Evidence from low income countries show that,Performance Based Financing (PBF) can improve health service delivery more successfully following a field experience in Nkambe Central of North West Region of Cameroon, it was discovered that the concept of PBF is a feasible strategy in Cameroon. The report of that field experience contains three chapters as follows:
- Chapter of this report will explore a brief history of PBF in Cameroon.
- Chapter is based on actual field work in the various health centres in Nkambe Health District.
- Chapter Three will be focus on the challenges faced in the field, recommendations and conclusion.
The performance of health institutions in the past has been guided by the Health Sector Strategic Plan 2001-2015 is based on health assessment and underpinned by national and global value fund in the law NO96/03 of 4th January 1996 on the health sector framework and UN millennium development goals. The health sector strategic plan reflects the will of Cameroon government to guarantee sustainable universal access to quality health care and services through the amelioration of health care delivery and financing demand.
The performance based financing (PBF) initiative in Cameroon in aimed at increasing health care provision. This initiative addresses the second strategy axes of health strategic development plan concerning issues related to quality health care delivery at the health centres and district hospitals of the health pyramid and to equally contribute in human resource development, amelioration of health coverage and the reduction of transmissible diseases related to morbidity and mortality and re-enforce human resource management in disease aspects especially in the covered health district.
The Actual Field Work
Field workers were trained on 1st, 2nd and 4th of December 2016 by performance based financing officials based on their partnership with COHESODEC (NGO). They were trained as community monitoring and facilitators and charged with the responsibilities of conducting two meetings (community and interface meetings) in the ten health centres assigned to COHESODEC within the Nkambe central Health District. In each of the community meetings, they evaluated how the health centre and the community health workers (CHWs) have been working toward the health benefit of community members. The outcome of the community meeting was that 5 issues were prioritized and 5 members from the community delegated to present these five issues in the interface meeting afterwards.
There was an interface meeting in which field workers were given the opportunity to guide both the community representatives and health staffs to build a business plan for the respective health centers base on the issues early raised in the community meeting COHESODEC was mandated to cover to health centers under Nkambe district as from the 7th December 2016 to 16th December. These Health Centres were; Lus integrated Health centre (IHC), Kom IHC, Binka IHC, Mbot IHC, Catholic Health Centre Tabenken, Tabenken IHC, Njap IHC, Presbyterian Health Centre Nkambe, Not for Profit Health Centre Tabenken and Mbirboh IHC. The community meeting did not include health staff or community health workers for any reason.
The first meeting on list was;
Lus integrated health centre.
It comprised both men and women and was held at Lus Baptist church on 7th December 2016. The meeting started at 10:15am with 35 members. The meeting was chaired by Mr Njabe Elvis who was nominated by community members, just after the introduction of the facilitators. The PBF manager Dr. Shu was also present in this meeting. Amongst the many problems raised, the following were prioritized by community members.
- Lack of potable water in the community.
- Insufficient drugs in the health centre and poor service on the side of the pharmacist.
- Problem of lighting in the health centre
- The need for more and qualified staff.
- Lack of refrigerator in the health centre
- Heath centre and community should jointly look for solution of the said problem (potable water)
- Chief of health centre should try to make drugs available in the health centre always.
- The health centre should try and buy a generator
- Chief of health centre should endeavor to recruited more staff.
- Chief of health centre should try and buy a refrigerator.
- The community meeting at 1:00pm and the five members appointed were ready to carry the five points raised to the interface meeting afterwards.
The interface meeting began at 1:45pm with 23 members. The facilitators were further introduced again. The purpose of the meeting was disclosed, and the following points were harmonized and ready for the business plan of Lus IHC.
- it was agreed that there is portable water in the health centre but that chief of HC should assist the community to better the cleaning and treatment of other sources of water in the community.
- Chief of HC agreed with community and said it was due to the inefficiency of the pharmacist and that he will be sent for further training.
- There is a generator but chief of HC simply needs to get a technician to do connection of cables in the health centre.
