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Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No: ICR00004251

IMPLEMENTATION COMPLETION AND RESULTS REPORT

(IDA‐ 44780, IDA‐564860, TF 17128)

ON A

LOAN

IN THE AMOUNT OF SDR15.3 MILLION

(US$25 MILLION EQUIVALENT)

AND

AN ADDITIONAL CREDIT

IN THE AMOUNT OF SDR13MILLION (US$20 MILLION EQUIVALENT)

AND

ADDITIONAL GRANT FROM THE HEALTH RESULTS INNOVATION TRUST FUND (HRITF)

IN THE AMOUNT OF US$20 MILLION .

TO THE

REPUBLIC OF CAMEROON

FOR THE

Cameroon Health Sector Support Investment (SWAP) (P104525) July 9, 2018

Health, Nutrition & Population Global Practice

Africa Region

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CURRENCY EQUIVALENTS

(Exchange Rate Effective {May 25, 2018})

Currency Unit =CFAF (XAF)

US$1=560.23978 (XAF)

US$1 =‐SDR 1.79

FISCAL YEAR January 1 ‐ December 31

Regional Vice President: Makhtar Diop

Country Director: Elisabeth Huybens

Senior Global Practice Director: Timothy Grant Evans

Practice Manager: Gaston Sorgho

Task Team Leader(s): Ibrahim Magazi, Jean Claude Taptue Fotso

ICR Main Contributor: Kofi Amponsah

ABBREVIATIONS AND ACRONYMS

ACV Contracting and Verification Agency (Agence de Contrôle et de Vérification) AF Additional Financing AFD French Agency for Development (Agence française de Développement) AIDS Acquired Immune Deficiency Syndrome ANC Antenatal care ARV Anti‐Retroviral ASLO Local Associations AWPB Annual Work Plan and Budget BCG Bacillus Chalmette–Guerin CAA Autonomous Depreciation Fund (Caisse Autonome d’amortissment) CEO Chief Executive Officer CTN National Technical Unit (Cellule Technique Nationale) CMU Country Management Unit CHW Community Health Worker CPF Country Partnership Framework

CNPS National Social Insurance Fund (Caisse Nationale de Prévoyance Sociale) CSI Core Sector Indicator DA Designated Account DPs Development Partners

DPML Directorate of Pharmacy, Drugs and Laboratories (Direction de la Pharmacie, des Médicaments et des Laboratoires) DHIS District Health Management Information System DHMT District Health Management Team DPO Development Policy Lending

DTC Diphtheria, Tetanus, and whooping Cough FA Financing Agreement FOSA Formation Sanitaire (Health Facility) FM Financial Management FSPS Special Fund for Health Promotion (Fond Spécial pour la Promotion de la Sante) FRPS Regional Fund for Health Promotion (Fonds Régional pour la Promotion de la Sante) GFF Global Financing Facility GoC Government of Cameroon GIP Public Interest Group (Groupe d’Intérêt Public) HIPC Heavily Indebted Poor Countries HIV Human Immunodeficiency Virus HMIS Health Management Information System HRITF Health Results Initiative Trust Fund HSPRP Health Systems Performance Reinforcement Project ICER Incremental Cost Effectiveness Ratio ICR Implementation Completion Repot IDA International Development Association IFR Interim Financial Report

IGSPL General Inspectorate of Pharmaceutical Services and Laboratories (Inspection Générale des Services Pharmaceutiques et des Laboratoires) IPP Indigenous People Plan ISN Interim Strategy Note

ISR Implementation Status and Results Report KfW German Development Cooperation LRSFHP Littoral Regional Fund for Health Promotion

MINEPAT Ministry of Economy and Planning (Ministère de l'Economie, de la Planification de l’Aménagement du Territoire)

MINSANTE Ministry of Public Health (Ministère de la Santé Publique) MDGs. Millennium Development Goals MWMP Medical Waste Management Plan MoF Ministry of Finance MoPH Ministry of Public Health M&E Monitoring and Evaluation MTR Mid‐term Review NGO Nongovernmental Organization NPTU National PBF Technical Unit OHADA Organization for Harmonization for Business Law in Africa (Organisation pour l’Harmonisation en Afrique du Droit des Affaires) PAISS Health Sector Support Investment Project (Project d’Appui aux Investissement du Secteur de la Santé)

PCA Complementary Package of Activities (Paquets Complémentaires d’Activités) PPA Performance Purchasing Agency PBF Performance‐Based Financing PDO Project Development Objective PFM Public Financial Management PHRD Policy and Human Resources Develepment PIU Project Implémentation Unit PMA Minimum Package of Activities (Paquet Minimum d’Activités) PNC Postnatal care PNDS National Health Development Plan (Plan National de Développement Sanitaire) POU Project Operational Unit PSC Project Steering Committee RHD Regional Health Delegation SDGs Sustainable Development Goals SDR Special Drawing Right SWAp Sector Wide Approach TB Tuberculosis TOR Terms of Reference TTL Task Team Leader UGP Unité de Gestion de Project UHC Universal Health Coverage UNICEF United Nations Children and Education Fund WB World Bank WHO World Health Organization

TABLE OF CONTENTS

DATA SHEET ............................................................................................................................ 1

I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ........................................................ 6

A. CONTEXT AT APPRAISAL ........................................................................................................... 6

B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE) ...................................... 10

II. OUTCOME ...................................................................................................................... 15

A. RELEVANCE OF PDOs .............................................................................................................. 15

B. ACHIEVEMENT OF PDOs (EFFICACY) ........................................................................................ 16

C. EFFICIENCY ............................................................................................................................. 21

D. JUSTIFICATION OF OVERALL OUTCOME RATING ..................................................................... 22

E. OTHER OUTCOMES AND IMPACTS (IF ANY) ............................................................................. 22

III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME ................................ 25

A. KEY FACTORS DURING PREPARATION..................................................................................... 25

B. KEY FACTORS DURING IMPLEMENTATION .............................................................................. 27

IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .. 30

A. QUALITY OF MONITORING AND EVALUATION (M&E) ............................................................. 30

B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE ..................................................... 31

C. BANK PERFORMANCE ............................................................................................................. 33

D. RISK TO DEVELOPMENT OUTCOME ........................................................................................ 34

V. LESSONS AND RECOMMENDATIONS .............................................................................. 35

ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ............................................................ 37

ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION ......................... 46

ANNEX 3. PROJECT COST BY COMPONENT............................................................................. 48

ANNEX 4. EFFICIENCY ANALYSIS ............................................................................................ 49

ANNEX 5. BORROWER, CO‐FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS ... 55

ANNEX 6. MAJOR REFORMS AND INITIATIVES ....................................................................... 57

ANNEX 7. SUMMARY OF IMPACT EVALUATION RESULTS ....................................................... 66

ANNEX 8. SUMMARY OF BORROWER’S ICR ........................................................................... 87

ANNEX 9. SUPPORTING DOCUMENTS .................................................................................... 98

ANNEX 10. MAP OF CAMEROON ......................................................................................... 100

The World Bank Cameroon Health Sector Support Investment (SWAP) (P104525)

Page 1 of 100

DATA SHEET

BASIC INFORMATION Product Information

Project ID Project Name

P104525 Cameroon Health Sector Support Investment (SWAP)

Country Financing Instrument

Cameroon Investment Project Financing

Original EA Category Revised EA Category

Partial Assessment (B) Partial Assessment (B)

Related Projects

Relationship Project Approval Product Line

Additional Financing P146795‐Additional Financing to Cameroon Health Sector Support Project

24‐Jun‐2014 IBRD/IDA

Organizations

Borrower Implementing Agency

Ministry of Economy, Planning and Regional

Development Ministry of Public Health, PBF Technical Unit

Project Development Objective (PDO) Original PDO

To increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases.


Page 2 of 100

FINANCING

Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$)

World Bank Financing IDA‐44780

25,000,000 24,962,097 23,420,436

IDA‐54860

20,000,000 20,000,000 18,393,471

TF‐17128

20,000,000 20,000,000 18,876,143

Total 65,000,000 64,962,097 60,690,050

Non‐World Bank Financing

Borrower 0 0 0

Total 0 0 0

Total Project Cost 65,000,000 64,962,097 60,690,050

KEY DATES

Approval Effectiveness MTR Review Original Closing Actual Closing

24‐Jun‐2008 03‐Mar‐2009 06‐May‐2013 31‐Mar‐2014 31‐Dec‐2017

RESTRUCTURING AND/OR ADDITIONAL FINANCING

Date(s) Amount Disbursed (US$M) Key Revisions

10‐Mar‐2014 19.49 Change in Results Framework Change in Loan Closing Date(s) Reallocation between Disbursement Categories

03‐Jan‐2017 42.01 Change in Institutional Arrangements

KEY RATINGS

Outcome Bank Performance M&E Quality

Satisfactory Satisfactory Substantial


Page 3 of 100

RATINGS OF PROJECT PERFORMANCE IN ISRs

No. Date ISR Archived DO Rating IP Rating Actual

Disbursements (US$M)

01 06‐Aug‐2008 Satisfactory Satisfactory .20

02 31‐Aug‐2008 Satisfactory Satisfactory .20

03 30‐Jan‐2009 Satisfactory Moderately Satisfactory .24

04 20‐Mar‐2009 Satisfactory Moderately Satisfactory .24

05 07‐Oct‐2009 Satisfactory Moderately Unsatisfactory .59

06 18‐Jun‐2010 Moderately

Unsatisfactory Moderately Unsatisfactory .64

07 09‐Feb‐2011 Moderately

Unsatisfactory Moderately Unsatisfactory .86

08 25‐Oct‐2011 Moderately Satisfactory Moderately Satisfactory 2.26

09 28‐Apr‐2012 Moderately Satisfactory Moderately Satisfactory 4.16

10 10‐Dec‐2012 Moderately Satisfactory Satisfactory 6.08

11 12‐Jun‐2013 Satisfactory Satisfactory 10.35

12 28‐Dec‐2013 Satisfactory Satisfactory 19.15

13 20‐May‐2014 Satisfactory Satisfactory 20.07

14 18‐Nov‐2014 Satisfactory Satisfactory 22.90

15 20‐Apr‐2015 Satisfactory Satisfactory 35.54

16 23‐Oct‐2015 Satisfactory Satisfactory 35.54





21 21‐Dec‐2017 Satisfactory Satisfactory 41.22


Page 4 of 100

SECTORS AND THEMES

Sectors

Major Sector/Sector (%)

Public Administration 30

Central Government (Central Agencies) 20

Sub‐National Government 10

Health 60

Health 60

Social Protection 10

Social Protection 10

Themes

Major Theme/ Theme (Level 2)/ Theme (Level 3) (%) Human Development and Gender 100

Disease Control 38

HIV/AIDS 13

Tuberculosis 25

Health Systems and Policies 62

Health System Strengthening 25

Reproductive and Maternal Health 13

Child Health 24

ADM STAFF

Role At Approval At ICR

Regional Vice President: Gobind T. Nankani Makhtar Diop

Country Director: Mary A. Barton‐Dock Elisabeth Huybens

Senior Global Practice Director: Lynne D. Sherburne‐Benz Timothy Grant Evans


Page 5 of 100

Practice Manager: Lynne D. Sherburne‐Benz Gaston Sorgho

Task Team Leader(s): Miriam Schneidman Ibrahim Magazi, Jean Claude Taptue Fotso

ICR Contributing Author: Kofi Amponsah


Page 6 of 100

I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES

A. CONTEXT AT APPRAISAL

Country Context

1. At appraisal, over 40 percent of Cameroon’s population lived below the poverty line due mainly to economic crisis that hit the country in the 1980/90s. The government undertook economic and financial reforms to improve the economy, but growth fell below 3 percent. The Government also embarked on the Heavily Indebted Poor Countries (HIPC) initiative, which unfortunately did not yield concrete results in terms of improved living standards and service delivery. At the same time, the government made considerable progress in Public Financial Management (PFM) reforms through the implementation of measures such as budget tracking; procurement reform and external auditing to tackle corruption, which helped to improve Cameroon’s score of transparency international from 1.4 in 1998 to 2.5 in 2007. These PFM reforms were also intended to improve the effectiveness of public services, including health services. Key among the reforms were the following (i) development of a medium‐term expenditure framework that linked sector strategies to government priorities, (ii) decentralization of budget execution responsibilities to line ministries, and (iii) computerization of the budget processes. Other measures implemented by the government were implementation of transparency and accountability projects, which were expected to improve budget credibility, transparency and stewardship.

2. To improve aid effectiveness, the Government demonstrated leadership in strengthening coordination of several development projects in accordance with the principles of Paris Declaration on aid effectiveness. The Bank played a lead role in the aid effectiveness agenda by promoting mutual accountability with emphasis on government ownership, and alignment of development assistance to the needs of the country. This initiative was promoted in the health sector through a Sector Wide Approach (SWAp) that brought together all the key stakeholders in the sector. Emanating from Paris Declaration for aid effectiveness, SWAp is an approach to development that brings together key government institutions, development partners (DPs), and other stakeholders in a sector. It encourages an open and inclusive dialogue, with allocations based on priorities, payments based on results, and harmonized aid flow. It is characterized by a set of principles1 that allows each DP to focus on the government’s priority areas of development. The Cameroon SWAp was intended to support implementation of the health sector strategy. Under the SWAp agreement, the Bank would finance recurrent costs while Agence française de Développement (AfD) and German Technical Cooperation (KfW) were to finance investment activities such as rehabilitation and equipment of health facilities. Despite this well‐thought initiative, the SWAp did not materialize, and the project essentially became a performance‐based financing (PBF) project financed by the Bank and government (see section B below).

1 1 Paris declaration outlined five principles: (i) ownership; (ii)alignment; (iii) harmonization; (iv) managing for results; and (v) mutual accountability.


Page 7 of 100

Sector Issues

3. Despite government’s efforts, health outcomes lagged other countries in the region, making Cameroon off track for reaching the health and nutrition Millennium Development Goals (MDGs). Child and nutrition indicators were not the best. Malaria accounted for over 40 percent of morbidity among the population, and HIV infection rate was high with a national average of 5.5 percent. This particularly made women vulnerable with the rate of 6.8 percent compared to 4.1 percent among men. Tuberculosis prevalence rate (134 per 100,000 inhabitants) varied among provinces, ranging from 60 per 100,000 in the western provinces to 261 per 1000,000 in the Littoral province. TB/HIV co‐infection rates were estimated at 30‐40 percent, compounded by the emergence of multi‐drug resistant TB, whose treatment was considered as lengthy and costly with serious side effects. There was inefficient public spending on health with larger proportion of health expenditure going into administration rather than supporting frontline workers who deliver health services. The sector’s performance was inhibited by significant governance problems such as: (i)informal or under the table payments which placed a disproportionate burden on poor patients; (ii) irregular procurement practices, sale of illicit drugs, and over‐billing which translated into higher prices for patients; and (iii) excessive focus on controls and lack of transparent management of human resources (combined with extremely low salary levels) which drove individuals to abuse public funds and facilities; (iv) weak monitoring and evaluation of health sector performance caused by lack of analytic capacity of the Ministry of Public Health (MoPH), and manual paper‐based data collection with limited feedback from the provinces.

Rationale for Bank Involvement

4. To assist the Government of Cameroon (GoC) in addressing the above issues, the Bank collaborated with other key sector Development Partners (DPs) to work towards improving health outcomes, including strengthening health systems in order to attain the health MDGs. The Bank’s contribution strengthened visibility and credibility of the government’s health program, and leveraged resources from other partners. The project was aligned with the pro‐poor service delivery pillar of the 2006 Interim Strategy Note (ISN) by supporting its three key dimensions of (i) managing for results by promoting contracting of health districts and NGOs to deliver a package of health services; (ii) addressing governance issues and (iii) strengthening harmonization and building partnerships in close collaboration with DPs in the sector.

5. Main Beneficiaries. The project targeted an estimated 2.5 million inhabitants in the original four regions (East, Littoral, North West and South West). The main beneficiaries were women of reproductive age, pregnant women and children under five years of age. The target population was increased by 88 percent (from 2.5 million to 4.7 million) through Additional Financing (AF) which was approved on June 24, 2014 (Credit No.54860), in the amount of 13 SDR million (US$20 million equivalent), and US$20 million TF No. 17128. The AF, which targeted the indigent, the poor and vulnerable population increased the geographical coverage to three additional regions (Adamaoua, North and Far‐North). Institutionally, the project benefitted key institutions in MoPH, district health institutions as well as the communities through targeted capacity building interventions.

Theory of Change (Results Chain)


Page 8 of 100

6. The Cameroon Health Sector Investment Project (P104525, Credit No. 44780) approved on June 24, 2008 in the amount of SDR 15.3 million (US$25 million equivalent) focused on the provision of health services delivery and institutional strengthening to increase utilization and improve quality of health services for the target population. The same theory of change applies to the AF which funded increased demand and activities through additional financing.

7. Activities outlined to address service delivery issues included supervision, community outreach, recruitment of contractors and payment of performance bonuses to health facilities, capacity building and technical assistance, supply of consumables, performance‐based contracting, rehabilitation and equipment of health facilities2. To increase utilization of maternal and child health services, the project introduced demand‐side interventions (e.g. fee waivers) for poor families. This was implemented through reimbursement of facilities for lost revenues. The expected outcomes of these interventions were: (i) increased health services utilization, and (ii) improved quality of health services. Key assumptions under which the operation was designed included the following: donor funding would be available; local implementation support would be provided by Fond Spécial de la Promotion de la Santé (FSPS3)/ Special Funds for Health Promotion (SFHP), and government would fully support performance‐based financing (PBF) interventions. Figure 1 shows the project’s results chain.

Figure 1.: PAISS Results Chain

2 Under the PBF, rehabilitation and equipment of facilities were financed by health facilities’ administrators using a portion of their PBF subsidies. 3 Now known as Fonds Régionaux de Promotion de la Santé

Impact PDO Outcomes Outputs Activities Inputs

Reduction in Infant Mortality Reduction in Maternal Mortality

Increased Health services utilization Improved Quality of health services

Contraception prevalence rate increased Pregnant women receiving antenatal care increased Tracer drugs available in target facilities TB treatment success rate increased

Rehabilitation/equipment of health facilities Procurement and distribution of drugs Capacity building Household visits Family planning services Community outreach/mobilization Setting up fee waivers mechanisms Monitoring and supervision

Project Funds (PBF Funds to health facilities

Action/Work Plans

Intermediate outcomes

Children Immunized People with access to basic health services Births attended by a skill health professional TB cases detected Women beneficiaries


Page 9 of 100

Key Administrative and implementation milestones and processes

8. Nine years of project implementation were marked by key milestones and processes (Table 1). Table 1. Administrative/implementation milestones and process

EVENT/PROCESSES DATES

Administrative Milestones

Approval June 24, 20008

Effectiveness March 3, 2009

Original Closing date March 31, 2014

Actual Closing Date December 31, 2017

First Restructuring July 2010

Second Restructuring February 5, 2014

Additional Financing June 24, 2014

Third Restructuring January 3, 2017

Implementation Milestones

Beginning of PBF 2012

First Extension March 31, 2014‐January 31, 2016

Second Extension January 31, 2016‐ December 31 2017

Project completion December 31,2017

M&E Processes

Baseline Impact Evaluation May 2013

Midterm Review (MTR) May 6, 2013

Midline Qualitative Impact Evaluation December 2014

End‐line Quantitative Impact Evaluation End‐line Qualitative Impact Evaluation

March 24, 2017 March 27, 3017

Project Development Objectives (PDOs)

9. The project development objective (PDO) as stated in the original financing agreement (FA) is to increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases.

Key Expected Outcomes and Outcome Indicators

10. To achieve the PDO the following key expected outcome and outcome indicators were agreed:

Increased Health Services Utilization:

Percentage of children immunized for DPT3 (< 12 months);

Percentage of births attended by a skilled professional;

Percentage of children under‐five sleeping under insecticide treated bed‐nets the night before the survey;

Tuberculosis treatment success rate (i.e. percentage of those who are smear positive and who are successfully treated).


Page 10 of 100

Improved Quality of Health Services:

Percentage of patients reporting satisfaction with health services.

Components4

11. Component 1: District Service Delivery (Appraisal Estimate US$15 million; Actual US$47.5). The objective of this component was to address three critical constraints to service delivery: (i) scarcity of funds available at the field level to meet operating expenses; (ii) lack of focus for the achievement of actual results and lack of accountability for performance of the district health system; and (iii) limited managerial capacity at district level. Through FSPS, the project would channel financial resources to districts to enable them to meet their day‐to‐day requirements of managing a district health system. The funds were to be used for operating costs, goods, and technical assistance, including payment of performance bonuses to health facilities, recruitment of contractual workers, supervision, community outreach, and consumables. To address the issue of lack of focus on results and limited management capacity, the project would support pilot‐testing, on a reasonable scale, of a few different approaches to performance‐based contracting/financing, including financing of contracts with private/NGO‐administered facilities.

12. Component 2: Institutional Strengthening (Appraisal Estimate US$5 million; Actual US$8.9 million). The objective of this component was to strengthen two key functions of the central Ministry of Health/Ministry of Public Health (MoHP), at the provincial and district levels through: (i) setting up institutional framework and systems and build capacity to prepare, negotiate, and manage contracts; and (ii) putting in place an information system to generate up to date, reliable, financial and programmatic data.

B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE)

Revised PDOs and Outcome Targets

13. The PDO was not revised.

Revised PDO Indicators

14. To track implementation progress and ensure reliability of data reporting, the project team revised the unit of measurement (from percentages to absolute numbers) and end‐of‐project targets of three PDO indicators (children immunized, births attended by skilled personnel, and consultation for the poorest households) in the results framework.

4 The higher actual costs over appraisal estimates for the two components was as a result of additional financing (US$20million IDA and US$20million HRITF) the project received for scaling up project interventions


Page 11 of 100

The team took this action because of difficulties in measuring the indicators in proportions. The team also reformulated and introduced new PDO indicators through restructuring.

Revised Components

15. The components were not revised.

Other Changes

16. Other significant changes include:

17. Change in project approach. As noted earlier, the SWAp brought new sense of enthusiasm and optimism to the

development of the sector. It brought together two key DPs (AfD and KfW). Under the SWAp agreement, AfD and KfW

were to carry out construction and rehabilitation of health infrastructure while the Bank would finance operational costs.

Operationally, the FSPS was to implement the project at district level, but it did not have legal status to operate effectively.

To obtain legal status required adoption of loi de Groupe d’Intérêt Public (GIP)5 . AfD and KfW had to wait for the adoption

of the law before they would commit to the SWAp agreement and that meant that they would not finance institutions

that had no legal status. Two years later in 2010 the law was adopted, after the two DPs had already pulled out of the

SWAp in 2008. The Bank continued with the design and implementation of PBF together with the government.

18. Key changes during implementation are summarized in table 2, and detailed reasons given in the following section. Table 2. Key of changes Activity Date Remarks

Restructuring

First Restructuring July 2010 Addressed institutional arrangement constraints to improve implementation

Second Restructuring February 5, 2014 Extension of closing dates from March 31, 2014 to January 31, 2016 for 22 months; Revisions to results framework; Reallocation of expenditure categories.

Additional Financing

Board Approval June 24, 2014 US$20 million IDA Credit and US$20 million Health Results Initiative Trust Fund (HRITF) grant respectively. The financing and grant agreements signed on September 26, 2014.

Amendment to the Financing Agreement

Amendment of Section 1.A.2 of the FA

June 24, 2014 Government request for amendment to FA: (i) Changed PIU name to PBF Technical Unit; (ii) extension of closing date from January 31, 2016 to December 3i, 2017; Revisions to

5 A law that provides territorial autonomy to public institutions and persons.


Page 12 of 100

selected indicators and their targets.

Restructuring

Third Restructuring January 2, 2017 Revised the FA to ensure flexibility of using funds from IDA and Trust Fund and vice versa; Transferred staff of PIU to PBF technical Unit to implement Health System Performance Reinforcement Project (HSPRP).

