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Scaling up Results-Based Financing for faster progress towards the Health MDGs: reflections on a recent donor meeting in Oslo

1/6/2014

24 Commentaires

 
Bruno Meessen (ITM, Antwerp) and Olivier Basenya (MoH, Burundi) report on a donor meeting hosted by the Ministry of Foreign Affairs of Norway dedicated to developing a road map for results-based financing (Oslo 11-12 December).

The countdown has begun: there are only 750 days left till the MDG deadline. On the side of donors and agencies, the ticking clock is only increasing the eagerness to accelerate progress. Politically speaking, this timeframe is indeed important in the North, especially in countries like Norway or the UK, where several political leaders have used much of their political capital to lobby for global health at national and international level. Against this backdrop, the PBF CoP facilitation team is fully aware that it also needs to attend donor meetings to explain, bring evidence and share experiences about Performance Based Financing. We were therefore happy to make the trip to Oslo to discuss with donors and aid agencies a road map for the scaling up of RBF(1).

The meeting was opened by Anthony Lake, the executive director of UNICEF, a strong indication that UNICEF is joining the club of agencies committed to integrating RBF in their policy toolbox. The first half-day of the meeting was dedicated to reporting on Results-Based Financing (RBF) progress. We heard about experiences in Tanzania, Zambia and Argentina – all of them belonging to the category of PBF schemes, which focus on barriers on the supply side (2). Olivier Basenya also presented the experience of Burundi. If you are involved in PBF projects, you probably won’t be surprised to learn that PBF is boosting indicators of key health services, especially those aligned with the MDGs, while also leveraging the whole system (in terms of work culture, accountability…).

On the second half-day, we first listened to aid agencies dwelling on recent developments on their part; some of these developments seem very favorable to RBF. For instance, we learned that the Global Fund has realized that their system of granting funding through ‘rounds’ created incentives for countries to avoid risks and in many cases led to proposals with very vertical approaches. The Global Fund will now adopt a more ‘health systems’-style approach, or at least to a greater extent than before. In the future, countries will be expected to organize a country dialogue going beyond the CCM (Country Coordination Mechanism). The new grant system of the Global Fund will also be much more supportive to strategies like PBF, which is seen as a great platform for integrating health service delivery at country level. Prospects seem also good on the side of the GAVI initiative. During the discussion about collaboration between agencies, the case of Benin was of course mentioned, as it is a country where PBF is being co-developed by the World Bank, GAVI and the Global Fund.

We then listened to donors’ (USA, Germany, Sweden, Japan, the UK and the Bill & Melinda Gates Foundation) own stance on RBF. All of them are positive about RBF, even if their involvement and financial commitment vary. Most obviously want to move at their own speed, for a number of reasons, including in line with the concern  not to outpace the progressive building of the evidence base. We realized that donor support to countries is still highly determined and shaped by their existing aid instruments (and national aid operators). So changes will perhaps come more slowly than we would like, in this respect, but we should already appreciate that Germany, the US,  the UK and the Bill & Melinda Gates Foundation are already funding pilot RBF schemes in different countries.

What are the key messages for countries?

In Oslo, we discussed of course many things. Here are some interesting messages for the ones among you who are involved in formulating and implementing RBF at country level.

  • RBF is recognized by the international community of aid actors as a key mechanism to accelerate progress towards the MDGs by focusing on frontline services. At country level, your own responsibility may be to use the MDG deadline to put pressure on donors and your government to commit to an agenda focusing on results. 
  • Having said that, it is also crucial to keep in mind that RBF must be anchored in broader and longer term agendas such as health systems strengthening and universal health coverage. This has important consequences: for instance, there was a consensus in Oslo that aid agencies adopting the RBF approach should support a single national RBF strategy (and not develop their own schemes). Hence, at country level, keep on working on the integration of your RBF strategy in the national health care financing strategy. Among other advantages, PBF is a great entry point for your Ministry of Health to learn to purchase health services in a strategic manner. 
  • Donors and agencies are willing to explore the many possible ways that exist for collaborating around RBF. For instance, it is of course possible to fund a RBF scheme without going through the Trust Fund managed by the World Bank. We felt a lot of commitment at this level, but some questions remain. We offered the service of the CoP to document and share some successful experiences (cf. Rwanda, Burundi, Benin…). 
  • Senior conference participants highlighted one of the greatest assets of RBF: the emphasis the strategy puts on learning and the opportunity it offers to improving one’s action. As illustrated by the experiences from different countries presented at the meeting, and aptly summarized by Tore Godal, the convenor of the meeting, RBF is a problem-solving strategy. Having said this, we believe that even more efforts could be taken to improve PBF, among other things, by better taking into account evidence generated outside the RBF community. For instance, to our knowledge, very few RBF schemes have already responded to the large body of evidence showing that neonatal mortality is one of the new priorities in sub-Saharan Africa. By the way, this is one of the many areas where UNICEF could contribute. 
  • Several experts shared their concern that at country level, RBF could suffer from system bottlenecks, such as poor availability of drugs and medical commodities. We agreed to coordinate our efforts to try to overcome this problem. On the side of the PBF CoP, our wish is to organize an event in 2014 whereby central medical stores would be able to meet their clients (health facilities). We believe that PBF has created a new ecosystem in which health facilities are much more demanding in terms of ancillary services. More about this soon.
  • One of the objectives of the meeting was to discuss the next stage (what needs to happen after the pilot stage). While it is hoped that donors will maintain and expand their support, the consensus is increasingly that domestic financing – or at the very least co-financing - will be the main solution in the future, especially in non-fragile countries. Our own assessment is that there still remains much to do at this level in many countries; in terms of advocacy and engagement (especially towards the Ministries of Finance), but also in terms of support (e.g. on how to adapt public finance mechanisms). 
 
