In Congo Brazzaville, Cordaid and Memisa Belgium introduced performance-based financing (PBF) in healthcare in 2012. They did so at the request of the Congolese government. PBF changed a lot of things, not only for the medical staff and patients in dozens of health centers, but also for the Congolese Ministry of Health. But it worked out well. So much so that the Congolese government has decided to sign performance based contracts with health care providers and administrators throughout the country for a total sum of 100 million dollars. “We have learned a lot from Cordaid,” said Dr. Bernice Nsitou Mesmer, medical doctor and coordinator at the Congolese Ministry of Health.
As in neighboring countries in the region, the health situation in Congo Brazzaville is bad. 426 to 100,000 pregnant women die during or after childbirth. Due to lack of motivated and well-trained staff and medical infrastructure in many villages people have nowhere to go if they need help. “There are places where people have to travel 50 kilometers for medical help. Moreover, 46% of the people are living in poverty in my country. They have no health insurance and for half of them medical services are too expensive and too far away,” says dr. Nsitou. Cordaid spoke with him during his short stay in the Netherlands.
“We see that more people go on consultation, patient satisfaction increases and the rates go down.”
“The government is doing everything to improve the situation and PBF plays an important role in our plans. The health situation has improved in recent years, maternal and child mortality rates have declined and some basic services such as malaria treatment are now given for free. The introduction of PBF further improved things. In the three provinces where the government, Cordaid and Memisa Belgium signed performance contracts with health providers in 2012 we see that more people go on consultation, patient satisfaction increases and the rates go down.”
Mother and child at the nursery of Mossendjo
How did this come about?
“PBF pushes health centers to become more autonomous and the government to decentralize some of its powers. Traditionally, doctors and nursing staff of health centers receive government assistance in kind: mainly drugs and other medical equipment. With PBF they are paid based on performance, the number of assisted births, vaccinations, consultations, etc. This means that they themselves are responsible for their income: more commitment and efficiency means more revenue. It also means that health centers are responsible for the financial management and that they have to manage their income and expenses. It comes with more responsibility but also with more satisfaction! Until recently, no health center in the country had its own bank account. This has changed with the introduction of PBF. I often visit the small medical posts in the interior and those who are working with PBF, have cleaner premises and buildings, prices are posted for all patients to see, staff is better organized, works more efficiently and provides better quality care. So it’s no surprise that they receive more patients.”
“Moreover, we note that rates for services go down. That is the effect of scale: more patients can be treated with relatively less money. In the three departments where we have introduced PBF with Cordaid – Plateaux , Pool and Niari – more poor people have more access to better health care – such as birth assistance, vaccinations – and they pay less than before.”
Why did the Congolese government decide to collaborate with Cordaid to introduce PBF in health care?
“Cordaid has a good reputation in this field, they have successfully developed and introduced the method in Africa, in countries like Rwanda, Zimbabwe. On behalf of the government I took part in a PBF training organized by Cordaid and their partners in 2010 in Rwanda. At that time, the Congolese government had started a major health program with the World Bank, focusing especially on children, women and other vulnerable groups. As the needs were so big we wanted to accelerate results and PBF seemed a good solution. Cordaid then won our international tender to roll out a PBF pilot program in three departments. Their expertise and experience in this field stood out.”
Beatrice Looijenga-Faucouneau (Cordaid) and Dr Bernice Nsitou
What was the role of Cordaid and Memisa Belgium ?
“It was crucial. They conducted basic surveys, made manuals and provided training for the staff of health centers in the three regions, but also for the local health authorities of the government and other parties such as suppliers of medicines and the local communities where patients come from. PBF is essentially a network of parties cooperating and making quality commitments and ensuring that these commitments are met. For this a good system of monitoring and quality control is a necessity. Have all vaccinations been done? How many pregnant women were assisted during labor and how well were they assisted? Etc, etc.. Inspection is crucial in PBF, and you have to organize it amongst doctors, government officials and patients themselves. Patients have to indicate that the services they were given are good before we pay the quality bonus for the services provided. This PBF network is now working successfully in the three departments.”
What lessons can you draw after two years PBF in health care?
“That it’s important that the participating health centers should be given the authority to recruit staff. This would increase their efficiency. At the moment recruiting is still a responsibility of the central government. We see that, even in PBF areas, the shortage of trained personnel remains a major problem. So we are working on this.”
“Distribution of medicines is also something that can be improved. Currently there is one central government distribution center. This is not always efficient. It would be a good thing to have two or three other purchase and distribution centers for drugs in the country. These may possibly be run by private parties, but should be under the supervision of the government. These centers could be included in the PBF network, so that we can make result based arrangements with them.”
“Finally, we have learned from Cordaid and the PBF approach that we can further increase the financial autonomy of health centers. We see that doctors and nurses manage their income and expenses more autonomous and more efficiently in a PBF setting. But in addition to PBF they receive other funds of the government, for example to buy office equipment. The government could perhaps increase their financial independence by providing cash they can invest themselves.”
“We learn from Cordaid and the PBF approach that we can further increase the financial autonomy of health centers.”
How hard is it to convince the Ministry of Health of this growing decentralization of its powers?
“The government obviously was one of the promoters of PBF itself. This being said, I constantly switch between doctors and nurses in rural areas and the central government and see that some officials are struggling with the changes. This is normal, because liberalization and decentralization mean that the government gives a portion of its power and control out of its hands. The more transparent the PBF projects are run and the more visible the results they deliver are to people who need it most, the better I can convince my colleagues at the ministry of Health. Because in the end the government wants one thing: that mortality and morbidity rates in the country drop.”
“The Congolese government is convinced of the value of PBF. Recently, the government decided to invest 100 million dollars of the state budget in the expansion of PBF to four new departments, meaning that health centers in 7 of the 12 departments will be financed with a PBF approach. This is government money, it does not come from international donors. It proves that we really believe in the approach that we introduced with the help of Cordaid.”
What role will Cordaid still play in the further expansion ?
“Cordaid will be present as an expert and consultant, no longer as a party that rolls out the program. This also proves the success of PBF, it gives rise to more ownership. The government has included PBF in the national strategic development plans. And so you see that from village level to national level PBF puts things in motion and that the health system and its reform are more and more in the hands of the Congolese themselves.”