Health Systems & Reform, 3(2):91–104, 2017 Published with license by Taylor & Francis ISSN: 2328-8604 print / 2328-8620 online DOI: 10.1080/23288604.2017.1291218 Research Article Transferring the Purchasing Role from International to National Organizations During the Scale-Up Phase of Performance-Based Financing in Cameroon Isidore Sieleunou1,2,*, Anne-Marie Turcotte-Tremblay2, Habakkuk Azinyui Yumo1, Estelle Kouokam3, Jean-Claude Taptu e Fotso4, Denise Magne Tamga5 and Valery Ridde 2 1 Research for Development International, Yaounde, Cameroon 2 eal, Qu University of Montreal, Montr ebec, Canada 3 e Catholique d’Afrique Centrale, Yaound Universit e, Cameroon 4 World Bank, Office of Yaound e, Yaounde, Cameroon 5 Agence d’Achat de Performance du Littoral, Douala, Littoral, Cameroon CONTENTS Abstract—The World Bank and the government of Cameroon launched Introduction a performance-based financing (PBF) program in Cameroon in 2011. To Methodology ensure its rapid implementation, the performance purchasing role was Results sub-contracted to a consultancy firm and a nongovernmental Discussion organization, both international. However, since the early stage, it was Conclusion agreed upon that this role would later be transferred to a national entity. References This explanatory case study aims at analyzing the process of this transfer Appendix: List of the Documents Reviewed using Dolowitz and Marsh’s framework. We performed a document review and interviews with various stakeholders (n D 33) and then conducted thematic analysis of interview recordings. Sustainability, ownership, and integration of the PBF intervention into the health system emerged as the main reasons for the transfer. The different aspects of transfer from international entities to a national body consisted of (1) the decision-making power, (2) the “soft” elements (e.g., ideas, expertise), and (3) the “hard” elements (e.g., computers, vehicles). Factors facilitating the transfer included the fact that it was planned from the start and the modification of the legal status of the national organization that Keywords: Cameroon, performance-based financing, policy transfer, became responsible for strategic purchasing. Other factors hindered the purchasing role, scaling-up transfer, such as the lack of a legal act clarifying the conditions of the Received 16 September 2016; revised 20 December 2016; accepted 26 transfer and the lack of posttransition support agreements. The December 2016. Cameroonian experience suggests that key components of a successful *Correspondence to: Isidore Sieleunou; Email: isidore.sieleunou@umontreal.ca transfer of PBF functions from international to national organizations Color versions of one or more of the figures in the article can be found online may include clear guidelines, co-ownership and planning of the transition at www.tandfonline.com/khsr. by all parties, and posttransition support to new actors. Ó 2017 Isidore Sieleunou, Anne-Marie Turcotte-Tremblay, Habakkuk Azinyui Yumo, Estelle Kouokam, Jean-Claude Taptu e Fotso, Denise Magne Tamga and Valery Ridde. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), INTRODUCTION which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The moral rights of the named Performance-based financing (PBF) programs have been author(s) have been asserted. implemented to improve the delivery of health care services 91 92 Health Systems & Reform, Vol. 3 (2017), No. 2 in low- and middle-income countries (LMICs).1-3 In a nut- transfer is framed as part of a wider process of program scale- shell, under such programs, health care facilities and health up. However, little evidence exists on such scaling-up and care workers receive financial resources upon taking measur- transition processes in LMICs11 because the efforts to share able actions or achieving predetermined performance targets. lessons learned in global health have been limited so far.26-28 Research has been performed on PBF in LMICs that In particular, there is a dearth of literature examining the trans- shows positive effects on several incentivized services4-10 fer of capacity to the national level, aimed at enabling scale-up but also some uncertain results.11-16 Despite the mixed find- and integration. This is particularly challenging because PBF ings, PBF has expanded rapidly in Africa, often in the form is not an easy intervention to implement and scale up—it of pilot projects that have later been scaled up.17 This rapid requires the development of new institutional arrangements or expansion has been enabled by the strategy taken by some existing organizations to take on new roles, including develop- countries as well as the main PBF funders, especially the ing and managing performance contracts, purchasing health World Bank, to accelerate its diffusion by adopting a quite services, and verifying results.29 standard PBF package, whose introduction is technically sup- In Cameroon in 2011, the World Bank and the government ported by international consultancy firms or nongovernmen- started a PBF program in four regions of the country. Accord- tal organizations (NGOs) staffed with international experts ing to the intervention model, performance contracts link key who have acquired PBF expertise in countries where PBF actors of the health care system to an independent performance had been rolled out earlier (e.g., Burundi and Rwanda). purchasing agency (PPA). The PPA is responsible for verifying This externally supported approach has a drawback: at the quantity and quality of services as well as purchasing the some stage, there is a need to transfer part of the capacity to services from health care centers on a fee-for-service basis. In national actors. This is significantly driven by the need for Cameroon, the PPA role was initially played by a local organi- external agencies to deploy resources most efficiently.18 zation in one region and two international organizations in three Thus, there is substantial interest