A global learning agenda

As observed by the participants affiliated to the World Bank, the Global Fund and GAVI, a key asset of the RBF approach could be that it will lead to more cooperation between these three agencies, something which failed to happen so far, by and large. The first signs are encouraging. This needs to be confirmed at country level, of course, but we are optimistic.

In Oslo, we all agreed that RBF is a global learning agenda and that learning should not be limited to the demonstration of the impact (or not) of a strategy. In many settings, adjustment of policies will need to take place, in an iterative process, which confirms that the knowledge agenda will have to be connected with implementation. The community of practice has its work cut out, in other words.

Notes:
(1) We also had the opportunity to attend the gala concert in honor of this year’s Nobel Peace Prize winner, the Organisation for the Prohibition of Chemical Weapons, a great experience which  compensated for the fact that this time of the year is not exactly the ideal period for visiting Norway.
(2) More about PBF in Argentina (and global football icon Lionel Messi!) in a forthcoming blog post. 

24 Commentaires
Alex Hakuzimana link
1/7/2014 02:13:16 pm

Thanks Bruno and Olivier for sharing your insights out of this high level consultative meeting. With my experience in design, piloting and implementation of RBF strategy in Sub Saharan African countries, I’d like to say that:
- It is the mandate of country governments to ensure geographical equity in mapping interventions to offer equal opportunities and fairness to access health services to the their population. We’d bear in mind different governments that are piloting or implementing RBF do not have enough expertise to do so given its complexity. The reality from the ground is that an RBF approach, once its feasibility is agreed upon, needs intensive ans strategic support from the funding agencies (and or implementing agencies) so that the local health systems matures and be able to take over all operations inherent to it.
- To make RBF a success and hence leading to its adoption as a national policy in the longer term, one of enabling factors is the government endorsement of RBF approach;
Although RBF should be adapted to local contexts, there is strong evidence that major health sector reforms are required for a smooth implementation and integration of RBF in the existing health systems. These include among others decentralization of health care systems and services together with devolvement of regulation and delivery of services to lower levels, strong partnership between governments and NGOs, improvement of accessibility to services, rule of law, control of corruption and accountability. Ownership by government and civil society is a key determinant of success of RBF. What are more important again are the autonomy of service providers and the existence of non-monopolized drug distribution system. To summarize, I would say that main reform areas should be on health financing, human resources, district health services, decentralization, pharmaceuticals, monitoring and evaluation, infrastructure and partnerships.
- The ultimate goal of RBF in a given country should be to implement one, single, financing mechanism that can, effectively, be used to deliver health outcomes. During my work in Mozambique, I learned that there were RBF schemes as many as funding agencies and their implementing agencies, say 6 RBF schemes. You can guess the challenge the MOH has been facing notably to coordinate and lead these RBF efforts. Scaling up RBF nation-wide in the health sector means that RBF would become part of an overall health sector financing strategy. It is then relevant to evaluate the current share of RBF in health sector financing in order to plan its possible evolution. Here I think the integration of the RBF mechanism with other financing sources is crucial.
- RBF helps governments to address two key priorities including health related MDGs and health systems strengthening especially when targeted service areas such as MCH and HIV/AIDS services are carefully incentivized. Although no strong evidence is so far available, but results from Burundi and Rwanda are there to highlight how by reducing inefficiencies in public health sector spending by financing services based on performance and addressing HRH shortages by focusing on maximizing the productivity and performance of existing healthcare workers and motivation of facilities and their workers to improve overall service quality, RBF schemes have contributing to reducing maternal and child mortality.
- Once again on institutional scaling up of RBF, I think there are many scenarios or options that are country specific. I will give examples of a scenario where there is full separation of roles of regulator, purchaser and provider; an integrated scenario where a given government entity (e.g. MOH) acts as national purchasing agency in contract with the Ministry of Finance as fund holder etc. There might be several transition scenarios, but all this will depend on stage of implementation and readiness of all stakeholders.
- So what is the future role of RBF? For a given country, RBF must be considered as a potential important new financing channel. The crafting of an overall health care financing strategy likely proposes a mixed financing approach with various mechanisms and RBF has to be developed in coherence with the other financing mechanisms. Most importantly, RBF might become a first step to develop demand side financing, especially in countries where the insurance coverage is still very limited. I see RBF becoming a forerunner for the development of a national health insurance given its principles of division of tasks, of contractual mechanisms and of establishing a pricing system.