- Chief of HC said he has been looking for a fridge that uses kerosene since there is no electricity in Kom. Meeting ended at 2:45pm.
Komcomity meeting comprised of women only and was held at kom village community hall. Meeting started at 10:25 am with 25 community members. Mrs.kekeiMagdalene was voted chair person of the meeting and was made to understand that she will later lead the 5 man delegation who will represent the community in an interface meeting after words. In the course of the meeting, 6 issues were raised as problems faced by community members with the health structure. Out of the 6 issues, 5 were voted as being more pressing. The 5 problems were accompanied by their respective proposed solutions as fallows;
Problems / issues
- Insufficient drugs in the health centre.
- Shortage of staff in the health centre.
- Poor road network which obstructs emergency cases during referrals to Nkambe.
- Malarial prevalence in the community.
- Insufficient infrastructure in the health structure.
- H C should ensure that availability of drugs in the HC always.
- Chief should recruit more staff in the HC.
- Community members should mobilize and do community work on the road.
- Continuous education on malaria prevention and more supply of mosquito nets.
The meeting ended at 12:30pm with the appointment of 5 members to present the problems identified by community in the interface meeting.
The interface meeting was made up of 5 community members and health staff including community Health workers. Meeting started at 1:15 pm with 22 members. After deliberating on the 5 points presented by community members, the following resolutions were agreed upon to be fitted into the business plan of the health structure;
- More drugs would be bought by January 2017 if funds are made available (PBF)
- More staff would be recruited by January 2017 when money is available (PBF)
- Community committee and health staff should mobilize and do community work on the road.
- Education on mosquito prevention should be intensified and more mosquito nets be given to community members.
- A new building to be constructed within the year 2017.
The interface meeting ended at 2:00 pm with closing remarks from the chair lady thanking the facilitators and wishing them journey mercies. The meeting was also rated by members present as being very good.
Community meeting in Binka IHC like that of kom was attended by women only. The meeting began at about 10:10am at Hadja Patou’s resident. Prayers were said, followed by the appointment of chair person by community members. Mrs.Bernadette chewe was appointed to chair the meeting.
As the meeting progressed, several problems were identified by community members as an obstacle to their proper use of the health structure. The following 5 worries were voted as being more challenging and were accompanied by proposed solutions;
- Shortage of staff.
- The need for a pharmacy attendant assistant.
- Poor services offered by health staff.
- Lack of privacy by patients.
- Lack of ANC/vaccination hall.
- Chief of HC should employ more staff.
- Pharmacist should be available in the HC always to serve patients.
- Chief should caution the staff to improve on their services.
- Chief should caution the lab technician to keep lab results of patients secret.
- Health centre should construct ANC/vaccination hall.
The Community meeting ended at 12:55pm with the appointment of 5 community members including the chair person to take part in the interface meeting. The total member of attendance was 38 women.
Interface meeting started at 1:35 pm at Binka IHC with 14 members including community health workers. The following points were harmonized and agreed upon to include in the business plan of the health centre.
- To recruit more staff by January 2017 when money is available.
- Emergency box have be created but needs to be communicated to the community members.
- Staff would be cautioned by chief to improve on the quality of their services.
- Lab technician should be reminded of his professional ethics in order to protect the privacy of patients.
- A new hall would be constructed before end of 2018.
The interface meeting finally ended at 3:05pm with a total numbers of 18 members. The meeting was rated as very good by the members present. From Binka, the next stop-over was Mbot Integrated Health Centre.
The community meeting in Mbot likes that of kom and binka was gender biased in favour of woman for obvious reasons. The facilitators and data collector were fortunate to have a PBF official in their team (Dr. Okwen.) meeting started at 11:15am with the introduction of team members, and the appointment of chair lady in the person of Mrs. TOKOB Elizabeth Nkfurnji.
The following problems or issues were raised as challenges faced by community members with the health unit, and with proposed solutions.
