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Towards constructive rethinking of PBF: perspectives of implementers in sub-Saharan Africa
  1. Serge Mayaka Ma-Nitu1,
  2. Lara Tembey2,
  3. Eric Bigirimana3,
  4. Christophe Y Dossouvi4,
  5. Olivier Basenya5,
  6. Elizabeth Mago6,
  7. Pacifique Mushagalusa Salongo7,
  8. Aloys Zongo8,
  9. Fanen Verinumbe9
  1. 1 Department of Management and Health Policy, Public Health School of Kinshasa, Kinshasa, Democratic Republic of Congo
  2. 2 Nigeria State Health Investment Project (NSHIP) Project Implementation Unit, National Primary Health Care Development Agency, Abuja, Nigeria
  3. 3 BREGMANS Consulting & Research, Bujumbura, Burundi
  4. 4 Health System Strengthening for Better Maternal and Child Health Results Project, Brazzaville, Republic of Congo
  5. 5 PBF National Technical Unit, Ministry of Public Health and Fight Against AIDS, Bujumbura, Burundi
  6. 6 National Nutrition Agency, Banjul, The Gambia
  7. 7 PBF National Technical Unit, Health System Strengthening for Better Maternal and Child Health Results Project, Kinshasa, Democratic Republic of Congo
  8. 8 Ministry of Health/RBF Program, Ouagadougou, Burkina Faso
  9. 9 Nigeria State Health Investment Project (NSHIP) Project Implementation Unit, National Primary Health Care Development Agency, Abuja, Nigeria
  1. Correspondence to Professor Serge Mayaka Ma-Nitu; sergemaya{at}yahoo.fr

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Summary box

  • As implementers of Performance Based Financing (PBF) in various countries in Africa, we have seen first-hand its benefits—but we acknowledge that there are challenges that require ongoing improvements, and that debates and critical analyses are opportunities to both question and strengthen the PBF approach.

  • However, constructive debates must be based on facts, value the large set of experiences and require that all parties listen attentively and objectively to the arguments of stakeholders, especially those with local knowledge and diversified institutional affiliations.

  • Notably, PBF was initiated in Rwanda, jointly by African and European experts—but we acknowledge that in our countries, PBF benefits from financial and technical leadership by the World Bank and other exogenous actors, and while exogeneity can raise problems, this is far from axiomatic.

  • PBF is an evolving strategy, with innovation and amendments by national actors based on their context—in Democratic Republic of Congo (a tool for a fair sharing of bonuses), Rwanda (community verification), Cameroon (urban PBF), Burundi (exemption of user fees), Burkina Faso (focus on indigents), Nigeria (coupling PBF with demand-side financing approaches) and Zimbabwe (risk-based verification to reduce administrative costs).

  • We see the value of PBF in its system-wide effects, such as improving coordination, decentralisation accountability and overall governance in the health system (including community engagement in health system governance), and completeness and timeliness of health information system data.

Introduction

Performance Based Financing (PBF) is a health systems reform approach with an orientation on results defined in terms of the quantity and quality of services. PBF has rapidly gained popularity in many low/middle-income countries (LMIC), in Africa especially, as a strategy towards better health outcomes, strengthened health systems and progress towards Universal Health Coverage (UHC). The World Bank’s Performance Based Financing Toolkit reports that in 2015 there were 34 PBF schemes, at either pilot or national level, …

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