Hope to read others' comments and reactions.
Alex

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Sieleunou Isidore
1/8/2014 03:53:25 am

Thanks Alex for your comments. I would also add my voice to your to thank Bruno and Olivier for this blog.
We really welcome this stronger partnership between several aid agencies/institutions for health centered around RBF which we consider as an innovative health financing strategy.

I particularly like the interest of the GF for this strategy. For several years that GF have started their programs, there were only busy checking receipts. With RBF, they will now learn to focus on measuring results and this represents a huge paradigm shift. These include performance indicators that are mainly inputs rather than outputs or outcomes, not rigorously measured and inaccurate, and only weakly linked to the money. At present the Fund still needs to ensure that part of a grant’s funds are explicitly linked to performance.
It also remains unseen how much voluntary uptake the Fund will be able to articulate an overall policy that improves from its current system.

Finally, from my own view, key policy messages at the level of the country requires: (1) strong political leadership and long-term commitment; (2) scaling up; and (3) fiscal sustainability

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Dr TAPTUE FOTSO Jean Claude
1/8/2014 05:29:08 am

Merci Bruno et Olivier pour ce blog et bonne et heureuse année 2014.
Les informations venant de cette réunion nous donnent beaucoup d'espoir et encourage à continuer de travailler avec les acteurs du terrain. ce sont les résultats du terrain qui vont inciter les changements, tant au niveau des partenaires techniques et financiers, qu'au niveau de nos gouvernements. Nous sommes contents de voir que les agences d'aides au développement peuvent se rapprocher pour soutenir le PBF. Les différents structures gouvernementales dans nos différents pays (ministère de la santé, ministère des finances, ministère de l'éducation, ect.) doivent également se rapprocher pour opérer les reformes et mobiliser les ressources nécessaires pour le développement du PBF. C'est l'un des chantiers sur lequel nous devons travailler en 2014, j'espère, pour que le voyage PBF continue avec un impact significatif sur notre système de santé.

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Louis RUSA
1/8/2014 06:28:52 am

Dear Cop Members,

Let me also start by thanking our collegues who played a key role in this very important meeting. I, by the same occasion salute Alex and Isidore for their observations.

I would like first to focus on the MDGs: For sure a big number of Countries won`t achieve the millenium goals, but it is important to notice that during these last ten years, so many progress have been made by the LICs in terms of health indicators improvement. So, my thaught is that the deadline be extended for almost five years (2020). For those which will achieve some MDGs, it is important to think about the sustanability of the achievement, because very soon they can become worst.

Having Said this; I recognize the efforts made by the donors such as GAVI, WB and GF. If they decide to invest more in health financing and health system strenghtening it will be a good aproach for them.

There is something we seem to forget: The Paris declaration. The traditional financing rules for many donors didn`t allow beneficial countries to align and harmonize, saying that countries don`t have capacity or there is no transparency in their financial system and so on....I think we need to revisit this declaration and recall all stakeholders that something failed.
Now about RBF: can it help accelerate the achievement of the MDGs? yes if it is well implemented and if goverments are involved in the process, but the demamd-side need in combination to be also seen as an other bridge to cross. Because RBF tackle the issue of quality of care and didn`t adress the issue of access to health care.
The decentralization of funds at lower level where it is mostly
needed is one of the reason of implementing RBF in order to strengthen the health system, but there is need of regulation to avoid misuse at that level.
For RBFers we need to focus on one pilar of RBF, which still is not well done: The contract management. In many situations the contracts well signed exist, but the management of these contracts is a headache. If we need to mantain a good image of RBF the contracts must be managed every month, which call for more managers.
Yours faithly

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BASENYA OLIVIER
1/8/2014 10:31:59 am

Thank Alex , Isidore, Jean Claude and Louis for your useful comments.
I think like some of you have pointed out it’s time to consider PBF in the overall framework of universal health coverage . In this context, countries should gradually develop a national funding strategy (if not done yet) taking into account all financing mechanisms include PBF. Regarding the universal health coverage agenda, my opinion is that PBF should play a major role in two areas : (i) Quality of care improvement and (ii) demand side strengthening (PBF at Community level) .

Obviously the involvement of Governments remain a key challenge and strong advocacy should be conducted towards Finance Ministries in order to get some public funds in PBF. In addition, it is also important to reform our health systems including giving more autonomy to health facilities to allow them more flexibility and therefore more performance.

One of the key issues discussed in Oslo is the poor availability of drugs and medical commodities. It was found in some contexts that facilities had sufficient resources to purchase drugs but were faced with shortages at central stores or other suppliers among others problems. This is a complex question to which the CoP will reflect during this year 2014.