19. First restructuring. On July 2010, the project underwent a level 2 restructuring. The restructuring was meant to address institutional arrangement challenges that inhibited project implementation progress after its effectiveness on March 3, 2009. Under the initial institutional arrangements, the FSPS was given the responsibility of purchasing health services from health centers. However, as of December 2009, their mandate had not been revised to reflect eligibility conditions stated in the FA. Also, the FSPS did not have enough autonomy from health service providers as Performance Purchasing Agencies (PPA). In addition, apart from the Littoral region by the project, the FSPS in the other regions, targeted by the project, did not have the technical capacity to develop and implement PBF as expected. This situation stalled project implementation for about two years, and as at March 2009 the project had only disbursed 6 percent of its total funds.

20. Second restructuring. On February 5, 2014, the project was again restructured. The restructuring was intended to: (i) extend the closing date of the project for 22 months from March 31, 2014 to January 31, 2016; (ii) revise and reformulate six indicators, their units of measurement and end targets; (iii) reallocate funds proceeds between expenditure categories. Major changes under the second restructuring included:

Changes in the results framework. As noted, the units of measurement and targets of the three PDO indicators were revised. The changes were deemed necessary as it was difficult to compute reliable estimates of the population covered. Similarly, the unit of measurement of the health facilities in targeted areas that used standard health management information system (HMIS) format indicator was changed from absolute number to percentage because the total number of health facilities implementing PBF had been established at the time of the review. The satisfaction indicator was dropped as the team decided to measure satisfaction through impact evaluation. Table 3 summarizes the revised indicators and their targets.

Table 3. Revised Indicators

No. Indicator Original target

Revised Target (number) Remarks

PDO Level Indicators

1. People with access to a basic package of health, nutrition, or reproductive health services

‐ 750,000 New indicator and target

2.

Percentage of children immunized for DPT3 (< 12 months);

85% ‐ Original indicator

Number of children immunized in targeted areas

‐ 100,000 Reformulated indicator


Page 13 of 100

3.

Percentage of births attended by a skilled professional;

66% ‐ Original indicator

Number of births attended by skilled professional in targeted areas


4.

Tuberculosis case treatment success rate in targeted areas.

80% ‐ Original indicator moved to intermediate outcome indicator level.

New cases of tuberculosis detected and treated in targeted areas


5. Direct Project Beneficiaries (number) ‐ 885,000 New indicator (CSI)

5.1 Of which female beneficiary(number) ‐ 443,000 New indicator (CSI)

Intermediate Outcome indicators

6. Pregnant women receiving antenatal care during a visit to a health provider


7. New acceptors of modern contraceptive methods in targeted areas


8. Children by the first anniversary who have received one dose of Vit. A in the last six months in targeted areas


Reallocation of funds. The project team also reallocated funds proceeds between expenditure categories as part

of the second restructuring. Funds were reallocated as follows: (i) goods and services for PBF (increased by 13 percent from SDR6.2 million to about SDR7.0 million); (ii) operating costs (increased by 8 percent from SDR1.2 million to SDR1.3 million); (iii) approved NGO fees (decreased by 21 percent from SDR3.million to SDR2.4 million); (iv) goods, services and drug supplies (increased by 41 percent from SDR2.8 million to approximately SDR4.0 million);, and (v) consultants’ services and training (decreased substantially by 67 percent from SDR2.1 million to SDR688,304). The reallocation was to meet demand for purchasing of health services, which increased at a faster rate than expected, resulting in quicker than expected disbursement and as more health facilities had signed contracts with the PPAs. The increase in operating costs category was to cover a two‐month transitional period costs of the Littoral PPA. The increase in goods and services category was meant to finance US$2 million costs of emergency procurement of ARVs to prevent a national shortage of Anti‐retroviral) ARVs drugs for the HIV/AIDS program. The decrease in consultant services and training category was to remove duplication of activities as a large part of the activities initially stated under this category were included in category 2 in compliance with Organisation pour L’Harmonisation en Afrique du Droits des Affaires (OHADA) regulations and procedures. Table 4 provides a summary of reallocation of funds among expenditure categories.

Table 4: Reallocation of funds between expenditure categories

No. Expenditure Category

Original Amount

(SDR million)

Reallocated Amount (SDR

million)

Increase (+)/ Decrease (‐)

(%)

1. Category1(a): Goods and Services (PBF)

6,200,000 6,999,492 +13

2. Category 1(b): Operating costs

1,200,000 1,293,105 +8

3. Category 1(c): Approved NGO fees

3,000,000 2,373,886 ‐21


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4. Category 2: Goods and Drug supplies

2,800,000 3,945,493 +41

5. Category 3: Consultant Services and training

2,100,000 688,024 ‐67

Total 15,300,000 15,300,000

21. Additional financing. On June 24, 2014 the Board approved a US$40 million AF, made up of US$20 million IDA Credit and US$20 million Health Results Initiative Trust Fund (HRITF) grant. The financing and grant agreements were signed on September 26, 2014. At the same time, the government requested an amendment of Section 1.A.2 of the Financing Agreement (FA) to change the name of the project implementation unit from Project Operational Unit (POU) to National PBF Technical Unit (NPTU). The IDA US$20 million AF was to extend the project to cover additional 2.2 million (from 2.5 million to 4.7 million) target population in the poorest region of the northern part of the country (Adamaoua, North and Far‐North). The AF was also meant to support institutional strengthening under component 2 of the project. The US$20 million HRITF was to: (i) support a scale‐up of project activities in the 26 districts implementing PBF by extending PBF to the impact evaluation group facilities and (ii) complete impact evaluation and use the results to fine tune the PBF national strategy. The AF extended the closing date from March 31, 2014 to December 31, 2017 to enable the project team to (i) carry out full implementation of component 1 activities; (ii) complete the conduct of impact evaluation to inform decision‐making; (iii) complete preparation for scaling up of PBF interventions; and (iv) allow the GoC to develop institutional, regulatory and fiduciary framework for extension of PBF coverage nationwide. In addition, most of the indicators’ targets at restructuring were met at the time of the approval of AF and given the pace of the results the project team doubled the targets (Table 5).

Table 5. Revised targets

No. Indicator Original target

Revised Target

AF Target Remarks

PDO Level Indicators


‐ 750,000 1,500,000 Target revised upward

3. Number of children immunized in targeted areas

‐ 100,000 200,000 Target revised upward

5. Number of births attended by skilled professional in targeted areas


7. New cases of tuberculosis detected and treated in targeted areas


8. Direct Project Beneficiaries (number)

‐ 885,000 1,770,000 Target revised upward

8.1 Of which female beneficiary(number)


Intermediate Outcome indicators

1. Pregnant women receiving antenatal care during a visit to a health provider


2. New acceptors of modern contraceptive methods in



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targeted areas

3. Children by the first anniversary who have received one dose of Vit. A in the last six months in targeted areas


Third restructuring. On January 2, 2017 the project was restructured for the third time. The third restructuring

was to (i) revise the financing agreement to enable flexibility in the use of funds from both the IDA credit and the trust fund for PBF activities, including PBF subsidy payments, in the North‐West, South‐West, East and Littoral regions as well as the North, Far North and Adamaoua regions, and (ii) move the PAISS PIU staff to the National PBF Technical Unit established to implement the new Health Systems Performance Reinforcement Project (HSPRP) currently under implementation.

Rationale for Changes and Their Implication on the Original Theory of Change

22. As noted, the first restructuring was necessary to address institutional arrangement constraints to implementation progress. The second restructuring was to extend the closing dates from March 31, 2014 to January 31, 2016 for 22 months as project implementation improved significantly and more time was needed to completed project activities. The third restructuring, which amended the FA was to ensure flexibility of use of funds between IDA credit and the trust fund. The changes to the indicators were deemed necessary as it was difficult to compute reliable estimates of the population covered. When revising the indicators, the team intentionally decided that quality would be measured through impact evaluation; and therefore, dropped the PDO level satisfaction indicator. The reallocation of funds between expenditure categories was needed to forestall a national shortage of ARVs. The additional financing was necessary to extend project coverage to the indigent and poor population, and scale up activities in the original regions. The above changes did not affect the original theory of change as the PDO and project components remained the same. The scope of the project increased and while the theory of change is the same, there would simply be more impact than previously expected.

II. OUTCOME

A. RELEVANCE OF PDOs

Assessment of Relevance of PDOs and Rating

23. Relevance of the PDO is rated high. The PDO is consistent with the Bank’s current Country Partnership Framework (CPF)‐FY17‐FY21, which emphasizes three strategic objectives: (i) addressing multiple poverty traps in rural areas (with a focus on northern regions); (ii) fostering infrastructure and private sector development; and (iii) improving governance6. The main objectives of strategic focus 1 include: (a) increased productivity and access to markets in the agriculture and livestock sectors; (b)

6 Country Partnership Framework, for the Republic of Cameroon for the Period FY17‐FY21 February 28, 2017, Africa Region

(Page 25)


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improved maternal and child health, and nutrition; (c) enhanced quality of, and more equitable access to, education; (d) expanded social safety nets; and (e) improved access to local infrastructure. PAISS is fully consistent with objective 2 (improved maternal and child health, and nutrition) of strategic focus 1, which is linked to SDG3: ensure healthy lives and promote well‐being for all at all ages. The project is also consistent with the GoC’s health development objective as enshrined in the National Health Development strategy‐PNDS (2016‐2020)7, whose overall objective is to make affordable priority essential and specialized health services available in at least 50 percent of District and Regional Hospitals by 2020. When the project was being prepared, Cameroon had poor child and nutrition indicators, and women were vulnerable to high morbidity because of prevalence of malaria and HIV AIDS. By aiming at increasing utilization and providing access to quality health services, PAISS buttresses the CPF’s objective of improving maternal and child health, and nutrition. To maintain relevance, during implementation, the project was extended to additional target population in the poorest region of the northern parts of the country through AF instrument.

B. ACHIEVEMENT OF PDOs (EFFICACY)

Assessment of Achievement of Each Objective/Outcome

24. PAISS has substantially achieved its development objective. The PDO was to increase utilization and improve the quality of health services with a particular focus on child and maternal health and communicable diseases. The project contributed to short to medium‐term interventions that sought to improve health services delivery, and directly benefited an estimated 7.8 million people (of whom 3.6 million were women) with access to improved health services. The project’s pro‐poor interventions enabled the poor and the vulnerable population to utilize quality health services. This is evidenced by an increase of original direct project beneficiaries from 2.5 million to 4.7 million (88 percent) to reach the poor communities in the northern parts of the country. Through PBF interventions the project strengthened health facilities capacity to deliver quality health care to the beneficiary population. The capacity building and coaching interventions provided by the project enhanced health facilities and frontline health workers and project managers’ technical capacity and ability to implement the PBF initiatives.

25. The PDO8 consists of two objectives: (i) increase utilization of health services with a focus on health and communicable diseases; and (ii) improve quality of health services with a focus on health and communicable diseases. An assessment of the achievement of the two objectives and their ratings is provided below. It is important to note that, a split rating was not done because most of the targets were increased and scope increased.

Objective 1: Increase utilization of health services with a focus on health and communicable diseases

26. This objective was achieved, and all its performance indicators’ targets were surpassed. The achievement of the objective is measured by: PDO indicator 1: People with access to a basic package of health, nutrition, or reproductive health services was fully achieved and its target surpassed. At the end

7 Plan National de Développement Sanitaire (PNDS) 2016‐2020, MINISANTE, Aout, 2016. 8 The achievement of the PDO is measured by the revised indicators and end‐of‐project impact evaluation.


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of the project, 7,166,077 (against a target of 1,500,000) had access to basic package of health, nutrition and reproductive health services. Intermediate outcome indicator 1: Pregnant women receiving antenatal care during a visit to a health provider butressed this achievement. At the end of the project, 1,094,661 (against a target of 200,000) pregnant women received antenatal care from a health care provider, exceeding the target by 17.7 percentage points. The results are also supported by intermediate outcome indicator 2: New acceptors of modern contraceptive methods in targeted areas. At the end of the project, the number of new acceptors of modern contraception was 165,062 compared to 40,000 people targeted by the project. Major activities that supported the achievement of the PDO indicator 1 included antenatal and prenatal care and family planning services carried out through the community PBF initiative.

27. PDO Indicator 2: Number of children immunized. This indicator was fully achieved and its target surpassed. At the end of the project, 392,889 children (against a target of 200,000) were fully immunized. The achievement of this indicator was supported by intermediate outcome indicator 3: Children by the first anniversary who have received one dose of Vit. A in the last six months in targeted areas. At the end of the project, 424,028 (against a targeted of 200,000) received one dose of Vit. A in their last six months. Community‐based intensive immunization campaigns were the main contributor to the achievement of this indicator. PDO indicator 3: Number of births attended by a skilled professional. This indicator was fully achieved and its target surpassed. At the end of the project 310,816 births (against a target of 60,000) were attended by a skilled professional. PDO indicator 4: New cases of TB detected and treated in targeted areas. This indicator was fully achieved and its target surpassed. At the end of project 14,916 new cases (against a target of 10,000) was achieved. Intermediate outcome indicator 4: tuberculosis treatment success rate in targeted areas supported the achievement of this indicator. At the end of the project, 80.36 percent (against a target of 80 percent) of TB cases were successfully treated. The achievement of the PDO was also measured by PDO indicator 5: Number of direct project beneficiaries9, disaggregated by gender, who utilized health services. At the end of project 7,779,897 (of whom 3,766,286 were females) compared to 1,770,000 (of whom 885,000 were females) utilized health services.

28. Major interventions that contributed to the achievement of objective 1 include: (a) PBF payment to health facilities to provide facility‐based services, outreach services provided at community level (coordinating household visits), and fee waivers for poor families (demand‐side interventions); (b) Payment to CHWs, basic curative care, household visits, community mobilization of health facility outreach activities, immunization and family planning campaigns, and patients referrals to facilities for complicated cases. Table 6 provides a summary of achievement of the project’s PDO indicators. Table 6. Achievement of key performance indicator for PDO 1 No. Indicator Baseline Target Actual % Achieved


‐ 1,500,000 7,166,077 474.4

2. Number of Children fully immunized ‐ 200,000 392,889 196.5

9 This is a core sector indicator introduced at midterm. It is measured by using three PDO indicators: (i) People with access to a package of health services (new consultations); (ii) Number of children fully vaccinated; and (iii) Number of births attended by qualified personnel.


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No. Indicator Baseline Target Actual % Achieved

3. Number of births attended by skilled professional

‐ 60,000 310,816 518.0

4. New cases of TB detected and treated in targeted areas

‐ 10,000 14,961 149.6

5 Direct project beneficiaries ‐ 1,770,000 7,779,897 439.5

5.1 Of which Female beneficiaries ‐ 885,000 3,766,286 425.6

29. Project level data showed sustained trends (over 2012‐2017 period) in the achievement of the PDO outcome indicators in the four regions (East, Littoral, North West and South West) for which data were available (see annex 1 for a summary of achievement of PDO indicators per year). This trend is explained by a sturdy increase in utilization of services in health facilities supported by the project. A total of 12,776,432 beneficiaries received a range of services such as hospitalization, outpatient consultation, normal delivery, complicated delivery, minor surgery, major surgery and cesarean section in the four original regions. Service delivery increased as well in the three additional northern regions (Adamaoua, North and Far North) with an estimated 1,344,847 people benefiting from the range of services in facilities that served their communities (see annex 3 for a summary table of service delivery utilization indicators).

30. The achievement of objective 1 is also corroborated by findings from end‐of‐project quantitative and qualitative impact evaluations, which consisted of health facilities and household surveys. The quantitative survey, which used difference‐in‐differences regression model methodology10 with a study period of between 2012 and 2015, found an increase in childhood vaccinations and utilization of modern family planning. The study found that antenatal care in facilities with the PBF intervention performed better than those facilities with only additional supervision. The survey showed positive outcome of full vaccination coverage among children between 12 ‐ 23 months of age in PBF facilities. Mothers or primary caregivers of all children under five years of age were asked about their child’s vaccination history. In the PBF group, there was a 17‐percentage point increase in full vaccination (0.170, p‐value = 0.076).

31. The survey also observed increased health services utilization by examining health facilities registers. It showed that health services provision as recorded in health facilities registers depicted a sturdy trend in utilization over the study period. It assessed the reliability of data by examining the health service counter‐verification data collected routinely as part of the PBF program design through community client satisfaction surveys. The health service verification occurred in all PBF health facilities, as well as in health facilities in control groups C1 (additional financing) and C2 (additional supervision). Figure 2 shows the percentage of patients who were reported by health facilities to the PBF verification teams and confirmed to have received health services at the health facility. In most quarters of the three‐year study period in all three study regions, over 80 percent of reported patients were confirmed. The trend in confirmed patients increased slightly over time in North‐West and East, with confirmation rates above 85 percent in all three regions during the final year of the study. Facilities in the full control group had less incentive to keep records of all services provided than facilities in PBF group.

10 The difference‐in‐differences regression model methodology hinges on a randomized control trials with four groups (T1: PBF with health worker performance bonuses; C1: Same per capita financial resources as PBF but not linked to performance; same supervision and monitoring and managerial autonomy as T1; C2: No additional resources but same supervision and monitoring as PBF arms and T1 and C1; C3: Status quo). Measure of statistically significance: * = p < 0.10, ** p < 0.05, *** p< 0.01


Page 19 of 100

Figure 2. Percent of reported patients confirmed during verification

Source : Cameroon PBF Quantitative Impact Evaluation Report, March 24, 2017

32. These findings were corroborated by end‐of‐project qualitative impact evaluation, which found out that providers and patients indicated that PBF interventions increased service utilization because of a change in service delivery practices (i.e. intensive outreach activities such as community visits, school visits, the establishment of outreach posts, etc.) of the beneficiary health facilities in the communities they serve. The survey further showed that family planning information were integrated in the delivery of services such as ANC or PNC visits, and childhood vaccination, which significantly sensitized and informed women of good family planning practices. The community PBF interventions (e.g. intensive community level outreach and sensitization program) introduced by the project were the major factors in increased utilization of health services in facilities in the communities in which the beneficiaries reside. (see Annex 7 for a summary methodology and findings of the impact evaluations). Objective 2: Improve the quality of health services with a focus on health and communicable diseases11

33. The PDO lacked indicators to measure quality. As noted earlier, there was original satisfaction indicator which was to measure the quality objective aspect of the PDO. But it was dropped during restructuring because the project team decided to measure satisfaction through impact evaluation. For that reason, the ICR team mainly assessed objective 2 with findings from two end‐of‐project impact evaluations (quantitative and qualitative). The quantitative survey found significant improvement in quality of health services because of project interventions. The survey also assessed quantity and quality of health supplies, medicines, and equipment in the health facilities, and observed a large and consistent impact on health workers’ satisfaction with the quantity and quality of equipment and other supplies at health facilities. It also found that both the PBF and the additional financing interventions resulted in large and highly significant improvements with about 20 percentage point increase in satisfaction with the quantity of equipment (p<0.05), a 25‐percentage point increase in reported satisfaction with the

11 Due to lack of PDO indicators to measure quality, the ICR team mainly used results of end‐of‐project impact evaluation (quantitative and qualitative) and project level data to assess the quality objective.

83

89

81

9894

86

40

60

80

100

Sept.2012

Dec.2012

Feb.2013

May.2013

Sept.2013

Dec.2013

Mar.2014

Jun.2014

Sept.2014

Dec.2014

Mar.2015

Jun.2015

Per

cen

t (%

)

North-West Est South-West


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quality of equipment (p<0.05), and a 40 percentage point increase in satisfaction with the availability of other supplies at the health facilities within the PBF and additional financing components (p<0.01). The survey’s findings are again buttressed by a key quality intermediate indicator 6: Health facilities achieving an average score of 75% of the quality index of services as measured in RBF in the targeted areas supported the achievement of this objective. At the end of the project 63.5 percent of health facilities (against a target of 60 percent) achieved an average score of 75 percent of the quality index of services.

34. Regarding ANC services, the overall satisfaction score for ANC reported during facility exit interviews showed that the PBF group was associated with an 8.6 percentage point increase in satisfaction (p < 0.077). Women’s satisfaction with health facility characteristics significantly increased as well. PBF was associated with a large and statistically significant 24.1‐percentage point difference from the control group (p<0.05) in women’s satisfaction with the health facility cleanliness. Focusing on reported facility cleanliness, women in the PBF and the additional financing group (p<0.05) both reported significantly higher levels of satisfaction than in the pure control group. Compared to the control group, PBF resulted in a large and statistically significant 15.4‐percentage point increase in satisfaction with the facility’s hours. There was also significant impact on child health services as PBF had a positive impact on overall satisfaction with child health services. Compared with the pure control group, PBF was associated with a statistically significant 9.9‐percentage point increase in satisfaction (p<0.05).

35. The qualitative impact survey supported the findings of the quantitative impact survey. Majority of respondents noted that structural changes such as availability of equipment, drugs and supplies, human resources and other important inputs, which have direct impact on quality of care in a health facility were the main factors that contributed to the achievement of this outcome. The survey further sought to establish adequacy of these important health care inputs in the health facilities surveyed. In the PBF intervention areas there were significant increases in the availability of the necessary equipment, particularly delivery and neonatal care materials. This enabled health workers to carry out a set of quality checks (vital signs: blood pressure, weight, conjunctiva, hemoglobin, rhesus, urine glucose, uterine size, feel heartbeat and fetal presentation) of health services provided in the facilities. The evaluation also emphasized better health infrastructure, including rehabilitation, expansion and upgrade of facilities and equipment financed by the health facilities’ management with their PBF subsidies. Most health facilities were fully equipped with generators, autoclave, fridge, laboratory equipment, delivery beds, weighting scales, bedsheets, nets, incinerators, placenta pit, toilets facilities. The facilities also benefited from provision of motorcycles and office equipment such as computers and TV screens for DHMTs.

Justification of Overall Efficacy Rating

36. The project’s efficacy is rated Substantial as all its outcome objectives were achieved with only minor shortcomings. All the utilization indicators’ targets for objective 1 were fully achieved and surpassed. There is also noteworthy evidence from the end‐of‐project impact evaluations (quantitative and qualitative), including project level data that supported the achievement of both objective 1 (increase utilization of health services) and objective 2 (improve quality of health services).


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C. EFFICIENCY

Assessment of Efficiency and Rating

37. Cost effectiveness analysis. To assess efficiency of project interventions a cost effectiveness analysis was conducted as part of project closure. The results of the analysis showed a US$401.99 incremental cost effectiveness ratio (ICER), estimated from available service delivery costs and output data at health facility level. Using the World Health Organization (WHO) standard for interpreting cost effectiveness analysis results (ICER = $/DALY averted < GDP per capita is very cost effective) the project was cost efficient as the estimated ICER ($401.99) is less than Cameroon’s per GDP of $1,374.5 (WDI, 2016). It must be noted that cost effectiveness analysis was not conducted at appraisal; and so, the ICR team could not compare the results (ICER) with any appraisal estimates.

38. Operational /implementation efficiency. The project encountered considerable delays (almost three years after project effectiveness) due to the weaknesses in the institutional arrangements for implementing the service delivery (PBF) component of the project. But this was corrected through project restructuring and extensions, including additional financing. The HRITF additional resources supported a scale‐up of project activities in the 26 districts implementing PBF. Operational efficiency was also assessed by comparing actual project component costs with appraisal estimates. The analysis showed a variance of US$31.4million (Component 1: US$27.5 and Component 2:US$3.9million) at the end of the project. Total project cost at appraisal amounted to US$25 million, made up of Component 1 (US$20million) and Component 2(US$5million) respectively. At ICR US$47.5million (237.7 percent of appraisal estimate) and US$8.9million (178.1 percent of appraisal estimate) were spent on components I and 2 respectively. The high variance was due to additional financing (IDA‐ US$20million and HRITF‐US$20million) provided to support increased coverage and scale up of project activities. As noted earlier, the IDA AF enabled extension of the project to additional 2.2 million target population in the poorest region of the northern part of the country (Adamaoua, North and Far‐North). The AF improved efficiency as it was pro‐poor and results‐focused. Available project results data shows that service utilization in the three poorest regions covered by the AF increased significantly with an estimated 1.3million indigents and the poor benefiting from a range of health services, including inpatient and outpatient consultations, minor surgery, normal and complicated delivery, cesarean sections etc.

