and prompted the
Ministry of Public Health to make the PBF project a high priority within the HSSIP
framework.
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Moreover, a contracting approach between the public and the private sector was already
proposed as a solution in order to improve the performance of health systems. In this respect,
the MoPH was engaged in a contractual relationship with the confessional health system.
To support the State in its mission of public service delivery, the choice made was henceforth
to apply the market rules in the management of health services through the implementation of
tools that allow real time measure of the health structures' performance.
The process of contracting within the health sector actually started from 2000s where
conditions were progressively put in place for the development of this policy: a collaboration
framework (2001), a health sector strategy (2001-2010 ), the appointment of a sub-director in
charge of national partnership (2002), and the gradual convergence of several partners around
the Division of Cooperation (DCOOP) of the MoPH on the need to develop a global
partnership approach (78). The process was accelerated by the coming of the debt relief
contract project, that provided a mandate to support the private not-for-profit sector, through
contracting. The work of drafting a partnership strategy was engaged in 2003 and ended in
2006 (78).
The results above suggest that the PBF program benefited from a series of national and
international meetings, study tours in other countries, and an ongoing health system as well as
public finance reforms to become embedded in the agenda of policy makers.
B. Formulation of PBF Cameroon
When the Minister of Public Health and most importantly his finance colleague were
convinced of the benefits of the new health financing approach, it was then time to couple the
solution and the orientation streams for the formulation of the PBF program.
Our analyses suggest that the formulation of the PBF program was made possible by the
convergence between the result-based financing solution (solution stream) and the
Government’s mandate to improve the health status of populations and above all improve the
management of public resources (orientation stream), which coincided with the political
preferences of policymakers and stakeholders. The convergence of various flux was initiated
by political entrepreneurs (Ministry of Public Health with support from the World Bank) by
exploiting a window of opportunity (several meetings focussing on health financing reforms).
Orientation stream
The GoC was prompt in embarking in the formulation process of the PBF project because of
some existing political agenda at the country level, namely the commitment to conduct the
ongoing health financing reform.
Most importantly, another circumstance where policy and politics collided in favor of the
formulation of PBF was the law on public finance reforms (politics) passed in December
2007. This law shifted the Cameroon finance law to the result-based budgeting scheme and
served as the legal framework that enable the smooth penetration and formulation of the PBF
in the health sector in this country.
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"Public finances were governed by the law of 1962 that evolved, and then in 2007, there is the
2007/008 law of 26 December 2007 that reforms public finances in Cameroon, changing the
budget from a means based to a results based budget " NC_Policy maker1
The idea was also fertilized by the context of institutional reforms within the health system,
with the adoption of the sector wide approach (SWAP), where we also noted the involvement
of high-level players. There was the implementation of a health sector support investment
project (HSSIP), under the SWAP. This opened a window of opportunity and prompted the
Ministry of Public Health to make the PBF project a high priority within the HSSIP
framework.
Policy Stream
According to the respondents, the Government of Cameroon through the MoPH approached
the World Bank for financial and technical support. The outcome of the negotiations from
these partners paved the way for the formulation of the PBF project in Cameroon.
"...For the formulation of the PBF project like I said, Cameroon wanted to borrow money to
improve the health of its people.... Then a consultant came, and did a mission to see if it was
feasible, and then there were missions in 2007, 2008, 2009, to evaluate the situation and see
how a PBF project could be designed ". NC_Policy marker4
The original Cameroon Health Sector Support Investment Project was a five-year US$25
million project (US$20 million District Service Delivery + US$5 Institutional Strengthening).
It received the World Bank Board approval on May 29th, 2008, and became effective in
March 2009. The project underwent a Level-2 restructuring on June 13th, 2011 and again in
March 2014, with a revised closing date of January 31st, 2016 (79).
Moreover, readily available funding from the World Bank was a monitory window of
opportunity for the formulation of this project. Actually, a loan of 25 million dollars served as
a catalyst for the political impetus in the formulation of the project in Cameroon.
"It has to be said first of all that this project has been the signing of a credit agreement No.
4478CM of a sum of 28 ... 20 million dollars ... sorry 25 million dollars, that's $ 25 million to
support this form of innovative financing strategy" NC_Policy marker2
This loan came within the context of the concessional rate loans programs of the International
Development Association (IDA) at first, then later in the Trust Funds program.
"Like I said, Cameroon was a little advanced. Cameroon had a credit in place before the
Trust Funds was set up. That is to say that for many countries, the Trust Funds served as
lever. In Cameroon, it is the credit that served as lever "NB_Partner4
The Government’s commitment to the PBF project led to the establishment of a steering
committee comprised of representatives of various ministries. This steering committee, which
was under the leadership of a senior official of the Ministry of Public Health, very close to the
Minister of Public Health, legitimates the priority given by the government in this project.
Although this inter-ministerial committee was created, the data shows that a key issue in the
formulation of the PBF program was the weak participation of sectors other than health, such
as the Ministry of Labour and Social Welfare and the Ministry of Finance. In addition, some
key directions of the MoPH such as the human resources department, that of pharmacy and
37 | P a g e
medicine, were not significantly included in the project formulation. Their views were sought
from time to time without being structured within regular and planned interactions.
"If people understand by central level the central technical departments, yes, they have not
been heavily involved" NC_Policy marker2
The data also shows that the initial project implemented by CORDAID in the East of the
country contributed a little to the formulation of PBF program in Cameroon. The
understanding of the CORDAID project by officials of the MoPH was that it was a very
localized intervention that probably deserved support from the government. However, the
political entrepreneurs did not consider it as a pertinent experience on which it was possible
to capitalize to help the start of the government PBF project. The interviews with some
respondents who played key roles in formulating the program give us more insight:
"Well frankly I think the project [CORDAID project] has come along in some way ... there
was not even an analysis at CORDAID for a claim to inspire others. All that was not clear.
First, it was very localized. It was not known. Even to the ministry people did not know what
was happening in the East" NB_Patner4
"The fact that we added the East2 is because CORDAID was already piloting a similar project
there. So we just needed to extend the CORDAID project to the 14 districts. ...... So
technically, we did not base ourselves on the experience of CORDAID in the East to
formulate the project, but rather added the East because of CORDAID" NB_Patner1
The design of the project was conducted by international consultants contracted by the World
Bank. This followed the signature of the loan agreement between the World Bank and the
GoC. The consultants came, did a feasibility study and designed the project. The consultants
transferred the design of the great lake model and adapted it to Cameroon. They also brought
the PBF ideology and rhetoric which were important for the process. Moreover, one of the
consultants designed the Cameroon international PBF course that became a mainstream
strategy to diffuse the PBF approach within the francophone African countries.
The approach was not very participatory and did not involve significant discussions with
different stakeholders.
"...For the formulation of the PBF project, like I said, a consultant came, and conducted
several missions in 2007, 2008, 2009, to evaluate the situation and see how a PBF project
could be designed. The approach was not a participatory approach where everyone sits down
and discusses. Consultants came, evaluated the situation and proposed things that the
Ministry and the World Bank validated together. So this is how the design of the project was
done ..." NC_Policy marker4
Globally, the Cameroon PBF model was based on the Great Lakes experiences, and most
especially that of Rwanda. Indeed, contracted consultants had built their experience in the
country that already showed initial positive results (77). It should be noted that, in addition to
the model proposed by international consultants, the World Bank team added an impact
evaluation of the PBF program that was implemented.
Four out of ten Regions of Cameroon were selected for the implementation of the "PBF pilot
project". These were the East, Littoral, North-West and South West Region. The East Region
was selected because the PBF was already implemented there since 2004 by the Catholic
Church, with the support of CORDAID.
2 the eastern region was added as a fourth region for the implementation of the project
38 | P a g e
On the other hand, the selection of the 3 other regions (Nord-Ouest, Sud-Ouest and Littoral)
was triggered by the presence in these regions of the Special Fund for Health Promotion, a
community-based entity put in place by German Technical Cooperation Agency (GIZ) to
promote the availability and accessibility of essential drugs and other health products at the
community level.
