1. PERFORMANCE BASED FINANCING
IN BURUNDI
By Dr BASENYA Olivier
President of the PBF Steering Committee in BURUNDI
Director General of the National Institute of Public Health

2. OUTLINE OF THE PRESENTATION
• INTRODUCTION
• WHY PBF IN BURUNDI?
• IMPLEMENTATION PROCESS OF PBF IN BURUNDI
• ROLE OF THE REGULATION IN PBF
• MAIN RESULTS
• FUTURE PERSPECTIVES
• KEY CHALLENGES
• CONCLUSION

3. INTRODUCTION
• In 2004, MoH organised “General States of Health» that underlined
key weaknesses of the health sector
• After the diagnosis of health sector, The MoH elaborated key
documents:
– National Health Policy 2005-2015
– National Health Developpement Plan (PNDS) 2006-2010 with a
four-fold objective:
• Reduce maternal mortality
• Reduce under five mortality
• Fight against transmissible and non transmissible diseases
• Strenghten the performance of the national health system

4. INTRODUCTION
• The fourth Objective of PNDS recommends the
reinforcement of the national health system
through contracting strategy among others;
• Contractual approach should allow:
– Quality improvement of health care and services at
different levels
– Improvement of health care management and
organisation
– motivation and stabilization of health personnel
– Population’ views taken into account in managing
health system problems

5. WHY PBF IN BURUNDI?
• The PBF was implemented in BURUNDI in order to deal
with main health system challenges such us :
– quantitative and qualitative lack of health personnel,
especially at peripheric areas: 50% of nurses and 80% of
Medical Doctors work in Bujumbura
– Instability and lack of motivation of health personnel
– Low quality of care provided to population
– Weaknesses in organisation and management of health
care system
– Low financial accessibility of populations to health care

6. WHY PBF IN BURUNDI?
• Facing such challenges, the governement decide to
implement some reforms and strategies :
– decentralisation of health system by setting up
operationnal health districts
– Output Financing health system based on performance
– Elaboration of human ressources development plan
– Initiate a common framework Committee for health and
Development with partners (Cadre de concertation et de
Partenariat pour la Santé et le Développement (CPSD)

7. WHY PBF IN BURUNDI?
• PBF was adopted in order to :
– Motivate and stabilize health personnel
– Encourage health personnel to work in peripheric areas
– Improve quality of health care
– Reinforce autonomy, organisation and management of
health care facilities
– Take into account population views in resolving health
problems

8. IMPLEMENTATION PROCESS OF PBF
• Preleminary missions for key staff of MOPH in countries with PBF
were conducted
• The MoH support NGOs (Cordaid and HNTPO) in implementing PBF in
three pilot zones
• In order to monitor the process, the MOPH set up a National Steering
Committee in charge to elaborate a National Contracting Policy. This
Committee includes staff from MoH, Other Ministries, Non for Profit
Private sector, health partners with a technical support of WHO
• The National Contracting Policy has been adopted in February 2007
by the Government, after technical approval by health sector
stakeholders.
– The National Contracting Policy document is a reference document that
provide guidelines in terms of contractual arrangements in the health sector.
• PBF is one of contracting strategies outlined in this document, among others.

9. IMPLEMENTATION PROCESS OF PBF
• PBF pilots experiences have started in November 2006
in 3 provinces : Bubanza and Cankuzo (CORDAID) and
the Health District of Kibuye in Gitega’s province
(HealthNet TPO)

10. INSTITUTIONAL SET UP OF PBF
• The set up of PBF respects the principle of
separation of functions :
– The regulation and stewardship function is the
responsability of the Ministry of Health and provincial
health authorities (Health Provincial Offices, Health
Districts)
– The function of funding (channeling of funds) :
is endorsed by Performance Purchase Agencies
« Agences d’Achat des Performances »
– The function of service provision is endorsed by the
health facilities
– The voice of the population is part of the system
through Health Comities and the local associations

11. INSTITUTIONAL SETUP OF PBF
• At central level of MOPH, there is 2 main Organs:
– a Technical Support Unit which has the role of:
– Follow up and monitoring PBF implementation
– provide a technical support to stakeholders
involved in PBF.
– a Steering Committee : Its role is to follow up the
implementation of National Contracting Policy, and
advocate for the contractual approach.

12. MAIN RESULTS OF PBF
• Improvement of Health Indicators
• Improvement in Health services quality
• Motivation and stability of health staff
• Availability of personnel and drugs even in remote health facilities
• The voice of the population is taken into account in the management
of health services
• Development of initiative and entrepeneurship among health facility
managers, progressively improving health services : i.e.
– Purchase of beds, sheets, and matrasses for patients
– Purchase of solar panels for health center
– Maintenance of facility (water adduction, doors, walls)
– Painting of several health centers
– Purchase of matterial for the cleaning
– Construction of incinerators

13. MAIN RESULTS OF PBF
• Comparison of Zones with PBF and zones without PBF was
made in 2008 by CORDAID:
– 22 out of 27 indicators are significatively higher in PBF
zones than in « input based financing » zones.
• Positive results in pilot areas has lead other actors to
implement PBF in other provinces
• Currently, 9 Provinces out of 17 have adopted PBF:
– Bubanza, Cankuzo, Makamba, Bururi (DS Rumonge),
Rutana, Ruyigi, Karuzi (CORDAID, Union Européenne)
– Gitega (HealthNet TPO)
– Ngozi (Coopération suisse)

14. FUTURE PERSPECTIVES
• The Ministry of Health target the scale up of PBF in
the whole country in 2009
• The Governement has voted a budget of 2,5
millions usd for PBF in 2009
• Several partners are committed to support the
governement in the scale up of the system
– The World Bank (in the entire country)
– The European Commission
– Bilateral partners

15. FUTURE PERSPECTIVES (2)
• The training of a critical mass of actors in terms of PBF :
– 2 international courses of 14 days on PBF have been
organized at the National Institute of Public Health
(INSP) with the support of Cordaid
• 60 health staff from Burundi, DRC, Cameroun and RCA have
been trained
– The INSP, with the support of the MoPH is planning to
organize a yearly course on PBF for service providers and
health staff, and a short training (3 days) for Policy
makers

16. MAIN CHALLENGES
• The future institutionalization of PBF in health sector: The
factors in favor of PBF are numerous :
– The positive results observed in the zones with PBF
– A political will (PNDS and PNC)
– The involvement of partners
– The sector wide approach: A Medium term Expenditure
Framework (MTEF) and a common monitoring and
evaluation framework are being designed.

17. MAIN CHALLENGES
• Instutionalization of fundholders and separation of
functions
– So far : the fundholder is a Performance Purchase
Agency dependent on NGOs and Projects
– In the future: the fundholders could become
• Non for profit organization from civil society? (asbl)
• Autonomous public agencies?
• A large debate will be initiated by the MoPH in order to
achieve a common ground with stakeholders

18. CONCLUSION
• PBF in Burundi is the result of a close collaboration
between MoPH and external partners
• The MOPH remains in charge of its mission of public
service
• The PBF has shown positive results, hence the
decision by MoPH to scale up the approach in the
whole country
• The institutional framework of PBF in a medium
term remains a challenge

19. Thank you