39. Efficiency was also enhanced as the project interventions led to better management of health

facilities’ revenues, reduction of parallel sales of drugs, display of costs of care services on notices,

laboratory examinations, and medicines. The project brought much more competition into drugs

purchasing and distribution of drugs and pharmaceuticals. Hitherto, drugs purchasing and distribution

was highly centralized as it was the sole responsibility of the FSPS.

40. Time overrun/underrun. In terms of timing, PAISS overall performed well, recording 19.5 months from concept to first disbursement compared with Cameroon average (36 months), Africa average (22.6) and Bank average (24 months). Project administrative cost was efficient as it was within the acceptable Bank‐wide practice. Given the length of the project due to project extensions, the total administrative


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cost12 of the project is deemed efficient as it is within the Bank’s overall administrative cost of between 5 to 10 percent of total project cost (see Annex 4 for a detailed efficiency analysis).

41. Although a comparison with the WHO cost effectiveness metric shows the project was cost effective, efficiency would have been much stronger if additional comparison could be made with results of similar analysis at appraisal. Given that such an ex‐ante cost effectiveness analysis/cost benefit analysis (traditional efficiency measures) that could have allowed a comparison of end‐of‐project estimate with that of appraisal estimate was not conducted, efficiency is rated modest.

D. JUSTIFICATION OF OVERALL OUTCOME RATING

42. Based on the project’s high relevance, substantial efficacy (achievement of development objective), and modest efficiency, the overall outcome is rated Moderately Satisfactory.

E. OTHER OUTCOMES AND IMPACTS (IF ANY)

Gender

43. The project had significant impact on women. As indicated above, available utilization data showed that of the 7,779,897 total project beneficiaries, 3,766,286 were women, representing 48.4 percent of total project beneficiaries. This was mainly due to increased utilization of some key maternal health services such

as antenatal care (ANC) and postnatal care (PCN). Available health services utilization data shows that 1,094,661 pregnant women utilized ANC services in facilities which benefited from PBF funding throughout the project life.

Institutional Strengthening

44. Major institutional development impacts occurred at national and subnational levels. At the national level, the project substantially strengthened MoPH’s capacity to develop norms and guidelines for use by operational level facilities. PBF changed the way business is conducted in the Ministry. Directorates were required to produce their expected outputs before bonuses are paid to them. They signed performance contracts with the MoPH where each directorate is evaluated by two or three other directorates. Through PBF government has strengthened the budgetary allocation system, whereby it uses PBF mechanism to pay money directly to health facilities through the Treasury. Also, PBF has significantly strengthened the MoPH’s management information system. An information management system‐ District Health Information System (DHIS2)‐ which tracks key performance indicators has been developed and rolled out to districts.

45. The project also strengthened the PIU’s capacity to manage and provide oversight of project activities. It strengthened its information management system by establishing a cloud‐based information

12 Although not specified in the OPCS guidelines, the ICR team included the costs of Bank staff who worked on the project from preparation to supervision/ICR to ascertain full cost of project management from both the PIU and Bank side.


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system known as FBP Cameroon. The system produces real time information on quantitative and qualitative indicators as well as financial data, published on quarterly basis. The software also gives instant graphical information on health facility level service delivery indicators, enabling the project team to interpret trends in the achievement of project results for effective decision‐making. To further strengthen the PIU and make it more operational, it was transformed into a National PBF Technical Unit (CTN), which is responsible for the implementation of the new Health Systems HSPRP.

46. At the subnational level, the project strengthened the capacity of heads of district health administrations to coordinate, evaluate and validate the performance of health facilities under their supervision. It strengthened the referral and counter referral systems by improving working collaboration between the health centers [providers of Paquet Minimum d’ Activités (PMA)] and the hospitals [providers of Paquets Complémentaires d’ Activités (PCA)]. Health facilities capacity to report on their activities improved significantly. The intermediate outcome indicator 7: Health facilities reporting monthly activities using standard report form in targeted areas provided evidence of institutional impact of the project at facility level. At the end of the project 100 percent of 75 target health facilities reported their activities using standard reporting form. The project also improved transfer of funds and the entire financial management systems at health facility level. The existing government’s card system of transferring funds is characterized by delays, making it difficult for the facilities to have funds to undertake small maintenance and replacement of equipment. With the introduction of PBF, funds could now be transferred directly into the accounts of the beneficiary health facilities. This allowed the facilities to have funds available always, and carry out their routine maintenance and equipment of the facilities. However, facilities suffered from persistent delays in payment of subsidies, a situation that need to be urgently addressed if PBF is to fully have development impacts.

47. The project strengthened the pharmaceutical system by substantially reducing the parallel sales

of drugs. Overall there is an improvement in financial governance as evidenced in better organization of

health facilities revenues, reduction of parallel sales of drugs, the display of costs of care services,

laboratory examinations, and medicines. Despite these improvements, the project could have directly

upgraded infrastructure in the most disadvantaged facilities and district health administrations. During a

field visit to Littoral region, the ICR team observed very limited space for some District Health

Management Team (DHMTs). A case in point is the Bangue, DMHT, which has 42 health facilities under its

purview, but have very limited office space to carry out its day‐to‐day business.

Mobilizing Private Sector Financing N/A

Poverty Reduction and Shared Prosperity

48. Poverty impact of the project was substantial. As noted above, through the AF interventions an

estimated 1,344,847 of indigents and the vulnerable population in Adamaoua, North and Far North

(Yagoua and Maroua) benefited from a range of services, including hospitalization (one day), minor

surgery, normal delivery, complicated delivery, outpatient consultation, major surgery, and Cesarean


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section in 201713. The intensive community PBF interventions (sensitization and outreach campaigns)

carried out by the project were the main factors that impacted on the utilization practices of this cohort

of the population. Table 7 provides a summary of key service utilization indicators in the three northern

regions of the country.

Table 7. Service utilization by indigent and vulnerable population‐ three Northern Regions (Adamoua, North,

& Far North)

Indicator Adamaoua North

Far North (Yagoua)

Far North (Maroua)

Total

2017 2017 2017 2017 2017

Hospitalization (one day) 111,375 63,258 55,662 144,596 374,891

Minor Surgery 15101 17516 8437 12673 53,727

Normal Delivery 14905 11667 6675 12670 45,917

Complicated delivery 378 238 112 355 1,083

Outpatient Consultation 251,755 173343 151,634 287,307 864,039

Major Surgery 1219 471 965 846 3,501

Cesarean section 730 315 359 285 1,689

Total 395,463 266,808 223,844 458,732 1,344,847

Source: PIU Database

Other Unintended Outcomes and Impacts

49. Hospital sector reform. Although the tertiary sector interventions were not integrated into project

design, the project supported implementation of PBF in a major hospital, Hôpital gynéco‐obstétrique et

Pédiatrique de Yaoundé (HGOPY), Yaoundé through technical assistance. Having observed PBF’s impact

on service delivery at health facilities in project intervention areas, the hospital management sought

support from the Bank to adopt and implement PBF initiatives with their own internally‐generated funds.

The Bank provided them with PBF experts who trained over 20 managers, including the Chief Executive

Officer (CEO). The hospital also obtained service quality assessment support from the Bank through

Littoral region’s ACV. In April 2015 PBF implementation started in three units of the hospital and

progressively extended to all clinical and administrative units. This led to improved hospital efficiency and

better management of resources: (i) an increase in bed occupancy rate, (ii) improved diagnostic and

treatment capacity; (iii) an increase in internally generated revenues; (iv) a reduction in unjustified

expenses; (v) a reduction in informal and under the table payments to staff; (vi) an improved quality of

13 It must be noted that activities in the three northern regions were mainly implemented in 2017 due to insecurity issues and

long procurement process of recruiting NGOs to establish performance purchasing agency for the project.


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care; (vii) an improved staff performance: punctuality, team spirit and technical competence; and (ix)

better remuneration for staff (Annex 6 for a summary of achievements).

III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME

A. KEY FACTORS DURING PREPARATION

Design

50. The project was designed as a SWAp intended to support implementation of the government’s health sector strategy. Project preparation fully involved key stakeholders from both government and development partners. The MoPH and Ministry of Finance (MoF), and Ministry of Economy and Planning (MoEP), were the key government institutions involved in project preparation. Major development partners involved in the preparation were AFD, KfW, World Bank (WB) and Health Organization (WHO).

51. Key designed features include:

Sound background analysis. As a prerequisite to project design, the Bank team supported studies on governance, fiscal space analysis, and M&E capacity assessment. These studies provided adequate background information as input into the project design. For example, a Bank financed study conducted revealed three major governance issues that inhibited sector performance. They include: (a) informal or under the table payments which place a disproportionate burden on poor patients; (b) irregular procurement practices, sale of illicit drugs, and over‐billing which translated into higher prices for patients; and (c) excessive focus on controls and lack of transparent management of human resources, coupled with low salary levels, which led to lack of commitment to work, particularly at facility level. The study recommended performance‐based contracting/financing approach to paying providers for results. This formed the basis for the design of the PBF interventions. The fiscal space analysis study outlined poor linkage between health spending and disease burden. The M&E capacity assessment identified limited data management and analytic capacity of MoPH, including issues related to data collection processes, which were largely paper‐based.

A novel design that focused on performance. The design was simple with clearly stated two components focusing on service delivery and institutional strengthening. The design incorporated performance‐based financing initiatives, which established contractual agreements between the various actors, at all levels, proven to be effective in other countries, in Africa, particularly Rwanda. In particular, the design integrated an important tool (internal performance contracts) for central departments/directorates within MoPH to improve governance and stewardship in the central MoPH departments/directorates, whereby a directorate is evaluated by two or three other directorates.


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Akin to the above is the Community PBF initiative introduced by the project. Under this initiative, local communities were involved in preparation of health facilities’ business plans and participating in community campaigns and sensitization programs. This initiative also empowered Local Associations (ALSOs)14 to serve as interface of the health system between local beneficiary population and healthcare providers. Their main functions were to (i) inform the population of a range of health services available in the health facilities, and encourage them to seek healthcare in health facilities their communities; and (ii) identify community needs for health and inform health care providers appropriately.

Results Framework. The results framework was logically formulated with both intermediate and outcome indicators linked to the PDO. The PDO was realistic with clearly defined two outcome objectives (increased utilization of health services and improved quality of health services). However, PDO level indicators disproportionately favored the utilization outcome objective. Only one indicator (percentage of patients reporting satisfaction with health services) was a measure of quality outcome objective of the PDO. As noted above, the project team later dropped this indicator because they decided to measure satisfaction through the conduct of impact evaluation.

Project risks. Project risks at appraisal was overall rated moderate. The project team appropriately identified key risks that could potentially affect implementation and outcome and outlined mitigation measures to address them. Prominent among the risks and their mitigation measures were: (i) the risks that fiscal imbalances could increase the country’s indebtedness and arrears (this risk was mitigated by increasing non‐oil revenues, reforming inefficient public enterprises, and increasing effectiveness of public finance; (ii) poor planning of procurement operations leads to an increase in costs and delays in procuring goods and services (this risk was mitigated by Bank‐supported reforms aimed at securing sustainable funding for improving national procurement systems and expenditure management); and (iii) informal payments to providers, lack of transparent management of personnel, and controls that slow down implementation (this risk was mitigated by introducing performance‐based contracting/financing initiative to enhance accountability and results).

Lessons learned from previous project. The preparation team included lessons learned from the previous health project into the design. They were: (i) adoption of a simplified design; (ii) involvement of local stakeholders; (iii) setting of realistic objectives and targets; (iv) establishment of systems for measuring results; (v) ensuring that implementation and institutional arrangements are in place; and (vi) providing close supervision and involving Bank management.

14 ASLOs signed a performance contract with PAAs and must produce a quarterly activity report and submit it to the PAA.


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Strong Government Commitment. Government commitment to supporting the implementation of the project was high. It demonstrated commitment by sending a team of four to study the PBF initiative in Rwanda. The government team worked closely with the Bank team and the other DPs to complete a successful project design.

B. KEY FACTORS DURING IMPLEMENTATION

52. The project was approved by the Board on June 24, 2008 and became effective on March 3, 2009. The delay in effectiveness was mainly due to delay in fulfilment of three effectiveness conditions: (i) adoption of an operations manual; (ii) establishment of operational unit; (ii) recruitment of a program manager (focal point), a procurement specialist, an accountant and an internal auditor, and; (iii) preparation of terms of reference for the recruitment of an external audit firm. After the initial delays (see para 46 below) project implementation commenced in earnest, and was aided by the following factors:

(a) Factors subject to government and/or implementing entities control

53. Government commitment. The GoC fulfilled its commitment to finance part of the costs of PBF subsidies, including the operational costs of the Performance Purchasing Agency (PPA) in the Littoral region and successfully paid US$1.6 million as part of its counterpart contribution. To further strengthen its commitment, MoPH budgeted about US$2 million for the PBF operations in the Littoral region in 2014. Specifically, the Ministry covered all output costs (i.e. purchasing of services from contracted facilities). This commitment was a good example of the momentum and buy‐in that PBF is gaining in Cameroon. The project also benefited from dedicated support from both the Minister of Public Health and the Head of the Project Steering Committee (PSC) who was respected among health professionals at operational and regional levels. The Littoral regional government also played very effective role at the outset of project implementation by writing to continue with the Bank after the Germans and the French pulled out from the SWAp.

54. Project management commitment. Despite the limited staff, the PIU staff were committed and worked around the clock to ensure smooth implementation of activities. The project coordinator was an asset to the project as he was among the first beneficiaries of the PBF training in Rwanda. He effectively coordinated activities with different stakeholders at national, regional and district level.

55. Results‐oriented initiative introduced by PBF enticed all actors and stakeholders to commit to results. Through contracting agreements between the various actors involved in implementation, every actor’s performance was evaluated by a superior actor and that drove everyone to focus on performance. For example, CTN’s performance was evaluated by MoPH. At the regional level, CTN evaluates the performance of Agence de Control et de Verification (ACV), the Délégation Régionale de la santé/ /Regional Health Delegation(RHD), and Fond Régionale de la Promotion de la Santé (FRPS)/Regional Fund for Health Promotion(RFHP). The RHD evaluates the performance of the District Health Management team (DHMTs), who in turn evaluates the performance of the health facilities. In addition, CTN conducts random verification of selected health facilities. This result‐driven approach was key to the success of the project.


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56. Despite these positive factors, the project encountered considerable challenges due mainly to the following factors:

57. Institutional set up. The project suffered from institutional constraints, which inhibited implementation for almost three years after project effectiveness. This was mainly due to the weaknesses in the institutional arrangement for implementing the service delivery (PBF) component of the project. The plan for implementing PBF was (i) contracting of services between the central MoPH and the intermediate agencies, FSPS in costal, southwestern and northwest regions; and (ii) contracting of services between FSPS and the district health service delivery facilities. The project documents did not include detailed technical requirements as well as mechanisms for implementing PBF. In addition, the FSPS, did not have adequate autonomy to operate on their own independently from the health facilities. Except for Littoral region, the two original FSPS of South west and North West had limited capacity to design and implement PBF interventions. Project implementation, therefore, stalled as these technical requirements were not adequately considered in the original project documents. To address these issues, the Bank and the government agreed to restructure the project by (i) granting exceptional status to Littoral Regional Special Fund for Health Promotion (LRSFHP), creating a Performance Purchasing Agency (PPA) housed in LRSFHP, and (ii) contracting experienced institutions to help design and implement PBF, and transfer capacity to implement PBF to the three regional FSPS. As noted, the project was restructured in July 2010, and a PPA was established in the Littoral Region, and the hiring process for experienced institutions to develop PBF in the other three regions was launched. However, the process stagnated due to a lengthy procurement process. It took almost two years before the process was completed.

58. Delays in payment of PBF subsidies to health facilities. There was reportedly a delay in payment of PBF subsidies to health facilities. This problem persisted throughout the project’s life. The delay in payment of subsidies to health facilities was mainly caused by accumulation of arrears because of a pile up of invoices at the national level. Two main factors accounted for this situation. First, funds from the initial IDA credit was exhausted in 2014. And to avoid interruption of implementation of activities the government requested for additional financing. The AF process, which started in March 2014 took nine months to complete. Second, in 2016 funds from IDA credit were used to finance trust fund activities in the project areas. But the provisions in the financing agreement did not require such practices. A project restructuring (see section B above) to remove the clause was initiated. Unfortunately, the restructuring took seven months to complete. These situations led to a pile up of invoices coming from the field, and given the limited staff (only three people) at the PIU arrears built up. The ICR team found out that in Bangue Health District in Douala, they are awaiting payment of arrears of the past five quarters.

59. Limited facility autonomy. Facility autonomy was regarded as the cornerstone of PBF’s theory

of change. But national policies limited the facilities’ ability to: (i) make independent decisions; (ii) operationalize their business plans, and (iii) manage their entire resources and staff. Health services providers and managers repeatedly mentioned lack of autonomy in making decisions due to conflicts between the PBF practices and the existing laws and regulations, particularly issues regarding management of funds and hiring of staff. These issues created tension and frustration for providers who decided to take no autonomous decisions at all, or take only some decisions, but with caution. However, with the adoption of loi de GIP15 in 2010, this problem was resolved.

15 A law that provides territorial autonomy to public institutions and persons


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60. Turnover of health workers at facility level. There is reportedly high turnover of health professionals at facility level. ACV and, indeed, heads of district health management teams lamented about this situation. After providing training to health workers, ACV finds new people all together when conducting next rounds of verification missions. This leads to retraining and continuous training. While this could be attributed to overall human resources for health issue, the delays in payment of subsidies to health facilities, in a large part, contributed to this situation.

(b) Factors subject to World Bank control

61. Adequacy of project supervision. The Bank supervision team consistently supervised the project. On average, supervision missions were undertaken every two months. During such missions, the Bank team proactively work with project team to address implementation challenges. For example, although it took nearly two years to resolve, the Bank team eventually resolved the institutional arrangement issue that inhibited implementation through restructuring.

62. Adequacy of reporting. All supervision missions were adequately reported with over 21 aid‐memoires and ISRs produced and documented. There was relatively low turnover of TTLs (three TTLs), which facilitated project reporting. The mid‐term review (MTR) conducted by the Bank further enhanced stakeholders understanding of PBF initiatives. Organized in a participatory manner, the MTR provided the opportunity for implementing partners at all levels to present updates of project implementation and discuss overall project progress and its associated issues with the Bank team. Implementing partners presented updates of their activities, which revealed interesting findings: (i) motivated health workers (ii) improved community voices, (iii) clean and better managed hospitals and health facilities; (iv) enhanced beneficiaries understanding of the PBF; (v) strong relationship between health facilities and the beneficiaries most of whom did not know that they could be cared for free of charge under the PBF.

63. Additional financing. The AF provided by the Bank significantly boosted implementation. To improve project implementation and increase health services utilization at community level, the AF introduced a Community PBF activities in the northern regions of the country. The aim was to improve health‐seeking behavior and geographical access to preventative and curative health services. Through the AF, the project introduced mechanisms to improve the poor and vulnerable households’ financial access to essential health services at community and health facility level. Prominent among the mechanisms were the establishment of exemptions systems for the poor to cover health services provided at the community and health facility levels as well as fee‐waivers for certain essential services for vulnerable households. To mitigate against revenue shortfalls for health facilities, health facilities were reimbursed for services provided free of charge to vulnerable households.

(c) Factors outside the control of government and/or implementing agency

64. Security situation in Northern Cameroon. Boko Haram operations in the project intervention areas in the northern regions hampered the project team’s ability to conduct regular field supervision and preparation activities. The scale‐up of project activities to the north was adversely affected by cross‐border violence from Boko Haram in several health districts covered by the project. This situation prevented the project team to conduct regular missions to the region.


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65. Reluctance of health facility staff. Most of health facility staff members were initially reluctant to implement PBF program, and, did not believe they could receive monetary bonuses. Moreover, health facility workers were hesitant to accept the drastic work‐style changes required by the PBF program before receiving payments for their performance. But, with the initial payment of bonuses, as well enhanced education, most of them became motivated and committed to implementing PBF interventions.

IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME

A. QUALITY OF MONITORING AND EVALUATION (M&E)

M&E Design

66. The M&E design included expected outcomes that measured progress towards the achievement of the PDO. The PDO was succinct in that it focused primarily on two main outcomes (increased utilization of health services and improve quality of health services). Although, the PDO indicators covered the two outcomes, they were largely utilization indicators. As noted, only one PDO indicator was a measure of quality. The design included a provision for reviewing and revising project indicators and target values as and when required. It also envisaged institutionalization of a system to improve availability, reliability, and timeliness of routine health services information system, including alignment to national processes; harmonization of approaches to performance assessment; capacity building and health information system strengthening; and systematic quality improvement. The design incorporated performance‐based contracting/financing whose impact was to be measured by impact evaluations (baseline, mid‐term, and end line).

M&E Implementation

67. M&E implementation was largely carried out through three rounds of impact evaluations (baseline, mid‐term, and end‐line). Although planned to be conducted earlier, the baseline survey was not conducted until 2011 due mainly to delay in project implementation. To ascertain evidence of project impact on beneficiaries, a mid‐line (qualitative) and end‐line (qualitative and quantitative) evaluations were also conducted. The quantitative impact evaluation used rigorous and randomized sampling techniques to measure project impacts at both household and health facility levels. The approach was mainly a regression model that uses difference‐in‐differences to assess the project’s impact. The end‐line qualitative impact evaluation, which sought to further deepen the results of the quantitative impact evaluation provided evidence of perspectives of health authorities at central, regional and district levels, health workers, and patients and beneficiary communities.

68. At the project level, data management was not the best. Although the project established a portal in which project results are entered, data was not adequately and systematically documented. Routine data collection and systematic monitoring of indicators facilitated by ACV were largely and systematically carried out at regional and local levels. However, at the national level, data were not systematically aggregated and consolidated. At the time of ICR, M&E consolidated report from the regions was not


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readily available. The ICR team also observed data gaps at the national level. There is a need to improve M&E data management capacity at project level.

69. As part of M&E implementation the Bank and the project team conducted an MTR in May 2013. The MTR aimed at reviewing implementation progress after the project was restructured in July 2010. The MTR identified the following issues: (i) lack of a national technical unit to guide PBF policy; (ii) health facility autonomy; (iii) delays in payment of PBF subsidies; (iv) absence of a centralized routine data collection and management system etc. The team worked with the project team to outline key actions that needed to be taken to address the issues.

70. The indicators in the results framework were consistently reported in the ISRs. Overall, 21 ISRs were produced throughout the project life. As noted, the M&E design envisaged a revision to indicators and targets. This initial requirement was consistently followed through by the Bank and the project team that revised the indicators and their unit of measurements. While this action ensured the project remained focused towards the achievement of the PDO, it resulted in a complete overhaul of the PDO indicators which ultimately tended to measure only the objective 1 (i.e. increase utilization of health services) of the PDO. As noted, the team decided to drop the satisfaction indicator as they would use impact evaluation to measure the quality. Therefore, the ICR team relied largely on the end‐of‐project impact evaluation to assess the quality objective. Despite this shortcoming, the M&E data collected were overall deemed reliable. The PBF requirement ensured data was consistently collected and verified by independent experts. At the project level about 26 indicators were monitored and collected at health facility level on monthly basis. These indicators were used as inputs into the determination of results framework indicators’ values.

M&E Utilization

71. M&E data, mainly in the form of regular supervision reports, were used to inform decision‐making at all levels of the project. The MTR, which was organized in a big workshop outside Yaoundé, provided the opportunity for program managers at national and regional levels to present and share their results and experiences with stakeholders. Various presentations of specific thematic areas were made. This was followed by discussion of issues and how to address them. In addition, findings from the PBF impact evaluations were officially disseminated through a workshop attended by the Minister of Health and stakeholders, including development partners in the sector.

Justification of Overall Rating of Quality of M&E

72. The M&E design was appropriate as it included impact evaluation to measure projects outcome. During implementation, the Bank and the project team used MTR as an intervention to identify and address implementation challenges. M&E information, including impact evaluation findings were used to inform decision‐making. However, there was inconsistency in routine data collection, and revisions to the results framework tended to favor only one aspect of the PDO. The overall M&E is rated modest.