"...... The regions concerned were the Litoral with 4 health districts, 4 health districts in the
North West, 4 health districts in the South West and 14 health districts in the East. I think I
should explain a little here. In fact, when we assessed the project, we realized that there was a
structure that was developed with the support of GIZ at the time GTZ. .... So, given all that I
have said, when we evaluated the project, we said ah! If there are structures that were able to
operate even in the informal sector in order to improve health services, we saw that there
were no drug stock outs, that drugs were available, and they had even began to invest
because they had a small warehouses for the medicines they distributed, they had even begun
the construction of their drug stores. So they were functional until the project was evaluated.
And so we said: we will use these structures as well to try to implement the PBF. So, it was
the Littoral, the North West and the South West Regions that were endowed with such
structures. These are the three regions that were presented from the beginning and that’s how
they therefore were included among the selected regions to support this project in its pilot
phase ..." NC_Policy marker2
"You know we wanted to work in areas where there was either capacity and/or interest to do
this kind of work. So South-West, North-West and Littoral were seen as good candidates
because there were already funds there [RFHP]" NB_Patner3
At the regional level, the criteria used to select the health districts for the pilot test were
mainly the performance indicators. In the North West Region, for example, 4 health districts
namely Ndop, Fundong, Kambe and Kumbo were selected on this basis.
"…In fact, I was there when the Health Districts were selected and I played a big role in
selecting the Health Districts because the health parameters were low and we selected these
four in order to see what difference it will make because they were even lower than the others
in the health performance districts..." NI_Policy marker2
The population size of the districts was another criteria. Health districts with larger population
were prioritized. This was the case in the South West Region where Buea, Kumba, Limbe and
Manfé were selected.
"Yes, there were many criteria for choosing the districts for the project: i) the size of the
population; ii) the performance of the district. So in South-West we have Limbé health
district, Buéa health district, Kumba and Manfé which were the district that were chosen and
which were involved in PBF in the region...." NI_Policy marker3
Moreover, in the Littoral region, geographical distribution (i.e., urban versus rural) was used
as a selection criteria for health districts. In this region, one urban, one semi-urban and two
rural health districts were included the project.
"So for this approach in our region, four pilot districts were selected. There is one district in
the city which is the urban, it is the Cité des Palmiers district; a semi-urban district, the Edea
district; a district that is almost rural, that of Loum and a rural which is the Yabassi health
District. So then these districts were selected on certain basis. Understand that the basis
were: urban, semi-urban" NI_Policy marker1
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Policy entrepreneurs
The formulation of the PBF project in Cameroon was the fruit of the cooperation between the
officials from the MoPH (central and regional level) and actors from the World Bank, most
importantly consultants contracted by this institution. International consultants contracted by
the World Bank played a pivotal role by convincing the MoH that the great lake model was
the suitable PBF approach for the Cameroon context.
In addition to the financial support, the World Bank played an important role in imbuing some
central MoPH cadres with the PBF approach. This role contributed to the emergence of local
officials with PBF-related skills. This pioneer local staff was then able to vouch for the
formulation of the new PBF program across regions. This motivation and commitment at a
higher level must have played an instrumental role in the formulation of PBF in Cameroon.
"There were quite a few people who were trained in PBF, Regional Delegates of public health
and some people who became the managers of the PPA" NB_Partner1
The management staff of the initial PBF project implemented by CORDAID in the East
Region influenced to a certain extend the formulation of the PBF project in Cameroon. An
advocacy spearheaded by this staff resulted in the enrollment of the East Region into the
government PBF project.
"It was in 2008 that we went to Yaoundé and finally met the people in the Ministry and also in
the GIZ. But they were not aware of the project in the East. So we discussed with them,
arguing that: listen, you want to start the PBF and we have already been doing this for three
years in the East. We want to expand because the Catholic approach is only for Catholics, so
we want to convert this to a broader approach but we lack the means. It was at that time that
they finally agreed to insert the East in the project of the World Bank ..... That's how the East
got into this project" NB_Partner5
It emerged from the data that the development process of the PBF in Cameroon faced
opposition from some actors, mainly from other assistance or cooperation agencies. These
actors in many cases were protecting the integrity of their interests and projects’ agenda.
With the support of GIZ, the Cameroon Government initiated in 1987 a pilot model in the
North West Region that involved the community to improve drug management at the
regional level. Based on the success of the approach, the model was expanded to two other
regions later on: South West (1989) and Littoral (1991). Known as the "Essential drugs
program" and initially grounded on associative framework, this model became RFHP in
December 2010, with a public interest group status thanks to a law. The RFHP are regional
dialogue structures and consist of representatives of the beneficiary communities, the Ministry
of Health and donors and thus constitute participatory governance bodies in the health system.
The RFHP are more or less autonomous structures with no hierarchical or formal link with
CENAME.
Although at the end, GIZ appeared as a facilitator in the selection process of the 3 regions
(Littoral, North-West and South-West), our data shows that in the beginning, this important
partner was not favorable about using the RFHP as purchasing agencies for the PBF project.
However, it was not that influential compared to the World Bank so their resistance did not
dampen the formulation of the project.
"No ... well I think since it was GIZ who supported the Funds [RFHP], of course there was
this discussion with GIZ to use the Funds for the PBF and as you well know, GIZ was against
40 | P a g e
PBF in the beginning uh maybe specifically because of the free drugs choice policy"
NB_Partner1
Conversely, domestic players did not explicitly express opposing views regarding PBF. It
seems this was due to the fact that the PBF approach was new and therefore probably
unknown by policy makers and healthcare entrepreneurs.
"Initially, there were very few people who supported at the partner level because it was
changing the traditional way that people did things and therefore people were not so
comfortable to do so. In terms of partners, there were very few who supported it. At the
Ministry, the central departments did not feel concerned at all, they did not feel like it was
their business" NB_Partner4
At regional level, the Regional Delegates for Public Health with the support of the district
medical officers led the selection process for the pilot PBF health districts. Also at this level,
the formulation process of the PBF project was challenged by the resistance of some members
of the Regional Special Funds for Health who were afraid to lose control over these
structures. Actually, the implementation of PBF using the Special Funds as Purchasing
Agencies required the adjustment of the status of these entities to enable them receive public
funds.
"The obstacles were that members of the management committees of the RFHP thought they
would lose their autonomy as members of the regional dialogue structures" (NC_Policy
marker3)
Windows of opportunities
Evidence shows that international and national meetings served as windows of opportunities,
and contributed to advancing the PBF formulation agenda in Cameroon. A first event was the
Africa flagship course on health sector reform held in Kigali (Rwanda) in June 2010. During
this course, a World Bank official from Cameroon presented the formulation process of the
PBF project in this country and received feedback from other participants mainly from the
Great Lake countries where PBF was already being implemented (48). In addition, some
consultants who were in charge of designing the Cameroon PBF program were also
participating at this meeting and they used this opportunity to interact with two other
participants from Cameroon who will later on be AAP managers during the implementation
phase.
The Results-Based Financing (RBF) Third Annual Impact Evaluation Workshop held in
Bangkok in October 2011 was another forum where the formulation of the Cameroon PBF
project was enriched. At this meeting, participants including high policy makers and World
Bank officials from Cameroon were drilled on impact assessment of the Cameroon PBF
projects. Most importantly, during this meeting, Cameroon featured as Country Case Study
for the integration of Impact Evaluation into the PBF program design (49).
C. Implementation PBF Cameroon
At the end of the third quarter of 2009, the PBF project was formulated and had to move to
the implementation stage.
Problems stream
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Our analysis pointed out the main problems faced by the health system that required a change.
This included the legal environment of the country, with laws that dated back to the 1980s.
Some of these laws were inconsistent with PBF’s best practices. In some places, certain
people began PBF by putting these laws on hold, and others did not have the same courage
and did not apply certain PBF principles. Some controllers and inspectors who arrived at
health facilities understood that the PBF was a pilot project and thus tolerated non-compliance
with the laws in force. On the other hand, others took this as a violation of the laws and as
utter threats.
This led mainly to the lack of financial management autonomy for some health facilities,
sometimes causing tensions between hospital directors and the inspectors from the department
of finance. Indeed, the finance laws required that hospitals deposit their incomes to the public
treasury and to withdraw them later, after justifying the use of funds with a preliminary
budget draft. In contrast, the PBF guidelines required that all revenues of health facilities be
retained and be available immediately to improve the quality of care.
