1.
November 24th 2015
Dar-Es-Salaam, Tanzania
Dr Eric BIGIRIMANA, BREGMANS Consulting & Research
Performance Based Financing, from scheme
to system: Burundi case study 2004 -2015

2.
Presentation plan
 Objectives & research questions
 Framework
 Data collection and analysis
 Findings
 Lessons learned
 Conclusion
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3.
Main objectives
 Describe the experience of Burundi with scaling up
PBF
 Identify the enablers and barriers that shaped the
scale up process
Our focus in this presentation!
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4.
Research questions
 What are the factors that have enabled or hindered the
scale up and integration of PBF in Burundi?
Hypotheses
 The active involvement of key actors influenced
(positively or negatively) the wide implementation of PBF
 Power relations between donors, policy-makers and actors
involved in the implementation process have played an
important role in extending PBF nationwide.
 The examination and use of scientific evidence have
convinced policy-makers on the need to implement PBF
nationwide.
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5.
Conceptual Framework
 Walt and Gilson (1994) comprised of 4 components -the
context , the content, the actors, the process and - is
quite pertinent for our case study.
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6.
Study design & research methods
 Qualitative retrospective study, both exploratory and
descriptive of cases relating to the evolution of PBF
in Burundi from its initial pilot projects to 2015
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7.
Data collection and analysis
- Documentary review/desk review
- Period: 2004-2015 (divided in 5 stages)
- Use of semi-structured interview guides
- In-depth interviews:
 People who worked at decision-taking levels
 Experts, researchers or technicians who actively took part in the
process
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8.
Research methods: Documentary review
Documents Number
Evaluation / Assessment reports 4
Annual Reports 6
Research publications/ working papers 10
Minutes of meetings 12
Official document approving PBF entity 6
Letter/ MOU 6
Report of consensus 1
Minutes of the Partnership steering
committee
7
Total 52
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9.
Key informants
Affiliation Number
MOH (policy makers) 4
Technical partners 5
International experts (Consultants, TA,
researchers/Evaluators)
4
Donors representatives 2
NGO representatives 2
Total 17
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10.
Findings: five stages
Pre-pilot 2004-
06
Pilot 2006-08
Geographical
scale up 2008-
10
National scale
up & policy
2010-12
Post scale up
2012-15
Our focus for this
presentation
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11.
Stage 3: the geographical scale up
 Period 2008-2010
 Some evidence was coming from the pilot areas
 Government and donors found the PBF interesting and decided to
extend PBF to 9 provinces.
 The UE : First partner to incorporate the PBF approach in its
projects in 2008.
 Some critics were questionning the sustainability as PBF was fully
funded by donors.
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Contextual factors
 Enablers:
 Relative political stability
 Positive influence from Rwanda/ International influence/ growing
international interest and support for PBF
 Barriers:
 Weak economic growth
 The health system is still weak with poor indicators
 The Free Healthcare scheme is overwhelming the facilities
with poor quality of care
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Actors
 Enablers:
 Cordaid published positive results and did active advocacy
 More national experts trained on PBF, getting more experience
 UE: adopting the PBF approach
 International expert invited to help to get consensus on
divergences on implementation (2009)
 Other provinces putting pressure to start PBF
 Barriers:
 Criticism from some partners on the technical and financial
sustainability
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14.
Content
 Enablers:
 “Encouraging” results from the pilot phase
 “Visible” changes seen in health facilities
 Barriers:
 Side effects due to the free health care scheme (delay of
payment)
 The rigour of the evidence is questioned
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Process
 Enablers:
 Workshop to get a consensus on the middle/long term
institutional set up (Funding matters/ Cost of international firms)
 Coupling the PBF and Free health care scheme (big
opportunity of funding/Government involved in funding the PBF
project)
 Hinderers:
 Rejection of suggestions by some stakeholders (Internalization
of the purchasing function)
 Divergences on the new application of the principles
(Separation of Functions, autonomy)
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16.
Dimensions covered
 Geographic coverage
 Donors involvement
 Country ownership
Country Ownership
Geographic
coverage
Donors
Involvement
Ideas,
Knowledge
Service coverage
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17.
Stage 4: the national scale up
 2010-2012
 The geographical scale up showed good results and more donors
got convinced on the effectiveness of PBF.
 Consensus led to new national set up (National PBF Unit,
Provincial Verification and validation Committees)
 New partners offered their support to apply PBF in remaining
provinces (GAVI Alliance, BTC)
 World Bank: Big actor involved in the funding of PBF in Burundi.
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18.
Context
 Enablers:
 More interest among International partners (World Bank)
 More receptiveness for PBF in the MoH
 High demand of PBF from the non PBF provinces and districts.
 Hinderers:
 Political turmoil after the elections, but limited impact on the
health sector
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19.