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Robert Soeters and Godelieve van Heteren link
1/8/2014 01:34:37 pm

En Français en bas

Dear Bruno and members of the COP PBF,

A happy 2014 to you all! We read Bruno’s report on the donor meeting in Oslo with pleasure. It is great to learn that so many donor agencies now converge on an agenda to stimulate performance in health systems. We feel the COP PBF efforts to engage and seek compromises have been paying off! Nonetheless, we like to stay involved with the shape that debate is now taking and therefore wish to share a few questions and observations.

First of all: the more stakeholders there are, the more clarity of terminology becomes important. In many training courses we still observe confusion around the exact meanings of RBF and PBF. We do not wish to enter tedious semantic discussions, but think it is important that the PBF community needs to continue to explain how RBF and PBF relate and use the terms accordingly. This because we do not wish to be punished in evaluations for projects, which were sold as PBF, but that were not properly conceived. Most experienced PBF community members already have a good idea about the best practices, theories and instruments that define PBF, but it remains important in repeating these explanations, in particular to those stakeholders who are new to RBF or PBF. In all countries, even in some of the PBF pioneer ones, there are many new participants; so to be clear about the terms is important. For details on the definition, best practices, theories and instruments consult: www.sina-health.com

In practice, we still observe that all kinds of different initiatives are labeled RBF and PBF, which may lead to confusion and difficulties in evaluating these activities. We encountered, for example, problems with the 2010-2012 RBF project in Katanga DRC that tried to mix RBF with free health care and a top down approach with little respect for the autonomy of health facilities. When this program was evaluated for their impact, it showed none, while at the same time other projects in DRC that were properly conceived such as in South Kivu and Kasai had been very successful. Similar problems occurred in the national RBF Sierra Leone and Afghanistan programs. In short, several RBF initiatives (whether from DRC, Afghanistan or Sierra Leone) did not pass the PBF feasibility scan we use to do a quick assessment of the PBF dimensions of a particular scheme. Other examples of problems with unclear RBF definitions can be observed in Malawi, Zimbabwe and Tanzania where donors and NGOs promoted RBF initiatives with some clear design problems in recent years which consequently did not immediately show the desired results Fortunately, in the process and by serious dialogue with the Ministry of Health leadership in several countries, the situations are sometimes mended. Lightheartedly, we sometimes say, “a certain amount of PBF puritanism remains important”: PBF projects should be designed properly based on what we know so far about PBF best practices. This does not mean we do not recognize the vital importance of different circumstances or change strategies, which may be necessary in different countries.

A second observation about the Oslo conference report concerns the part about the Global Fund and their willingness to adopt performance system. Yet, as far as we understand, the GF plans still remain too centralized and their budget remains for 80% input-based. The last point unfortunately constitutes a killing assumption for successful PBF. We know that changing from input to performance payment systems takes time, because it is like the proverbial big oil tanker changing direction. We also suspect that certain informal lobbies in and around the Global Fund may wish to maintain the centralized input approach because jobs may depend on it. So how do we - as PBF community - find the right balance whereby on the one side we encourage the Global Fund leadership to change course, but remain cautious about the fact that the GF has not yet fundamentally decentralized the decision-making responsibility on inputs from Geneva (and the Principal Recipients) towards the health facilities with a healthy dose of competition. Endorsing the Global Fund too simply would be counterproductive and may again dilute and confuse the potential of properly designed PBF initiatives.

A third observation about the Oslo conference report pertains to the following statement: "Several experts shared their concern that at country level, RBF could suffer from system bottlenecks, such as poor availability of drugs and medical commodities. We agreed to coordinate our efforts to try to overcome this problem. On the side of the PBF CoP, our wish is to organize an event in 2014 whereby Central Medical Stores would be able to meet their clients (health facilities). We believe that PBF has created a new ecosystem in which health facilities are much more demanding in terms of ancillary services. More about this soon".

In different PBF projects (such as in

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Bruno Meessen
1/9/2014 01:48:50 am

Dear Robert,

Thanks for your message. One of the main goals of the CoP is to identify good practices and to share them. I believe that all of us, through different channels, have been quite successful in this endeavor, even if much has still to be done (including in the identification of good practices – let’s not stop self-satisfied in the scrutiny: cf the invitation in the blogpost to get all of us thinking how PBF could contribute to better address neo-natal/infant mortality). I believe that the forthcoming publication of the PBF toolkit will be another major step in this knowledge process.

There is a multitude of people and actors trying to address various health system problems in very different contexts. This leads to a variety of approaches (and acronyms). My observation is that once experts recognize that there is a need to get incentives right, at the end, they often come to similar conclusions. In Oslo, Olivier and I were struck how the experience in Argentina, which has not been in contact with the body of experience in Africa, shared similarities with PBF (importance of autonomy…). When Anna Gorter, Por Ir and myself reviewed the evidence across RBF schemes (vouchers, PBF, Performance-Based Contracting) (cf
http://www.bmz.de/en/healthportal/knowledge/issues-discussion/RBF-maternal-health/index.jsp), we also realized that many lessons were converging. It is our responsibility to share our experience and body of knowledge, but it is field experts’ responsibility to design and improve their schemes. If they are professionals, they will do their best to learn from others’ experience, pay attention to the design (and adapt it to their context), monitor progress of their schemes and improve them progressively. I believe a lot in this constant learning process.

