Presentation of Isidore Sieleunou realised for an organised session on Application and challenges to the use of mixed methods in health systems research, held at HSR 2016, the Fourth Global Symposium on Health Systems Research, Vancouver, 14-18 november 2016.

1. TRANSFERRING THE PURCHASING
ROLE FROM INTERNATIONAL TO
NATIONAL ORGANIZATIONS DURING THE
SCALE-UP PHASE OF PERFORMANCE-
BASED FINANCING IN CAMEROON
I. Sieleunou, AM. Turcotte-Tremblay, H. Yumo, E.
Kouokam, JC. Taptue, D. Tamga, V. Ridde

2. Context
PBF project in Cameroon :
 Started in 2011
 Budget : 25 millions USD
 Performance Purchasing Agency (PPA) =
International NGOs (3) + Government (1)
 Implemented in 26 district hospitals, 4/10
regions, population ≈ 3 million
 Impact evaluation in 3 of the 4 regions : 4
arms of randomization

3. Objective
Assess the transfer of the performance purchasing role
from international NGOs to National agents during
scaling up phase

4. Methods
 Design: explanatory case study with two concurrent
qualitative data collection methods
 Documents review (n=20)
 Important to understand the PBF policy, design and
implementation
 Provided background and context
 Corroborating and augment evidence from KI
 In-depth interviews
 Purposive sampling of 33 KI
 Topic guide

5. Methods
 Conceptual framework : Dolowitz and Marxh (2000)
 What are the purposes of the transfer?
 Why do actors engage in institutional transfer?
 Who are the actors involved in this process?
 What are the sources of transfers?
 What are the different forms of transfers?
 What are the factors that promote or restrict transfers?
 Whether and to what extent the observed transfers resulted in a success or a failure?
 Data analysis
 All interviews were tape-recorded, transcribed and analyzed using QDA miner
 Hybrid deductive-inductive approach
 Ethical clearance : Cameroon National Ethics Committee for Human
Health Research and the WHO Research Ethics Review Committee

6. Post
transfert
Intensive
phase
Results
6
Feb. 2012 Apr. 2012 Sep. 2012 May 2013 Apr. 2014 Jul. 2014 Aug. 2014 Dec. 2014
Pre-intensive phase

7.  Decision-making power
" They transferred all their power to the special funds. Because special funds became
like the bosses of PPAs ... I think that when we say transfer, it is at all levels. ..."
NI_Implementer8
 Transmitting ideas, expertise, “the PBF spirit” (soft)
 Transfer of equipment, logistics and all technical tools
(hard)
What did the transfer consist of?

8.  Sustainability and ownership
"The PBF is an importation. When we import, we must first bring the know-how into
the country. Foreign expertise must not stay forever. It must be transmitted to the
Nationals because it is more sustainable and cheaper like I said earlier. So, it is more
likely to remain when it is nationals who are in control and it’s evidently much cheaper
than importing work forces" Policy maker4
 “Horizontalization" of the health system
"The PBF program is still viewed as a vertical program because it is implemented by a
vertical structure. It is important to replace the international NGO by a national
structure that was already carrying out other health activities" Implementer5
The purposes of the transfer

9. Engaging in and the source of the transfer
PBF Steering Committee
Management Unit of
PAISS Project
Fund holder
Agency
Community Based
Organisations
Health care providers
IHC, CMA, DH
Regulator RDH
Regulator DHS
- Verifies the reported
care/services provided
(Quantity, Quality and if real)
- Pays subventions to the
health facility, community
based organisations and
regulators after verification
-Guarantees the respect of
norms and standards of health
care /service delivery;
-Supervises the PBF process;
- Participates in the Quality
assessment (verification)
Provides Health care
and services to the
population
Community
Verification
Takes Strategic
Decisions
Monitors the
project on a
daily basis and
draws lessons
Purchase
Regulation
Purchase
Purchase

10.  Ministry of Public Health (Central and regional level)
 The World Bank
 International organizations in charge of implementing the PBF
scheme in 3 regions (AEDES and CORDAID)
 Regional Funds for Health Promotion
 GIZ
Main actors involved in the transfer

11.  Transition planned from the start (Gardner et al. 2005)
 International training courses on PBF
"Now, we must have more than 200 people trained in the 14-day PBF course, with all
of the approaches, all of the philosophies. So there is the material, there are resources
in Cameroon. " Policymaker2
 Modification of the RFHPs’ legal status and changes in the
RFHPs’ organizational structure
"The re-organisation of the regional funds for health promotion to a public utility
institution made it a good structure into which the PBF could fit" Implementer7
 Experience in the Littoral region (proof of concept)
Main factors that facilitated the transfer

12.  No legal framework
"The contract remained somewhat vague with respect to the transfer modalities. Hence, there
was a need for a ministerial memorandum to clarify the conditions and contents of the
transfer. But you know how things happen in our country. It always takes time. The result is
that the note was signed at the time the transfer process was supposed to be completed"
Implementer10
 Short timeline during the intensive phase of the transition
 No cohabitation period
 No formal post-transition support agreements
 Lack of agreement regarding the issue of managing human resources
Point 2 of Article 3 of the ministerial note : "The staffing plan will highlight the positions
filled or to be filled in such that recruitment is launched within the best possible time, based
on validated terms of reference and the profiles required by the post".
(Vian et al. 2013)
Main factors that hindered the transfer

13.  No contracts signed with health institutions, regulators and community-
based organizations
"As soon as the RFHP took the control of the PPA, it caused some delays in the transfer of funds
and it created a lot of problems in the health units, until some personnel had to leave. They
resigned. They resigned because they could not be paid. The reserves that were usually kept, were
exhausted and some of the personnel left. Projects that were planned in the business plan were
suspended and so many things went wrong". NP_Implementer8
 No coaching activities, reporting / verification and quality evaluation
"All the activities that were supposed to be going on, they are now frozen. The new PPA has not
signed contracts with the health units up till now. The region has not come down for supervision
despite the fact that, we at the district, are still going and trying to see how we can actually carry
out our activities. Ironically, we have received a letter from the regional delegate that we should
continue to carry out the activities as if the contracts were already signed". Implementer12
 Contracts with the RFHP many months after the withdrawal of the
international NGOs
 All the highly qualify staff left the project
Criticism of the transfer process

14. Key lessons
1 Start discussing and planning the transition early on
2 Set up inclusive policy dialogue to seek high level commitment and participation from different
actors
3 Consistently build country capacity (e.g., training on the intervention to be transferred)
4 A well-established transition plan with a clear timeline of activities should be prepared at the
beginning
5 Explicit guidance outlining the objectives, actors, sources, and forms of transfer should be
developed at the central level with budgetary line
6 A communication plan involving all stakeholders, from the central level to the frontline staff,
should be worked out
7 A legal framework to conduct the transfer should be established before starting the intensive
phase of the transfer
8 An overlap period during which the outgoing team supports the new team should be
implemented to facilitate the transition process and ensure a greater continuity for PBF activities
9 A formal post-transition support agreement should be clearly defined
10 Transition plans should include explicit procedures for absorbing human resources and
harmonizing pay scales early on so that staff don’t have to take lower salaries or be motivated to
leave during the transition