B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE


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73. Safeguards. The project fully complied with the Bank’s safeguards policies and procedures at appraisal. It was classified as category B and triggered two safeguard policies: Environmental (OP 4.01) and Indigenous People (OP 4.10). An environmental assessment conducted at appraisal, found significant concerns about management of medical waste in most health facilities across the country. To address the issues and mitigate any potential risk associated with disposal of medical wastes, the government prepared and disclosed a Medical Waste Management Plan (MWMP) and Indigenous People Plan (IPP), but its implementation was never documented. The plans were updated in 2016, but again issues around its implementation were not documented. Fiduciary Compliance

74. Financial management. Overall, the project operated a sound financial management (FM) system, buttressed by strong PBF mechanisms. PAISS complied with the Bank’s FM operational policies and procedures (OP/BP 10.02). The project’s FM team consistently submitted Interim Financial Management Repots (IFR), but overall not always on time. At the time of ICR, the 2016 audit report had been submitted with qualified opinion, but its recommendations had not been implemented. The recruitment of the external auditor for fiscal year 2017 was ongoing at the time of ICR, and is expected to be completed by May 31, 2018. Despite a good disbursement rate at project closure, the fund flow mechanism did not completely work well throughout the implementation period as the project did experience, sat some point in time, inactive Designated Accounts (DA) situation for more than 6 months.

75. Despite complying with FM policies, there were significant issues associated with FM implementation. At project closure, the project had accumulated a total debt of US$7.0 million. This was mainly due to lack of routine contract management at project level. At the last FM supervision mission, the project team requested for the debt to be paid with funds from the new HSPRP. The Bank FM team asked the project team to submit a detailed report on the debt situation to see what could be paid through PAISS and the new project. However, the report was only submitted recently, but did not cover the whole project commitment. As a result, no action had been taken at the time of ICR mission. Other FM related issues include a fraudulent payment made by the National Payment Agency (CAA) and ineligible expenses (see annex 3) identified following an in‐depth FM review conducted by the FM team. The FM performance, following the review, was rated moderately unsatisfactory.

76. Procurement. The project also complied with the Bank’s procurement policies and procedures (OP/BP 11.00). At its inception, the project team prepared an 18‐month procurement plan, which was consistently updated to consider new activities that emerged during project implementation. However, procurement was rated moderately satisfactory for most parts of project implementation due to issues such as weak procurement capacity, weak coordination among the PIU staff, delays in preparing terms of reference (TORs) and inadequate technical specification at the beneficiaries’ level. The situation improved progressively as the Bank closely monitored procurement activities and organized procurement clinics and trainings to improve the capacity of the procurement staff. The staff were also trained in the new Bank STEP system, and have started using the system.

77. Disbursement. Disbursement was overall satisfactory. At ICR, the project had disbursed 96.4 percent of project funds.


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C. BANK PERFORMANCE

Quality at Entry

78. As noted in section III, the Bank team effectively led the preparation process by bringing together major development partners to participate in the project preparation. With funding from Japan’s Policy and Human Resources Development (PHRD) grants, the Bank facilitated key sector studies and assessments, which provided substantial background information for the project design. The Bank team also worked with the project team to incorporate lessons learned from previous project into the design. Together with the project team, the Bank appropriately identified project risks and developed measures to mitigate them. Regarding capacity building, the Bank sponsored two key project staff to a PBF workshop in Rwanda. This enhanced the project team’s understanding of PBF mechanisms. The project components were reasonably developed and linked to the achievement of the PDO. However, the PDO outcome indicators as stated in the results framework were disproportionately skewed toward measurement of the utilization of health services objective.

Quality of Supervision

79. The project did not suffer extended period for replacement of TTLs. Although there were three TTLs during the life of the project, the second and third TTLs who took over project management were all part of the project team. Project supervision received impetus as the second TTL resided in the country. The presence of the TTL at the country level, ensured smooth supervision and prompt resolution of project issues with both the PIU and the government. The ICR team’s investigation revealed that the government was satisfied with the proactiveness of TTLs in resolving implementation issues with them. Bank performance was also manifested by the extent to which the Bank team carried out and maintained policy dialogue at the highest level of government. The team worked with International Monetary Fund (IMF) and the Country Management Unit (CMU) to trigger PBF mechanisms in the country’s Development Policy Operation (DPO). This greatly helped push the PBF initiative at the higher level of government and that enticed Ministry of Finance to commit to supporting its implementation.

80. The Bank was proactive in undertaking supervision missions, which enabled it to resolve key implementation issues with the government. As noted, the Bank team carried out an average of two supervision missions per year. The team adequately documented supervision reports, such as ISRs, back‐to‐office‐reports, aide‐memoires, etc. In all, over 21 ISRs were prepared and documented. Together with the project team, the Bank appropriately addressed implementation issues, particularly those that related to fiduciary. The Bank, however, did not see through implementation of safeguard activities even though two plans were prepared and updated. At the end of project, no documented assessment of safeguard issues could be found at project level. The Bank provided regular procurement and FM support to staff on daily basis, the procurement and FM team were always willing and ready to help. However, the Bank should have integrated flexible clauses in the legal agreement to allow easy transfer of funds from IDA designated account to trust fund account and vice versa.

81. As noted, the team identified difficulty in measuring project indicators and revised the indicators accordingly, but decided to drop the satisfaction indicator that would measure the PDO objective 2 (improve quality of health services) and used impact evaluation to measure quality. At the end of the


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project, all the revised PDO indicators could only be used to measure the PDO objective 1 (increase utilization of health services). While this was a shortcoming it was compensated by end‐of‐project impact evaluation whose findings allowed the ICR team to assess the achievement of PDO outcome 2.

Justification of Overall Rating of Bank Performance

82. Based on the above discussion, the overall Bank performance is rated satisfactory. The Bank effectively guided project preparation and supervisions. At the design stage, the Bank ensured quality at entry by financing key background studies, which served as the basis for the project design. Whenever there were implementation challenges, the Bank worked with the project team and government to address the challenges through projects restructuring and MTR. The Bank ensured that there was no gap in TTL replacement, effectively guaranteed flow of project supervision, and avoided long learning curve for new TTLs.

D. RISK TO DEVELOPMENT OUTCOME

83. Major risk to development outcomes is financial risk. Through PBF interventions, the project financed subsidies to health facilities. The subsidies enabled the facilities to undertake maintenance, renovation and equipment as well as paying bonuses to staff as motivation. However, transfer of subsidies to health facilities were characterized by delays over the life of the project. The delays led to accumulation of arrears in payment to health facilities. This situation poses significant risk to development outcomes as it will stifle the health facilities from having the financial wherewithal to deliver quality health services to the population they serve. It will also affect the health facilities ability to improve their infrastructure and equipment, and address the issue of rampant turnover of health workers. To address the issue of payment delays, in the HSPRP, all payments will be made electronically through PBF portal at the national level.

84. Despite the above risk, the project is deemed sustainable as a number of policy initiatives are being implemented: (i) through DPO the government has fully taken ownership of moving PBF forward by allocating 15 percent of operating budget to support PBF implementation in regional and district health facilities, decentralizing the investment budget, and empowering the RFHPs to procure pharmaceutical products from accredited wholesalers (public or private) through simplified procedures. The DPO include key triggers that must be met by the government; (ii) a joint circular for modalities for managing regional and districts public health facilities’ financial resources, using PBF mechanism has been signed by Ministers of Health and Finance. The circular has been distributed to facilities at all levels of the health system; and (iii) GFF investment case has been launched allowing IDA funds to be match by GFF trust funds (See annex 6 for a summary of key reforms and initiatives). There is also ongoing follow‐on operation (HSPRP) which has scaled up PBF to the entire country.


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V. LESSONS AND RECOMMENDATIONS

Lessons Learned

85. The following are key lessons learned:

Obtaining the government’s buy‐in and support, including health officials and health facility managers is essential in motivating health workers, particularly at the outset of the PBF program and prior to receipt of PBF subsidies. The level of commitment demonstrated by health officials at all levels of government was key to the success of PBF implementation.

Empowering districts, communities and health facility level management improves transparency and accountability. PBF strengthened the managerial capacities of health facility administrators by enhancing the culture of work through transparency and accountability.

Ensuring that there is uninterrupted payment of PBF subsidies to health facilities is essential in motivating health personnel and improving health felicities’ operating environment. PBF revolutionized the way business is done in the Cameroon’s health sector. But it was bedeviled by arrears in payment of subsidies, which led to lengthy delays in payments.

Harmonizing provisions of financing agreements of IDA credit and trust funds is essential for ensuring uninterrupted implementation of activities. The additional financing from IDA credit and HRITF brought significant resources to support project implementation. But differences in legal and financial covenants caused considerable delay in project implementation, including transfer of subsidies to health facilities.

Empowering key stakeholders (government, health facility, and community) through a results‐focused contractual agreement improves collaboration and working relation among them. Through PBF interventions, the project strengthened the existing ties between regional and district supervisory teams with health facilities, and between health facilities and the communities they serve. The reporting requirements of the PBF program compelled stakeholders to collaborate more cohesively, as opposed to working as separate independent entities within a larger system.

Supporting and providing the health facilities with the requisite resources improves transparency and accountability. PBF has improved governance at health facility levels through better management of revenues, improvement in the pharmaceutical subsector by reducing parallel sales of drugs, displaying costs of care services, laboratory examinations, and medicines.

Establishing a strong M&E systems and mechanisms with competent and adequate staff is essential for effective M&E implementation. Although the project achieved remarkable results, systematic and consistent M&E data collection, consolidation, and reporting was still a challenge at the national level.


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Involving higher level of government, particularly the Ministry of Finance, at the outset of discussion of PBF implementation could lead to a significant policy development impact. Through development policy operation, PBF has now been institutionalized in the national budget with a budget line item.

Integrating hospital sector interventions in the design of future PBF project could help transform the operations of hospitals and improve efficiency in service delivery. PBF has proven to be an effective tool for hospital sector reforms. Although not included in PAISS design, Hôpital gynéco‐obstétrique et Pédiatrique de Yaoundé has demonstrated that PBF could be used to improve efficiency and management of hospitals.

Recommendations

86. Based on the above lessons the following recommendations are proposed:

The government should continue its commitment to sustain PBF in Cameroon. This will require allocating uninterrupted sufficient financial resources for implementation of PBF interventions at health facility level.

The health authorities should integrate sustainable managerial training programs for district and health facility administers. This will require, among others, providing them with the requisite financial and material resources to carry out the training programs.

To ensure timely transfer of funds to health facilities, future projects need to improve the overall financial management systems and practices and ensure that FM units are adequately staff to carry out their day‐to‐day activities. The move to electronic system of payment under the new HSPRP is in the right direction.

To avoid undue delays resulting from rigidities of provisions in IDA and trust fund legal agreements, future projects should harmonize and integrate provisions that would ensure flexibility of transfer of funds between the IDA and Trust Fund accounts.

The government needs to make the PBF program pro‐poor by appropriately targeting the poor and providing demand‐side interventions as well.

Government should strengthen health facility level governance by continuously providing them with the resources and materials for effective operations of their day‐to‐day activities.

To improve M&E implementation, future projects should establish a strong M&E system staffed with requisite and competent personnel.

The Bank should consider and incorporate hospital sector interventions in future PBF design with significant funding support in both investment and technical assistance. .


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ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS

RESULTS INDICATORS A.1 PDO Indicators

Indicator Name Unit of Measure Baseline Original Target Formally Revised

Target

Actual Achieved at Completion

People with access to a basic package of health, nutrition, or reproductive health services (number)

Number 0.00 1500000.00 1500000.00 7116077.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): 474.4% of the target people had access to basic package of essential services.


Target


Children immunized Text 0 0 200,000 392,889

.


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(number) 31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): 196.5% of the target children fully immunized


Target


Number of births attended by skilled professional in targeted areas

Text 0 0 60,000 310,816

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): 518 % of the target number of births were attended to by skilled professional


Target


New cases of TB detected and treated in targeted areas

Number 0.00 0.00 10000.00 14916.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): 149.6% of the target new cases of TB in the target areas were detected and treated


Target



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Direct project beneficiaries Number 0.00 0.00 1770000.00 7779897.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Female beneficiaries Percentage 0.00 0.00 885000.00 3766268.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): Over 7.8 million (439.5% of target) people benefited from project intervention.

A.2 Intermediate Results Indicators

Component: District Service Delivery


Target


Pregnant women receiving antenatal care during a visit to a health provider (number)

Number 0.00 0.00 200000.00 1105937.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): Comment: 117% ‐ End of project target is surpassed ‐Source: reports from health centers. Verified by PPA verification process.

Unlinked Indicators


Target



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New acceptors of modern contraceptive methods in targeted areas

Number 0.00 0.00 40000.00 556458.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): 56% of end of project target is achieved ‐ Source: reports from health centers. Verified by PPA verification teams


Target


Children by the first anniversary who have received one dose of Vit. A in the last six months in targeted areas

Number 0.00 0.00 200000.00 525746.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): 212.0% of target children received one dose of Vit. A in the last six


Target


Tuberculosis treatment success rate in targeted areas

Text 0 0 80% 80.36

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): 80.36 % success rate in targeted areas achieved

Indicator Name Unit of Measure Baseline Original Target Formally Revised Actual Achieved at


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Target Completion

Tracer drugs available in targeted health facilities on the day of the visit

Percentage 0.00 0.00 75.00 20.97

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): Comment: 45% of health facilities have 100% of tracer drugs available the day of the last visit, over 382 total number of PBF health facilities. Source: reports from PPAs


Target


Health facilities achieving an average score of 75% of the quality index of services as measured in RBF in the targeted areas

Percentage 0.00 0.00 60.00 61.47

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): Comment: 75 % for a target of 72.8% ‐ There are 286 health facilities using the standard report form from a total of 393 involved in the reporting facilities. Source: reports from PPAs


Target


Health facilities reporting monthly activities using standard report form in targeted areas

Number 0.00 0.00 75.00 75.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): Comment: All the 75 target health facilities reported their monthly activities using standard report form


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Target


Consultations provided to people from the poorest quintile as measured by asset index in targeted areas

Percentage 0.00 0.00 75000.00 866402.00

31‐Mar‐2009 31‐Mar‐2009 31‐Dec‐2017 31‐Dec‐2017

Comments (achievements against targets): Comment: 1,155.2% of end of project target achieved ‐ Source: reports from health centers. Verified by the PPA verification teams.

Table A.1. Summary of achievement of PDO indicators per annum (2012‐2017)

Indicator 2012 2013 2014 2015 2016 2017

People with access to a basic package of health, nutrition, or reproductive health services 415,803 984,908 1,389,928 1,362,430 1,455,664 1,557,344

Number of Children fully immunized 42,213 65,477 58,611 68,567 75,103 82,918

Number of births attended by skilled professional 25,389 46,399 51,932 56,061 59,439 71,596

New cases of TB detected and treated in targeted areas 1,564 2,396 2,764 2,907 2,623 2,707

Direct project beneficiaries 482,453 1,093,697 1,414,397 1,487,313 1,590,112 1,711,925

Of which Female beneficiaries 231,577 524,975 678,911 713,910 763,254 821,724


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A. KEY OUTPUTS BY COMPONENT

Objective/Outcome 1: Increase utilization of health services with a focus on health and communicable diseases

Outcome Indicators

1. People with access to a basic package of health, nutrition, or reproductive health services (number) 2. Children immunized (number) 3. Births attended by skilled professional(number) 4. New cases of TB detected and treated in targeted areas (number) 5. Number of direct project beneficiaries (number) 6. Of which female beneficiaries (number)

Intermediate Results Indicators

1. Pregnant women receiving antenatal care during a visit to a health provider (number) 3. Children by the first anniversary who have received one dose of Vit. A in the last six months in targeted areas (Number). 7. Health facilities reporting monthly activities using standard report form in targeted areas (Number). 8. Number of consultations provided to people from the poorest quintile as measured by asset index in targeted areas.

Key Outputs by Component: District Service Delivery (linked to the achievement of the Objective/Outcome 1)

1. Hospital admissions (one day)‐ 4,859,585 2. Minor surgery: 694,422 3. Normal Delivery: 333,438 4. Complicated delivery: 20,063 5. Cesarean Section: 25,036 6. Major surgery‐ 54,401 7. Outpatient consultations: 8,134,334


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Objective/Outcome 2: Improve the quality of health services with a focus on health and communicable diseases

Outcome Indicators N/A

Intermediate Results Indicators

1. Tracer drugs available in targeted health facilities on the day of the visit, 2.Health facilities achieving an average score of 75% of the quality index of services as measured in RBF in the targeted areas supported the achievement of this objective

Key Outputs by Component: (linked to the achievement of the Objective/Outcome 2)

Table B.1: Summary of Service delivery indicators by region

Indicator Est Littoral North West South West Total Adamaoua North Far North (Yagoua) Far North (Maroua) Grand Total

2012‐2017 2012‐2017 2012‐2017 2012‐2017 2012‐2017 2017 2017 2017 2017 Total

Hospitalization (one day)

1,472,303 1,261,970 769,640 980,781 4,484,694 111,375 63,258 55,662 144,596

374,891 4,859,585

Minor Surgery 136,537 199,714 171,618 132,826 640,695 15101 17516 8437 12673 53,727 694,422

Normal Delivery 90,436 87,814 53,978 55,293 287,521 14905 11667 6675 12670 45,917 333,438

Complicated delivery

5,360 139 9,532 3,949 18,980 378 238 112 355

1,083 20,063

Outpatient Consultation

2,606,287 1,780,693 1,268,786 1,614,529 7,270,295 251,755 173343 151,634 287,307

864,039 8,134,334


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Indicator Est Littoral North West South West Total Adamaoua North Far North (Yagoua) Far North (Maroua) Grand Total

2012‐2017 2012‐2017 2012‐2017 2012‐2017 2012‐2017 2017 2017 2017 2017 Total

Major Surgery 15,446 11,062 6,427 17,965 50,900 1219 471 965 846 3,501 54,401

Cesarean section 5,520 6,078 4,150

7,599 23,347

730 315 359 285 1,689 25,036

Total 4,331,889 3,347,470 2,284,131 2,812,942 12,776,432 395,463 266,808 223,844 458,732 1,344,847 14,121,279


Page 46 of 100

ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION

A. TASK TEAM MEMBERS

Name Role

Preparation

Supervision/ICR

Ibrahim Magazi, Jean Claude Taptue Fotso Task Team Leader(s)

Ibrah Rahamane Sanoussi, Monique Ndome Didiba Epse Azonfack

Procurement Specialist(s)

Celestin Adjalou Niamien Financial Management Specialist

Helene Simonne Ndjebet Yaka Team Member

Aissatou Chipkaou Team Member

Emanuela Di Gropello Team Member

Aissatou Diallo Team Member

Kristyna Bishop Social Safeguards Specialist

Damien B. C. M. de Walque Team Member

Kouami Hounsinou Messan Team Member

Sariette Jene M. C. Jippe Team Member

Robert Anthony Soeters Team Member

Paul Jacob Robyn Team Member

Maud Juquois Team Member

Nneoma Veronica Nwogu Counsel

Idrissou Mounpe Chare Team Member

Hamadou Saidou Team Member

Maria Ward Steenland Team Member

James Dunaway Long Team Member

Chrystelle Isabelle Mfout Tapouh Team Member


Page 47 of 100

Cyrille Valence Ngouana Kengne Environmental Safeguards Specialist

Kofi Amponsah Senior Economist (Health)

STAFF TIME AND COST

Stage of Project Cycle Staff Time and Cost

No. of staff weeks US$ (including travel and consultant costs)

Preparation

FY07 17.978 100,977.71

FY08 35.781 257,802.60

FY09 0 0.00

Total 53.76 358,780.31 Supervision/ICR

FY09 15.754 102,172.15

FY10 22.198 158,995.28

FY11 29.070 222,608.26

FY12 10.433 166,625.47

FY13 11.325 209,822.83

FY14 6.990 70,851.03

FY15 5.900 60,301.24

FY16 20.732 157,702.63

FY17 25.734 162,643.35

FY18 33.365 228,510.40

Total 181.50 1,540,232.64


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ANNEX 3. PROJECT COST BY COMPONENT

Components Amount at Approval

(US$M) Actual at Project Closing (US$M)

Percentage of Approval (US$M)

District Service Delivery 20 47.6 237.6

Institutional Strengthening 5 8.9 178.1

Total 25.00 56.500 225.600

Note: The over 200% of actual to total approval amount was due to two additional financing (IDA 20 million and HRITF US$20 million) granted during implementation. At the time of ICR, expenditure was still being made; therefore, actual expenditure could be higher that what is reported.

Ineligible Expenditures

A total payment of FCFA 59,469,411 from IDA funds for workshops and other missions

were made without receipts and justifications.

Payment of FCFA 5,400,000 were made to CTN‐PBF officials for bonuses over the period

September to December 2017, but their contracts expired on September 30, 2017.

Payments totaling FCFA 6,000,000 for the remuneration of the National Technical

Coordinator of the PBF for the period September 1, 2017 to December 31, 2017. His

payments were made with no justification. The person’s contract expired on August 31,

2017.

Irregular payments amounting to CFAF 39,706,977 were made to EMECAM from the

PAISS designated account D, based on fraudulent documents from the CAA.

Table 3.1. Ineligible expenditure

No. Description Expenditure

(FCFA)

1. Non‐justifiable expenditure since 2016 59,469,411

2. Bonuses of civil servants without contract 5,400,000

3. Payments to National Technical Coordinator without a valid contract

6,000,000

4. Irregular payments to EMECAM 39,706,977

5. Expenses on ineligible transaction 21,856,311

TOTAL 132,432,699


Page 49 of 100

ANNEX 4. EFFICIENCY ANALYSIS

1. This analysis includes: (A) analysis of cost effectiveness of project interventions; (B) operational efficiency analysis, which includes a comparison of actual project costs with appraisal estimates; and (C) analysis of administrative and operational costs incurred on project implementation management unit.

A. COST EFFECTIVENESS ANALYSIS

2. To ascertain whether project resources were efficiently used we measured efficiency by

conducting a cost effectiveness analysis (CEA) using available data at project level. That is, we assessed

the cost of project interventions per agreed health outcomes. The key outcome metric for measuring

efficiency is incremental cost effectiveness ratio (ICER). This was the focus of our analysis.

Methodology

3. Project Costs: Project costs included all costs associated with procurement and financial

management, including additional financing. Since transfers of subsidies went directly into the delivery

of services at health facility level, the total cost of transfers of subsidies to all the project intervention

areas’ health facilities were the main cost elements included in the analysis. Total costs of subsidies

transferred per facility were aggregated by region amounted to US$29.9 million16. To make a meaningful

comparison and arrive at acceptable ICER, health services utilization data from selected PBF and non‐PBF

facilities were obtained from the regional level project database.

4. Health gains. The analysis used Disability Adjusted Life Years (DALYs) as a key measure of health

gains resulting from utilization of health services. A DALY is a common metric that allows direct

comparison across diseases as well as diverse types of interventions. It is a standardized quantitative

method of a burden of disease. Using the available data on selected PBF facilities and non‐PBF facilities,

we estimated the number of maternal deaths averted (i.e. reduction in maternal mortality, MMR) and the

number of death averted among children under the age of 5 (U5MR) resulting from increased utilization

of health services across the project regions. Through PBF interventions, particularly the community

outreach programs the project significantly increased utilization of health services in the beneficiary

facilities. These health services, among others, include outpatient consultations, inpatient consultations,

antennal care (ANC) for pregnant women, post‐natal care (PNC), minor surgery, normal delivery and

complicated delivery etc. Because DALYs have two components (mortality and morbidity) we estimated

DALYs incurred due to mortality and morbidity respectively. Mortality is life expectancy minus the age at

death, which translates into life years lost due to diseases (LY). The mortality component of the DALYs

was calculated using the life expectancy (55 years) in Cameroon. The general effect of morbidity is given

as disability weight, which usually ranges from 0 (fully health) to 1 (fully disabled). Because effects of

morbidity can be long term, we factored in the risk of morbidity for its duration. Thus, we multiply the

disability weight by the duration of disability and arrived at Disability Adjustment (DA). We then combined

the mortality and morbidity factors to arrive at a full DALY scores for the interventions. The estimated

values for both PBF and non‐PBF interventions were then discounted at the discount rate of 12 percent

(see below). Table 4.1 provides a summary of our estimates of health gains (DALYs averted).