However, if active knowledge management can do a lot, we should not be naïve. Power is also a key determinant. I have heard of RBF schemes which are mainly serving the interest of their implementers (with a large share of the budget not reaching the health facilities). Your eagerness to fight these practices is really helpful. I believe that the question “how much of your aid goes directly to the frontline?” will become, in a close future, one of the main ones to assess aid.

As for drugs (and the Global Fund), see my response at the bottom of your second message.

Best,

Bruno

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Robert Soeters & Godelieve van Heteren
1/9/2014 01:43:22 am

In different PBF projects (such as in South Kivu in DRC and Douala in Cameroon) we learned that it is important for autonomous PBF health facilities to have access to multiple distributors of essential drugs, equipment etc, which are accredited by government regulators. So the fundamental change is that the system needs to become demand driven instead of supply driven through one Central Medical Stores system. In such logic, the focus of the PBF program becomes to strengthen the pharmaceutical regulatory authorities with performance frameworks. This assures that there is competition and that also private sector health facilities will have access to accredited good-quality distributors. In the long run this would mean that ALL pharmaceuticals come under regulatory control by encouraging the high quality distributors and discourage or even close down the poor quality ones. To the contrary, the Oslo conference statement above could be read as an endorsement of a single government central medical store. In urbanizing Africa, this would completely overlook the reality that most out of pocket health expenditure passes through the private sector and that for health systems to have an impact we should engage with the private sector and regulate them on quality. Maybe we misread the Oslo report statement but then it would be good to add something along the lines that the COP PBF community during 2014 aims "to strengthen the regulatory capacity of government partners to better assure the quality in the pharmaceutical market operating in competition".

Looking forward to hearing from you,

Robert Soeters and Godelieve van Heteren.

Summary of main observations:

We propose to remain clear on what exactly is the meaning of the terms RBF and PBF. This because PBF projects should be well designed based on what we know so far about PBF best practices. Poorly designed PBF initiatives may consequently not show results and become a risk for the reputation of PBF.
While we applaud the Global Fund willingness to adopt performance systems we also understand, that the GF plans remain centralized and for 80% of the budget input-based. This would unfortunately constitute a killing assumption for successful PBF. Endorsing the Global Fund too simply could therefore be counterproductive and confuse the potential of properly designed PBF initiatives. The COP PBF should therefore further engage and advocate for the proper design of GF programs.
One of the Oslo conference statements could be read as an endorsement of a single government Central Medical Store system. Maybe we misread the statement but then it would be good to add something along the lines that the COP PBF community during 2014 aims "to strengthen the regulatory capacity of government partners to better assure the quality in the pharmaceutical market operating in competition".



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Bruno Meessen
1/9/2014 02:47:27 am

Dear Robert and Godelieve,

On drugs (and to some extent the Global Fund):

Two caveats first:

1/ Ensuring quality of drugs is something really complex. I do not consider myself as an expert in this field (even if I managed a Prefectoral Medical Store during two years at the beginning of my career), but my assessment is that the Global Fund is very attentive to this aspect. See here http://www.theglobalfund.org/en/procurement/

2/ Let's never forget either that there are returns on scale on drug procurement, storage and management – so buying drugs in a centralized way can be very efficient (this does not mean however automatically a monopoly, but expect an oligopoly at least).

Having said this, two remarks:

(1) there is a strong commitment at our level to address the persistent problems of drug shortages in many countries; we will do this without dogma. We also heard a lot of goodwill from several actors present in Oslo to address this problem. Hopefully, a coalition is in the making.

(2) I fully agree with your reformulation of our blog post: the COP PBF community during 2014 should also try to aim "to strengthen the regulatory capacity of government partners to better assure the quality in the pharmaceutical market operating in competition".

This is, by the way, also very in line with two priorities identified at the Dakar Conference organised by the CoP Health Service Delivery. I quote:

Priority 1. Steering pluralistic health systems - Ministries of Health and other actors have to embrace a much more inclusive and flexible vision of local health systems which recognizes that the African societies of today are pluralistic. This new vision has many major institutional and operational implications. The main one is the requirement to adopt comprehensive, informed and flexible stewardship approaches that mobilize, both at national and district levels, new mindsets, skills and policy instruments (such as data intelligence, benchmarking, strategic purchasing and mechanisms ensuring accountability to citizens).
Priority 7. Public private partnership - Private providers are both a challenge and an opportunity. We strongly recommend governments to create the right conditions for bringing the private sector on board, by defining partnership policies, guidelines, criteria for collaboration and health care financing schemes which offer a long term perspective to the collaboration; this requires the development of the expertise and the appropriate toolbox of policy instruments to align private-for-profit providers on the goal of UHC, and this both at central and district level.