Problems / issues
- Insufficient staff in the HU.
- Lack of a medical Dr.
- Lack of multiple entrances into the health centre.
- Lack of capacity by health centre to attain to female related health problems.
- More staff should be recruited.
- HC should employ a medical Dr.
- More entrances should be created leading into HU.
- H U. staff should be sent for further training.
The meeting ended at 2:30pm with 27 members. Four members were nominated by community members to join the chair lady and represent them at interface meeting.
The interface meeting started at 3:12pm with 16 members at the mbot IHC. The main facilitator introduced the purpose of the interface meeting and cautioned participants to be objective and positive in the course of deliberating. The following points were harmonized and agreed upon to be included in the business plan of Mbot integrated Health Centre.
- That more staff would be recruited by January 2017.
- The community was advised to use the HC more to enable the HC to raise more money to employ a doctor and also, to give reasons why a medical doctor should be employed.
- HC staff and community committee should educate the comity on reasons to close other entrances into HC since it is the D.O who ordered for the closure for obvious reasons.
- It was also agreed that some staff will be trained to be able to meet up with other female medical checks or tests as required by the community.
Interface meeting ended at 4:00pm and the members who attended the meeting unanimously agreed that the meeting should be scored as very good. And the next meeting on the list was catholic Health Centre Tabenken, on 10thDecember 2016.
Catholic HC Tabenken
The community meeting in Tabenken catholic health centre of 11th December 2016 was attended by 35 women. It started at 10:10am and was held at catholic Primary school Tabenken. The main facilitator introduced the team members including the data collector. This was followed by the appointment of chair person by community members, Mrs. NsamiNicoline.
Some of the prioritized issues which came up in the community meeting regarding the health centre were;
- High cost of drugs and services.
- Community members’ reluctance to pay their debts in the health centre.
- Poor portable water supply.
- The prices of drugs and services in the health centre should be reduced.
- CHWS and staff should intensify their education on community members to pay their bills always.
- Chief should inform the church to bring pipe-borne water in the health centre.
The community meeting ended at about 1:30pm, and was exceptional in the sense that just 3 issues were raised instead of 5 as expected. However, 5 community members were selected as usual to take part in the interface meeting shortly afterwards.
This meeting was held at Tabenken Catholic health centre. Meeting start at 2:00pm with an attendance of 11 members. The purpose of the meeting was disclosed after roll call and self introduction by facilitators. The following points were agreed upon to enable the health centre to include them in their business plan;
- The chief of health centre and staff will intensify education of the community on the quality of drugs and services rendered to them come January 2017.
- Health staff and community committee will jointly intensify education of community members on the importance of health services and medical advice.
- Health centre and community will plead with elites and village association for proper protection of water source.
One serious issue which came up in the interface meeting was the zonal conflict problem. It was also agreed that chief will communicate with both PBF and DMO to resolve the problem. Meeting ended at 3:00pm with the score of very good by meeting members. The next meeting after Tabenken health centre was Tabenken integrated health centre, slated for 12th December 2016.
Tabenken Integrated Health Centre
The meeting in Tabenken integrated HC was going to be made up of both men and women. Meeting began at 10:10am at sub-chiefs palace. With prayers and later self introduction by facilitators and the nomination of chair person by community members as usual. Mr. Bah Franklin was generally accepted to be the chairman. The challenges brought up by the community against the health unit were purpose;
- The need for a president of HC and chief to other staff to stay close to the HC
- High cost of drugs.
- Lack of potable water in the health centre.
- The need for an ambulance (bike)
- Nonpayment of hospital bills by community members.
- At least one or two staff should be at work especially in the night.
- Prices of drugs should be reduced.
- Chief should try to buy water storage containers or other means for water to be available in the HC.
- Chief should at least buy a bike for the HC.
- CHWs should educate the community members to be more responsible over paying their hospital bills.
At the end of community meeting attendance was made up of members. And 5 community members were appointed to take part in the harmonization of the points raised the community meeting.
