Cameroon has the 18th highest maternal mortality rate in the world, reaching 782 deaths per 100,000 live births (DHS, 2011). Significant progress has been made to reduce infant and under-five child mortality in many regions, but child mortality remains nevertheless extremely high in the poorest parts of the country, such as the North or the Far North, where close to 20 percent of the children born die before their fifth birthday.
The three northern regions of Cameroon face particular challenges such as highest chronic poverty headcounts and substantial barriers to facility-based services (limited staffing in facilities, long distance to facilities, rough terrain and cultural factors). The human resources for health challenges in these regions are substantial and different from the rest of the country. Not only is the health worker density less in the north, but managerial and clinical capacity for service delivery are weaker, in part augmented by difficulties in retaining qualified workers in remote parts of the north.
RBF AT A GLANCE
The Health Sector Support Investment Project uses Results-Based Financing to improve health service access for the poor. It implements a pre-existing supply-side Performance-Based Financing (PBF) scheme in four regions as well as scales up its model to three additional regions in northern Cameroon. Under this PBF scheme, an autonomous agency – contracted by the Ministry of Health of Cameroon to purchase services and verify results – signs performance agreements with health facilities to enhance the provision of either the minimum or the complementary package of services. Based on the verified delivery of contracted services, health facilities receive monthly PBF payments which they can use to respond to their specific needs, including for the incentivization of personnel and supporting health facility operations. PBF payments are calculated according to a monthly equity bonus based on a dynamic set of criteria, currently including remoteness and poverty levels. They also include a quarterly quality bonus. In addition, since July 2015, a community PBF intervention is being piloted to address demand-side barriers to service utilization. Under this scheme, health facilities subcontract community health workers (CHWs) to carry out household visits to monitor health statuses, provide basic curative care and referral services. CHW PBF payments are tied to health facility PBF payments, but they are disbursed in cash.
The Performance Purchasing Agency leads the RBF verification function. Specifically, it carries out monthly assessments of the quantity of services delivered using health facilities’ monthly activity report. Conversely, service quality is assessed through the administration of a quality checklist – by district medical teams at health center level and by peer hospitals at hospital level. The quality of care is further assessed at community level: community-based organizations (CBOs) contracted by the autonomous agency to ascertain that patients accessed health facility services as reported. In addition, CHWs referrals are verified monthly by a coordination committee which compares CHW referral forms with health facility forms.
Status and achievements
The extension of PBF to northern regions became effective in August 2016. Further, PBF-related responsibilities were transferred from international Non-Governmental Organizations to national actors, namely the Regional Funds for Health Promotion in December 2014.
In October 2015, the government of Cameroon called for a national scale-up of PBF by 2021. In this light, a new World Bank operation supported by the Global Financing Facility was prepared and approved by the World Bank Board in May 2016. In a first instance, the extension process will focus on reaching 100 percent coverage in the selected northern regions.
To strengthen central-level PBF management and leadership, a workshop focusing on central-level performance contracts was conducted in June 2016. This workshop contributed in enhancing the Ministry of Health’s ownership and buy-in, particularly at central level.
Cross-sector partnerships (e.g. between health and social protection) can promote innovation, enhance project design and simultaneously address supply and demand-side barriers to improved health access.
EVALUATION AT A GLANCE
The endline survey inherent to the pre-existing PBF program was completed in July 2015, and initial results were presented in-country in June 2016. Conversely, the impact evaluation of the extended PBF will include an Enhanced Program Assessment focusing on community RBF as well as community score cards for both CHWs and health facilities. The baseline survey was completed in August 2015 and implementation began in mid-2016.