16 This amount is the total of subsidies costs data per region obtained from PIU’s FM unit.


Page 50 of 100

Table 4.1: Maternal and children deaths averted

Region

Health Gains (Deaths Averted)

PBF 2012

non‐PBF 2012

PBF 2013

non‐PBF 2013

PBF 2014

non‐PBF 2014

PBF 2015

PBF 2015

PBF 2016

non‐PBF 2016

PBF 2017

PBF 2017

Total PBF

Total Non‐PBF

Total Cost PBF (in US$ m)

Total Cost non‐PBF (US$m)

Littoral

Maternal deaths averted

89 78 362 233 302 243 367 233 489 348 493 358 2,102 1,493 7.1

0.26

Children under 5 deaths averted

463 210 1,923 854 3,749 1,762 4,637 2,571 4,340 3,042 4,255 2,309 19,367

10,748

Est


102 99 439 201 387 277 488 308 368 207 462 190 2,246 1,282 9.7

0.35


265 201 2,001 844 2,233 1,011 6,462 2,604 4,353 1,760 4,666 2,701 19,980

9,121

Sud Ouest


146 121 683 542 843 643 863 527 865 532 965 544 4,365 2,909 6.1

0.22


621 400 1,422 730 1,195 855 4,501 1,987 4,632 2,568 3,700 1,740 16,071

8,280

Nord Ouest


232 117 1,441 645 1,369 940 1,398 938 1,269 876 1,367 1,367 7,076 4,883 6.6

0.24


866 534 2,643 932 3,217 2,076 8,013 5,047 6,478 3,549 7,012 4,680 28,229

16,818

Adamaoua


689 500 1,241 754 1,166 933 1,698 867 1,486 750 1,854 809 8,134 4,613 0.23

0.01


855 471 2,654 876 3,227 2,477 5,213 3,890 7,410 3,741 6,222 2,403 25,581

13,858

Nord


347 256 1,350 956 1,465 861 1,491 901 1,279 956 1,441 860 7,373 4,790 0.23

0.01


998 634 2,634 1,254 3,257 2,002 6,112 4,000 6,236 3,680 6,798 4,570 26,035

16,140

Total


1,605

1,171

5,516 3,331 5,532 3,897 6,305 3,774 5,756 3,669 6,582 4,128 31,296

19,970

29.9

1.08


4,068

2,450

13,277

5,490 16,878

10,183

34,938

20,099

33,449

18,340

32,653

18,403

135,263

74,965

Total deaths averted

5,673

3,621

18,793

8,821 22,410

14,080

41,243

23,873

39,205

22,009

39,235

22,531

166,559

94,935

Key underlying Assumptions

Net costs are defined as program costs adjusted for resulting changes in medical cost.

Prevention interventions (e.g. immunization for children) would lead to a fall in medical cost

which would allow the beneficiaries to avert diseases.

Cameroon per capita GDP= $1,374.5(2016, WDI)

Life expectancy in Cameroon= 55 years.


Page 51 of 100

A 12 percent discount rate was used as a proxy for average opportunity cost of capital, based on

the average bank lending rate in Cameroon.

From the project costs data, the GoC’s portion of the PBF funds transferred to health facilities

amounted to U$1,075,216 (3.6 percent) of total PBF funds. Given that government spends on

other interventions in the sector, we assume that the 3.6% of PBF costs for each region is the

costs of non‐PBF interventions in the regions.

Exchange rate= 1US$= FCFA 548

ICER = $/DALY averted < GDP per capita is very cost effective (WHO standard for interpreting

ICER results).

Estimation of Incremental cost effectiveness ration (ICER)

5. Upon the basis of the above methodology and assumptions, we estimated the ICER by comparing

net costs with a health outcome metric (DALYs averted). From the available costs data, we calculated the

ICER numerator by subtracting the discounted costs of non‐PBF (B) from the discounted costs of PBF (A)

interventions to arrive at net costs. For the ICER denominator we subtracted discounted non‐PBF DALYs

averted from discounted PBF DALYs averted and arrived at net health gains. This allowed us to estimate

cost effectiveness ratio (the costs for standardized unit of health gained), which is the increment of health

gained per increment of spending. We then estimated ICER using the formula as shown in box 4.1 below.

Box 4.1: ICER calculation formula

∆ Costs/∆Health Outcomes

ICER= [Costs of A‐Costs of B]/ [Life Years A‐Life Years B].

Added Costs/ DALYs averted= [Net cost of A‐Net Costs of B /DAILYs of A‐DALYs of B]

Where: ∆ Costs is the change in the cost of A and B respectively

∆Health Outcomes is DALYs averted (A) and DALYs averted (B)

Results 6. Substituting the total values of costs and death averted in PBF and Non‐PBF facilities in Table 4.1

we estimated the ICER as follows:

Total costs: PBF=$29,867122; Non‐PBF=$1,075,216

Total Deaths Averted: PBF=166,559; Non‐PBF = 94,935

[$29,867122‐$1,075,216] $28,791,106 ICER=‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐= ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐= $401.99 [166,559‐94,935] 71,624


Page 52 of 100

Limitations

7. Given that a cost effectiveness analysis was not conducted at appraisal, we cannot compare the

results of the CEA at ICR with expected results at appraisal for this project. We cannot also validate any

assumptions in terms of expected health gains that would have been stated at appraisal. The analysis was

also limited with data gaps due to the shortcomings of M&E implementation at project level.

OPERATIONAL EFFICIENCY

B. OPERATIONAL/IMPLEMENTATION EFFICIENCY

8. This section assesses operational efficiency of PAISS implementation. It includes (i)

implementation efficiency, including a comparison of actual component costs at the end of the project

with estimated component costs at appraisal(ii) time overrun/underrun; (iii) analysis of operational and

administrative of project management unit.

9. The project encountered considerable delays (almost three years after project effectiveness) due

to the weaknesses in the institutional arrangements for implementing the service delivery (PBF)

component of the project. But this was mitigated through project restructuring and extensions, including

additional financing. The HRITF additional resources also supported a scale‐up of project activities in the

26 districts implementing PBF.

Comparison of Actual and Estimated Component Costs

10. The estimated total project cost at appraisal was US$25 million made up of Component 1

(US$20million) and Component 2(US$5million) respectively. Available expenditure data at ICR shows that

US$47.5million (237.7 percent of appraisal estimate) and US$8.9million (178.1) percent of appraisal

estimate) was spent on Components I and 2 respectively. There is a total amount of US$31.4million

variance (Component 1: US$27.5 and Component 2:US$3.9million). The high variance was due to

additional financing provided to support increased coverage of project activities in three additional

regions (Adamaoua, North and Far‐North). Table 4.2 compares actual and estimated component costs.

Table 4.2: Actual Component Cost vs. Estimated Component Cost as at 12/31/2017

COMPONENTS

Appraisal Estimate (US $m)

Actual (US$ m)

Variance (US$)

% 0f Appraisal (Actual/ Estimate)

Component 1: District Services Delivery 20,000,000 47,531,100 27,531,100 237.7


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Component 2: Institutional Strengthening 5,000,000 8,903,630 3,903,630 178.1

Total Project Costs 25,000,000 56,434,730 31,434,730 225.7

Source: PIU expenditure database

11. As noted, IDA additional financing of US$20 million enabled extension of the project to additional

2.2 million target population in the poorest region of the northern part of the country (Adamaoua, North

and Far‐North), and to support institutional strengthening under Component 2. At the same time,

additional US$20 million HRITF was granted to support a scale‐up of project activities in the 26 districts

implementing PBF, and complete impact evaluation. The additional financing increased efficiency as it

was pro‐poor and results focused. Available project results data shows that service utilization in the three

poorest northern regions (Adamaoua, North, and Far North) covered by the AF was impressive within one

year of implementation. As shown in Table 4.3 below, as many as 1,344,847 [ Adamaoua (395,463), North

(266,808), Far North‐Yagoua (223,844), and Far North‐Maroua (458,732)] indigents and vulnerable

population utilized a range of services, including hospitalization (one day), minor surgery, normal delivery,

complicated delivery, outpatient consultation, major surgery, and cesarean section in 2017 (table 4.3).

Table 4.3. Service utilization by the indigent and vulnerable population in the three Northern Regions

Indicator Adamaoua North

Far North (Yagoua)

Far North (Maroua)

Total

2017 2017 2017 2017 2017

Hospitalization (one day) 111,375 63,258 55,662 144,596 374,891

Minor Surgery 15101 17516 8437 12673 53,727

Normal Delivery 14905 11667 6675 12670 45,917

Complicated delivery 378 238 112 355 1,083

Outpatient Consultation 251,755 173343 151,634 287,307 864,039

Major Surgery 1219 471 965 846 3,501

Cesarean section 730 315 359 285 1,689

Total 395,463 266,808 223,844 458,732 1,344,847

Source: PIU Database

12. Efficiency was also enhanced as the project interventions led to better management of health

facilities’ revenues, reduction of parallel sales of drugs, display of costs of care services on notices,

laboratory examinations, and medicines. The project brought much more competition into drugs

purchasing and distribution of drugs and pharmaceuticals. Hitherto, drugs purchasing and distribution

was highly centralized as it was the sole responsibility of the FSPS.


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Time overruns/Underrun

13. PAISS was prepared in approximately 7 months (from concept to approval). This is less than

Cameroon (14.7 months), African (14 months) and Bank (14 months). Despite relatively faster

preparation, on average, from approval to effectiveness took 9.0 months to complete, compared to

Cameroon (8.6 months), Africa (6.4 months) and Bank (5 months). Time from effectiveness to first

disbursement is higher than Cameroon (1.6 months), Africa (2.8 months) and (Bank 4 months) averages.

The project had slow disbursement rate (6 percent) after effectiveness. A slow start of activities because

of institutional challenges the project encountered contributed to the slow disbursement. Table 4.4

provides key project delivery times.

Table 4.4. Project processing and implementation times.

Concept to Approval

Approval to Effectiveness

Effectiveness to First Disbursement

Concept to First Disbursement

PAISS 7.1 9.0 4.5 19.9

Cameroon 14.7 8.6 1.6 36

Africa 14 6.4 2.8 22.6

Bank 14 5 4 24

Source: Client Connection; Note: Number in months

14. Staff turnover was relatively stable at the PIU level, and the project coordinator was still at post

at the time of ICR. On the Bank side, the project did not suffer extended period of TTL replacement as

both the first and second TTLs were replaced pretty much faster. As noted, the TTLs already had

experience on the project as team members. This obviously reduced the learning curve for new and

inexperienced staff.

OPERATING AND ADMINISTRATIVE COSTS

15. Total operating/administrative costs of the project management amounted to US$3.9million,

representing about 6.9 percent of total project cost (US$56.9millon). Three expenditure items: regional

level monitoring (US$561,153.12 or 14.5 percent of total), seminars and workshops (US$ 604,011.79 or

15.6 percent of total expenses), training of UGP/PIU staff and others (US$443,247.17 or 11.4 percent of

total) constituted the bulk of the PIU’s operating expenses. On the Bank’s side total expenditure on staff

time spent on project preparation and supervision amounted to US$1,823,359.05 (Preparation‐

US$358,780.31 and Supervision ‐US$1,464,578.74), a 3.1 percent of total project cost. Combined with

the administrative cost of the PIU, the project spent a total of US$5,703,836.92 on management and

operational activities. Given the length of the project because of project extensions, the total

administrative cost of the project is cost efficient as it is within the Bank’s overall administrative cost of

between 5 to 10 percent of total project cost. Table 4.5 shows the operational costs of the project as of

December 31, 2017.


Page 55 of 100

Table 4.5. Project’s operating and administrative costs

Item of Expenditure Amount Amount

% of Total (in FCFA) (in US$)

Fuel and Maintenance 61,711,956 114,281 2.95

Personnel‐Salaries 698,769,502 1,294,018 33.35

Bank charges 14,809,751 27,426 0.71

Communication 159,205,474 294,825 7.6

Regional level monitoring 303,022,683 561,153 14.46

Supervision 18,972,084 35,134 0.91

Seminars and workshops 326,166,369 604,012 15.57

Training of UGP staff and others 239,353,471 443,247 11.42

Insurance 29,817,992 55,219 1.42

Rental 134,775,000 249,583 6.43

Study tours (domestic and International)

1,045,000 1,935 0.05

Refreshment 7,203,865 13,341 0.34

Personnel Salaries (PIU) 100,604,902 186,305 4.8

Total 2,095,458,049 3,880,478 100

Bank staff

Preparation 358,780

Supervision 1,464,579

Subtotal 1,823,359

Total 5,703,837

% of Total Project Cost (Actual) 10.0%

ANNEX 5. BORROWER, CO‐FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS


Page 56 of 100

16. No comments were received from borrower and/or stakeholders.


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ANNEX 6. MAJOR REFORMS AND INITIATIVES

1. DEVELOPMENT POLICY IMPACT

Pillar 3: Improve Social Services and Expand Social protection 17. To increase the level of funding and improve management capacity of health facilities, the

government has signed a decree that allows health facilities at all levels of the system to retain all

resources in the health facility (eliminate transfers from facilities to government) and allow health

facilities to directly procure pharmaceuticals and other medical inputs from accredited providers (public

or private).

18. In terms of budgetary allocations, the 2018 Health Budget uses a resource allocation formula

based on regional / geographic health needs. It allocates at least 15% of the operating budget to primary

and secondary care institutions and regulatory agencies to enable them to practice performance‐based

payments in PBF regions and districts (providers / region / district). The investment budget has also been

decentralized for health facilities in PBF areas through "investment units or service delivery quality

improvement bonuses". And the Regional Funds for Health Promotion is empowered to procure

pharmaceutical products from accredited wholesalers (public or private) through simplified procedures.

19. The 2019 Public Health Budget follows the same line as 2018, but increases the minimum

allocation to primary and secondary care facilities and regulators to 20%. And new health professionals

introduced into the public service are recruited and managed at the regional level through a competitive

recruitment process, distribution of new positions is based on the health needs of the population.

Percentage of the public budget allocated to primary and secondary schools and regulators. Baseline

(2017): 8% Target: 20%.

20. The government has expanded the administrative coverage of the PBF program by introducing at

least 4 performance contracts at the central level of the Ministry of Public Health and extended coverage

of the PBF program at the operational level to at least 40% of the country's population.


least 8 performance contracts at the central level of the Ministry of Public Health (and funding of at least

50% of its budget through these contracts) and extensive coverage of the PBF Program at the operational

level to at least 75% of the country's population with contracting and verification agencies established in

the 10 regions.


least 12 performance contracts at the central level of the Ministry of Public Health, including CENAME


Page 58 of 100

(and funding of at least 50% of its budget through these contracts), and Extended coverage of the PBF

program at the operational level to at least 90% of the country's population.

23. The importance of the above DPO triggers were reinforced by the following Joint Circular singed

by the Minster of Health and Minister of Finance.

Joint Circular of Ministry of Health and Ministry of Finance for modalities for management regional and districts public health facilities’ financial resources under performance‐based financing (PBF) 24. In view of the tremendousness results of the Cameroon’s health sector PBF approach, since 2011,

the PBF is henceforth adopted as a national strategy to assist the government to achieve universal health

coverage(UHC) for its population.

25. In accordance with the PBF principle all facilities involved in the implementation of PBF (primary,

secondary, and regional and tertiary health facilities) and all the regulatory institutions (district, region,

and central level) with PBF contracts are authorized to benefit from special condition of the PBF program.

These conditions are defined in Cameroon’s PBF implementation manual validated on August 9, 2017

under the chairmanship of the Minister of Public Health.

26. All the special rules for accounts management are defined in the PFM manual which must be

followed by all the health facilities involved in PBF program in Cameroon.

27. We expect strict application of these provisions from the date of this signature.

2. PHARMACEUTICAL SUBSECTOR REFORM

A Ministerial Circular Specifying Terms and Conditions for supply of pharmaceutical products by Regional Funds for the Health Promotion (FRPS) 28. In accordance with Article 10 of the initial convention of each Regional Fund for Health

Promotion (FRPS), one of its main functions is to support the Ministry of Public Health in the supply of

quality essential drugs, preferably generic, to health facilities at the operational level.

29. For this purpose, I authorize each FRPS to purchase from the licensed private wholesale

distribution companies in the event of a stock shortage at the Central Medical Store in accordance with

the principles of good governance. For any order from FRPS to CENAME, the latter has a maximum period

of 72 working hours to send a proforma invoice, indicating the quantities available for delivery of the

products ordered. If the central medical store (CENAME) fails to respond within this timeframe or there


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is unavailability of certain pharmaceutical products, the FRPS shall consult a minimum of three licensed

private wholesale distribution companies with preference to generic essential drugs.

30. For any proforma invoice received, the FRPS has a maximum of 72 working hours to confirm

the order with CENAME. For any order confirmed, CENAME is required to deliver on time within a

maximum period of one month. After this deadline, the FRPS shall initiate the procedure for approved

wholesale as described. Each FRPS must make its annual projected needs known to CENAME not later

than 15 January of each year, and update them if necessary before July 5. To do this, they must collect

the needs of each FOSA for consolidation.

31. The frequency of orders from FRPS to CENAME should be as much as possible quarterly.

However, for any other order, transport and removal ordered products are the responsibility of the FRPS.

The FRPS should work as much as possible during acquisitions, to obtain wholesale suppliers, competitive

prices for the departmental catalog of ceilings to patients. The FRPS is obliged to deliver to the health

facilities and provide them with assistance in the good practices in storage, inventory management, and

secure destruction of medicines unfit for consumption (expired, damaged, counterfeit, etc.). FRPS shall

inform CENAME in storage and distribution to health facilities and Public Health Programs for drugs such

as ARV or during epidemics. Each FRPS update the Minister of Public on their orders from CENAME on

quarterly basis. The General Inspectorate of Pharmaceutical Services and Laboratories (IGSPL) and the

Directorate of Pharmacy, Drugs and Laboratories (DPML) are each responsible for the control, monitoring

and strict application of these instructions in all the Health Districts of the country which, will be evaluated

in the first half of December.

32. I expect all institution to adhere to and implement the provisions of this Circular.

3. SUMMARY OF GFF INVESTMENT CASE

33. While the final list of interventions and strategies to be supported by the GFF trust fund will be

validated at the national level in mid‐2016, the GFF Investment Case prioritization workshop that was held

in February 2016 identified several key areas for which support will be provided. These include:

Support to a multi‐sectoral approach to address adolescent health, education and demographic challenges in the northern regions of Cameroon.

Provide support to reinforce nutrition services to ensure that services supported through PBF payments are of high quality and high impact;

Support to the development and implementation of a communication and behavioral change strategy including formative research, identification of priority behaviors, key message development, development of communication tools and training manuals for health and nutrition;


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Support to the piloting of Kangaroo Mother Care (KMC) to reduce risks related to low birth weight; and

Provide critical support for maternal health, neonatal health and family planning services, family planning and adolescent health services, responding to gaps in financing of the Strategic Plan for the National Multisectoral Program for Combating Maternal, Newborn & Child Mortality in Cameroon (2014‐2020).

34. Aligned with the Sustainable Development Goals, and taking into account the need to move

towards universal health coverage, the overall objective of the investment case is to help reduce, by the

end of 2020, maternal mortality / morbidity, neonatal and infant‐juvenile, and to promote the

reproductive health of adolescents / young people primarily in the regions of Adamaoua, the East, the Far

North and the North. To achieve this objective, one of the main strategies is to cover the intervention area

with a set of specific and multi‐sectoral interventions that ensure complementarity and synergy to

facilitate the achievement of expected results while ensuring better outcomes. allocation and utilization

of available resources for health. To this end, the government aware that Cameroon can no longer

continue to do the business as usual and is committed to health financing reforms. The following are key

priority areas of intervention:

Prioritization of the most vulnerable and at‐risk populations.

Scaling up of best practices for better coverage of interventions.

Capitalization of the comparative advantages of actors in the field.

Intensification of collaboration / partnership as part of the multi‐sectoral approach

Decentralization of the decision‐making space and the empowerment of the actors, to favor the use of the most adapted solutions to the different contexts to meet the needs of the beneficiaries.

35. These will be achieved through innovative strategies for effective implementation. Box 6.1.

provides key Initiatives of the Investment Case.

Box 6.1. Key investment case initiatives The reconfiguration of the mode of financing of health by favoring, as much as possible, the allocation

of resources according to the obtained results.

Selective contractualization of public and private services with a view to optimally exploiting the comparative advantages of the actors of the health system.

The extension of the performance‐based financing (PBF) strategy to system regulators, for better performance of the health system.

The "discriminatory" subsidy (the poorest pay less than the poorest) health care for vulnerable groups and economically weak.

Strengthening Community‐Directed Interventions Across Versatile ASCs and Qualified CBOs.

Strengthening the integrated offer of promotional, preventive and curative care and services at every contact of clients with the health system.

Strengthening the multi‐sectoral approach to RH in view of the multifactorial nature of the causes of maternal and infant‐juvenile mortality.

Social mobilization targeting opinion leaders including traditional authorities, men, mothers, and mothers‐in‐law as key partners.


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Optimal exploitation of ICT.

Strengthening social control and the "voice" of the community.

Taking into account socio‐economic equity and geographical prioritization as needed.

The use of innovative approaches such as "Development Impact Bond" to finance the implementation of Kangaroo Mother Care.

The use of ROLES MODELS to mobilize different target groups.

The holistic framework of adolescents / young people in terms of life skills including education, physical, sexual / reproductive, socio‐economic.

The introduction of PBF in the education sector with emphasis on the retention of girls in school.

36. Among the expected results, the main ones are the following especially at the level of the "out‐

come" (Box 6.2).

Box 6.2. Summary of key results Modern contraceptive prevalence among women of reproductive age in union is increasing by at least 30%

by the end of 2020 in the regions of Adamaoua, East, Far North and North where they are currently respectively 7.7%, 14.6%, 3.5% and 6.1% (MICS 2014).

The proportion of women aged 15‐49 who had a live birth during the last 2 years preceding the survey, who benefited from the NPC4 offered by qualified personnel, increases to at least 70% by the end of 2020 in Adamawa, East, Far North and North where it is currently 50%, 45.2%, 37.8% and 46.8% respectively (MICS 2014).

The proportion of pregnant women tested for HIV + on ARV treatment according to national guidelines is at least 95% by the end of 2020 in Adamawa, East, Far North, North, Center, Littoral, North West, West, South and South West where the current proportions are 87.4%, 68.4%, 62.2% 78.7%, 92%, 87%, 93%, 84%, 74.6% and 88%. (PROGRESS REPORT PMTCT N ° 10 of 2015).

The proportion of deliveries assisted by qualified personnel has increased by 20% by the end of 2020 in Adamaoua, the East, the Far North and the North, whose current rates are 53%, 57%, 29% and 29% respectively. % and 36% (MICS 2014).

The proportion of recorded prematurity / low birth weight cases that are supported by standards, including the incubator and / or Kangaroo method, is at least 80% in Adamaoua, East, Extreme North and North.

Percentage of women aged 15‐49 who had a live birth in the last 2 years preceding the survey and whose last birth had a post‐natal consultation for the baby within 48 hours after delivery, increases to at least 30% by the end of 2020 in Adamaoua, East, Far‐North and North where it is respectively 9.6%, 6.7%, 4.9%, and 9.6% (MICS 2014).

The proportion of malaria cases managed according to national standards (ACT the same day or the day after) among children under 5 is at least 40% by the end of 2020 in Adamaoua, East, Far North and North where current rates are 7.0%, 3.9%, 0.3% and 5.6% respectively.

The proportion of children aged 0 to 11 months who received VARR increased to at least 95% by the end of 2020 in the Adamawa, East, Far North and North regions where current rates are 80%, 99% (refugee coverage), 84%, and 82% (2015 EPI Routine Data).

The proportion of cases of acute malnutrition expected in children who are identified and supported according to the standards is greater than or equal to 75% in the regions of Adamaoua, North, Far‐North and East.

The proportion of teenagers / youths admitted for STIs / HIV who are supported according to the norms in the FOSA of Adamawa, East, Far North and North is at least 80% d 'here at the end of 2020.