"The finance law requires that money produced by the hospital must be deposited at the
public treasury. You see? With the PBF, you need to retain the money; but with the finance
rule, you do not have the right to retain the money. The finance law is against PBF. The proof
is that the health centers, hospitals, must produce their money and deposit it at the public
treasury. But this is absurd! I fight against this procedure. Someone has his money, instead of
using it to produce more, you ask him to go and deposit it into the public treasury. Where
does their money go? How do they get it? At the end of the day, you have to walk behind
someone in the treasury office in order to receive part of your money, and this is after a
commission of 10%, 20%". Reference NI_Implementer10
The lack of human resources management autonomy was also an issue. Despite the fact that
some health facilities recruited local staff and paid them with their financial resources, staff
management remained centralized. Sometimes health facilities influenced the posting of
personnel in their structures by the MoPH while they were already overstaffed and, on the
other side, best trained PBF personnel were snatched from other structures, leaving them to
start all over with new people. This instability did not reassure the staff of health facilities to
invest their revenue to improve the productivity of the health facility in order to benefit in
future. They were not sure of being there later to reap the benefits of their sacrifice.
"... So we have a centralized management of human resources. That's a big problem. How are
we going to solve this? It is a difficulty. You see ... But if the state had a system let’s say for
example that a health center must have 5 trained staff, and their wage is wired to the health
center. The day that these staff do not work, they do not have their payment. You ...the head
was supposed to have authority over your personal such that if you do not work, you do not
even have salary and he recruits someone who is available to do the work. "
NI_Implementer2
The late payment of health facilities and health services was a major challenge for the PBF in
Cameroon. Delays of up to six months following submission of the payment constituted
difficulties for the health facilities regarding the execution of their business plans.
"Yes, the payment! Because what happens is that you are supposed to be paid at the end of
each month when you declare what you have done. When you do your declaration it is paid
but it is not regular sometimes for instance up to the end of year we were not paid from June".
NP_Implementer25
42 | P a g e
"The main problem with payments is that the payments were delayed and this makes our work
difficult. For example, if the business plan shows that we are to purchase some articles at a
particular point in time, the lack of these funds keep us helpless". NP_Implementer22
The abilities of some health facility managers to take responsibility for the transparent
management of huge amounts of money given to them, using management procedures that
they were not used to, was very challenging.
"So, how can the personnel who was familiar with small amounts of money now manage such
a huge funds? This is another problem. And we detected that many do not even know how to
spend in a manner that respects public spending standards. They have to be trained on how
to use these funds in a transparent manner because the aspect of good governance is very
important in the PBF" NI_Implementer2
There were also risks of conflicts of interest for the RFHP, the organisation that held the
monopoly of sales of essential medicines in public health facilities before the PBF program.
The pharmacies of health facilities belonged to the RFHP, which kept the profits from the sale
of drugs. With the coming of PBF, pharmacies of the health facilities were reassigned to
health facilities, and in addition they had the freedom to buy their drugs elsewhere apart from
the RFHP.
The majority of health financing in Cameroon is allocated to the central level of the MoPH as
well as the central and general hospitals. The operational level receives a small proportion of
the funds. In 2005, only 34% of the budget of the Ministry of Health was allocated at the
peripheral level compared to 61% at the central level, despite the fact that 80% of the
population uses services at the peripheral level (80). Moreover, several key informants noted
that only a very small part of the proportion that is allocated to the peripheral level actually
reaches the health facilities, due to enormous administrative procedures and corruption.
"But you know the input system? Eh, the ... the ... the management is centralized in Yaoundé.
Before money leaves Yaoundé on paper, only 3 to 4% may be left. There are leaks throughout.
And what are the consequences? The consequences are that health facilities are poorly
equipped, they are old, the staff is demotivated, you see? Priorities are not those expressed by
the facility itself; it is someone who is in Yaoundé who decides what to put in place in a health
facility which he has never seen" NI_Implementer10
District Health Services do not do regular supervisions due to lack of financial resources.
Some data indicates that the District Health Services imposed payments from health facilities
equivalent to a certain percentage of their budget to enable them to conduct their supervision
and coordination activities. In addition, the equipment purchased by the central level and sent
to the peripheral structures do not always match their needs.
Policies Stream
Once the formulation was done, the project had to find a suitable model to be implemented at
the level of regions. In order to ensure the sustainability and ownership of the intervention, as
well as to build on what already existed, policy makers identified, in each region, structures
with some degree of autonomy that already played a key role in the health system. These
structures were recruited to ensure the role of the Performance Purchasing Agency. The
Regional Funds for Health Promotion (RFHP), which are dialog structures in the regions,
consisting of technical and financial partners (1/3), members of the community (1/3) and
43 | P a g e
members of the administration (1/3) existed already in three regions (Littoral, South West and
North West). Their main mission was to supply of essential generic drugs in health facilities.
They also had a certain level of credibility and autonomy in the way that they managed their
financial resources. The policy makers decided to rely on RFHP for the implementation of the
project.
"It was giving some good results in these two interesting Funds [RFHP], North-West and
Littoral. And we thought : there must be something that we can build on with these activities
because first of all, all these things had several elements in common. One was: there was a
sense of accountability, there was an important attachment to good governance, there was
participation from several society. And most importantly, they were getting some good results
from...like for the two funds, you know, the drugs were available, and the inputs"
NB_Partner3
The East Region did not have a RFHP, it was initially proposed that the government would
sign by mutual agreement a contract with CORDAID, which was already implementing a
smaller PBF Project. The government committed to provide 2.5 million Euros to CORDAID
for a 2-year period during the intervention. Negotiations were well advanced and activities
were about to start when suddenly, the Government decided to stop the process, following a
recommendation from a consultant hired to formulate the project. This interview abstract is
from one of the key informant on this subject:
"Back in 2008, at that time the MoPH told us to propose a project without a call for tender,
and over time I even went to the Diocese of Batouri to develop a project document and I have
it here in front of me, it’s a project from 2009 to 2012, on request of the MoPH. This project,
we formulated it and negotiations dragged on ... and finally, I think in 2009 ....., the project
was accepted, and we even started. We had an opening session with the governor to start this
project in the East, and it was about to start in the Diocese of Batouri. It is the World Bank
consultant who told the minister not to execute this project. So, there was a workshop to
launch this project, but the official documents of agreement was not signed yet, and finally the
activities of this project never started; it was in 2009" NB_Partner5
We further investigated the reason why the Government decided to stop the process of the
mutual agreement with CORDAID. According to stakeholders, the main reason was the fact
that the initial CORDAID project (RESSEC) on which the agreement was built was too
closely linked to the Church authorities and could not be objective in playing the performance
purchasing role.
"In the East Region, there were major concerns notably the fact that RESSEC was linked to
the Catholic diocese and may not be able to assume the performance purchasing role with
public facilities. NC_Policymaker4
In the Littoral, North-West and South-West regions, although RFHP had already been
identified to implement the project, there were no major advances. The difficulties were
related to the ability of these RFHP to implement the interventions. Amongst these
difficulties, there was the problem of qualified human resources, especially the managerial
vision of these entities, which in their design and mandates were not accountable for
performance. In addition, the regulations in place did not allow the RFHP, which were public
interest groups, to receive public funds and to manage them according to market rules.
"In fact, from the point of view of designing PBF … it was thought that what was there could
do the job and that we could use the tools and structures that existed to do everything. None
44 | P a g e
of these structures had a vision and understanding of what the project was".
NI_Policymaker3
A re-assessment led to the conclusion that of the three RFHP, only that of Littoral had
sufficient capacity to be able to implement the project. The alternative that was offered was to
recruit international organizations with experience in the implementation of PBF to ensure the
PPA role in the other three regions (East, North West and South West). These structures had
to play the role of PPA and would in turn have a contractual performance relationship with
the health services and health facilities, that allowed them to directly receive cash funds
according to their performance and decide priorities to solve with these funds.
"Special Funds already existed but they were working on drugs, they did not know PBF. Well,
in evaluating the project, we said: It is them who will implement PBF. The Littoral was able
because it had qualified personnel. What therefore happened to the other regions? So the
Ministry and the Bank agreed to recruit international actors with proven experience in PBF,
who had already implemented it in other countries, on the basis of an international open
tender. Thus the European Agency for Health Development, that is AEDES won the contract
for the North West and South West. They were therefore the ones to develop the performance
purchasing agency in each of these regions" NC_Policy maker2
Policy entrepreneurs
Several actors played various roles in the PBF implementation in Cameroon, namely
policymakers from the central and regional levels, RFHP managers and technical assistants
from international organizations.
