“Better infrastructure, better staff, better drug supply. This, in a nutshell, is what Cordaid’s results-based financing (RBF) approach brings to health centers in the Central-African Republic”, says Dr Peter Bob Peerenboom, tropical doctor and independent RBF expert. As a result, the EU has asked Cordaid to help scale up RBF in the country’s health system.
(Cordaid supported hospital in Bouar, 2016, © Eddy van Wessel / Cordaid)
One of Cordaid’s health system strengthening programs in the Central African Republic is financed by the Bêkou Fund, the European Union’s trust fund for the Central African Republic. It supports 53 primary health care facilities in three of the country’s most impoverished districts, improving basic health services for more than 300.000 people.
Cordaid program manager Beatrice Looijenga: “This program does more than support health facilities through results-based financing (RBF). It also trains sorely needed health staff. It’s part of Cordaid’s wider RBF health program in the CAR, which supports some 300 health centers throughout the country.”
Cordaid approach becomes national policy
The Bêkou funded program will complete its 2nd phase by the end of this month. The EU has invited Cordaid to submit a proposal for the 3rd phase. Looijenga: “One of the main national health objectives in Central Africa is to reduce maternal and child mortality, which is still staggeringly high. The minister of Public Health publicly said that Cordaid’s RBF approach is instrumental in reaching this goal. It’s the main reason the government has recently adopted RBF as a national health policy. It’s also why the minister has asked Cordaid to support other EU funded health agencies in rolling out RBF programs. Last week’s working conference in Bangui was the launch of that process.”
Cordaid’s Bêkou funded program improves basic health services for more than 300.000 people in the country’s most impoverished districts.
Peter Bob Peerenboom, who facilitated the working conference, was involved in Cordaid’s Central African health program right from the start in 2008. “Cordaid introduced RBF in the district of Bouar”, he says. “Soon after, it expanded to other regions.”
The impact of 10 years RBF
Summing up the impact of 10 years of RBF he says: “What we see as a result is that staff payment increases, drug supply improves, facility infrastructure is better maintained and staff is better equipped.”
“Cordaid finances the health providers directly, by purchasing services that meet a set of previously agreed criteria”, he continues. “It gives them the opportunity – and the responsibility – to invest in the improvement of their services. In short, RBF motivates local health teams to work out and implement plans to organize themselves better.”
The fact that the government has now integrated the approach in its national policy, testifies to the success of Cordaid’s RBF programs. “10 years ago government officials had never heard of RBF”, Peerenboom remembers. “Today, that same government has its own RBF national coordination team, its own experts and is a staunch supporter of the system. Apart from the improvement of local health facilities, that is also an important outcome of Cordaid’s efforts. It’s also why the EU will continue to fund a 3rd phase of the Bêkou program.”
Fragility and RBF
Peerenboom is the first to admit there are limits to what RBF can achieve in the extremely volatile and fragile setting of Central Africa. “RBF works best if you can uphold the system for longer periods of time. In certain places eruptions of violence forced us to stop for a shorter or longer periods, during which aid agencies had to focus on emergency aid. This happens when health staff flees and it simply becomes too dangerous to stay and manage health centers. War has made it impossible to structurally improve the country’s health system as a whole. But in places that were relatively secure in the past decade and where Cordaid was able to continue its RBF program, we definitely see the improvements I mentioned. For example in Bouar. This is why the EU wants to expand it’s RBF funding in the coming years.”
Transferring drug distribution to local partners
Cordaid is currently supporting a local Central African partner in taking over drug storage and supply management from Cordaid. “This will be an important step forward in the Bêkou funded program”, says Peerenboom. “No public health system works without drug supply. Handing over this responsibility improves the durability of the local health chain.”
Some Central African regions do not even have one medical training institute, even though they are twice as big as the Netherlands.
Peter Bob Peerenboom, RBF expert
In the first 2 phases drugs of the Bêkou funded program were purchased in Europe and transported by air. In the 3rd phase the plan is that a local partner will set up drug storage and distribution facilities in the country. RBF contracted health centers will then purchase their drugs from this partner. “This makes the health system less dependent on international support”, Peerenboom explains. “But these supply systems only work if thorough monitoring and control systems are in place”, he continues. “You don’t want drugs to end up on the black market. Preventing this with a good set of control mechanisms is a priority.”
Finding qualified staff for rural health centers
Another important condition for health systems to work, is making sure there’s sufficient qualified staff. Especially in rural areas. “Most rural health centers in Central Africa have no qualified staff at all”, Peerenboom says. “They are run by people who learned by doing. No qualified nurses, let alone doctors.”
The reason is simple. Some Central African regions do not even have one medical training institute, even though they are twice as big as the Netherlands. If on top of that there is a lot of insecurity and volatility, it becomes next to impossible to attract qualified staff from elsewhere. The good thing is that rural health centers that are part of Cordaid RBF programs manage to pay staff adequately, to attract qualified staff and to provide quality care. But on a national scale, recruiting and keeping qualified staff in rural areas remains the biggest challenge. “That’s why Cordaid is also exploring ways to support young people from the rural areas to be trained in the capital. Once they are nurses and doctors, they can work in health centers in their places of origin”, Peerenboom concludes.
(Featured image: Cordaid supported hospital in Bouar, 2016, © Eddy van Wessel / Cordaid)