It started at 1:35pm at Tabenken integrate HC with 9 members. Those who attended the meeting were briefed on the objectives which were aimed at building a business plan for the HC. Emphases were equally laid on the need for positive and mature deliberations. The resolutions of the meeting were that;
- There is a permanent staff that is resident at the health centre. Community members should be informed about this development.
- Staff should intensify their education of the community members on the fact that drugs are rather cheap and the cost depends on a patient’s health situation. The need for early consultation.
- Community committee and chief to talk with the water committee for a solution to the water crisis from January 2017.
- Chief will buy a bike for the health centre before end of 2017,
- Health staff and community committee to educated the masses more on their responsibility to pay hospital bills regularly.
The hospital staff also brought up the issue of zonal conflicts which is plaguing the Tabenken community. It was agreed that chief mill call the attention of PBF and DMO to resolve the problem by January 2017. Meeting ended at 2:45pm with an attendance of 11 members. The next meeting of 13th December 2017 was to be held at Njap Integrated HC.
Njap Integrated Health Centre
The meeting at Njap was made up basically of women folk. It began with 21 women and at about 10:30 am with the introduction of facilitators and data collector in NgiWomens’meeting hall. Introduction was later followed by the appointment of chair person by name Mrs. Tangiri Chantal. Present were also the two wives of the fon of Njap as community members, some of the points they raised as challenges faced by the community in the health unit were as follows:
- Location of health centre in the palace.
- Inaccessibility of the health centre by some patients due to poor location at one part of the village.
- Insufficient infrastructure leading to lack of privacy in the HC
- Lack of water in the health centre.
- Insufficient staff
- Health centre should be relocated from the palace due to noise
- Health centre should be constructed at the proposed site (Njere) Ngi quarter to be accessible to other quarters of the village.
- Health centre should be constructed with more structures to solve the problem of poor privacy and the spread of contagious diseases.
- Washing basin and tap at the health centre should be repaired to make water available at the health centre.
- Chief of health centre should recruit more staff in order to facilitate effective work in the health centre.
Meeting ended at 1:00pm with the nomination and subsequent appointment of 5 community members by them to take part in the interface shortly after at health centre.
Interface meeting strutted 45 minutes after the community meeting, at 1:45pm in Njap health centre. The meeting began with 9 members present. Prayers were said by the chair lady which was gradually followed by the introduction of the teach of facilitators.
The following points were harmonized by both the Health staff and the 5 community representatives;
- Health centre will be constructed before the end of 2017 (chief)
- Health centre will be constructed at the proposed site (Njere) Ngi quarter which is centralized enough to give better access to other quarters in Njap village
- For the main time, washing basin and tap at the health centre will be repaired in order to enable clean water to flow in the health centre by January 2017.
- Chief of health centre will recruit more staff by January 2017 if PBF makes funds available.
The closing time was announced at 2:30pm, and the meeting members unanimously rated the meeting “very good” based on the lessons learnt from the meeting. The next meeting on the list was scheduled to take place at Presbyterian Health Centre in Nkambe Town, on 14th Dec. 2016.
Presbyterian health centre Nkambe
AfterNjap integrated health centre, Nkambe Presbyterian Health Centre was the next stop points community meeting was for both men and women and was held at Presbyterian primary school Ntik- Nkambe. Meeting started at 1:00am with 17 members. The meeting was honoured with the presence of a councilor, Mr. Luc. The facilitators introduced themselves after which the community members chose their chair man in the person of Mr. Nducho Cletus.
The main facilitator for the day rolled the expectations of the meeting, after which the community members in the absence of no health staff came up with several issues, and the following 4 were prioritized
- The need for a medical Doctor in the health centre.
- High cost of drugs and services
- Noise from primary school which is close to the health centre
- The creation of a health post at Ngwayuh
- A medical doctor. should be employed to handle critical cases and also to attract more patients as was the case before.