HSSIP ensures the management and coordination of the project at the national level and the
Project Steering Committee provides strategic orientations. The project coordinator and the
president of the steering committee played an important role in bringing the regional delegates
of health to adhere to the project. Most importantly, they negotiated the participation of
regional administrative authorities, especially during the launching of the project and they
contributed to the randomisation process of groups for impact evaluation.
These authorities from the central level of the Ministry of Health built alliances with actors
from the regional level to couple the problems with the policy streams. With their good
communication skills, lobbying abilities and political influence, they were able to persuade
the majority of the peripheral actors to adhere to the implementation of the PBF program.
The Bishop of the Diocese of Batouri and his team were also key actors in the implementation
of the PBF program in the East Region of the country. They influenced the Minister of
Health to extend the project to this region.
"What is it all about my lord? CORDAID, are you the one experimenting? The Minister was
not aware. CORDAID gave the floor to his lordship. His lordship returned the floor to us. I
presented the project and its strategies .... when we presented this approach to the Ministry
and the Bank, the Minister Olanguena said to the World Bank officials: I think you're right.
I’m convinced by this approach. I think that the East should be included" NI_Implementer2
The Littoral RFHP was the first entity to start the implementation of the PBF Project in late
2011. It influenced the implementation of the project in the other three regions. At the Littoral
RFHP, the following key actors succeeded in negotiating the autonomy of the PPA, despite
the risks of conflicts of interest: the Littoral Regional Delegate of Public Health, who was the
45 | P a g e
president of the Littoral RFHP management committee, the Manager of the Littoral RFHP
and the PPA Manager.
The technical assistants of AEDES and CORDAID also contributed to the coupling of the two
streams. They drafted the project implementation procedure manuals in their respective zones
of intervention, and were able to mobilize other actors, such as community-based
organizations, to be part of the project. In the North West and South West Regions, these
actors continuously negotiated with the FRPS to ensure their adhesion to the project and
especially their ownership.
The presence of all of these political entrepreneurs was an important success factor in the
opening of the windows of opportunities during the implementation of the project by
connecting the two streams of problems and policy.
In contrast to the Littoral RFHP, the RFHP of the North West and South West were not very
enthusiastic about joining the project. Although the actors of these regional entities did not
explicitly express their opposition with respect to the PBF - this may be understandable due to
the fact that directives came from the highest authority of the Ministry of Public Health -,
their attitudes, however, suggests that their position was much more mitigated.
"Because I'll tell you that the former manager of the Funds had been so resistant to the PBF. I
think it's one of the reasons uh ... that led to its replacement" NI_Implementer10
Windows of opportunity
The implementation of the PBF program benefited from a series of national, regional and
district meetings in order to move forward. In the East, North-West and South-West regions,
the official launching of the program was coupled with a two-day workshop. Participants
were frontline managers, community representatives and regional health stakeholders. The
PBF national coordination actors, the World Bank officials and the international
implementing agencies used the opportunity to explain the underlying principle and the raison
d'être of the program through several presentations, followed by discussions.
The majority of implementing actors in health facilities were trained in cascades during one-
week courses by the Performance Purchasing Agencies, health districts and regional health
delegations. These training opportunities helped them understand the PBF project and apply
its principles and best practices.
"We had one week of training at the regional level. After the regional level training, we came
back to the level of the Division where there was a one-week training. The first training was
in Bamenda at the regional level, our second training was at the district level".
NP_Implementer1
"We had a training on everything that concerns PBF: why a PBF program, how it will
function. So the training here was to see how the PBF activities should be carried out. With
training, people understand the project and then are motivated and there is an effort to
implement the PBF principles and best practices, especially regarding the autonomy, which
has given much zeal to others to be able to implement it, although there has always been some
bottlenecks" NP_Implementer19
In each of the four regions, a quarterly 3-day meeting in each district that was implementing
the program was scheduled to review the performance progress of each health facility. This
coordination meeting was a real opportunity to improve the knowledge and practice of the
46 | P a g e
front line managers. During the meeting, challenges related to the implementation of the
program were discussed and solutions were sought. Moreover, it is during this meeting that
the contracts between the PPA and the health facilities were renewed on the basis of a new
quarterly business plan.
"Each quarter, we have a restitution meeting in which we sit down, and we look at
performance at the district level, performance at the facility level ok, the facilities are based
on three different categories and … based on that they have subsidies which are paid to them.
Everybody is challenged at the different levels; at the district level, the district medical officer
is challenged, the director of the hospital is challenged and when we meet we identify factors
that cause poor performances and look for solutions". NI_Policymaker4
Other important opportunities seized by the PBF stakeholders to improve the implementation
of the program were the inter-PPA meetings. Under the coordination of the PBF national
coordination unit, a quarterly rotating meeting was organised between the four PPAs, the PBF
project management unit and the World Bank. Problems that could not be solved in situ
during the quarterly district coordination meeting were reported and discussed during this
national coordination meeting. For instance, the harmonization of the implementation of the
program across the four regions was a major recurring theme of the meeting.
Finally, two national focussing events were organized by the World Bank. On September 12th
- 13th, 2012 following a supervision mission in the four regions, the World Bank convened a
workshop in Yaoundé to discuss the progress, challenges and the way forward for the
successful implementation of the PBF by the four PAA (55). An interesting point discussed
during this workshop was the finding in bind with the imbalance in favour of curative services
at the expense of preventive ones in the delivery package of PBF activities.
The second event was the PBF national meeting on May 14th - 16th, 2013, that followed the
mid-term evaluation of the program (56). Major findings and solutions were discussed in
order to improve the implementation of the program.
"So during the assessment in May 2013, multidisciplinary teams visited the four regions. The
teams consisted of people from several departments of the MoH, partners, etc. They went and
evaluated how the PBF was running on the field. The evaluation intended to see if the
implementation was going as planned, to address the challenges encountered and propose
solutions". NC_Policymaker2
Perceived changes
The assessment of changes recorded with the introduction of PBF was mostly positive.
According to interviewees, data management and reporting improved significantly in the PBF
facilities. Patient statistics that were not initially being collected were collected when PBF
came. The emphasis on data and monitoring, which stimulated better reporting, benefitted
both the health facilities and the districts. In addition, through improved data quality, it also
increased the potential to improve the health management information system and decision-
making for other interventions.
"The PBF program has changed the system considerably. It has brought the improvement of
completeness and timeliness of data. And not only PBF data per se, but of the overall system.
Now, using data from health facilities, we are able to plan the best areas of intervention. This
was not the case before the arrival of the PBF". NP_Implementer25
"Before PBF, when we were told to carry out vaccination, we used to go and sit under a tree,
then check and fill the records. And few days or months after, there were measles outbreaks
47 | P a g e
because no child was actually vaccinated. Now with PBF, you cannot do that because as soon
as you check immediately, as soon as you come out, you send the report, two teams will go
down. Guys from the PAA will come to check what has been done through direct observation
and community survey by the local community based association. If those children are
vaccinated, the community itself will testify". NP_Implementer16
The drivers of success at the health facility level were related to clarifying the roles and
responsibilities of staff, enhancing supervision from the regulation level, and increasing the
reliability of service delivery from the financing and verification agency. Facilities required
support in planning and data management, as well as regularity in funding in order to
demonstrate to communities that quality services would be available. The appreciation of the
PBF program reveals that changes in work attitude occurred as workers became more
committed and where challenged to produce good results.
"We observed a change in the provision of health care facilities. Our registries revealed that
we gave consultations to many more people in a month than before. Moreover, today there is
a better division of labour: some personnel consult, others take care of the registries, others
take care of the pharmacy while others work in the laboratory. This prevents staff from being
over worked, rendering them more efficient at their various tasks. This was not possible
before". NP_Implementer22
The PBF approach pushes a level of autonomy to allow service providers to be imaginative
and inventive in order to improve the quality of care in their facilities. One such way was for
each health center and hospital to develop its own business plan stipulating activities to be
achieved in each quarter. This was done by all staff in participatory way in order to create a
sense of ownership. Informants in the in-depth interviews reported that they conducted their
daily tasks without any business plan before the PBF program. After the PBF training, though
challenging, things changed in some of the facilities as narrated by a chief of health center:
"There are lots of changes with PBF because the staff is now awake, work is now running
seven days per week, 24 hours / 24. And so, I think that's always the PBF vision which
facilitated the promotion of that program and especially the development of the business plan.