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The number of adolescents / youths (aged 10 to 19) who have received life skills training increases by at least 30% in the regions of Adamaoua, East, Extreme North and North

37. It is recommended that the following results be achieved within 4 years of implementation of

the interventions planned in this investment case (Box 6.3).

Box 6.3. Contribution to key health outcomes Contribute to a 5% annual reduction by the end of 2020 in the national maternal mortality ratio of 596

deaths per 100,000 live births (WHO estimate).

Contribute to reducing by at least 4.5% per annum, by the end of 2020, the neonatal mortality rates in the Adamawa, East, Far North and North regions, which are 40, 39, 40 and 42 deaths per 1000 live births, respectively (MICS 2014).

Contribute to reducing by 30%, by the end of 2020, the intra‐hospital mortality rate among newborns of low birth weight and / or premature babies receiving kangaroo care (Baseline to be determined).

Contribute to reducing from 19.6 to 16.1 deaths (4.5% per year) per 1000 births, by the end of 2020, the national stillbirth rate (DHS 2011).

Contribute to reducing by 5% per annum, by the end of 2020, infant and child mortality rates in the regions of Adamaoua, East, Far North and North which are respectively 127, 127, 154 and 173 deaths per 1000 live births (MICS 2014).

Contribute to reducing to less than 5%, by the end of 2020, the prevalence of global acute malnutrition among children aged 0‐5 years in the regions of Adamaoua, East, Far North and the North where it is respectively 6.8% (15233), 1.0% (1022), 13.9% (82515) and 6.5% (530689) (2015 SMART Nutritional Survey).

Contribute to a reduction of at least 7.5 points by the end of 2020 in the prevalence of chronic malnutrition among children under 5 in the Adamawa, East, Extreme North and North where it is respectively 37.8%, 35.8%, 41% and 33.8% (MICS 2014).

Contribute to reducing the prevalence of teenage pregnancies by at least 30% by the end of 2020 for girls aged 15 to 19 in the Adamawa, East, Far North and Montenegro regions. North where it is respectively 31.7%, 53.1%, 29.0%, and 28.7% in 2014 (MICS 2014).

Contribute to increase the adjusted net enrollment rate of secondary education (TNF) of girls by at least 50% by the end of 2020 (Baseline to be determined).

Contribute to reducing the incidence of catastrophic health‐related expenditure (ECAM 5) from

1. HOSPITAL SECTOR REFORMS 38. Although the tertiary hospital sector interventions were not integrated in PAISS design, there

was a spillover effect on a major hospital, HGOPY. Having observed PBF’s impact on service delivery at

health facilities in project intervention areas, the hospital management sought support from the Bank to

adopt and implement PBF initiatives with their own resources. The Bank provided them with PBF experts

who trained over 20 managers, including the CEO. They obtained service quality assessment support from

the Bank through Littoral ACV. In April 2015 PBF the hospital started PBF implementation in three units

and progressively extended to all clinical and administrative units. This led to improved hospital efficiency

and better management of resources: (i) an increase in bed occupancy rate, (ii) improved diagnostic and

treatment capacity; (iii) an increase in internally generated revenues; (iv) decrease in unjustified expenses;


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(v) a reduction in informal and under the table payments to staff; (vi) improved quality of care; (vii)

improved staff performance: punctuality, team spirit and technical competence; and (ix) better

remuneration for staff.

RESULTS Increased Services Delivery

Table 6.1. Key service delivery indicators

Indicator

2013 2014 2015 (PBF Start‐up)

2016

Nombre de consultations 70 557 74 458 75 971 78 869

Nombre de CPN 9,755 9,813 10,066 11,327

Nombre d'hospitalisations 10 593 10,546 11,760 13,958

Nombre d'accouchements 2,886 2,778 2,860 3,062

Nombre de césariennes 661 721 744 898

Nombre de femmes reçues pour planning familial

679 1,194 1,807 3,146

Nombre d'interventions chirurgicales 2,040 2,068 2,079 2,590

Nombre d'enfants malnutris pris en charge 21 27 62 93

Durée moyenne de séjour 4.20 jrs 3.63 jrs 3.49 jrs 3.41 jrs

Taux d'occupation des lits d'hospitalisation 53.45% 45.25% 47.31% 56.25%

Indigents 98 90 85 166

INTERNALLY‐GENERATED REVENUES Figure. 6.1: Trends Internally generated funds


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Average monthly revenues before and after PBF implementation

2013 2014 2015 PBF start‐up 2016 2017

Recettes Moyennes 115,402, 442 118,756,691 135,531,319 161,431,591 167,503,120

Trend 14.12% 35.93% 40.05%

QUALITY OF SERVICES

0

100,000,000

200,000,000

300,000,000

400,000,000

500,000,000

600,000,000

Début du PBF


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BASE T2 2015 (Mars 2015 Début PBF)

T3 2015 T4 2015 T2 2016 T3 2016 T1 2017 T2 2017

QUALITE DU SERVICE

25% 31% 29% 50% 56% 61% 67%

39. Following the successful pilot of the PBF, the Cameroon health team and the WBG’s Africa

Region Vice President visited the hospital to observe the results on the ground. The visit served as

motivation and encouragement to the hospital management.

4. FOLLOW‐ON PROJECT: HEALTH SYSTEMS PERFORMANCE REINFORCEMENT PROJECT 40. The Cameroon Health Systems Performance Reinforcement Project(HSPRP) is a follow‐on

project of PAISS. The Project Development Objective (PDO) is to increase utilization and improve the

quality of health services with a particular focus on reproductive, maternal, child and adolescent health

and nutrition services. The main direct beneficiaries are women, adolescents and children under 5, as well

as displaced and refugee populations affected by the insecurity in the region.

41. The IDA allocation for this project is US$100 million. A grant of US$27 million from the Global

Financing Facility (GFF) Trust Fund will support investments in RMNCAH and nutrition (US$25 million) and

civil registration and vital statistics (CRVS) systems (US$2 million).

42. The project will support the ongoing implementation of PBF in the 26 health districts covered

by the PAISS the 18 health districts recently added through the Additional Financing, and an incremental

roll out of PBF to national coverage. With a coverage at 25 percent of the population in 2016, the

operation would support a gradual scaleup of approximately an additional 20 percent of the population

per year between 2017 and 2020. During the first phase of the extension (2016‐2018), the HSRPP will

focus on scaling up to the remaining 36 districts in the three northern regions of Cameroon (Far North,

North, and Adamawa) to address the urgent and growing needs in those regions. In total, the three

northern regions include 54 health districts with a population of 7,614,882 (2016).

43. Following a successful pilot of PBF at the national pediatric hospital in Yaoundé to test PBF at

the tertiary level, the HSPRP will increase the geographical coverage of PBF by providing technical

assistance in rolling‐out PBF to regional and tertiary‐level hospitals in the country. Under the pilot, PBF

subsidies were paid with internally‐generated revenues. To avoid incentivizing overproduction of services


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to increase hospital revenue, the main function of the PBF program in the tertiary hospital was to

redistribute revenue based on performance outcomes linked to quality improvements.

44. Under HSPRP, the implementation of PBF at tertiary hospitals, including payment of subsidies,

will be supported by both the public budget and internally‐generated revenues. HSPRP project will not

finance the actual payment of PBF subsidies to tertiary facilities, but will provide the necessary technical

assistance to design and implementation of PBF interventions, including providing support to contract

management and verification activities to be conducted by the CDVAs in each region.

ANNEX 7. SUMMARY OF IMPACT EVALUATION RESULTS

45. To ascertain the evidence of project results/outcome, two rounds of end of project impact

evaluations (quantitative and qualitative) were conducted at the end of the project. The ICR team used

the results of the two evaluations to support the assessment of the achievement of the project

development objective. A summary methodology and sampling techniques are as follows:

Quantitative Impact evaluation:

46. Methodology and sampling techniques. The methodology for the quantitative impact evaluation

is as follows:

Selection of study groups:

47. Four study groups were formed by randomizing medicalized health centers, or primary health

centers with a medical doctor on staff, as well as integrated health centers (i.e. primary health care centers

without a doctor). To ensure that all stakeholders were fully represented, the evaluation team publicly

organized randomization ceremonies in the intervention regions. This brought together all health facility

management staff in the districts covered by the evaluation. Box 7.1 shows the selected treatment groups.

Box 7.1. Selected study groups T1: PBF with health worker performance bonuses.

C1: Same per capita financial resources as PBF but not linked to performance; same supervision and monitoring and managerial autonomy as T1.

C2: No additional resources but same supervision and monitoring as PBF arms and T1 and C1

C3: Status quo.

Basis of the evaluation

48. To distinguish between the influence of the different components of the PBF reform and ascertain

the desired results, the evaluation team considered four key packages. They include: (i) the standard PBF

package, (ii) the same level of financing but not linked to performance, and with the same levels of


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supervision, monitoring, and autonomy as PBF, (iii) no additional resources or autonomy, but the same

levels of supervision and monitoring as PBF, and (iv) pure comparison. The randomization took place at

the health facility level, and overall, the four study groups were well balanced at baseline. The analysis

also established that the levels of financing between the first two groups (standard PBF and additional

financing) was indeed equivalent at end‐line. The evaluation used a combination of household and health

facility surveys conducted at baseline and end‐line to assess the impact of PBF interventions.

49. Health facilities in group T1 implemented all the above package. Group C1 received a fixed per

capita budgetary supplement that matches the per capita budgetary allocation for T1 facilities but the

supplement was not linked to performance. C1 facilities received the same supervision, monitoring, and

managerial autonomy over the budgetary supplement received. Both T1 and C1 facility managers had the

autonomy to hire staff with their PBF budget supplements. They also had the autonomy to fire these staff

if need be. T1 and C1 facility managers also had the autonomy over how to use PBF revenues. No

additional funds were given to group C2 facilities, but they benefited from the same supervision and

monitoring as T1 and C1 facilities. District‐level supervisors of T1, C1 and C2 facilities used the same tools

and received the same supplementary payments for visits to facilities in these three groups. Quality scores

were linked to facility payments only in the case of T1 facilities. C3 facilities were the ‘business as usual’

facilities and did not receive any additional resources or inputs. C2 and C3 facility managers did not have

the autonomy to hire/fire staff or financial autonomy. Public and private health facilities in the 14 study

districts who registered with the Ministry of Public Health (MPH) were included in the study. Given the

critical role that the 14 districts hospitals play in supervising and acting as a source of referrals, they were

included in the study.

50. The main methodology used for the analysis was difference‐in‐differences regression model with

a study period of between 2012 and 2015

Data sources 51. Two main sources of data were used for the evaluation: (i) household survey: A household survey

implemented at baseline (i.e., before implementation of PBF began), and at end‐line (i.e., after PBF was

implemented) and; (ii) Facility‐based survey implemented both at baseline and end‐line.

Sampling technique 52. A total of 259 health facilities (226 public and 33 private) were sampled. In the Eastern Region,

79 health facilities [public (81%) and private (19%)] were sampled. In the North‐West region, 105 facilities

[ public (57%) and private (43%)] were sampled. Finally, in the South West 75 facilities [public (66%) and

private (43%)] were sampled. Table 7.1 shows a summary of the sampled facilities


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Table7.1. Sampled health facilities

District

Number of health facilities

CSI Public CMA Public

District Hospital

Confessional CSI/ CMA/ Hospital

For‐profit/ Para‐public Total

Private (%)

Bingaman 14 2 1 4 2 23 27

Doume 9 1 1 2 1 14 23

Lomie 7 2 1 2 0 12 18

Messamena 9 1 1 2 0 13 17

Nguelemendouka 5 0 1 1 0 7 17

Kette 9 0 1 0 0 10 0

Total in East 53 6 6 11 3 79 19

Kumbo East 17 2 1 6 4 30 34

Nkambe 11 2 1 4 2 20 32

Ndop 12 2 1 8 4 27 46

Fundong 9 3 1 12 3 28 56

Total in North West 49 9 4 30 13 105 43

Mamfe 11 1 1 1 0 14 8

Kumba 10 1 1 5 1 18 35

Buea 10 3 1 0 9 23 41

Limbe 10 1 1 1 7 20 42

Total in South West 41 6 4 7 17 75 34

Pilot Zone total 143 21 14 48 33 259 33

RESULTS 53. Based on the above methodology, the following results were achieved.

A. HEALTH SERVICES UTILIZATION

HOUSEHOLD SURVEY UTILIZATION RESULTS

Coverage of Reproductive Health Services among Women who were Pregnant in the Previous 24 months 54. For antenatal care, facilities with the PBF intervention performed better than those facilities with

only additional supervision. There was no difference between the control group and the PBF group, or the group that received additional financing in the change in skilled delivery over the study period. (Table 7.2). Table 7.2. Delivery with a skilled birth attendant

Indicator Impact estimate


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Skilled Delivery -0.043 * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on reproductive health service use among female respondents included in the household survey who had been pregnant in the previous 24 months. Regression model adjusted for individual (age, marital status, education level, religion, ethnicity, working status and type of work) and household control variables (number of individuals in the household, housing type, house ownership, water source, and type of sanitation). Standard errors were clustered at the health facility level.

Full Vaccination Coverage Among Children Between 12 ‐ 23 Months of Age 55. Mothers or primary care givers of all children under five years of age were asked about their

child’s vaccination history. For all children with a vaccine card, study enumerators recorded all

documented vaccinations and their respective receipt dates. Mothers/primary caretakers were also asked

to report any vaccinations that were not recorded in the vaccine card. For these questions, enumerators

asked a separate question for each vaccine type that referenced the vaccine name and gave an indication

of its method of administration (i.e. for polio “that is drops in the mouth”) as a guide for respondents.

Only children between 12 – 23 months of age were included in these analyses. Both outcomes include the

following vaccines: oral polio vaccine, yellow fever, diphtheria, tetanus, and whooping cough (DTC),

measles, and Bacillus Chalmette–Guerin (BCG). Table 7.3 shows in the PBF group, there was a 17‐

percentage point increase in full vaccination (0.170, p‐value = 0.076).

Table 7.3 Full Vaccination Coverage Among Children Between 12 ‐ 23 Months of Age


Fully vaccinated documented by vaccine card 0.170*

* = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on child vaccination among children (12 – 23 months) included in the household survey. Regression model adjusted for individual (age, father in the household, religion, ethnicity) and household control variables (number of individuals in the household, housing type, house ownership, water source, and type of sanitation). Standard errors were clustered at the health facility level.

FACILITY SURVEY UTILIZATION RESULTS

The results of PBF on health services provision as recorded in facilities registers. 56. The study examined the health service counter‐verification data that was collected routinely as

part of the PBF program design through community client satisfaction surveys. Health service verification

took place in all PBF health facilities, as well as in health facilities in control groups C1 (additional financing)

and C2 (additional supervision). The study sampled 35 for 7 health service categories each quarter. Figure

7.1 below shows the percentage of patients who were reported by health facilities to the PBF verification

terms, who were later confirmed to have received health services at the health facility. During most

quarters of the three‐year study period in all three study regions, over 80% of reported patients were

confirmed. The trend in confirmed patients increased slightly over time in North‐West and East, with

confirmation rates above 85 percent in all three regions during the final year of the study. Facilities in the

full control group had less incentive to keep records of all services provided than facilities in PBF group.

Figure 7.1: Percent of Reported Patients Confirmed During Verification


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Source : Cameroon PBF Quantitative Impact Evaluation report March 24, 2017 QUALITY OF HEALTH SERVICES PATIENT SATISFACTION Overall Satisfaction Score for Antenatal Care Reported during Facility Exit Interviews 57. Women were asked a series of twelve questions related to their satisfaction with individual

elements of their visits including, for example, their satisfaction with costs, wait times, and health worker

communication. For each, a statement was read, and women were asked if they agreed, were neutral, or

they disagreed. Binary variables were created by coding responses as “1” if a woman agreed, and “0”

otherwise. Overall satisfaction scores were calculated by averaging over these twelve components. An

overall score of “1” indicates that a woman agreed with all twelve questions, while a score of “0” indicates

that she either disagreed or was neutral on all twelve questions. The impact of the interventions on overall

satisfaction are shown in Table 7.4 below. There is no indication that satisfaction changed over time in

the control group (β = 0.006, p = 0.847). Relative to the pure control, the PBF group was associated with

an 8.6 percentage point increase in satisfaction (p = 0.077). The results suggest a stronger effect in the full

PBF than in the additional supervision group (10.5‐percentage point increase).

Table 7.4 Overall ANC satisfaction score (PBF vs. Control group)


Satisfaction score 0.086* * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression model examining the effect of PBF on the overall satisfaction score for antenatal care reported by patients during facility exit interviews. Regression model adjusted for individual (age, literacy, marital status, education level) and facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.

83

89

81

9894

86

40

60

80

100

Sept.2012

Dec.2012

Feb.2013

May.2013

Sept.2013

Dec.2013

Mar.2014

Jun.2014

Sept.2014

Dec.2014

Mar.2015

Jun.2015

Per

cen

t (%

)

North-West Est South-West


Page 71 of 100

Satisfaction with health facility characteristics during antenatal care reported during facility exit interview 58. Women’s satisfaction with health facility characteristics increased significantly. PBF was

associated with a large and statistically significant 24.1‐percentage point difference from the control

group (p<0.05) in women’s satisfaction with the health facility cleanliness and facility hours. Compared to

the control group, PBF results in a large and statistically significant 15.4‐percentage point increase

satisfaction with the facility’s hours, while the additional supervision is associated with a non‐significant

reduction in satisfaction relative to the pure control (Table 7.5).

Table 7.5: Satisfaction with health facility characteristics during ante natal care


Satisfaction score on cleanliness 0.241** Satisfaction score on operating hours 0.154**

* = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on satisfaction with health facility characteristics reported by patients during facility exit interviews. Regression model adjusted for individual (age, literacy, marital status, education level) and facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.

Satisfaction with health worker characteristics during antenatal care reported during facility exit interview 59. Table 7.6 provides an overview of women’s reported satisfaction with health worker

characteristics. Women attending facilities receiving the full PBF intervention reported significantly

higher levels of satisfaction with health worker communication than did women attending control clinics

(β=0.106, p<0.05), but there was no evidence of an impact of PBF on the courteousness of health staff,

time with health workers, or the ease of getting prescribed medicines.

Table 7.6 Health worker satisfaction during ANC score


Satisfaction score on health worker communication 0.106** * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on satisfaction with health worker characteristics during antenatal care reported by patients during facility exit interviews. Regression model adjusted for individual (age, literacy, marital status, education level) and facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.


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SATISFACTION WITH CHILD HEALTH CONSULTATIONS (< 5 YEARS OLD)

Overall satisfaction score for child health consultations reported during facility exit interviews 60. PBF had a positive impact on overall satisfaction with child health services. Relative to the pure

control, the PBF was associated with a statistically significant 9.9‐percentage point increase in satisfaction

(p<0.05). Table 7.7 shows satisfaction score of PBF against C2 and C3.

Table 7.7 Overall child consultation satisfaction score


Satisfaction score 0.099*** * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression model examining the effect of PBF on the overall satisfaction score for child health consultations reported by mothers during facility exit interviews. Regression model adjusted for individual (child age, child sex, maternal literacy, marital status, education level) and facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.

Satisfaction with selected health facility characteristics during child health consultations reported during facility exit interviews 61. As shown in table 7.8 PBF is associated with a large and statistically significant impact on

satisfaction with the health facility cleanliness (β=0.227, p=0.090). Neither the additional financing nor

the additional supervision intervention groups (C1 and C2) performed better on cleanliness at end‐line

than they did at baseline. Focusing on waiting times, all the intervention arms appear to result in

improvements over the control group, although none of the differences were statistically significant. All

the arms also resulted in increased satisfaction with the privacy at health facilities, and the very large

point estimate on the PBF (33.6 percentage points) is significant at p<0.01. Satisfaction with the opening

hours did not change over time in any of the treatment groups, and there were no differences between

groups for this outcome.

Table7.8 Satisfaction with selected health facilities


Satisfaction score on cleanliness 0.227* Satisfaction score on privacy 0.336***

* = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on satisfaction with health facility characteristics reported by mothers during facility exit interviews. Regression model adjusted for individual (child age, child sex, maternal literacy, marital status, education level) and facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level


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HEALTH WORKER SATISFACTION AND MOTIVATION

Physical condition of the health facility and ability to provide high quality care given health facility conditions 62. Table 7.9 below provides an overview of reported satisfaction with the physical condition of

health facilities. Health workers in the PBF arm were 31 percentage points more likely to be satisfied with

the physical condition of the health facility building, relative to the pure control (p<0.01).

Table 7.9 The physical condition of the health facility building


Satisfaction on physical condition of the health facility building

0.306***

* = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression model examining the effect of PBF on the overall satisfaction score for antenatal care reported by patients during facility exit interviews. Regression model adjusted for individual (age, literacy, marital status, education level) and facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.

HEALTH WORKER AVAILABILITY IN THE HEALTH FACILITY

Number of nurses present at the health facility on the day of the survey 63. The facility survey asked the head of the health facility, or the most informed staff member, to

list the names of the all the health workers employed at the health facility. The staff roster also collected

information on the post occupied by each health worker and on whether they were present on the day of

data collection. Table 7.10 below presents results from analysis of the number of nurses present at the

health facility on the day of data collection. There was a small and non‐significant increase in the number

of nurses present over the study period. The increase in the number of nurses in the PBF group was greater

than in the full control group (p‐value 0.010). Adding the coefficient on the interaction term of PBF and

post to the coefficient on the post indicator (0.191+1.222=1.413) indicates that there was an average

increase of almost 1.5 nurses present in PBF facilities over the study period. The coefficients on the two

other treatment groups – additional financing and additional supervision – were not statistically

significant; however, there was a larger increase in the full PBF group compared to the change in the

additional supervision group.

Table 7.10 Number of nurses present at the health facility score


Number of nurses 1.222*** * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on the number of nurses present at the health facility on the day of the survey. Regression model adjusted for facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.


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DRUGS AND EQUIPMENT IN THE HEALTH FACILITY

Quantity and quality of health supplies, medicines, and equipment in the health facilities

64. There was a large and consistent impact on health workers’ satisfaction with the quantity and

quality of equipment and other supplies at health facilities, shown in Table 7.11 below. Both the PBF and

the additional financing arms resulted in similarly large and highly significant improvements in these

measures: an approximately 20 percentage point increase in reported satisfaction with the quantity of

equipment (p<0.05), approximately 25 percentage point increase in reported satisfaction with the quality

of equipment (p<0.05), and a 40‐percentage point increase in satisfaction with the availability of other

supplies at the health facilities within these two arms (p<0.01).

Table 7.11 Quantity and quality of health supplies


Quantity of equipment in the health facility 0.190**

Quality and physical condition of equipment in the health facility 0.256**

Availability of other supplies in the health facility 0.404*** * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on the quantity and quality of health supplies, medicine, and equipment in the health facility reported by health workers. Regression model adjusted for individual (age, sex, marital status, education level) and facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.

65. A composite indicator was created to assess any impact on the availability of basic clinical

equipment. The indicator included information on the presence of a clock, a child weighing scale, height

measure, tape measure, adult weighing scale, blood pressure instrument, thermometer, stethoscope,

fetoscope, otoscope, flashlight, stretcher, and wheelchair. Scores indicate the proportion of these thirteen

pieces of equipment that was available at a given facility and range from 0 to 1. Point estimates indicate

the estimated impact on this score.

Availability of Basic clinical equipment available at health facilities 66. As shown in table 7.12. Both the PBF and the additional financing intervention arms resulted in

large and statistically significant improvements in the availability of equipment. Facilities in the PBF arm

had a 10.0 percentage point increase over that seen in the control (p<0.05), while those in the additional

financing arm had an increase of 12.5 percentage points over the control (p < 0.01). This increase was not

seen in the improved supervision arm; while the point estimate was positive, it was small and not

statistically significant. There was no measurable difference in the impacts of the PBF and financing only

arms, but there was statistically significant difference between the PBF intervention and improved

supervision (p<0.05).