You can access the full report of the Dakar conference, the 10 other priorities and many more recommendations here: http://www.health4africa.net/harare25/

Improving the quality of all the drugs circulating at country level will obviously be a challenging endeavor, which will take time. If we want our CoP to play a role in that, we will have to realize that our role will be partial and will require us to develop a broad coalition of actors. We are about to write a concept note presenting the event we want to organize in 2014. We will not necessarily limit our list of participants to public central medical stores. We will make sure to have pharmacists with us (we must accept, humbly, that we have to listen to them as well). I am personally not against having some private for profit wholesalers with us as well. I also understood from Oslo, that several agencies will be willing to help us with this program.

So it seems that we are starting 2014 with quite high ambition!

Best,

Bruno

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Bruno Meessen
1/9/2014 04:41:44 am

A useful blogpost for this discussion:
http://blogs.cfr.org/patrick/2014/01/07/guaranteeing-that-our-medicines-are-safe-building-a-global-coalition-of-regulators/

Michel Muvudi
1/9/2014 02:03:10 am

Merci pour vos riches commentaires
Je pense que de plus en plus, le doute sur le PBF se dissipe, principalement grâce aux preuves scientifiques et factuelles que cette stratégie de financement a apportées dans le cadre de l’amélioration de l’accès de la population aux soins de santé de qualité. Le terrain nous a montré que le PBF en synergie avec d’autres mécanismes de financement potentialise l’atteinte des résultats de qualité et principalement dans le domaine de la santé mère et enfant.
En RD Congo, par exemple, le dialogue entre les Bailleurs de fonds (Union Européenne, Banque Mondiale, Unicef etc) et le Ministère de la santé se cadre de plus en plus sur la mise en place des stratégies provinciales de financement incluant très fortement le PBF comme outil de financement. Cette inclusion du PBF n’est pas magique mais elle est tributaire des bénéficies générés par le PBF dans le cadre de l’amélioration de l’accessibilité de la population aux services de santé de qualité. Des expériences sont légion et dans des contextes variés que présente la RD Congo
A ce jour, le PBF est en train d’insuffler un vent fort dans les reformes du secteur de la santé en cours en plaçant au centre, la santé de la population dont la participation et la voix ont été fortement améliorées partant des vérifications communautaires initiées dans le cadre de la mise en œuvre du PBF. L’interface patient-prestataire présente de plus en plus un visage positif. Vu jadis comme un simple outil de financement, le PBF représente toute une reforme du financement de la santé qui remet en place la pyramide d’allocation et d’utilisation des financements de la santé (multi-source) dans un pays ou le gros du financement se place souvent au sommet. Le PBF permet ainsi d’allouer plus de financement à la ligne de front, au niveau ou les soins de santé sont produits.

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Robert Soeters & Godelieve van Heteren link
1/9/2014 02:49:27 am

Traduction en FRANÇAIS des commentaires postés hier en Anglais - 1

Cher Bruno et tous les membres de la CdP PBF,

Un heureux 2014 à vous tous! Nous avons lu avec plaisir le rapport de Bruno sur la réunion des bailleurs à Oslo de Décembre. Il est bon de savoir que tant de bailleurs de fonds convergent maintenant sur des initiatives de performance pour les systèmes de santé. Nous pensons que les initiatives de la CdP PBF pour chercher le dialogue ont porté leurs fruits ! Néanmoins, nous nous plaisons à rester impliqué dans la forme que le débat est en train de prendre et donc souhaitons partager quelques questions et observations.

Tout d'abord : plus les acteurs sont nombreux, plus la clarté de la terminologie devient important. Dans de nombreux cours de formation, nous avons observé encore de la confusion autour des significations exactes des termes « RBF » et « PBF ». Nous ne voulons pas entrer dans des discussions sémantiques fastidieuses, mais pensons qu'il est important que la communauté PBF doive continuer à expliquer les significations des termes RBF et PBF. Si non, nous risquons d’être puni dans les évaluations de projets, qui ont été vendus comme PBF, mais qui ne sont pas correctement conçus. Les membres de la CdP PBF plus expérimentés ont déjà une bonne idée sur les meilleures pratiques, les théories et les instruments qui définissent le PBF. Cependant il reste important de répéter régulièrement ces explications, en particulier pour ceux qui sont nouveaux dans le RBF et le PBF. Dans tous les pays, même dans quelques-uns des pionniers du PBF comme le Rwanda et le Burundi, il y a beaucoup de nouveaux participants, de sorte qu’il est important d'être clair sur les termes. Pour plus de détails sur la définition, les meilleures pratiques, les théories et les instruments PBF voir le livre PBF à: http://www.sina-health.com

Dans la pratique, nous observons encore que toutes sortes de différentes initiatives sont étiquetées comme RBF et PBF, qui peuvent conduire à une confusion et des difficultés dans l'évaluation de ces activités. Nous avons rencontré, par exemple, des problèmes avec le projet RBF 2010-2012 au Katanga en RDC qui a essayé de mélanger le RBF avec des soins de santé gratuits et une approche de haut en bas avec peu de respect de l'autonomie des structures de santé. Lorsque ce programme a été évalué, il a montré aucun impact, alors que dans le même temps d'autres projets en RDC qui ont réuni les critères de PBF plus correctement comme au Sud-Kivu et du Kasaï ont eu beaucoup de succès. Des problèmes similaires se sont produits dans les programmes nationaux RBF de la Sierra Leone et l’Afghanistan.

