Learning from Experiential Performance-Based Financing Knowledge in Burundi and Cameroon

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June 21, 2016

‘Don’t worry, you’re in Cameroon: you’re among friends’. This was our welcome to Cameroon, after losing our luggage between Bujumbura and Yaoundé airport, followed by a hunt for World Bank-worthy clothing on a Sunday afternoon in Yaoundé – our Cameroon friends helped us out…..

What Works, What Doesn’t, for Whom and Why?
In our district a nurse was being accused of charging varying amounts of money for medication. The community expressed their concerns and the nurse came to us, crying and asking us to believe her: she did not charge additional money for medication for her own benefit. We explained to her that this was a matter between her and the community. Within the PBF institutional framework, it is not us who hold her to account, it is the community to whom she has to answer. Subsequently, she went to the community to discuss the complaints with them. She was able to understand their complaint and was able to explain to the community why she charged different amounts of money for differing medicines. This is how the problem was solved and how PBF incentivizes health workers to become more accountability towards the end-users. - Manager of a Performance Purchase Agency in Cameroon.

This was a good start to the second week of our mission to Burundi and Cameroon. Our assignment from the World Bank was to identify interesting approaches, experiences and results from the Performance-Based Financing (PBF) programs and projects from both countries that the World should know about, so that needed to be documented and then shared with global audiences.

Two Different PBF contexts
We are proud to share the documented knowledge originating from PBF implementation in two very different contexts. In Burundi, PBF has been scaled up to the national level with the aim to strengthen accountability mechanisms that were weak in the Free Health Services policy. This is being implemented under the leadership of a National Technical Unit within the Ministry of Health. Whereas in Cameroon different implementing agencies operate in a set of pilot regions, each developing a program that responds to the context-specific challenges. Their approaches depend on the role of the private sector in the respective districts, for example, or on the extent to which vulnerable or poor populations are present in their target geographical areas.

A Wealth of PBF Knowledge
These two PBF pioneers hold a wealth of knowledge on how to implement performance-based financing at pilot or national scale. Usually their daily work keeps them so busy that they don’t have sufficient time to document their knowledge, to analyze and to reflect on lessons learnt. However, this experiential “how to” knowledge is of great value to colleague pioneers, beneficiaries, governments, technical and financial partners and the research community to improve implementation design of PBF in a country. A reason for the World Bank to provide these front-line PBF workers with the “luxury” to take the time to analyze their work and to take stock of lessons learnt from implementation.

As a participant from Cameroon said: “we have our own web-site, and we have now quite some materials to publish our experiences – and we know now how to develop more materials.”

Six New PBF Publications
In the publications linked to below, members of the National Technical Unit for PBF in Burundi analyze the financial sustainability of PBF, coupled with the Free Health Services policy in their country. The team describes how PBF improved transparency and accountability in the health sector; and shares the results in terms of PBF indicators after four years of nationwide implementation.

Petra Vergeer, a senior health specialist at the World Bank, has worked on building the capacity and knowledge of World Bank teams and country counterparts, including providing technical support to RBF pilot countries on design and implementation of RBF mechanisms, since 2009. She says: “I always joke with the teams I support that it is okay to make mistakes - but that these must be new mistakes. Although each context has its own nuances, there is an immeasurable value in sharing lessons and experiences. 

PBF implementers from Cameroon share their experiences on how PBF enhanced community participation; how PBF can contribute to strengthening public-private partnership in the health sector; and make a compelling case for the importance of autonomy at the health facility level, as an enabler for the successful implementation of PBF.

Developing these case studies has strengthened analysis and dialogue on PBF implementation in both countries, and can also inform dialogue on PBF in other countries. Some are policy papers, some are case studies, and some are articles:




The Writeshop Method
In order to surface experiential knowledge, KIT developed a methodology to facilitate a structured analysis of experiences during a one-week ‘capitalization write-shop’, which we used in both Burundi and Cameroon. The aim of these write-shops was to facilitate the identification, analysis and documentation of experiences, practices, lessons learned, and promising experiments in the field of RBF. At the same time, each write-shop also facilitated the participants’ knowledge-sharing amongst each other and critically reflect on each other’s experiences – with the ultimate “reward” in delivering a publication produced collaboratively. Following each write-shop, we worked closely with the participants to finalize the draft products. In this case these were written products with the aim to influence or convince key stakeholders about the benefits of the PBF approach. It could also have been blogs, songs, radio programs, short films, or even theatre productions.

Why Capitalization?

Jurrien Toonen, senior advisor and coordinator Universal Health Coverage (UHC) at KIT Health, “Performance (or Results) Based Financing is a dynamic process – it’s far from being finished; there is still so much to be improved. It is for that reason good to capitalize on what worked, why and for whom, and what did not. The reward for PBF practitioners is not only in the publication at the end, but perhaps even more: in the joint analysis, sharing and learning – this is a luxury we should afford ourselves more often! It brings such a lot of energy to the participants – they don’t stop at 5 pm.”

During such a capitalization write-shop, participants transform individual and institutional experience and knowledge into capital that can be used by others now or in future, for example to inform new practices to solve existing problems, to alert other practitioners about promising
practices, or to influence policies on the basis of real-life experiences. The focus of a capitalization activity can be on concepts, strategic orientation, or on operational activities. The output is the sharing of lessons learned and good practices, with the aim to induce changes and redesign policies or practices so that they better fulfill their purpose.[1]

PBF actors during the capitalization workshop in Burundi, May 2014.

Clockwise from left to right: Claudine HAKIZIMANA (CTN-FBP), Jurrien TOONEN (KIT), Richard SHUGUGU (WB), Christel JANSEN (KIT), Josiane MANIRAMBONA (CTN-FBP), Olivier BASENYA (CTN-FBP), Rigobert MPENDWANZI (WB), Juvénal NDAYISHIMIYE (CTN-FBP, Cordaid), Thaddée NDINDURWAHA (CTN-FBP), Emmanuel SEHEYE (CTN-FBP), Jean KAMANA (CTN-FBP, coordinator), Léonard NTAKIRUTIMANA (INSP), Carmen MUHORAKEYE (CTN-FBP), Galbert FEDJO (CTN-FBP, BTC). Not in the picture: Sublime NKINDI, (CTN-FBP).

PBF actors during the capitalization workshop in Cameroon, June 2014.

From left to right: Somono Mkondem MBUNYA (AAP, Littoral), Idrissou Mounpe CHARE (University of Yaoundé I), Joseph Atanga SHU (AEDES, AAP North-West) , Christel JANSEN (KIT), Jurrien TOONEN (KIT), Patrice NGOUADJIO KOUGOUM (AEDES, AAP South-West), Moussoumé EKOUNGUE (Cordaid, AAP East), Omer ZANG (WB), Bernard BANGUE (Ministry of Health), Kum GHABOWEN (AEDES/Ministry of Health, AAP North-West), Francis SIMO PEUMO (AAP South West), Jean Pierre TSAFACK (AAP East), Jean Claude TAPTUE FOTSO (AAP, Littoral), Valery Che NJI (AAP, North-West). Not in the picture: Marie-José ESSI (University of Yaoundé I), Henock MFOUAPON (Ministry of Health), Natalie TCHOUMBA (WB), Gaston SORGHO (WB).

More information
To learn more about the World Bank’s PBF and capitalization efforts please email – and on KITs support to facilitation of capitalization activities: or

[1] More information can be found at 


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