For example, the laboratory that used to be opened five days per week, now it works 7/7".
NP_Implementer13
Most of the participants implementing the project indicated thatthere were no clear financial
systems in their health facilities before the PBF program. With the PBF, all the staff sat
together with the community representative to establish a financial system in their facilities.
This improved the facility management. The PBF provided materials and equipment in the
hospital. Improvement of the governance was also mentioned as a great achievement of the
program.
“Before the PBF came here, there was no placental pit, we dug the placental pits. Thanks to
PBF, we have bought many beds, and that is a fridge there, a fridge which uses both
electricity and gas bought with the PBF funds. Then these blankets we just bought with
mosquito nets, all these things were not here” NP_Implementer20
"It's a magic pill [(laughs), magic pill], it's a magic pill. It is what we have to encourage.
Decisions should be taken according to needs. It should not be taken from above because it
has changed the face of hospital and between these months, between this period I can say the
change that we have had in two years is greater than what we had in twenty years".
NP_Implementer8
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Globally, informants mentioned that there were improvements in patients flow, community
satisfaction, standards of care and health personnel motivation.
"Yes, for example, the consultation rate has increased, the delivery rate has increased, quality
of care has improved, operation with the presence of doctor and outreach activities have been
put in place". NP_Implementer2
Most of the benefits mentioned were those related to the workplace. Nevertheless, the
interviews revealed some positive appreciation at the community level. Beneficiaries of the
PBF program mentioned that they appreciated the changes brought by the PBF program,
especially in regards to the improvement of the quality of care. Moreover, they reckoned that
the health personnel became more responsible and accountable. Interestingly, the vulnerable
population seems to also profit from the program due to some innovative strategies that health
facilities attempted to put in place in order to increase their utilization rate.
"Now in the health center, orphans or vulnerable children, when they don't even have money
they can have a consultation and they'll be still given drugs, and this is because of PBF".
NP_Beneficiary3
"At first, all of us here, we were not even interested in the health facilities around because
there was almost no staff, and even the services were expensive. And we used to hire vehicles
to go to Njinikom (75 km). But now, everything has changed and all the people here now use
the health facilities around. Even Bororos who used to deliver at home are using now the
health center". NP_beneficiary7
Despite the above-mentioned positives changes, there were some concerns about the cost of
such a strategy. The big concern focused on the sustainability of the PBF program. Many KIs
raised concerns about the medium and long-term sustainability of such a program when
external funding elapses.
"The PBF is a very expensive way of reaching results, I mean we have to pay the health
workers, medical doctors or nurses or I don't know who else to perform while they received
already a salary. My question is certainly on the long term because now this initiative is
heavily funded by the World Bank. What if the World Bank withdraws and there is no other
financial or technical partner? For some years, as the World Bank invests in PBF, that same
nurse will have not one hundred but one hundred and thirty thousand. Now if the World Bank
withdraws she falls back to one hundred, will she continue to do what she did for one hundred
and thirty thousand for one hundred thousand? The sustainability of the PBF is not certain
after the World Bank will withdraw the PBF funds in Cameroon". NC_Partner4
Some abnormalities were noted on the field such as the selection of incentivized activities.
Some care providers focused more on paid activities while neglecting the quality in order to
increase quantity.
"Other problems … is that the staff now tends to focus on indicators that produce more money
at the expense of the others. And it is the population that suffers. Other things, they also tend
to focus on the indicators with higher per unit cost and that are easy to achieve, so that they
can quickly get money". NC_Policymaker2
"I can tell you that one day I went to supervise a health center in a remote health district. And
when I arrived in the morning, I saw the security guard with a registry. Not knowing who I
was, I asked him what he was doing and he answered: I am the watchman, I just finished
work, I'm doing my home visit. You see ... it's the watchman, a security guard. who does not
understand anything, who was carrying out the home visit. Is this a home visit? What advice
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is he giving? The only thing is that he fills out the registry in order to have money".
NI_Implmenter10
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VII. TRANSFER OF THE PERFORMANCE PURCHASING AGENCY (PPA)
The handover of the purchasing role from an international operator to a national agency is
analyzed following an adaptation of the Dolowitz framework on policy transfer. Drawing
from this framework, we broke down the transfer process into several key dimensions: i)
Engagement of the transfer ii) Actors involved in the process iii) Purposes of the transfer iv)
Sources of transfers v) Different forms of transfers vi) Factors that promoted or restricted the
transfer and vii) Appreciation of the transfer.
We identified the dates that correspond to two key events in the transition phase. These dates
allowed us to segment the transfer process in 3 phases: (i) a pre-intensive phase, (ii) an
intensive phase, and (iii) a post-transfer phase. These two events are: 1) the PPA meeting that
was held in September 2014 and 2) the end of the contracts of the international organizations
(particularly AEDES) on December 31st, 2014. The period before September 2014
corresponds to the pre-intensive period. The months of September through December 2014
corresponded to the intensive phase. The post-transfer phase started in January 2015.
During the inter-agency meeting of September 2014, the question regarding the level of
preparedness for the transfer of the PPA management to the RFHP was raised. The
discussions focused on : (a) the inventory of the PPA’s properties and equipment; (b) the
PPA’s procedure manuals; (c) the number of personnel who were to be part of the PPA, their
profile and their proposed wages; (d) the estimated budget of the PPA (operation and
purchase of performance). Following the exchanges on these points, activities were proposed
and timelines were set to continue the transfer.
A. Engaging in the transfer process
In 2009, it was determined that the three RFHP in the Littoral, South West and North West
Regions could be eligible for a direct contract with the government, whereas the RESSEC
could be eligible in the East Region. However, in 2009, a follow up mission found that the
special funds in the South West and North West Regions were too weak and too involved in
the monopolistic system of essential drugs. In the East Region, there were major concerns
such as the fact that the RESSEC was too closely linked to the Church authorities and may not
be sufficiently objective to play the performance purchasing role. Thus, it was decided that a
mutual agreement would be given to the Littoral RFHP and that international organizations
would be recruited to play the PPA role in the three other regions (East, NW, SW). AEDES
was recruited for the South West and North West Regions while CORDAID was the PPA in
the East Region.
Thus, from the start, the RFHP was identified as a potential entity to perform the PPA role. It
was planned that the PPA role would be transferred to the RFHP after a certain period of
implementation in the three regions. In the meantime, this role was to be played by
international actors.
The vision of the transfer was established at the national level by the government of
Cameroon, as specified in the contract (47) with the international NGOs that played the PPA
role: "... the Ministry’s vision is to ensure that the performance purchasing agency role be
progressively assumed by RFHP "
"In their terms of reference, it was clear in the signing of contracts that the international
organization was to implement the purchasing agencies and prepare the transition. It was
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necessary to prepare the transition and it was already clear at that moment that it was to be
passed to the RFHP" NC_Policy maker2
B. Actors Involved in the transfer process
Several actors with varying levels of interest and influence were involved in the transfer
process.
Firstly, there are actors from the central and regional level of the Ministry of Public Health.
At the central level, there were mainly officials of the PBF project management unit (PMU).
These actors were very influential in the transfer process, because it is primarily at this level
that the guidelines and main orientations of the process were established. The transfer of the
PPA to national entities was a very important step for the PMU. At the regional level, the
regional delegates to whom the powers of the Minister of Public Health were delegated
ensured that the directives and guidelines from the central level were respected. They had the
ability to influence the implementation of the process and even the decisions at the central
level. Thus, the regional delegates of health greatly influenced the transfer process and their
level of commitment could facilitate or hinder the activities.
The technical assistants from the international organizations (AEDES and CORDAID) were
also at the heart of the transfer process. In most cases, they were the ones who initiated
contacts and meetings with other stakeholders at the regional level in order to help the
transition progress. It should be noted that the mandate of these international organizations
clearly stated that they were responsible for preparing strategies to enable the RFHP to take
over the project at the end of the contract.
The managers of the RFHP were another group of important actors in this process. The
RFHP, as the structure that had to take the new function of PPA, was of course a key element
in the process. It should also be noted that the regional delegates of health had a dual role in
the transfer process. More specifically, they acted 1) as regulator by virtue of powers
delegated by the Minister of health and 2) as the chairman of the RFHP management
committee.