En bref, plusieurs initiatives RBF (si de la RDC, l'Afghanistan ou la Sierra Leone) n'ont pas réussi le teste de faisabilité que nous utilisons pour faire une évaluation rapide des critères PBF d'un projet particulier (voir le page 86 du livre de cours PBF). D'autres exemples de problèmes de définition RBF obscures étaient observées au Malawi, au Zimbabwe et en Tanzanie, où les bailleurs de fonds et les ONG ont initialement promus des initiatives RBF avec de sérieux problèmes de conception, ce qui par conséquent, n'ont pas montré immédiatement les résultats souhaités. Heureusement, dans le processus et par un dialogue sérieux avec le Ministère de Santé des différents pays, ces problèmes de conception sont parfois réparés. D’une manière gaie, on dit parfois que « une certaine quantité de puritanisme PBF reste important ». Ainsi, les projets PBF doivent être conçues sur la base de ce que nous savons sur les meilleures pratiques PBF. Cela ne signifie pas que nous ne reconnaissons pas l'importance vitale de différentes circonstances ou des différentes stratégies de changement, qui peut être nécessaire dans des pays différents.

Une deuxième observation sur le rapport de la conférence d'Oslo concerne la partie sur le Fonds Mondial et leur volonté encourageante d'adopter le système de performance. Pourtant, aussi loin que nous comprenons, les plans de FM restent encore trop centralisés et leur budget reste pour 80% ciblé sur les intrants or « input based ». Ce dernier point constitue malheureusement une hypothèse fatale pou

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Delmond Kyanza
1/9/2014 04:30:05 am

Chers tous,

Bonjour.

Je suis d’accord avec Robert sur la question de la sémantique. Il est clair que plus d’une fois, parce que le PBF est entrain de percer, beaucoup d’organisations qui donnent un paiement de performances disent être entrain de faire le PBF sans respecter ses principes et ses meilleures pratiques.

Pour ceux qui respectent ces dernières, il est important que soit partout partagé le consensus qui a été obtenue il y a plus d’une année sur la nomenclature et comprendre que le RBF ou FBR est un terme générique qui se pratique au niveau de l’offre ou à la demande. Ainsi, pour être plus précis, on doit comprendre que dans ce cadre, le PBF concerne seulement les achats au niveau de l’offre, prenant les trois niveaux de la pyramide sanitaire, avec des incitants financiers et non financiers impliquant principalement les institutions quoiqu’ils puissent concerner aussi les individus… dans le respect des meilleures pratiques. Dans plusieurs pays et institutions financières, il y a beaucoup d’effort à fournir à ce niveau car les intervenants sont parfois obligés de s’aligner aux noms pour lequel les autorités ou le bailleur a opté. Les techniciens devraient beaucoup les aider et le CoP-PBF peut y contribuer.

Etant donné que les concepts sont clarifiés, la question qui se pose est de savoir sur quoi est focalisé notre propre Communauté pratique. Est-ce que c’est le RBF de manière globale (PBF, PBC, PBF communautaire et CCT) ou seulement le PBF au sens strict.
S’agissant du Fonds Mondial, les récents changements montrent que les choses peuvent bouger dans le sens positif. Il est bon de continuer un plaidoyer pour décentraliser davantage et surtout leur montrer pourquoi leur approche d’achat des performances n’est pas efficiente pour qu’ils adoptent les meilleures pratiques qu’offre le PBF. Il faudra de la prudence comme l’a souligné Robert et de la persévérance car c’est une grosse machine.

S’agissant des médicaments, je propose que ça soit un des principaux sujets d’un futur atelier de CoP-PBF car il est important qu’on y réfléchisse et qu’on trouve un consensus sur cette question très brulante. Il y a presque une année et demie, Bruno voyait aussi la question de cette manière.

En fin, comme l’a indiqué Michel, la RD Congo est un pays dans lequel le système de santé a des défis complexes pour lequel le PBF ou le FBR de manière globale offre des grandes perspectives d’amélioration des performances dans la santé et même dans d’autres secteurs tels que l’éducation et la santé. Ce serait bon que le CoP réfléchisse sur la tenue d’un atelier en RDC pour booster les efforts locaux.

Mes vœux les meilleurs pour l’année 2014.

Delmond

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Robert Soeters & Godelieve van Heteren link
1/9/2014 02:58:29 am

Traduction en FRANÇAIS des commentaires postés hier en Anglais - 2


Alors, comment pouvons-nous - en tant que communauté PBF - trouver le juste équilibre dans lequel, d'une part, nous encourageons les décideurs du Fonds Mondial de changer, mais restons prudents sur le fait que le FM n'a pas encore fondamentalement décentralisé la responsabilité de la prise de décision sur les intrants de Genève (et les Récipiendaires Principaux) vers les structures de santé avec une bonne dose de concurrence. Approuvant le Fonds Mondial d’une manière trop simple serait contre-productif et peut encore diluer et confondre le potentiel des initiatives PBF bien conçus.

