"The PBF Project Can Transform the Health Sector in Cameroon" Dr. Bijingni Kuwoh Pius
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The last time Dr. Bijingni Kuwoh Pius worked with the Public Service in Cameroon was as Director of the Limbe Regional Hospital. However, just when he was handing over from the post of Director of the Limbe Regional Hospital, he received a call requesting him to work as a Consultant with the Performance Based Financing (PBF) project in Yagoua in the Far North Region. The Non-Governmental Organization IRESCO was chosen to execute the project. The experienced Public Health Physician, had been contacted earlier but they called him that day to inform him that he had been selected to coordinate the pilote phase of the PBF project. The erstwhile Director of the Limbe Regional Hospital started the job in August 2016. He begins this revealing Interview by giving a detailed description of the nature of his job in the Far North Region of Cameroon.
"There was an antenna in Yagoua that took care of five Health Districts. There was another antenna in Maroua which took care of Six Heath Districts. There was a manager in Maroua and then I was Manager in Yagoua. We managed the Pilote Phase from August 2016 to December 2017 and because the results were encouraging, the Government asked us to extend the project to all the 30 Health Districts in the Far North Region in 2018. From January 2018 we started the expansion and then I was also moved from Yagoua to Maroua where the Head Quarters is found. We succeeded in extending the project to all the 30 Health Districts in 2018. This is 2019 and we are still working at it. The project ends in 2022"
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Your appointment in the Far North came at a time when the Boko Haram insurgency was at its peak. How challenging did this make the execution of your job?
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The attacks from Boko Haram did not spare our Health Facilities. It makes the life of Health officials and the movement between Health Facilities very difficult. Health Facilities were attacked and burnt and were forced to be closed. This pushed Health Officials to go and seek for space in other existing facilities in order to continue with consultations. Most of these burnt facilities are not in main town Maroua but are instead around the border with Nigeria and Chad. It has made work very difficult in those areas but we have however succeeded in working in all the 30 Health Districts. Sometimes we've had to work with Administrators and the Forces of Law and Order to escort personnel to facilities. In fact Health Personnel have left the dangerous areas to stay in safer areas. They only go there to carry out their duties. These are some of the strategies used to continue providing Health Services to the people.
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Can you briefly describe how the project is organized and how it functions?
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The contracts with IRESCO ended in September 2017. The IRESCO program is being funded by the World Bank. The World Bank wanted to collaborate with a local NGO and so they chose IRESCO. The NGO was co-implementing the project in collaboration with the Ministry of Public Health. When the contract with IRESCO ended in December 2017, the project was then put under the Special Fund for Health Promotion SFHP. In 2016 and 2017, the Special Fund for Health Promotion SFHP had not yet been put in place in the Far North Region. The structure executing the project is called the Contract Development and Verification Agency (CDVA).
This project shifts away from the traditional way of financing Health Projects where Credit Cards are given by the Government. We call them inputs and when they don't give the inputs we sit and wait. Performance Based Financing (PBF) moved away from the traditional way of financing to an output way of financing. The PBF comes out with what we call indicators like consultations, deliveries, surgeries, transfusions and so on. We work with what they call verification agents and the hospitals carry out their activities normally. At the end of the month we send our verification agents to the hospitals. They are given the registers of the health facility and they go in and count. The verification agents come in and count these indicators. The hospital staff may have declared 100 consultations but the verification team may acknowledge or validate only 98. Each of these activities has a unit price that you multiply by it and have a certain amount. At the end we make the total and come out with invoices that are sent to the Technical Team at the Ministry of Health that processes them and sends them in for payment. Apart from this we carry out community Surveys every three months so we work with Community Based Organizations (CBOs). They go down into the field every three months and get information from people in the community who benefit from services of health facilities. We also worked on the management aspect with an intention of improving upon the management quality of our facilities. We have a tool which we call the Indice Tool in which the Health Facility has to declare all that it has as revenue and also declare all its expenditure. In PBF we believe that the staff must be motivated. We have a tool that we use to evaluate the performance of our staff. We believe that at the end of every month, there should be some money left for the motivation of staff so that it will deter them from doing parallel activities and encourage them to work better.
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How successful do you think the project has been so far?
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The general objective of the project is to strengthen the performances of the health system in Cameroon. It also aims at reaching the population especially the poor and vulnerable with quality health care. From the data that we are assembling we see that the number of people who are attending health facilities is going up. Also the number of poor and vulnerable who are receiving health care is increasing. Health facilities are improving their infrastructure and equipment. Health facilities have also been able to recruit personnel. More and more health facilities are paying performance bonus to their staff. There are some Health Facilities that have acquired Solar Panels, some have employed Personnel and improved upon infrastructure. This has made the personnel generally happier and more motivated with these bonuses that are being paid. The patients themselves are getting more satisfaction and if you see their ratings of their satisfaction with services at the facilities you will see that it falls from 80% upwards. Some even go above 90%. For technical quality, the score ranges between 60% and 70%. On Management, the score ranges between 50% and 60%. On the whole its been very successful and the Government is relying on it to attain the Universal Health Coverage.
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Briefly speaking, has it been a smooth sail?
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Not at all. Firstly it is about introducing a change in the way services were being managed. When you talk about change those who feel threatened will oppose if they see their interest threatened. The credit cards are transformed into subsidies and paid directly into the account of the health facilities. So no more 30%. Also the heads of the health facilities have to manage the resources in a transparent manner. They have to sit down with their collaborators and plan and discuss how resources have to be managed. Even those who accepted did not know how to go about it so we had to organize trainings before enrolling health facilities into the project. But gradually even those who were opposed at the beginning are becoming convinced of the positive changes that the project was bringing especially when they started receiving the first payments. Yes at the beginning we give the facility what we call Quality Improvement Budget. So facilities that have infrastructural problems are given what we call Quality Improvement Bonus (QIB). There are some Health Facilities that have acquired their Solar Panels, some have employed Personnel and improved upon infrastructure.
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For a Professional of your caliber how satisfying is your present occupation?
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I am that kind of person who likes to work especially when I am convinced that the results will bring about a positive change. I believe that if it is well implemented it will bring about the big change that we expect in the Health Sector. It fits in with my vision of what the Health Sector should be.
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Do you think the COVID-19 Pandemic is going to find a solution that quickly? Secondly, what message do you have for Cameroonians with regards to the pandemic?
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The COVID-19 they say is similar to the SARS. Its infectious but less deadly than the SARS. A lot is still to be known about the COVID-19. For the moment Cameroonians should implement the safety measures that have been prescribed. Washing of hands and avoiding the touching of their faces as well as maintaining Social Distancing. These measures have worked elsewhere and can work here as well. The Cameroon health system is not strong enough to respond to such a Pandemic if huge numbers of patients storm our health facilities in a very short time. The best option is to stick to safety measures, while hoping that a cure or a vaccine is found very quickly.
Interviewed By Francis Ekongang Nzante on the 18th of May 2020
Edev Newspaper
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