Content
 Enablers:
 Scientific evidence - more publications on the PBF experience
in Rwanda
 Consensus on the National Institutional set up (
Harmonization of procedures and package of services)
 Discussion on “Common basket fund”
 PBF in national Hospitals in 2010 / complaints raised on the
PBF cost
 Community PBF initiated in 2011 in Makamba province
 Barriers:
 Confounding factors related to the Free Health care scheme
 Limited attribution of results to PBF alone
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Actors
 Enablers:
 New actors come on board: the World Bank, the Government
 CTN is active to coordinate and adjust the implementation
 Creation of the CPSD (facilitation between Government and
Donors)
 Resistance is gone
 Cordaid taking initiatives to pilot the Community PBF (2011)
 Hinderers:
 Vertical programs are still protecting the input based financing
system
 The PBF Unit is working in a “routine mode”: few proactive
actions to involve vertical programmes and new donors
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Process
 Enablers:
 CPSD meetings to share health information and to take new
orientation
 The routine of PBF implementation started in new provinces
 Virtual “pooling of funds” working
 Barriers:
 The country is still adopting new projects with Input- Based
Financing approach, especially with vertical programmes
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22.
Dimensions covered
 Geographic coverage
 Donors involvement
 Country ownership
Geographic
coverage
Country Ownership
Donors
Involvement
Ideas,
Knowledge Service coverage
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23.
Stage 5: the post scale up
 Period: 2012- 2015
 The PBF cost issue in health facilities led to revision of the unit
costs for indicators
 Overconsumption of budget and payment limitations
 Introduction of the Health Insurance Card reform in an impromptu
manner / budget requirements and constraints
 Stagnant quantitative indicators and need of revision for quality
 Political turmoil/hesitation of Donors/ Deterioration
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Context
 Enablers:
 Use of available funds
 PBF is still attractive and popular
 Barriers:
 Electoral period shifting priorities (Political intentions)
 New political decisions in an impromptu manner: CAM (Medical
Insurance Card)
 Delays of payment to the health facilities (Financial burden
getting heavier, unpaid money for past periods, etc)
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25.
Content
 Enablers:
 What inherited from the nationwide scale up phase (Content,
actors, process, context)
 Extension of Community PBF in 2013
 Hinderers:
 Hospitals complaining of the low rate of payment
 Adjustment of Unit costs which increases the budgetary
burden (high budget consumption)
 Political priorities are on Universal Health Insurance
 Questioning the strategic view: Need of more quality than
quantity (stagnating results on quantity)
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Actors
 Enablers:
 More Donors supporting the Burundian PBF programme
 Virtual “pooling of funds” in place
 Other donors like GAVI Alliance supporting the Community PBF
 Barriers:
 Government and some donors: Delays of payments
 Demotivation of health facilities
 Donors hesitant to support the political agenda (UHC, CAM)
 Vertical programmes remain out of the PBF project
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Process
 Enablers:
 Routine of work and stakeholders are following the procedures
manual
 Hinderers:
 Delays of payment with immediate impact in hospitals and
health centers
 Health facilities demotivated to maintain the PBF procedures
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Dimensions covered
 Dimensions covered
Country Ownership Donors
Involvement
Geographic
coverage
Ideas, Knowledge Service coverage
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Lessons learned:
 Geographical scale up (2008- 2010)
 The emergence of the critical mass brought new requirements
from the policy makers and partners.
 Divergences on PBF implementation were solved in adequacy
with the country context while trying to keep fundamental PBF
principles.
 The technical assistance hired was helpful to bring together
antagonistic groups.
 A resolution for consensus took into consideration all the
challenges to design a new set up for future.
 The coupling of PBF and Free Healthcare Scheme was a good
symbiotic merger.
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30.
Lessons learned :
 Nationwide Scale up (2010- 2012):
 The separation of functions was not effective with the creation of
the National Technical PBF Unit (CTN) and the Verification and
validation Committees in provinces (CPVV). Some conflicts of
interest were found at different levels.
 The decision to change the unit costs for some indicators was
not well prepared to contain the budget consumption.
 The induced budget consumption disturbed the financial
forecast with serious delays of payments to health facilities (The
Government budget was not able to cover all the costs)
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Lessons learned:
 Post Scale up (2012- 2015)
 The budget overconsumption and delays of PBF payments:
concerns on sustainability in Burundi.
 Three trends are found to solve the problems:
 Revision of the PBF implementation with more focus on the quality of
care (PBF Second Generation) and the integration of the National Drug
Supplier et the National Health Information System (NHIS)
 Revision of the Health Financing Policy and move towards the
Universal Health Coverage with different funding mechanisms
 The combination of the two first trends.
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CONCLUSION
 Burundi has experienced a long history of PBF from 2004- 2015
 The coupling of PBF and Free Health Care Scheme has shown
some advantages and limitations.
 Different dimensions: integration was obtained after some
negotiation between key stakeholders
 A combination of technical omissions and financial constraints
threaten the future of PBF sustainability in Burundi (Crossroads)
 Need of technically enlightened choices to move towards a better
National Health Financing policy inheriting the PBF Principles and
practices.
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 THANKS
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