"Well of course the MoPH and the regional funds itself, the local governments, the people
working for the purchasing agency currently and some technical experts. And they either
came from Cordaid or they came from some...well locally, we have some local experts who
have a lot of experiences establishing regional funds and had structure for it and also worked
in the transfer". NB_Partner7
"Well, the key actors involved were staff from the RFHP, the PPA and the South West
Regional Deligation of Public Health". NI_Implementer7
Finally, an actor, no doubt, less influential during the process, but very concerned about this
transition was the GIZ. In fact, it was this German bilateral cooperation structure that
supported the implantation of RFHP through technical and financial support.
C. The purposes of the transfer
Several reasons justifying the purpose of the transfer emerged from the data. Although the
project’s contract documents did not mention any justification for the transfer, the objectives
of this process seemed quite clear for some of the stakeholders.
One of the first reasons for the transfer was the "horizontalization" of the health system. With
a configuration where an international organization assured the PPA role, it gave the
impression that the PBF project was one of numerous vertical programs that exists in the
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country. The particularity of these programs is related to their partially autonomous
functioning in responding to one or a few specific areas of the health system and a lack of
integration within existing structures to strengthen the system in its entirety. Moreover, in the
context of Cameroon, a vertical program is often attributed to the donor or NGOs who
provide financial or technical support to the program. Therefore, it was not unusual for many
people in the community and even those within the health system to perceive the PBF project
as an AEDES or CORDAID project. This impression was reinforced by the fact that these two
organizations that assumed the PPA roles had their offices far from the buildings of health
services, and used vehicles that bore no sign of the MoPH, but only the logos of these
organizations.
"The PBF program is still viewed as a vertical program because it is implemented by a
vertical structure. It is important to replace the international NGO by a national structure
that was already carrying out other health activities" NI_Policy maker4
If the point of view described above represents the vision of the operational level players, the
understanding of actors at the central level seemed more focused on the aspects of
sustainability and ownership of the project. The ownership of the project was an essential
issue raised by actors at the decision-making level as well as the partners. In order for the PBF
approach to have a chance of being scaled up, it needed to be integrated within the existing
structures of the health system. This would increase its legitimacy for the partners and make it
easier to defend the government’s budgetary decisions. The objective of sustainability was
also partly linked to this ownership dimension. There was no doubt that the concerns of
sustainability and scalability of PBF were already part of the issues that arose at the central
level of the Ministry of Public Health. The transfer to the national structures was seen on one
hand as a strategy to minimize costs (the international organizations were more expensive)
and on the other hand as an excellent strategy to anticipate constraints during the scaling up.
"The PBF is an importation. When we import, we must first bring the know-how into the
country. Foreign expertise must not stay forever. It must be transmitted to the Nationals
because it is more sustainable and cheaper like I said earlier. So, it is more likely to remain
when it is nationals who are in control and it’s evidently much cheaper than importing work
forces" NC_Policy maker4
"The goals of this transfer as I said, is first of all, the ownership. It’s necessary that the
Cameroon government owns this approach more and more. And secondly, it aims... to
facilitate the scaling up of the project in the coming years" NC_Partner2
Some policymakers also saw the transfer as a way to legitimize the political ideology of the.
However, we were not able to dig further to know whether it was a political opinion
supporting or criticizing the actions of the ruling party.
"Handling the implementation of the project through a national organisation is a matter of
legitimacy, to demonstrate that the government is keen to ensure that citizens are fully part of
the project" NI_Policy maker2
The actors from the central level worked with experts from the World Bank, especially those
at the sub-regional office in Yaoundé, in order to plan the activities of the transfer process.
The World Bank’s main interest in the transfer process, as a technical and financial partner,
seemed to be the cost-reduction.
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D. The sources of the transfer
It was mentioned in the contractual documents that AEDES / CORDAID would contribute to
the training of the RFHP. To this effect, a competence development plan, with specific
objectives, expected results and time frame for the results was to be produced and discussed
with both the Ministry of Health as well as the regional delegations of health [Item 8.
Contractual document] (47). However, only CORDAID was able to provide us the plan.
Furthermore, the ministerial decision giving precise guidance for the transfer process noted
that the responsibility of AEDES / CORDAID in the management of the Performance
Purchasing Agency will be finished when the transfer is complete, indicating unambiguously
that the transfer process was to occur from the international organizations to national entities
[Article 5. Ministerial decision] (54). Finally, it was planned that the MoPH had to sign a
protocol of collaboration with RFHP for the implementation of the project [Article 4.
Ministerial decision] (54).
E. The different components of transfer
The first form of transfer which clearly emerged from our analysis was the transfer of
equipment, logistics and all technical tools. This transfer category labeled as "hard", aimed at
moving everything bought or developed by the old PPA to the new PPA to ensure the smooth
operation of the project; e.g. computers, vehicles, procedures manuals and others. In
accordance with the ministerial note of December 2014 on the transfer, it was stated in
paragraph 2 of Article 2 that the transfer would be preceded by an open inventory, with a
report signed by both parties. This would be conducted under the supervision of the Regional
Delegate of Health (54). The deadline for this transfer was set for December 30th, 2014.
"Good, all the equipment has been given to the RFHP, with minutes from the PPA because
the contract linking the international actors to the state, says that all equipment acquired
during the implementation of the project will be given back to the State at the end of the
implementation of the project. So all the equipment was given to the delegates, as instructed
by the central level, such that the delegates will in turn give it to the RFHP. So there were
three signatories to the minutes: the PPA , the delegation and RFHP" NC_Policy maker2
The other form of transfer was labeled as the "soft". It was about transmitting ideas, expertise,
and even what some called "the PBF spirit." This form of transfer was less measurable than
the first. It was essentially carried out through meetings, exchanges and trainings. In the East,
the common work period of six months was also a great opportunity to strengthen this form
of transfer.
The third form of transfer referred to the decision-making power. It was by acquiring all the
rights to make decisions that the RFHP gained their new title as PPA entities. This decision-
making power focused on the content of the PBF program. It included dimensions such as
management contracts with the regulators, care providers, and community-based
organizations. Although the cooperation agreement between the MoPH and the RFHP was
slow to put in place, the right of decision-making was granted de facto since it was guaranteed
at the end of the transfer. It materialized by the ministerial note of December 2014 and was
enforceable from January 1st,2015 in the North-West and South-West (54).
"they transferred.... not only documents. They transfer all their power to the special funds.
Because special funds became like the bosses of PPAs ... actually I think that when we say
transfer, it is at all levels . ... When there are furniture, logistics, they must transfer all of this
to the special funds" NI_Implementer8
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Finally, there was the issue of whether or not human resources would be transferred. There
was less unanimity between the technical assistants of the international organizations and
RFHP managers regarding this issue. The ministerial directives appeared to leave some
shadow areas that are open to interpretation. It was mentioned in point 1 of Article 2 of this
note (54)
"The present transfer involves human resources, logistics work, equipment and technical tools
to ensure continuity in the functioning of the Performances Purchasing Agency".
This was interpreted by some actors as meaning that the staff of the outgoing PPA would be
transferred to the new PPA.
"... The staff who was staff at AEDES will now become RFHP staff" NI_Implementer10
"I can’t really tell the components of the transfer as there is no memorandum for the transfer
up to now [End of February 2015]. Eeehhhmm, I think the components to be transferred
include: workers, assets, funds (some funds have been transferred representing the 4 months
owed to the health facilities). Some workers of the PPA will work at the regional fund. There
is no organisational chart or related documents" NI_Implementer7
F. Factors that facilitated the transfer
The most important factor that influenced the success of the transfer was the fact that this
transition was planned right from the start. Thus, before the project started, the consortium of
international actors clearly knew that they would transfer the PPA to the RFHP at the end of
their contract.
Another main factor that favoured the transfer process was the existence of qualified national
staff. Indeed, each year, Cameroon houses international francophone trainings on PBF.
Organized by a Dutch firm (SINA HEALTH) in collaboration with some national actors, this
intensive 2-week PBF course attracts more than 25 people coming from all francophone
African countries. Cameroonians usually represents half of the participants.
