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Table 5 PBF innovations and adaptations during crisis

From: Performance-based financing in three humanitarian settings: principles and pragmatism

  South Kivu / DR Congo Central African Republic Adamawa State / Nigeria
Coping with acute crisis (Shabunda and Lulingu health zones in 2009):
“Stay put” (rather than evacuate personnel) to build local trust and relations with the authorities in health and other sectors, but also with rebel forces when needed. The AAP was composed of local staff with established knowledge in the area, which may have helped with this strategy (KIIs)
Negotiations with all sides, including armed groups (tactics included offering free care to armed groups although this became more challenging as violence intensified). • Few managers continued to provide health services to the non-displaced populations in conflict-affected areas, and later claimed PBF subsides
• Creation of 5 PBF-funded mobile clinics to provide services in conflict-affected areas, with ‘hit and run’ approach – moving to key spots when the situation allowed to deliver first-line care and transferring critical cases to facilities in safer areas.
• Armed hunters trained to carry out community health worker functions for those who had remained in the villages.
Procurement Direct procurement of drugs and equipment for facilities, given the absence of functioning markets (Fonds Bekou) Direct procurement of drugs and materials for facilities via a faith-based supplier, given the absence of functioning markets or Central Medical Store (this happened despite the stark debate going on in Bangui in which PBF was seen as incompatible with ‘push’ procurement systems) (KIIs) Drugs purchased and imported from neighbouring Cameroon. PBF funding used to pre-finance drugs and essential supplies, later reimbursed with non-performance based cash transfers by other donors
Staff recruitment (Fonds Bekou) Cordaid directly helped facilities to recruit qualified staff, given shortages and the underdeveloped labour market Nationwide, the State agency for PHC recruited specific PBF staff.
In Adamawa State, additional health staff was recruited for the mobile clinics
Funding rehabilitation and construction • Flexible provision of non-performance based, advance funding (bonus de demarrage), not paid in cash but used by AAP to purchase construction materials not available locally
• Mobilising communities’ labour and locally-available materials (sand, stones, bricks) ([41]; KIIs).
Under both Fonds Bekou and PASS programmes: direct support for rehabilitation and construction.
• Fonds Bekou: more space for non-performance based funding
• PASS: requests can be made to a ‘quality improvement fund’. However, several key informants perceived these measures to be insufficient since, given the badly functioning markets and the low number and skills of staff, funds are often underutilised and inputs, rather than cash, was seen as more effective in such context (KIIs; FGDs).
WB-funded PBF programme and other (non-PBF) programmes funded rehabilitation and construction, once Boko Haram had left the area.
PBF payment Cash to facilities in absence of banking infrastructure.
AAP staff distributed PBF payments to facility staff during zonal meetings or carried cash to facilities, at high personal risk (KIIs).
Cash to facilities in absence of banking infrastructure Cash payments when no banking facility is available
PBF verification Payments without verification (KIIs) Payments were made at times without verification Payments at times made without verification (FDG)
Dealing with internally displaced populations (IDPs) Free care provided to about 20,000 IDPs. Free care was subsidised by increasing by 10–40% the PBF bonus for facilities most affected ([61]; KIIs) Free care to IDPs in emergency areas. Nearby facilities used PBF funds to sub-contract newly set-up clinics operating in IDP camps. Teams of 4–5 health workers living in the IDP camps or purposefully transferred from the SPHCDA were subcontracted to staff these outreach clinics, where care was provided for free to registered IDPs. Thanks to the PBF programme, a system to register IDPs was developed.