Une troisième observation sur le rapport de la conférence d'Oslo se rapporte à la déclaration suivante: "Plusieurs experts ont partagé leurs préoccupations qu’au niveau des pays. Du côté de la CdP FBP, notre souhait est d'organiser un événement en 2014 selon laquelle les pharmacies centrales seraient en mesure de répondre à leurs clients des structures de santé.

Dans les différents projets PBF (comme dans le Sud-Kivu en RDC et à Douala au Cameroun), nous avons appris qu'il est important pour les structures de santé autonomes d'avoir accès à plusieurs distributeurs de médicaments essentiels, de l'équipement, etc, et qui sont accrédités par les organismes de la régulation gouvernementaux. Ainsi, le changement fondamental est que le système doit devenir entraîné par la demande (demand driven) au lieu d’entraîné par l’offre (supply driven) régies par un système d’une pharmacie centrale gouvernementale. Dans cette logique, l’objectif du programme PBF devient de renforcer les autorités de la régulation pharmaceutique qui aussi entre dans des contrats de performance. Ceci assure la concurrence et que les structures privées auront également accès à des distributeurs accrédités de bonne qualité. À long terme, cela signifierait que tous les produits pharmaceutiques seront sous la contrôle de la régulation en encourageant les distributeurs (privés et publics) de haute qualité et de décourager ou même fermer les distributeur de pauvre qualité. La déclaration de la réunion d'Oslo ci-dessus pourrait être interprétée comme un endossement d'une seule pharmacie centrale du gouvernement. Avec l’urbanisation en Afrique, cela ne tient pas avec la réalité que la plupart de dépenses de santé des patients passe par le secteur privé et que les systèmes de santé pour avoir un impact, devraient s'engager aussi avec le secteur privé en assurant la qualité des produits pharmaceutiques. Peut-être que nous avons mal interprété le rapport de la conférence d'Oslo, mais il serait bon d'ajouter quelque chose comme : Que la communauté COP PBF pendant 2014 vise à « renforcer la capacité de la régulation des partenaires gouvernementaux afin de mieux assurer la qualité dans le marché pharmaceutique opérant en concurrence".

Au plaisir de vous entendre, Robert Soeters et Godelieve van Heteren.

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Christophe Dossouvi
1/10/2014 01:41:57 am

La question cruciale des inputs nous pose à nous tous des problèmes. Malheureusement nous n'arrivons pas encore à nous faire entendre ou plutôt beaucoup d'oreilles restent sourdes à nos argumentations. Dans ce débat la position de la BM et du FM est déterminante. Je ne suis pas certain que les consultants de la BM en pbf d'une part et ceux du FM d'autre part partagent les mêmes points de vue sur la question.
L'autonomie des centres de santé en rapport avec la gestion les ressources humaines constitue également un autre gros problème . Pour le contourner cette difficulté certaines unités de gestion du FBR, structures contractantes procèdent au recrutement en lieu et place des formations sanitaires notamment des hôpitaux. Cela ne met-il pas à mal le principe de séparation des fonctions?

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Joël Arthur Kiendrébéogo
1/9/2014 03:45:17 am

I would like to further emphasize on what Louis Rusa mentioned. I think scaling up RBF schemes would provide a unique opportunity for donors and aid agencies, with governments, to revisit their commitments made in Paris Declaration on aid effectiveness and Accra Agenda for Action: ownership, alignment, harmonization, managing for results and mutual accountability. This will also provide another framework/platform to assess their operations.

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Ramanana Rahary Didier
1/10/2014 06:48:07 am

Je félicite cette grande initiative mais je voudrais que rapidement ces intentions se mettent réellement en pratique.

Pour cela, chaque pays doit rapidement disposer d'une politique ou de stratégies claires de financement de son système de santé, incluant bien sur le PBF parmi les mécanismes à utiliser.

Je dis cela car sur le terrain, et pour un grand pays comme la RDC, la mise en œuvre des différents projets financés par les différents bailleurs de fonds (GAVI, Fonds Mondial, UE et même la Banque Mondiale) peine à obtenir des résultats cohérents et reproductibles. Chaque bailleur essaie de définir le montage de FBR qu'il pense être le mieux, parfois sans une vraie étude préalable et le résultat en est qu'à la fin, il y a tout sauf le FBR (le système de vérification se limite parfois aux vérifications comptables, le plan de management est ignoré par les acteurs, l'évaluation de la performance de la qualité des soins se fait en auto-évaluation sans aucune vérification à posteriori......)

Comme il a dit Michel, si les contextes des provinces sont différents, et dans le cadre d'une vraie décentralisation, peut être que c'est l'appui aux différentes provinces pour avoir une bonne stratégie de financement adaptée à ses réalités qui pourrait être la solution.

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Shannon
5/19/2024 11:28:47 pm

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