"We are currently organizing the 6th course, international course, in Douala. The first course
was here. All the other managers were trained with CORDAID. Now, we must have more than
200 people trained in the 14-day PBF course, with all of the approaches, all of the
philosophies. So there is the material, there are resources in Cameroon. ... for example in the
Littoral, they had no international organization. It's the people we trained who successfully
implemented the PBF in the Littoral" NI_Implementer2
An important point that was at the center of the transfer had to do with the restructuring of the
RFHPs. From their original status as associations, the RFHPs became Public Interest Groups,
following a law voted on December 21st, 2010. This new legal status confirms that the
RFHPs are dialogue structures, exercising a public service mission. It establishes a
partnership between the Government, several technical and financial partners, as well as the
community of the region represented by the members of dialogue structures. According to this
agreement, the RFHP acquired a legal status and financial autonomy. In June 2012, the North-
West, South West and Littoral each signed a Public Interest Group convention. Initially, it
was legally impossible for the RFHP to receive public funds and to manage them according to
market mechanisms. This transformation removes this obstacle.
While it initially focused on managing drugs and other health products, the RFHPs have,
since October 2013, developed a new organizational structure that includes a support
55 | P a g e
department for health promotion activities and partnership. It is this new section which hosts
the PPA.
"The re-organisation of the regional funds for health promotion to a public utility institution
made it a good structure into which the PBF could fit" NI_Implementer7
A level of commitment from the RFHP was also seen as an element of success in the process.
Since the MoU between the MoPH and the RFHP was slow to develop, the RFHP had to take
the risk, in some cases, by pre-financing certain activities pending reimbursement.
"So we are the ones who pre-financed the activities, just to make the process move forward
while waiting to sign the memorandum of understanding with the Ministry. I think what we
have pre-financing today should be more than 10 million (F CFA) now" NI_Implementer11
Unlike the North West and South West, the consortium of NGOs in the East had a six months
contractual extension to allow them to prepare for the transition. This was because the region
did not have a RFHP and thus had to create one. This was somewhat beneficial because it
seems that the difficulties observed in the first two regions allowed the latter to learn and be
better prepared. For example, in the East, there was a period of joint work and a well-
organized work plan with a clear deadline and budget.
"... In the East, we were able to do it, because CORDAID negotiated an extension with the
World Bank, so as to really give us the time to do the transfer ... we transferred correctly by
training people, supervising them, and it has a cost. It certainly has a cost, but it's worth
putting that cost and having a correct and structured transfer, than just giving the structures
randomly and saying that each person should struggle" NB_Partner5
"For the East Region, a six month extension of the contract was proposed because the
Regional Fund for Health Promotion was created in the East just in November 2014 and their
first constituent general assembly was held on January 28th, 2015. So now CORDAID will
stay for another six months to help them set up the agency for the first three months and then
follow up with them for a while. When they fly on their own, they will then withdraw
definitively" NC_Policy marker2
G. Factors that hindered the transfer
During the active phase of the transition, there were limited possibilities to plan the
implementation of the process due to the tight timeline (four months). This planning should
have been done long before this active phase. However, during the pre-intensive period, a few
actors were really concerned with the transition. Discussions often focused on how to
effectively drive the process. The different stakeholders, in some cases, appeared to
underestimate the level of effort, time and planning required for this transition.
The lack of planning during the pre-transitional phase manifested itself in different ways. For
example, it was not explicit whether there were clear guidance to carry out the process at the
central level, thus, leaving it to each region to drive things in their own way. With the
exception of the East, we did not find budgetary lines dedicated to the transition process.
A major difficulty was related to the legal framework in which the transfer was conducted.
There was supposed to be an official legal act in order to materialise the transfer. This act,
which was finally signed on December 24th
, 2014, stipulated that the transfer of the
management of the Performance Purchasing Agency to the Regional Funds was to be
effective from January 1st, 2015, in accordance with various contracts.
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"There was supposed to be a legal act which materialized the transfer of the PPA. So, here on
my desk I can show you the decisions that the Minister signed on the transfer of management
from AEDES to regional funds in the South West and North West" NC_Policy maker2
"The contract remained somewhat vague with respect to the transfer modalities. Hence, there
was a need for a ministerial memorandum to clarify the conditions and contents of the
transfer. But you know how things happen in our country. It always takes time. The result is
that the note was signed at the time the transfer process was supposed to be completed"
NI_Implementer10
Communication between the PPA managers and central and regional health authorities
appeared to be generally very good during the transition, but the front line staff was less
informed about the transition. The results of our analyses suggest that the participation of non-
executive staff was virtually nil during the many meetings devoted to the transition.
As mentioned above, the ministerial directive concerning human resources seems to have left
some gray zones open to interpretation. Likewise, point 2 of Article 3 of the ministerial note
(54) stipulated that: "The staffing plan will highlight the positions filled or to be filled in such
that recruitment is launch within the best possible time, based on validated terms of reference
and the profiles required by the post".
This different understanding of the directives from the central level created some tensions
between the outgoing PPA managers who expected that their staff would automatically be
transferred to the new PAA and the RFHP managers who considered that it was legitimate for
them to constitute a new team for the new PPA. Job offers were finally launched for the
recruitment of new staff, but in reality, it was the same personnel from the old PPA who were
selected, except those who, for various reasons, no longer wanted to be part of the project.
Although significant efforts were made to develop the skills and align the individual
objectives of the staff with those of the transfer, it was difficult to cope with the wider
consequences of the transition on the staff, particularly the fact that the Government’s budget
standards generally imposed lower wages for the new PPA staff compared to the wages
offered by the international organizations. The salary scales varied from one PPA to another.
PPA staff employed by international organizations were better paid (e.g., managers and
assistant managers) with the exception of verificators, than the staff employed by the PPA of
RFHPs. The transfer of the PPA to RFHP raised the issue of salary scale harmonization across
the different PPAs. The salaries of the staff (e.g., managers and assistant managers) was
reduced, leading to the drop out of almost all of this staff.
"The working conditions that the state offers for example, is not necessarily the conditions of
international organizations. Uhh, we have a little difficulty at this level because there are
many who are in the process of leaving because they prefer ..Euhh, some went to Nigeria,
some to Ethiopia because they already have the experienced, and then uhh .. We think it is
legitimate. We cannot oblige someone to work somewhere when he can have better conditions
elsewhere." NC_Policy maker1
"I do not know the salaries of the RFHP personnel, but what is certain is that the wages paid
by the international organizations are significantly higher than what the RFHP will pay. ...
What I regret the most is the staff that was trained under the PBF. I say nationals will not stay
in the country. That's regrettable" NI_Implementer10
Another concern had to do with the ability and willingness of the RFHP in terms of
competence and motivation to implement PBF through the PPA role. In July 2013, it appeared
that the North West RFHP was not yet ready to take over the PPA activities. This was evident
by the open reluctance of some of its actors. Some did not demonstrate that they wanted to
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possess the PBF-related skills and systematically blocked the process of giving the drug
management autonomy to the health facilities. In the South West, we noted some resistance
by the fund in handing over the management of drugs to health facilities and a weak
exhibition of ownership in the approach.
"You see, we made a first proposal for him [the manager of the RFHP] to go for training. He
denied that he will not go for the training. Most recently, I learned that, there is currently a
course expected for the Littoral and we asked him to attend. I think he still refused to go for
the training. How can someone manage the PBF activities if he is not trained? He had to be
removed! We cannot entrust one billion six hundred thousand dollars to someone who does
not know what is inside so uh ... that's it, it is very important that the institution, the
Management Committee of the fund accept the PBF" NI_Implementer1
The intervention of the HSSIP steering committee brought orientations regarding the different
steps to follow in regards of the scaling-up phase: (1) use the existing and functional
structures while waiting for the others to develop, (2) generalize the approach in other regions
that have RFHP, (3) extend and further reinforce the RFHP to eventually extend its mandate
to other projects of the Ministry of Health. Nevertheless, the shortcomings in the legislation
still persisted. For example there was no collaboration agreement clarifying the expectations
of each party between the RFHP and the MoPH. This was unlike the case between the
international organizations and the state in which contracts were signed, until end of March
2015.
“The Memorandum Of Understanding, MOU, between the Funds [RFHP] and the MoH is not
yet ready. So what is the benefit of Funds if the MOU is still on the table?” NI_Policy maker2
In addition, there were no formal post-transition support agreements in place. Instead, the
government’s guidelines defined a date when all of the activities of the international
organizations had to stop. From our analysis, it appears that this issue was never discussed
either before or during the implementation of the transition. This contributed in underpinning
some confusion. For example, the human resources problem of whether RFHP had to recruit
new staff or use the staff that worked for the international organizations.