Table 7.12 Basic clinical equipment available at health facilities



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Basic clinical equipment 0.100** * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on the basic clinical equipment available at the health facility. Regression model adjusted for facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level

Delivery equipment available at the health facility

67. Table 7.13 shows the impact on delivery equipment, which includes the following: delivery bed,

partograph, delivery light, aspirator, newborn resuscitation bag, newborn eye drops or ointment, scissors,

umbilical cord clamp or sterile tape/tie, suturing material, examination gloves, sterile cotton gauze, hand

soap or detergent, hand scrubbing brush, sterile tray, plastic container with plastic liner for the placenta,

plastic container with a plastic liner for medical waste, adult stethoscope, pinard or fetal stethoscope,

blood pressure instrument, kidney basin, protective apron and plastic draw sheet, baby scale, needle

holder, syringes and disposable needles, 16‐ or 18‐guage needles, speculum, clamps, hand or foot

operated suction pump, vacuum extractor, and a uterine curette. Both the PBF and the additional

financing interventions had large and positive impacts on the availability of delivery equipment. Scores in

the PBF arm improved by 21 percentage points more than did those in the control.

Table 7.13 Delivery equipment available at the health facility score


Delivery equipment 0.209*** * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on the delivery equipment available at the health facility. Regression model adjusted for facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level.

Family planning methods available at the health facility 68. The same is true for family planning methods as shown in Table 7.14. The index is comprised of

condoms, oral contraceptive tablets, Depot Medroxyprogesterone Acetate (DMPA), and implants. The

estimated impact for PBF is large at 16.8 percentage points and statistically significant (p < 0.10). The point

estimates indicating the effect of the other two different treatment arms are also positive, though they

are not large enough to pass the test of statistical significance. Also, the effect in the PBF group was

statistically significantly different from the effects observed in the other treatment groups.

Table 7.14: Family planning methods available at the health facility


Family planning 0.168* * = p < 0.10, ** p < 0.05, *** p< 0.01 Results from difference‐in‐differences regression models examining the effect of PBF on family planning methods available at the health facility. Regression model adjusted for facility‐level control variables (type of health facility public/private/religious, urban/rural). Standard errors were clustered at the health facility level


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QUALITATIVE IMPACT EVALUATION

Summary of qualitative impact evaluation 69. The qualitative impact evaluation focused exclusively on intervention (PBF) facilities and their

catchment areas. It aimed at assessing the impact of the PBF intervention on many health service

provision and health outcome indicators, measured both at the facility and the household levels.

Methodology and sampling technique: 70. The roles of qualitative research imbedded in a PBF impact evaluation are numerous. They

include:

To determine the set of issues that are relevant to the specific country context;

To construct relevant quantitative measures.

To explore relevant issues in greater levels of depth and detail.

To understand the role of place, time, practices and processes.

To enhance interpretation of quantitative results.

Table 7.15. Sampling technique

Level Type of Respondent

Respondent Details

Estimated number of respondents

Instrument Type

Description of Data

National and Regional

Ministry of Health officials, Policy makers, Program implementers

• Individuals in the Ministry and partners • Regional delegates and/or PBF focal point • Regional managers and/or assistant of Purchasing Agency

Ministry official: 5 Regional delegates: 3 Purchasing agency personnel: 3 Tot. = 11

IDI

Challenge of implementing PBF in Cameroon and solutions devised to address the challenges. The role of PBF in shifting operating processes within the health system at regional and national levels (i.e. the introduction of a Purchasing Agency has changed the dynamics at the regional and national levels). The ways in which PBF reinforces (or


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Respondent Details


Instrument Type

Description of Data undermines) autonomy across levels. Awareness, knowledge and application (perceived or enacted) of PBF components targeting the very poor, and challenges with targeting the very poor.

District

District Medical Officer

District Medical Officer

District Medical officers: 3 in each region Tot. = 9

IDI

Changes in daily work schedule brought about by PBF. How context affected PBF’s ability to influence indicators (particularly as relevant to performance indicators in PBF, i.e. vaccination, family planning, childbirth). How challenges associated with PBF are mitigated. The role of PBF in improving (or undermining) retention of facility‐based providers. Awareness, knowledge and application (perceived or enacted) of PBF components targeting the very poor, and challenges with targeting the very poor.


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Respondent Details


Instrument Type

Description of Data

Facility Level

Hospital and Health Center

Providers within 1 hospital and 3 health centers per region

Hospital‐based providers: 3 per hospital (tot. 9) Health center‐based providers: 2 per health center (tot. 18) Tot. = 27

IDI

PBF’s role in influencing indicators (particularly as relevant to performance indicators in PBF, i.e. vaccination, family planning, childbirth). Perceptions of autonomy in relation to PBF. Facilitators or barriers to enacting change within the context of PBF (specifically contextual factors such as the supply chain). PBF’s impact on the lives and daily routines of providers. Levels of satisfaction with operational aspects of PBF and opportunities for improvement in this regard (probing on distribution of funds and governance aspects). Awareness, knowledge and application (perceived or enacted) of PBF components targeting the ultra‐poor; process/challenges with identifying and ultimately reaching (or not reaching) the very poor


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Respondent Details


Instrument Type

Description of Data

Community

Female Patients/Clients

• 3 FGDs per region (1 per district) • 3 IDIs/region with women who delivered at home • 5 IDIs per region with women who use/do not use FP methods

FGDs Tot. = 9 IDIs: 5+3 per region Tot. = 24

IDI and FGD

Care‐seeking pathways and preferences and PBF’s influence on the experience of seeking and receiving care. Community understandings related to care‐seeking for specific illnesses or conditions (particularly as relevant to performance indicators in PBF, i.e. vaccination, family planning, childbirth). Community sense of engagement in PBF and perceptions of PBFs impact on access to care among the very poor.

Total IDIs = 71 FGDs = 9

71. Key evaluation questions are:

At the National and Regional level:

What were the challenges the Ministry and regions faced to implement and support PBF? What are the solutions adopted?

How did the national level stakeholders address the challenges posed by PBF? (including the lack of counter‐verification).


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How has the introduction of a Purchasing Agency affected health system dynamics at regional and national levels?

How is the concept of autonomy (as it is advocated by PBF) perceived by the authorities?

What is the awareness, knowledge and application (perceived or enacted) of PBF components targeting the ultra‐poor, and what are the challenge associated with targeting the ultra‐poor?

At the District level:

How has daily work changed in the context of PBF? (Including supervision, production and use of data)

What contextual factors have facilitated or inhibited change in terms of implementing the PBF program?

How did district level staff address the challenges posed by PBF?

How (if at all) did PBF affect provider retention?

What is the awareness, knowledge and application (perceived or enacted) of PBF components targeting the ultra‐poor, and what are the challenges associated with targeting the ultra‐poor?

At the (Facility‐based) Provider level:

How has PBF brought about changes in some aspects of service provision (vaccination, FP) and not others (skilled birth attended) – as suggested by the changes captured on the single PBF indicators by the quantitative impact evaluation?

How has autonomy and limits to autonomy influenced the ability to produce change?

How has the context (including the drug supply chain) influenced the ability to bring about change or otherwise?

How has daily work changed following the introduction of PBF? (Including reference system, workload, social control, home visits, production and use of data).

Are providers satisfied with the system of distribution of money and governance applied by the PBF program?

How (if at all) has care for indigents been established in given facilities?

What is the awareness, knowledge and application (perceived or enacted) of the PBF components targeting the ultra‐poor? What process/challenges are inherent in identifying and ultimately reaching (or not reaching) the ultra‐poor?

At the Community level

Where does the community go for treatment and why? How has PBF affected decisions related to care‐seeking pathways? Has PBF redirected demand towards specific facilities?

Why has PBF produced changes in some aspects of service and not in others – as suggested by the changes captured on the single PBF indicators by the quantitative impact evaluation?

How has PBF affected the community perception of quality of health care?

How has the community been engaged in PBF?

How has PBF impacted access to care among the poorest of the poor (if at all)?


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RESULTS

72. The results of the qualitative impact evaluation show that PBF improved staff satisfaction and

motivation, and led to better quality of care and improved work environment. Facilities were equipped

and stuffed with better drugs and better equipment. Supervision and coaching also improved significantly.

Major improvements noted are as follows:

73. Improved attitude of health workers toward work. Through PBF interventions, the project

significantly changed workers’ mentality and attitude towards work. PBF changed health workers’

mentality and attitude towards work. Majority of health workers indicated that PBF requirements and

standards they had to meet helped them to become more serious with their work and strived for

excellence. The change in mentality and attitude was triggered by the requirements in PBF contracts,

which defined the quantity of services provided (which leads to higher PBF revenues for facilities) and

standards for service delivery. Box 7.2 provides testimonies of some health workers. Box 7.2: Development impact of PBF interventions (1)

“The changes I have seen with PBF are more positive than negative. Now we have means of measuring our own output, which in turn gives you some satisfaction. And above all most of our services have improved in the eyes of the users. (...) PBF has brought a change in mentality. It has made people to be more focused, it makes some of us in leadership positions feel that we are doing something” (a DMO). “In the first few years, it was exciting. We saw a lot of improvement in quality and quantity which motivated the workers. They were all excited about it. There was even some contamination effect, the extent that even those who were not in the program started copying the good practice that are in the program” (Regional Delegate). “Now they have improved. If you work well you are going to be motivated and it also gives us a sense of direction which is very important (...). PBF has made us change our attitudes: it is good to give your clients goods services, which PBF can also buy” (Provider, District Hospital).

74. Enhanced capacity of health workers. A considerable number of health workers indicated that

they learned a lot from PBF initiatives, which enabled them to effectively use clinical and administrative

tools such as the partogram during deliveries and the facilities’ business plan (Box 7.3).

Box 7.3 Development impact of PBF interventions (2)

“(We had) improvements in our district supervision. I think PBF has opened our eyes to things which we didn't do before” (DMO). “They supervise us to ensure that everything is well done. I have seen that they are really making us change our attitude towards work and we learn new things every day. When they come (for supervision), they teach us” (Provider, Health Center, South‐West region).


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75. Improved supervision and coaching at facility level: Facility level service providers were supported

immensely under PBF because of increased supervision from the DHMT as well as training provided by

staff of the purchasing agency (Box 7.4).


“Everything is codified in such a way that one had to work within a certain rhythm. I have the contract with the district and the region I must sign for that. They tell you specifically that, you have to do this number of supervisions and you have to have this or that., Because the rules are very clear, it allows for transparency, clarity, …initiatives, pro‐activity, good governance, good management, and so many things that are for the common good of all and not individuals” (DMO). “Au début du programme, ils (staff de l’AAP) venaient avec des informations pendant les supervisions

de qualité. Ils venaient nous montrer ce qu’il faut faire. Donc, ils venaient nous former dans les

connaissances que nous on n’avait pas avant (…). Ils nous ont montré beaucoup de techniques que nous

appliquons déjà maintenant. Le PBF nous a amené à comprendre. Par exemple, au niveau des

prescriptions quand il s’agit des IST (infections sexuellement transmissibles), avant on prescrivait

vraiment n’importe quoi. Ils sont venus avec le protocole national des IST qu’on nous on n’avait pas ici”

(Provider, Heath Center, Eastern region).

76. Improved reporting at the central Ministry of Health. Directors and health authorities at the

central level emphasized that PBF strengthened the use of reporting tools and enforced standards in

service delivery in both public and private facilities. Before PBF, private facilities did not provide any

information to the Ministry of Health (Box 7.5).


“There is virtually no distinction between public health unit and private for profit and conventional, because all

of them produce the same results. That is a substantial change. Now private health units produce reports

statistics” (central‐level interview).

77. Changes in the work environment.: PBF significantly changed the environment within which

health facilities operate. It led to: (i) clean work places; (ii) improved infrastructure; (iii) effective

procurement of drugs and pharmaceuticals; and (iv) increased number of health personnel.

Clean workplace: Health workers and district managers reported that their workplaces are now

cleaner, tidier and more hygienic than before. Thanks to the additional financial resources that

they received from the project.

Improved health infrastructure and equipment: PBF also led to better infrastructure and buildings

(e.g. upgrade facilities’ premises, renovation of infrastructure, etc.) and equipment, including

generators, autoclave, fridges, laboratory equipment, delivery beds, weighing scales, bedsheets,

nets, incinerator, placenta pit, toilets for facilities; and motorcycles, computers and TV screens

for DHMTs. These improvements were realized because of availability of extra funds from PBF,

and the fact that the facilities had to ensure that basic infrastructure and equipment existed,


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which were a requirement under PBF and were linked to the quality score and payment

calculation. However, PBF did not adequately address the major challenges such as lack of running

water and electricity, and the so‐called plateau technique (i.e. the availability of technical

equipment for service delivery) remained uneven across the facilities and districts (Box 7.6).


“The environment has greatly changed, there is a lot of order, the place is clean, there is no odor. They have renovated the buildings too, they have painted the walls and put tiles on the floor” (Provider, District Hospital). “On await des préoccupations en matière d’approvisionnement en intrants , en médicaments, en matière d’infrastructures, d’équipements, en matière même des ressources humaines, mais avec le PBF, il y a quand même une amélioration dans les infrastructures, il y a beaucoup de structures sanitaires qui ont eu à assurer leur extension en termes d’équipement aussi en ressources humaines, il y a eu beaucoup de personnels qui ont été recruté sous fonds PBF, voilà, je pense que c’est tout au moins des améliorations qui sont assez palpantes, oui, oui” (Regional Delegate). “Je prends l’exemple de l’hôpital de District de la Cité des Palmiers, qui est un exemple patent. Quand le projet

commençait, il n’avait qu’un bâtiment. Mais avec les possibilités que le PBF lui a apportées, les activités de

l’hôpital de district se sont tellement agrandies qu’il a dû étendre les bâtiments, il a même voulu construire un …

Malheureusement avec le problème administratif, il n’a pas pu, mais il a étendu vraiment ses activités” (central‐

level interview).

78. Improved human resource situation: Improved human resource situation: The implementation of

PBF interventions allowed facilities to have budgets and managerial autonomy, which enabled them to

address human resource challenges. With PBF funds, the facilities could recruit and pay salaries of new

staff in most workplaces. It’s been reported that there are positive effects on the quality of care in most

health facilities. However, delays in PBF payments affected retention of staff recruited with PBF funds.

Some of these workers did not receive their salaries for several months and so left their posts after some

time. Also, rigidities in administrative and labor regulations affected the legal status of the locally‐

recruited workers as there was no clarity of their minimum contributions to the Caisse Nationale de

Prévoyance Sociale(CNPS) (Box 7.7). Box 7.7 Development impact of PBF interventions (6)

Quand le PBF est arrivé à l’Est, on avait par exemple dans le district de santé de Moloundou qui est le district le plus éloigné, on avait 70% des FOSA publique qui étaient fermés parce qu’il n’y avait pas de personnel. Aujourd’hui, toutes les FOSA publique du district de Moloundou sont ouvertes parce qu’il y a des personnels recrutés sous fond PBF” (CVA manager). “Avec les retards de virement, les 75% du personnel qui avait été recruté dans le District de santé de …1 ont tous démissionné par faute de salaire !” (DMO).

79. Strengthened relationship between facilities: PBF has indeed strengthened working relationship

between health facilities’ staff as well as the communities they serve. Through a participatory process of


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developing business plans, staff working relations has significantly strengthened. There are now more

collaborations and better transparency in decision‐making. There are also regular weekly and monthly

staff meetings. By employing the index tool provided by the PPA, decisions for sharing bonus to staff are

done without conflict. District and health centers’ providers point of view are as follows (Box 7.8). Box 7.8 Development impact of PBF interventions (7) "It (staff meeting) involves everybody, everybody comes, and sit and we take decision and prioritize the needs. And then, we take the need that are favorable and we tackle them. It is a bottom‐top approach” (Provider, District Hospital). “Je peux dire qu’on nous paye selon l’indice, selon les performances de tout un chacun. Ça n’a jamais

créé les problèmes ici, mais… bon, nous sommes quand même des êtres humains, donc [sourire] pour

la répartition, comme on sait que c’est selon l’indice, c’est selon les performances, les catégories et

tout tout tout, la responsabilité et tout ça, bon. On calcule avec le chef par rapport à ça. [Chercheur :

et tout le monde est d’accord ici ? Ça ne créé pas des tensions ?]. Ah ! Parfois. Mais plus généralement,

ça ne créé pas des tensions, on gère selon l’indice. On a un chef et le chef quand lui il décide, on marche

selon ce qu’il dit et selon les décisions aussi” (Provider, Health Center, Eastern region).

80. While PBF has improved working relations among staff of health facilities, there are others who

held opposing views. Some of them indicated that there are less positive relations amongst staff. They

contended that they were rarely involved in decision‐making and that there was lack of transparency in

the use of funds (i.e. facilities’ investment funds, recurrent costs, and individual staff motivation funds).

In some instances, certain managers; though, absent from work assign themselves with high scores to

obtain high PBF bonuses. Aggravating the situation is delays in payment of bonuses, which made some

staff get the impression that their managers are siphoning their money for personal gain. The survey

shows that hospitals and the larger facilities suffered worse interpersonal relations than the smaller ones.

Moreover, health workers in the facilities that provided services other than those related to maternal and

child health (which are covered by the PBF program) pointed out tension between staff working in the

maternity and pediatric wards and staff working in the other wards. Testimonies of providers in health

centers are as follows (Box 7.9).

Box 7.9 Development impact of PBF interventions (8) “La réalité que j’ai observée dans notre hôpital c’est que c’est la direction qui prend les décisions de tout, que ce soit le business plan, les ten keys, la répartition des finances, l’outil indice, c’est eux qui gèrent tout à leur niveau. Et bon donc… et nous, on ne participe pas beaucoup, par exemple dans mon unité, je ne sais pas…“ (Provider, Health Center, South‐West region). “Il (chef du centre) n’est jamais là. Mais lors des partages des subsides, lui il est présent. Il a ses points complètement. Par contre, nous nous perdons nos points. Oh, tu as eu l’absence de trois ou quatre jours, on te fait perdre les points comme ça là (…). Je pensais que le PBF allait mettre une ligne que c’est : chacun bouffe à la sueur de son front, que normalement c’est ce qui devait se passer, mais je me rends compte que tu travailles et les autres mangent” (Provider, Health Center, Eastern region).


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“Les payements des subsides ne sont pas régulier ‐ vous voyez. Le personnel lui il ne comprend pas ça forcement

‐ vous voyez, il va attendre six mois. Par exemple là, il y a des subsides de mars qui ne sont pas payés. Donc vous

voyez qu’ils vont attendre, ce qui fait que ce n’est pas toujours bon pour nous lorsqu’on commence à se laisser

aller au découragement, on commence même à boycotter, parfois en se disant que le directeur, il a reçu malgré

ce qu’il nous dit là, il a reçu. Il s’est assis sur l’argent ou bien…” (Provider, District Hospital).

81. Improved relationship with patients and community.: While in general the relationship between

providers and patients were reported to have improved (at least, from the perspective of the providers)

as health workers were increasingly aware of the importance of a good reception of patients, specific

accounts of their relations with the community were both positive and negative. In particular, under PBF,

feedback from patients was collected during the community verification and then shared with providers.

This feedback was appreciated by majority of the respondents and valued as a means of enabling health

workers to improve their practice. In some cases, however, the feedback caused tension in the

communities when the health workers were found to disagree with the assessment made about their

work.

82. Community participation in decision‐making is also, in principle, requested by PBF which requires

regular meetings with the health management committee (COSA, COGE, CODESA,), and needed their

participation in the drafting of the business plan. However, in practice, this was rarely mentioned in the

interviews with the health workers, and district managers interviewed indicated that community

participation to the management of the facilities was still very limited and problematic.

83. Health care seeking behavior. The survey shows that women who sought antenatal care in a

facility close to their area of residence was 60.9 percent, 55 percent for deliveries, and 60.6 percent

postnatal care. At baseline, 52.3 percent for women who received antenatal 51.9 percent delivered, and

only 56.1 percent sought postnatal care in facilities close to their area of abode.

The “health care shopping” behavior whereby households bypass the closest health facility is also present

for deliveries and postnatal care. At baseline, focusing on women for whom we have information about

the service location and who sought care in a facility, only 51.9 percent delivered, and only 56.1 percent

sought postnatal care in linking changes to a facility with their corresponding treatment group.

Knowledge of PBF and project 84. Despite its remarkable success, PBF was only known among few women in the communities.

Majority of the women did not link the changes to the efforts of PBF. Only few women correctly linked

PBF to the home visits carried out by the facility staff to check the hygiene standards in the homes in the

community, and had a positive opinion of those visits. Some women knew about it because they had

been involved in a CBO in charge of carrying out the community verification, or because they had been

selected as patients to be checked during the community verification.


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Changes in health facilities: 85. During the FGDs, women were also directly asked about the changes that they observed in the

facilities over time, with reference to the facility in their community, selected only from the treatment/full

PBF group. In their responses, they mentioned that indeed some (mostly) positive changes had occurred

in terms of infrastructure (new buildings, new blocks, laboratory facilities, separate wards, etc.),

availability of drugs (though not in all facilities), increase in outreach activities, extended opening hours

and availability of staff. However, in some facilities in the North‐West region, participants said that there

were fewer nurses and lack of equipment (7.10).

Box 7.10 Development impact of PBF interventions (9) Il y avait manque des infirmiers. Mais maintenant là, le jour comme la nuit il y a les infirmiers de garde et les numéros de téléphone sont là ; à n’importe quelle heure tu arrives, tu vas trouver l’infirmière là. (...) Et tu vas trouver les médicaments. Ce n'est plus comme avant ou il fallait aller chercher les autres médicaments ailleurs“ (FGD, Eastern region). “Il (infirmier titulaire) accueille bien ses malades et il est trop gentil. Même si que tu accouches que tu n’as pas l’argent, il va dire je t’accouche, je te fais accoucher, tu vas chercher l’argent après. Il est trop gentil!” (FGD, Eastern region). “There is a new structure, a lab, separate ward for women, new maternity. It is clean (...). The number of nurses

increased. There are now 3 nurses and 1 midwife, formerly there was only one nurse here” (FGD, North‐West

region).

86. Demand Side interventions and assisted delivery. Secondly, extending the point above further,

demand‐side barriers emerged as a key factor to influence uptake of certain services. Such barriers

included, critical, geographical and financial ones which are related to the distance to the facility as well

as direct and indirect (e.g. transport) costs of accessing services. Demand‐side barriers were not explicitly

addressed by the PBF program, and for some services, such as assisted delivery, they would have been

more difficult to overcome by providers alone. For example, during outreach in the communities, both

vaccinations and family planning can be provided and women can be informed about family planning and

be provided related devices when at the facility for other reasons., Assisted deliveries on the other hand

require patients to physically go to the facility, and at specific point in time. This may be complicated

because of lack of transport or funds to cover it, or because of the costs associated to delivery in facilities.

87. Finally, it is important to stress that PBF was not introduced in a void. A number of other programs

and projects continued to be implemented in the same facilities and were likely to influence health

outputs and outcomes. These programs included, the introduction of delivery kits mentioned above,

support to family planning provided by the GIZ, to vaccination from UNICEF, and to other services by other

donors, and the creation of mutuelles de santé or externally‐supported insurance schemes (e.g. for

women’s care by GIZ), etc. It could be interesting to explore whether these programs similarly affected

facilities across the regions, districts, and the different arms of the trial or whether they were


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implemented only in some areas/facilities. This would allow investigating whether PBF has a multiplicative

effect when coupled with other interventions, and those addressing demand‐side barriers.

88. The analysis contributes to further explore and shed light on one of the findings of the quantitative

impact evaluation which found a significant increase in child vaccinations and utilization of modern family

planning. Even though significant changes were not noted in assisted deliveries between PBF and control

facilities, both providers and patients’ narratives indicated that, there had been change over time in the

service delivery practices. Providers and women’s narratives converged to indicate that outreach activities

(whether in the form of community visits, school visits or the establishment of outreach posts) had

become more common in recent years. Interestingly, providers’ narratives further explained that

increased investments in outreach activities were made possible by the increase in the resources provided

by PBF. The investment was made considering a clear understanding that it will further enhance one’s

utility through the attainment of a specific set of performance indicators.