- The prices of drugs and services should be reduced to equally attract more customers or patients
- School should relocate or a fence be constructed to reduce congestion especially during vaccination.
Meeting closed at1:00pm after selecting 5 members from community who will take part in the interface meeting shortly after the community meeting. Meeting was scheduled to take place at the health centre proper.
Interface meeting which was held in the Presbyterian health centre started at 1:35 pm with 16 members. Prayers were said, after which a facilitator set the ball rolling. The meeting was highly interactive, as a result ended up with the following points to include in the business plan of the health centre;
- Chief of health centre assures that a medical Doctor will be available before the end of 2017.
- Chief said the health centre deals with quality drugs and with standard prices but said they will reduce the price of services come January 2017.
- Chief equally assured the relocation of the primary school very soon. The church needs land to buy for that purpose.
- Health post according to chief cannot be created at Ngwayuh because they are mobile services rendered which are equivalent to services offered by health post.
It was at this point that the meeting closed its doors at exact by 2:50 pm. The facilitators left while preparing to visit “Not for Profit” health centre in Tabenken the next day.
Not For Profit Health Centre Tabenken.
The venue of this community meeting was in Home Be Home Bar in Tabenken. And the meeting was made up of both men and women. The turnout was quite encouraging with 29 members. There was introduction of the facilitators which was followed by the appointment of Mr. Amos Konfor as the chairman of the occasion. He welcomes and thanks everyone present and encouraged community members to feel free and express their worrier for the interest of all the community members raised several points among which were;
- Poor waste disposal (lack of incinerator)
- Insufficient infrastructure(lack if privacy)
- Lack of an ambulance(motor bike)
- Poor attitudes of some staff.
- An incinerator should be constructed and in a safe area
- Chief should construct more buildings to accommodate patients and referrals
- The price of drugs should be reduced.
- Some nurses should be polite towards patients and also respect their professional ethics
Meeting started at 10:15 am and ended at to take place shortly after the community members including the chair person were to represent the community member in the interface meeting.
Meeting began at the health centre with 17 members at about 12:35 pm. There was the second introduction of N.G.O members and data collector. The main facilitator did a review of the community meeting and the issues raised against the health structure. The five community members presented the worries politely and maturely one after the other. These issues were harmonized and recommended as follows;
- Chief promised to dig a good pit for proper disposal of medical waste while waiting for money to construct an incinerator by January 2017
- Chief promised to raise another building before end of 2018
- Chief assured the community to buy a bike by March, 2017
- Chief explained that her price is the lowest around Tabenken but that she will rather adjust the cost of services
- Chief promised to caution her staff through or by intensifying internal meetings and will use financial discipline in staff who are stubborn
Mbirboh integrated Health Centre.
The meeting was made up of both men and women, and was the last of the ten meetings assigned to COHESODEC within Nkambe Health District. Meetingd started at 10:15 am with 24 members in Amumba bar, MbirbohMbot. The facilitators introduced themselves as well as the purpose of the community meeting. This was followed by the appointment of chair person by community members. Mr. Shey Rene was appointed chair person and also charged with the responsibility to later represent the community in the interface meeting at the health centre amongst four other members.
The following came up in the meeting as worries faced by the community with the health structure
- Electricity problems, due to lack of electricity meta by health centre
- Non permanent residence of staff around the health centre
- Lack of ambulance in the health centre
- Insufficient water supply in the health centre
- Insufficient drugs in the health centre.
- Health centre should apply for a permanent SONEL meta
- Staff should stay close to the health centre
- Chief of health centre should buy an ambulance to assist patients during emergency referred cases.
- Chief should solve the problem of water supply in the health centre
- Drugs should be made available in the health centre always to meet patients health needs.
The community meeting ended at 11:45 pm, and was followed by heavy refreshment by everyone who attended the meeting. The next agenda after feeding was the interface meeting which was to be held at the health centre.