The management of the transition process required a very high level of investment by various
stakeholders, necessitating repeated meetings between the staff of international organizations
and that of RFHP. However, the opportunity to extend this framework to include other actors
was missed. In practice, the efforts during the transition were limited between the incoming
and outgoing PPA actors. Little attention was paid to other stakeholders such as implementers
at the peripheral level.
From another angle, with an exception of the East, the transfer process was conducted without
establishing a cohabitation period during which the outgoing team would support the new
team. Instead, the new PPA was set up after the former team had stopped operations.
"In October, I asked the Funds to publish the job posting for managers ... so that we would be
able to do the recruitment one month after, in November, according to the law of the country.
It was also to take the months of November and December to guide the new managers, to
train them and transmit the project. Unfortunately, the central level requested that we
suspend the process" NI_Implementer10
"It is not a transfer only on paper, but all actors must really be involved in the business. And
generally, I found that the national level does not sufficiently take into account this support.
This should be organized, budgeted and having a correct and structured transfer, rather than
having the structures one after the other, saying that everyone should try their way"
NB_Partner5
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H. Appreciation of the transfer
While there were plenty of good reasons to do the transition, the process seemed very difficult
in the North West and the South West Regions, leading actors, especially those at the
operational level, to have some bad opinions on the transfer process.
"All the activities that we were supposed to be going on, they are now frozen. The new PPA
has not signed contracts with the health units up till now. The region has not come down or
supervision despite the fact that, we at the district, we are still going and trying to see how we
can actually carry out our activities. Ironically, we have received a letter from the regional
delegate that we should continue to carry out the activities as if the contracts were already
signed. You see, there is clearly a big gap. It is not moving the way it was moving".
NI_Implementer12
During the first three months of 2015, the post-transition period on which our analyzes were
done, the real achievement was the administrative effectiveness of the transfer, in the sense
that the consortium of international organizations had already withdrawn, giving room to the
RFHP, which was henceforth responsible for piloting the PPA.
The striking thing during this first quarter was the absence of contract for the PPA staff.
Furthermore, activities related to the implementation of the PBF program seemed to have
been in slow motion, e.g. the performance contracts with health institutions, regulators and
community-based organizations were not yet signed. Thus, there were no coaching activities,
reporting / verification and quality evaluation conducted in the two regions mentioned above
during this period. This was exacerbated by the fact that the central level had materialized
contracts with RFHP many months after the transition process officially ended in North West
and South West Regions. During our data collection period, the transition process was still
ongoing in the East because there was a six months extension.
"As soon as the RFHP took the control of the PPA, it caused some delays in the transfer of
funds and it created a lot of problems in the health units, until some personnel had to leave.
They resigned. They resigned because they could not be paid. The reserves that were usually
keept, were exhausted and some of the personnel left. Projects that were planned in the
business plan were suspended and so many things went wrong". NP_Implementer8
Lastly, the lack of immediate "gains" in the North-West and South-West regions seems to
have been a significant obstacle for the whole transition program, but could also have
contributed to better preparation of this process in the East.
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VIII. CONCLUSION
A group of policy entrepreneurs from the World Bank collaborated with senior government
officials to develop the PBF program in Cameroon, place it on the agenda, assure its adoption,
and conduct its formulation. While the pilot CORDAID project did not contribute to the
emergence of this World Bank project, it however influenced its design.
Currently, the scaling-up process is situated in-between the adoption and the
institutionalisation phases. The program has moved from a pilot project to a national scheme
(though not covering all the regions) and is currently attempting to progress to a national
policy with the integration of the scheme into the national health care financing.
Overall, the assessment of PBF-related changes seemed to be positive. Despite these positive
changes, there were some concerns about the sustainability of the program. Moreover, some
abnormalities were reported such as the pursuit of incentivised activities compared to non-
incentivised activities.
While the program may improve quality and health services' utilization, policy-makers must
remain vigilant to prevent or lessen its potential undesirable effects by paying particular
attention to deviant behaviours, more than ever during the scaling-up phase.
The experience in Cameroon suggests that key components for a successful transfer may
include: clear policy guidelines, an extended and sequenced timeframe for transition, a co-
ownership and planning of transition by both parties, a detailed transition planning, an
engagement of staff in the transition process, and the development of a post-transition support
phase.
Further researches need to encompass issues on health systems reforms that have to be carried
out in order to guarantee a smooth integration of the PBF in the health system during the
scaling-up.
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X. ANNEXES
A. Annex 1: Guide for in-depth interviews with key informants
Description of PBF
1) How was the PBF project initiated in the country?
A. CORDAID project: (starting, ending, beneficiaries, actors, funding
sources, setting, design, budget, content, monitoring and evaluation,
results, modifications, events ...)
B. Government project (starting, actors, beneficiaries, setting, design,
funding sources, budget, content, monitoring and evaluation, results,
modifications, events, phases, ....)
2) What pushed the government to engage in piloting the PBF project?
(Health Problems in the country at that moment, public health priorities, what
were the solutions developed by the government to resolve these priorities,
why was PBF adopted, who were the actors who contributed to the adoption of
PBF, what were the obstacles, what were the factors promoting, probe for:
country macroeconomic picture, donors aid conditionality, national leadership,
ongoing reforms, opinion leaders, health system performance, salary
levels, available evidence on PBF, expectations of the PBF, etc.) ....
Formulation
3) How the government project was designed (method)?
(the project formulation (use evidence, experiences ...), why this design (the choice
of regions, districts, .....), who influenced the process, who were the actors who
contributed to the formulation of PBF, what were the obstacles observed in PBF
formulation, the favouring factors, what was the contents, its definition, the
budget, the sources of finance,) ....
4) How was the government project implemented?
(Implementation (contents, problems and reactions of actors toward these
problems, adaptation strategies...), the results, the changes (positive or negative)
observed in the health system, existence of institutional archives, problems that
PBF has permitted us to resolve)
5). what are the factors (context, and actors) that favoured?
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(Promoting (competences, the prices, policy ...), restricting (very low salary, non
adapted legislations, lack of state leadership, absence of technical unity of PBF at
the central level ...)
5) What are the factors (context and actors) that hindered the implementation?
(Promoting (competences, the prices, policy ...), restricting (very low salary, non
adapted legislations, lack of state leadership, and absence of technical unity of PBF
at the central level ...).
6) How do you appreciate the project?
7) What are the strategies put in place by the government to scale up the PBF?
Assess the transfer of the purchasing role from international NGOs to National
agents in two regions (North-West and South-West regions) during scaling up phase;
8) Why did actors engaged in institutional transfer?
(Sustainability, existence of national competences, visible policy: ownership ...).
Why the choice of RHPF: Regional Fund for Health Promotion (RFHP) to insure
the role of PPA (Performance purchasing agency).
9) Who are the actors involved in this process?
10) What are the purposes of the transfer?
(Sustainability: utilisation of national institutions, cheaper...),
11) What are the sources of transfers? (From International NGO (AEDES) to a
national institution (grouping of public interest: FRPS NW and SW) (look
organigrams of the different entities).
12) What are the different forms of transfers? (functions (contents,
strategies, activities, responsabilities ...), equipments, human resources
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13) What are the factors that promote or restrict transfers?
(Promoting (competences, the prices, policy ...), restricting (very low salary, non
adapted legislations, lack of state leadership, and absence of technical unity of PBF
at the central level ...).
14) To what extent do the observed transfers resulted in a success or a failure?
( was it a complete transfer (only the new agency lead the activities) or partial (the
two agencies lead the activities), signature of contract by the new agency, existence
of resources (human, logistics, financial) in the new agency, are there still
activities carried out by the old agency?, appreciation of primary results (contracts
signature, coaching, payment of subsidies, coordination meetings, ....),was the
transfer done according to the calendar or there were some deviations?, does the
new agency have some specific difficulties?, how was the transfer process done
(degree of communication between the two sources of transfer, how often they work
together, exchange of documents, training of personnel,..).
Effect of PBF induced drug supply system liberalization on drug
accessibility
A. How was the drug supply system before the implementation of PBF?