89. Moreover, it seemed that sensitization of family planning has increasingly been provided to

women outside of situations that target specifically family planning and information about it. This has

somewhat been integrated in the delivery of other services (for example, women are informed during

ANC or PNC visits, or during child vaccination). Women also generally identified providers as their primary

source of family planning knowledge16. These findings seem to imply that providers have proactively

changed the practices related to the delivery of some services, to increase utilization to maximize their

income. This change was aimed at activities and services that were known as ‘low hanging fruits’, e.g.

where a substantial change in coverage could be obtained at a low cost. In most cases, the strategies

enacted consisted of increased outreach and sensitization which are likely to have had an impact on family

planning and vaccination outputs.

ANNEX 8. SUMMARY OF BORROWER’S ICR

90. The implementation of PAISS took place in Cameroon in a context marked by inefficiency of health

expenditure and the policies which were implemented. In fact, between 2001 and 2010, Cameroon had

more than doubled its health expenditure (public and private) per capita from $26 in 2001 to USD in 2010,

but most of its health indicators stagnated or improved very slowly, with an even more worrisome

situation in the impoverished areas. It should be noted, however, that at the same or lower expense, most

low‐income countries can achieve better results.

91. To cope with this situation and to sustainably improve the performance of the health system in

Cameroon, particularly maternal, neonatal and infant mortality, the government, with the support of the

World Bank, implemented the PAISS project and introduced a new reform, known as the performance‐

based financing in the health sector.


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92. The objective of this project was to improve the quality and accessibility of healthcare services.

The focus was on maternal and children’s health and the prevention of communicable diseases. The PAISS

implementation approach is PBF, which is results‐oriented (quality, efficiency, equity) reform of the health

system. It involves transferring financial resources to health facilities in proportion to their monthly

benefits. To benefit from more resources, each health facility (and staff) were supposed to put in place

innovative strategies to improve the quantity and quality of healthcare services provided.

93. The Financing Agreement for the project was signed between the government and the World

Bank on October 30, 2008 and its effective date was declared on January 29, 2009. Given the success

of the project, it was agreed upon that an additional funding of $ 20 million and another $ 20 million

donation be given on September 19,2014 and September 26, 2014 respectively.

94. Project activities were organized around two components, namely:

Component 1 "Provision of services at district level”: This component provides support to financing contracts based on past performance of regional funds for health, district health committees, NGOs and / or health centers.

Component 2 " institutional strengthening" This component includes financial and technical support to strengthen two key normative functions of the Ministry of Public Health at the national, regional and district levels. Support is provided in two main areas: contract management and design, and the establishment of a unified information system.

95. Under the terms of the credit agreements IDA credit No. 4478‐CM and No. 5486‐

CM and Don number MDTF‐HRI GRANT No. TF017128, a final evaluation of the project is provided by the

government and the transmission ratio of the said assessment submitted by IDA no later than December 31,

2017.

96. This completion report is a document prepared by the Government to assess the performance of

the ISSA project while analyzing its relevance, effectiveness, efficiency, sustainability and impact,

97. Specifically, it was to:

Evaluate the design and relevance of the actions carried out by the Health Investment Support Project in view of the policies in force and the expectations of the beneficiary populations;

Measure the performance of the Health Sector Investment Support Project in terms of the level of execution of the activities and the results, including measures taken for their sustainability;

Determine the effects and impact of the Project on the beneficiaries and the health sector in general;

Evaluate the institutional and organizational scheme of the Project;

Evaluate the procurement and monitoring‐evaluation systems of the project;

Evaluate the project planning mechanism;

Evaluate the performance of the various actors involved in the implementation of the project;


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Analyze the financial management of the project;

Identify the difficulties encountered and the solutions applied or envisaged;

Evaluate the impact of exogenous factors on the performance of the implementation and the quality of the responses;

Identify lessons learned;

Evaluate the prospects for sustaining the achievements of the Project, the actions to be taken to ensure the sustainability of the infrastructures set up by the project.

98. To achieve these objectives, a methodological approach based on five key milestones was

adopted. They are;

(i) the establishment of a working group in charge of the final evaluation following the decision of the

Minister of Economy, Planning and Spatial Planning,

(ii) the collection and exploration of findings in the documents made available by PAISS project

implementation according to age and other factors.

(iii) the organization of a workshop for the adoption of the project intervention approach and the

guidelines for the report.

(iv) the organization of the focus groups on the appreciation of the implementation of PAISS with the

participation of the beneficiary health facilities.

(v) the organization of two workshops devoted respectively to the review and validation of the draft

version of the completion report.

99. At the end of the process, the overall performance of PAISS was deemed

satisfactory. The disbursement rate at December 31,2017 is 96.36% and the project achieved (see below)

its objective since the targets of all the related indicators were largely exceeded. Indeed, the

implementation of the project made possible the signing of 584 performance purchase contracts with

health facilities:

(i) 3,175,893 people (instead of 1,500,000) have had access to a basic health

package.

(ii) increased the number of births attended by skilled personnel i.e. from 57 139 per

quarter to 147,269 (a 245% achievement rate).

(iii) increased the number of fully immunized children (PENTA 3) 90 595 to 182,901

(a completion rate of 91%).

RELEVANCE

100. To evaluate the relevance of the PAISS project, we analyzed the following:

(i) The alignment of the development objective with national policies in the health

sector.

(ii) The relevance of the mechanism put in place for performance‐based financing.

(iii) The consideration of expectations of beneficiaries.


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101. At the end of the evaluation, the performance of the PAISS project in terms of its relevance was

considered satisfactory because it received at least a satisfactory rating for each of the three criteria.

The development objective of the project that remained aligned with the policies in the

health sector including the ECSD regarding its axis human capital development and the health sector

strategy was concerned with the servicing aspects of all the health districts with a view to achieving the

MDGs.

102. Regarding the PBF approach, it should be noted that the implementation process has not

undergone major changes throughout the implementation of PAISS. The improvement was concerned

with only the simplification of the payment procedures using the grant of this function for the PMU. Thus,

in accordance with PAISS's rating methodology for this criterion, its performance was

judged satisfactory because of the slight changes made in the implementation mechanism of the PBF.

103. In terms of considering the expectations and needs of the beneficiaries, the latter indicated that

despite their weak involvement in the project preparation: (i) the performance indicators were in line with

the priority needs of the health system, and (ii) the training received was fully consistent with their needs,

although there are still additional training needs. Despite the low involvement of the beneficiaries, the

performance of PAISS is taking into account the fact that their expectations were considered satisfactory

due to the consistency between the indicators purchased and the priority needs of the health system, the

MDGs and the sectoral strategy.

EFFECTIVENESS

104. The effectiveness of the project was rated satisfactory. The targets of the indicators selected to

assess the level of achievement of the expected results of the project implementation have been reached

at more than 90%, which is largely exceeded (achievement rate above 125% and reaching up to at 245%

for some indicators). One of the key success factors of the project remains the strong political will of the

government and the good appropriation of the approach by all the actors of the PBF chain.

105. Despite the positive results achieved, it should be noted that the satisfactory implementation of

the business plan remains one of the major challenges that the operationalization of the PBF approach in

the health sector still faces as one of the main constraints. The following were noted:

(i) The cumbersome payment procedures resulting in the irregularity of such payments.

(ii) The decline in FOSA receipts due to the unilateral change in the cost of purchasing certain

indicators.

(iii) The cumbersome procurement procedures that prove to be mandatory for the realization

of investments whose cost is greater than 5 million FCFA.

EFFICIENCY


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106. The performance of the PAISS project in terms of its efficiency is considered satisfactory. Looking

at the functioning of the institutional mechanism of the project and that of the of the PBF, all the

structures put in place have adequately fulfilled their functions although some challenges remain in PBF

communication and awareness, on one hand, and the annual organization of the indicator review work

on the other.

107. In terms of timing, it should be noted that the implementation deadlines were extended by two

years for initial funding due to the lack of consideration of the time needed for the project formulation.

This was necessary for the appropriation and implementation of all the tools of the PBF approach. This

time frame was met for additional funding and donation, given that the above constraints had already

been tackled.

108. With respect to procurement, it should be noted that the number of contracts to be awarded was

quite limited compared to other projects in the portfolio. However, the main constraint was the

cumbersome procedure. Despite this constraint, the project's performance is considered satisfactory.

109. With respect to fiduciary management, it is important to note that the disbursement rate of all

the resources made available to the project was 96.36%. Project performance was satisfactory given that

resources were disbursed according to plan and compliance with reporting obligations and auditing.

110. Regarding monitoring and evaluation, it should be noted that all the products expected had been

produced. Moreover, the effectiveness of the functions of the PBF portal must simplify the process of data

transfer.

SUSTAINABILITY 111. The appreciation of PAISS in terms of sustainability is satisfactory because it has, on one hand

supported the establishment of new sustainable institutions in the health sector and on the other

contributed to the capacity building of this sector. This was done during the introduction of the funding

mechanism based on the performance as an innovative approach to improving access to quality health

care.

112. The provisions relating to the establishment of these institutions, particularly the CTN and the

regional health funds are a guarantee for their legal survival, given the key role played by these structures

in the field of health and the framework of the institutionalization of the PBF approach in Cameroon.

113. In terms of financial sustainability, the government has not only mobilized additional resources

for the scaling up of the PBF approach, but also plans to allocate at least 20% of MINSANTE's budget to

the purchase of performance in health facilities.

114. In addition, in view of the results obtained, the PBF approach was chosen as a transversal

dimension of implementation of the new health sector strategy covering the period between 2016‐


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2027.Despite this, there are still some challenges in strengthening PBF ownership and involving all

stakeholders in the process of updating the PBF implementation tools. In this regard, we make the

following recommendations:

IMPACT 115. The implementation of the PBF approach through PAISS has considerably increased the level of

attendance of health facilities under PBF contract which increased from 2,448,270 people in 2013 to

3,774,895 in 2016 (i.e. 54.18% increase in almost three years). This situation had a positive impact

on maternal and child health indicators in the targeted regions, particularly in the Eastern Region where

almost all (14) the health districts were covered. The delivery rate witnessed an increase of 8% while it

stagnated in almost all the other parts of the country, per the results of the MICS 2014.

116. Worthy of note is the fact that the implementation of PBF has helped to increase the number

of assisted childbirth by medical staff (1.3% increase) in health facilities under PBF while it fell by 0.7% in

other health facilities. The implementation of PAISS has also improved the quality of services and health

care. The level of availability of essential drugs has increased by more than 10% at the health facilities

under PBF while it has stagnated (1% increase) in other health facilities. In addition, the quality of technical

equipment of health facilities in PBF has improved. The proportion of essential equipment for delivery has

increased significantly in the health facilities under PBF while it has virtually stagnated in other health

facilities. As a result, the level of beneficiary satisfaction with services provided for children under 5

increased by 15% for PBF facilities while this indicator decreased by 7% in the other health facilities.

117. Also, a prelude to the introduction of the PBF approach indicate that, Cameroon was one of the

countries where health expenditure is found to be too high for mediocre results. In this regard, it should

be noted that, in accordance with the conclusions of the impact study, health expenditure has decreased

at the level of households attending health facilities under PBF, whereas they would have increased

considerably in households frequenting other health facilities. The same is true of parallel payments,

which would have increased considerably at the level of health facilities that are not under PBF while they

have dropped by 882 FCFA at the level of health facilities under PBF.

118. Worthy of note is the fact that the beneficiaries expressed their satisfaction with the changes

made by PAISS in their health facility. In addition to improving the quality of the management of these

establishments, PAISS made it possible for several investments to be made. This is particularly the case

of the district hospital of the city of palms which has built new buildings, has new services and raised its

technical platform. Several other health facilities in other regions have inexperienced staff who would be

more efficient under a PBF contract, which has not only improved the quality of care but also increased

the package of services offered by the said health facilities.

PERFORMANCE OF PARTNERS

119. The main implementing partners for PAISS were the government (MINEPAT, MINSANTE and

MINFI through CAA) and the World Bank. In the case of the World Bank, it should be noted that its

performance was rated “very satisfactory”. This is because this partner played its role appropriately both

in terms of resource provision and facilitation, supervision and coaching for successful implementation of


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PAISS. In addition, it has always issued its Non‐Objection Notice (NOA) and its comments on the AWPB,

the PPM, the Terms of Reference, the Technical Specifications and the various stages for the markets

subject to a prior approval within deadlines. This was quite impressive (i.e. one to two days maximum).

In the case of the government, its performance is rated “satisfactory” because, despite the delays in the

implementation and the respect of payment deadlines, it performed its functions appropriately. One of

the main challenges facing this partner must resolve is the timely mobilization of counterpart funds and

the budget allocated by the government for the payment of subsidies. SUMMARY OF LESSONS LEARNED AND RECOMMENDATIONS:

Lessons learned from the relevance of the project:

120. In general, the PAISS project has been perfect in terms of the country's development policies,

particularly in the health sector. From the relevance analysis, the main lessons learned focus on the

implementation of the PBF approach in Cameroon, the involvement of beneficiaries in the development

of tools and the monitoring chain of project implementation. It should be noted that:

The results obtained in the implementation of the PBF approach have enabled Cameroon to

become a privileged destination for sharing experience in the field, and encouraged the

government to transform budgetary resources of PBF and spread to other themes such

as education, early childhood development, marital status and public finance (public

procurement.);

The weak involvement of regional health delegations and health districts in the revision of

PBF operationalization tools (performance indicators, cost of purchasing indicators, method

of validation of services provided to users, etc.) has not facilitated the appropriation of the

said tools by implementing PBF stakeholders at the decentralized level (health facilities,

district s health, etc.);

The weak involvement of health facilities in the process of validating their bill was not only a

factor of demotivation, but also a major constraint in the implementation of their business

plan (to the extent that they no longer received all resources planned and necessary for the

smooth implementation of their business plan);

The lack of a complaint handling and redress mechanism would not have allowed the

beneficiaries to express their concerns. This situation would have led to the withdrawal of

some health facilities that their grievances had been ignored by the PBF;

Lack of knowledge of subcontracting management mechanisms, the lack of transparency of

the main co‐contractor and the fact that the co‐contracting party receives 20% of subsidies

from subcontracting health facilities is likely to discourage certain health facilities from joining

the PBF;

The relatively low cost of purchasing subsidies as well as the modification of the Community

PBF indicators have not been favorable factors for the implementation of the Community PBF;

Health facilities and other stakeholders of the PBF seem more oriented in their activities to

areas where the cost of purchasing indicators seems quite high. This situation could create an

eviction effect on the implementation of their business plan.


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Several activities carried out by health districts, like routine controls, would not be included

in performance indicators purchased under the PBF, which could negatively impact the quality

of regulation at the district health level.

On the effectiveness of the project:

121. Regarding the effectiveness of the project, the following were lessons learned:

The implementation of the PBF approach has strengthened the managerial capacities of

health facility managers through transparency in management and has also introduced

the culture of accountability at the level of regulators and providers.

Instituting a rule that requires health facilities to purchase medicines primarily from

regional health funds has led to the lack of tracer drugs in some health facilities

The administrative workload imposed by the PBF and other MINSANTE programs have an

impact on the amount of time that the health care staff devote to health care delivery

This is because of the detailed documentation of information about each program,

project, and PAISS which they were required to send to the Ministry of Health at the end

of every month.

The modification of data collection parameters on performance indicators without prior

information from the FOSA reduced their performance.

The replacement of the indicator linked to the supervision of community pharmacies in

the health districts by the supervisors of the community pharmacies led to the absence

of tracer drugs in certain health facilities.

Regular non‐payment or late payment of subsidies to regulators and providers poses a

serious threat to the PBF.

On the efficiency of the project:

The lack of a timetable for the elaboration of the AWPBs made it impossible to have it on time.

Failure to comply with the deadline for submitting invoices created a delay in the processing of

invoices for the payment of subsidies.

The understaffing of the project's fiduciary team also led to the delay in the payment of

subsidies. Indeed, after the restructuring of the project, the workload of the fiduciary team

increased. This situation improved slightly with the recruitment of financial assistance within the

UGP.

The non‐operational effectiveness of the PBF portal led to the continuity of manual invoice

processing, particularly in the South West and Littoral regions.

On the performance of the partners:

Ownership of the project in MINSANTE and the involvement of the Minister of Public Health in

the project enabled the mobilization of about 670 million in the budget of MINSANTE for the

payment of subsidies in 2016.


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On the sustainability of the project:

The establishment of a Health Programs Monitoring Committee made it possible to federate all

efforts to achieve the objectives of the SSS.

Capitalization of PAISS staff in setting up the PBF National Technical Unit at MINSANTE

II‐ RECOMMENDATIONS

122. In view of the difficulties encountered and lessons learned in the implementation of PAISS, the

following recommendations were made:

Relevance of the project

Organize consultations of actors at the deconcentrated level as a prelude to the revision of PBF operational tools.

Reinforce the appropriation of the operational tools for implementing the PBF approach, such as

the index tool by providers (health facilities).

Put in place a mechanism to resolve complaints within the framework of the PBF.

Define a clear mechanism and credible criteria for the selection of health districts and facilities

eligible for PBF.

Initiate a reflection to identify additional indicators that could be purchased at health districts to enable the team to accomplish their mission.

Involve health districts in the regulatory activities of hospitals in their area of responsibility.

Recruit an expert in communication and knowledge management to better communicate and

document the best practices observed in operationalizing the PBF approach.

Reflect on improving the management of subcontracts under the PBF.

Initiate consultations to better determine the cost of purchasing indicators for the community

PBF.

Effectiveness of the project

123. To improve the performance of future projects implemented under the PBF approach, the

following recommendations were made:

Speed up the PBF portal's scalable maintenance process so that it can acquire new features

to enable the facilities to use electronic invoice processing.

Simplify the chain of payment of subsidies so that the NTC can pay bills directly without going

through the Minister of Public Health and by the CAA.

Ask the health districts to draw up the AWPB of the actors in their geographical area of

competence.


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Increase the number of CTN's financial services staff so that they can play their role of

payment agency.

Initiate a reflection with a view to setting up a mechanism to ensure that the expenses

incurred on the payment of subsidies are consistent with the activities planned in the FOSA

business plans.

Create a special account at the level of the Public Treasury for the payment of subsidies to

health facilities / PBF providers.

Establish processing time folders to all levels of the chain.

Simplify and harmonize data collection and processing sheets for all projects operating at the

level of a FOSA.

Extend the period of updating the business plan to six months to reduce the administrative

workload at the level of the FOSA.

Initiate a reflection with a view to simplifying the procurement mechanisms in the framework

of the realization of investments to be financed by PBF resources.

Efficiency of the project

124. In view of efficiency in the implementation of future operations in the sector, we recommend the

following;

That CTN is enabled to fulfill its communication and outreach functions by strengthening its

staff through the recruitment of a communications specialist.

That the PBF approach should be strengthened by (given the scalability of the PBF approach)

the CTN workforce to facilitate the implementation of cross‐check activities trimestral/ semi

benefits at the health facilities.

That workshops be organized annually with the involvement of all actors for the revision of

the indicators such as cost costs, and that criteria should be predefined.

That the annual national PBF seminar be regularly organized.

That a schedule for the development of the AWPB for the project be developed and

disseminated. This schedule must include the constraints on the transmission of AWPB for

non‐objection no later than November 30 of each year.

That the period of ownership of PBF tools be considered in the formulation of future projects

to be operationalized following this approach, if a pilot phase of the approach is to be

experienced in the project preparation phase.

To document the truncated practices of the financial execution monitoring mechanism so

that it can be capitalized as part of the ongoing operation.:

To carry out another impact evaluation of the PBF.

Partner Performance

Concerning the MINEPAT, it is necessary to indicate in the correspondence, the required

legal documents and a deadline for the receipt of the documents taking into consideration

the deadlines for fulfilling the conditions of entry into force.

Regarding the MINSANTE, it was recommended that steps be taken to expedite the

disbursement of counterpart funds in collaboration with MINEPAT.


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Sustainability

125. The following recommendations were made:

Consideration should be given to setting up an. CTN financing operating mechanism to limit its financial dependence on HSPP capacity. Its staff should be strengthened to make the transition across the region a PBF approach.

That the administration and maintenance of the PBF portal be progressively transferred and that the IT department of the Ministry of Health institutionalize this tool.

That a manual of the PBF standard operating procedures portal be developed for the transfer of certain powers relating to the introduction of invoices and the updating of data from health units to health districts

That regulatory indicators be introduced in the PBF portal.

That the annual PBF indicator map validation workshops be held with the effective participation

of district health representatives, graves and stroke.


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ANNEX 9. SUPPORTING DOCUMENTS

1. Aide‐memoires 2008‐2017

2. Audit Social en faveur des Indigents et des Populations Autochtones, volume 1 : Evaluation

Sociale, CHEUMANI NOUDJIEU Charlotte, Février 2016, Consultant Socio‐environnementaliste.Des

indigents et des Populations Autochtones, Volume 2, Plan d ’Action. Fevrier 2016. CHEUMANI

NOUDJIEU Charlotte, Consultant Socio‐environnementaliste.

3. Elaboration du Plan de Gestion des Déchets Biomédicaux du Project d’Appui au Investissements

dal le Secteur de la Sante. DJOCGOUE Pierre François, Socio‐environnementaliste Rapport révise,

Février 2016.

4. Enquête de Base de l’Evaluation de l’Impact du Financement Base sur le Résultat dans le Secteur

de la Sante Réalisée par : L’Institut de Formation et de Recherche Démographiques (IFORD)

Rapport Final, Yaoundé, Mai 2013.

5. Financing Agreement (Additional Financing for Health Sector Support Investment Project)

between REPUBLIC OF CAMEROON and INTERNATIONAL DEVELOPMENT ASSOCIATION, Dated 26

SEPT 201f ,2014

6. International Bank for Reconstruction and Development, International Development Association,

International Finance Corporation, and Multilateral Investment Guarantee Agency, Country

Partnership Framework for Republic of Cameroon for the Period 2017‐21, February 28, 2017.

7. International Development Association, Project Paper on a Proposed Additional Credit, in the

Amount of SDR 13 million, (US$20 million equivalent), with an Additional Grant from the Health

Results Innovation Trust Fund (HRITF) in the Amount of US$20 million to the Republic of

Cameroon for the Health Sector Support Investment Project May 30, 2014.

8. Manuel de Procédures Administratives, Financières et Comptables du Projet d’appui aux

Investissements dans le Secteur de la Sante (PAISS).

9. Midline Qualitative Study Findings Report, Cameroon PBF Impact Evaluation, December 2014.

10. Plan National de Développement Sanitaire (PNDS) 2016‐2020, MINISANTE, Aout, 2016.

11. Project Appraisal Document on a Proposed Credit in the Amount of SDR 15.3 million (US$25 million equivalent) to the Republic of Cameroon for a Health Sector Support Investment Project May 29,2008.

12. Project paper on a Proposed Additional Credit in the Amount of SDR13 million (US$20 million equivalent) with an Additional Grant from the Health Results Innovation Trust Fund (HRITF) in the Amount of us$20 million to the Republic of Cameroon for the Health Sector Support Investment Project, May 30, 2014.

13. Qualitative Research to Explain and Unpack Quantitative Findings from a Performance‐Based

Financing Pilot in Cameroon Final report March 27, 2017.

14. Rapport d’Achèvement du Project d’Appui aux Investissements du Secteurs de la Sante,

Décembre 2017.

15. Republic of Cameroon, Cameroon PBF impact evaluation, March 24, 2017.

16. Restructuring Paper on a Proposed Project Restructuring of Cameroon Health Sector Support

Investment Project Credit: 4478‐CM to the Republic of Cameroon May 11, 2011.


Investment Project Credit: 4478‐CM to the Republic of Cameroon February 5, 2014.


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Investment Project Credit: 4478‐CM to the Republic of Cameroon January 2, 2017.

19. Rapport de la Revue Approfondie de la Gestion Financière, Projet d’Appui aux Investissement

dans le Secteur de la Santé « PAISS », Mars 2018.

20. Dossier d’investissement pour l’amélioration de la santé de la reproduction, de la mère, du

nouveau‐né, de l’enfant et de l’adolescent/jeune au Cameroun 2017‐2020.


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ANNEX 10. MAP OF CAMEROON

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