Meeting started with a word of prayer offered by Pastor Nyabambo. The facilitators again introduced themselves and cautioned everyone to be positive and mature during deliberations. Meeting properly began at 12:15 pm with 16 members. The above given points were agreed upon by both the community representatives and health staff to be included in the business plan of the health centre as need be;
- Concerning the issue of electricity meta, chief of health centre said he already applied for a meta, but promised to buy a generator by March 2017 while waiting
- Chief of health centre promised that the problem would be solved in the long run since there are mo houses to let around the school. He assured community that he will adjust program in the health centre to meet patients demands come January 2017
- Health centre boss agreed to buy bike for the main time by June 2017 if funds are available while hoping to buy a real ambulance in due course.
- It was confirmed that water is now flowing in the health centre but that chief will install a tap out of the health centre in January 2017.
- As regard drugs shortage, chief said that was in the past, but that drugs are available bow but needs to be communicated properly to the community members
- The meeting ended at 2:00 pm with the chief of health centre thanking everyone most especially the facilitators and hoped for subsequent meetings of this nature. He on behalf of the rest of the members scored the meeting as very good.
Challenges Encountered in the field
The twin (Interphase and Community) meetings held by COHESODEC in the ten assigned health centres within Nkambe Health district were highly appreciated by most of beneficiaries. However there were some challenges, considering that it was the first phase of such meetings. Some of the challenges encountered in the field were as follows;
- Majority of mobilizers did not master the concept and phases of the meeting. In some areas like catholic health Centre in Tabenken and Mbot Health Centre we met old women who were invited on the bases that the meeting was for widows. Elsewhere, others came with consultation books, thus, delaying the meeting starting time since the mobilization had to be redone.
- Also, Njap HC and Not For Profit Health Tabenken Centre were programmed on the day which is 13th 2016. This situation handed the facilitators into extra cost as we had to call and explained situations to the chiefs who had already mobilized their community members. More so, some of those who were initially invited felt reluctant to readjust and come the second time.
- The exercise was really cumbersome in the sense that the program did not take advantage of “country Sunday”, this seriously disturbed meeting the targeted population. The facilitators had to go round some villages for mobilization in order to avoid failure. This was the case in Mbot and Mbirboh integrated health centre’
- Another issue was equally that the training of N.G.O failed to properly exploit the filling of documents which became too challenging in the field.
- Also, PBF failed to educate those in charge of mobilization on how to use the finances given them. These brought about embezzlement in some communities, leading to conflicts which may affect turn out during the next phase of the project. An example is Tabenken Health Centre
- The most disturbing if the challenges were at the level of finances. Below is the cost of transport and logistics. We will calculate the cost per individual multiplied by four facilitators
Having witnessed a couple of challenges in the course of facilitating the meetings with the community stakeholders, it is necessary to propose recommendations to improve understanding of the concept of the program.
- It will be very necessary that those concerns with mobilization be properly guided on the concept and objectives of community and interphase meetings. This will seriously help them in the process of mobilization. Another possibility will also be to sub-contract the aspect of mobilization to NGOs.
- Also, the meeting programs or letters should be prepared and sent to the field early enough for collections to be made in time if any. This will serious curb the issue of allocating one day to two different health centres.
- It will equally be very important that community meetings be planned putting into considerations country Sundays. This will very much improve on the attendance by community members.
- It is importance that serious practical work is done on the filling of documents in order to facilitate the work of facilitators in the field. This should be done during training workshops.
- There is need to educate those concern with mobilized briefly on how the finance should be managed so as to avoid further conflicts in cases of embezzlement in due course. It will also solve the problem of inviting lesser population so that more money remains in your pocket.
- It will also be very necessary that money for transport and logistics be increase inorder to redeem the facilitators from the stress experienced in the last field work. This increment will equally serve as a booster to effective and efficient work in the field.
In spite of the challenges highlighted above, it’s worth mentioning that the field work was a wonderful experience. They equally pray for the sustainability of this program and the privilege to be part of it during the subsequent phases.