in how to best plan for and other regions. In the Littoral Region, a local organization called implement transitions from external organizations to local the Regional Fund for Health Promotion (RFHP) was recruited counterparts and19 to reduce costs and ensure sustainability through mutual agreement. In the Northwest and Southwest, an after the funders’ withdrawal, a well-known challenge for international organization called European Agency for Devel- development projects.18 opment and Health (AEDES) was recruited through an interna- Indeed, inadequately executed transfers risk reversing tional call for tenders to play the role of PPA.30 Similarly, in health program gains.20 In many programs, transitions have the East Region, an international organization called Catholic been conducted on an ad hoc basis, where the division of Organization for Relief and Development Aid (CORDAID) responsibility between international and local organizations was recruited as the PPA. However, it was agreed upon at an has not been clearly outlined and purposeful monitoring dur- early stage that a Cameroonian entity—that is, the RFHP— ing the posttransition period was not defined.20,21 However, would eventually take over the purchasing role for all regions the Avahan experience in India, for example, a project aim- to facilitate sustainability and ownership of the PBF program in ing at reducing the spread of HIV, suggests that transition the long term. can also take the form of a positive and enabling process that The PBF experience in Cameroon provides a unique improves program functioning and enhances local opportunity to further our understanding of how transfer pro- leadership.22 cesses unfold. We conducted a case study as part of a multi- In addition, health systems display the characteristics of country research initiative supported by the Alliance for complex adaptive systems,23 and as de Savigny and Adam24 Health Policy and Systems Research that examines scale-up point out, an intervention in one area will typically have con- processes for PBF in low- and middle-income countries. sequences, often unforeseen, for many others. Therefore, Within the broader research, the objective of this study is to understanding an intervention such as PBF requires focusing specifically assess the transfer process of the purchasing role attention on power relations and on the ways in which it from international to local organizations during the scaling- might be possible to construct new forms of “social contracts up phase of the PBF program in Cameroon. In addition to for health care which build on existing areas of competence informing Cameroonian decision makers regarding the PBF and good practice, whether mediated by states, markets or transition process, our study has implications for other coun- other institutional actors.”25 tries seeking to transfer PBF purchasing functions to national For PBF programs, the complexity of the transfer from organizations, as well as more generally for those seeking external organization to local counterpart is substantial as the insights on transferring institutional arrangements for health Sieleunou et al.: Transferring Performance-Based Financing 93 systems strengthening to country-level organizations and Document Review institutions. A document review was important for this study to under- stand the PBF policy, design, and implementation. Docu- ments provided background and context, allowed us to METHODOLOGY identify additional questions, provided supplementary data, served as a means of tracking change, and enabled triangula- Study Design tion of findings. Moreover, documents were useful to gather Our study takes the design of an explanatory qualitative case data on events that could no longer be observed and on infor- study.31 The case is defined as the PBF program in Cameroon mation that has been forgotten.36 from late 2011 to March 2015, and the levels of analyses are A total of 20 documents were reviewed, including con- related to the conceptual framework described below. tractual documents, PBF program design documents, imple- mentation guidelines, strategic meeting reports, the road map Conceptual Framework for the PPA transfer, and evaluation reports. Appendix 1 is a Examining the transfer of the purchasing role from interna- list of the documents reviewed. tional organizations to national agencies in a PBF program requires understanding the process by which knowledge related to or generated by the previous system is used in the Individual In-Depth Interviews new one. Based on that, we adopted the institutional transfer Using semistructured questionnaires, we interviewed 33 approach to examine these dynamics. The term institutional actors involved in the transfer process. These key informants transfer was first coined by David Apter in the 1950s.32 Insti- were selected using a purposive approach that provided con- tutions are the rules of the game in a society or, more for- trasting views in terms of the work, level of activity (central/ mally, are the humanly devised constraints that shape human regional/peripheral), and categories of actors.37 The main interactions.33 They can be formal (laws, constitutions, con- selection criterion was their involvement in the transfer pro- tracts) as well as informal (custom, traditions, ways of con- cess. Respondents included donor representatives, policy duct). The main role of an institution is to reduce uncertainty makers, international organization staff, and researchers. We by establishing a stable structure to shape human interaction.33 also interviewed managers of health services at the district We adapted our framework from Dolowitz and Marsh’s34 level, health care providers working in public, private not- work and broke down the concept of institutional transfer for-profit as well as for-profit health facilities, and managers into several key dimensions that could feed our analysis and of the national and regional drug supply system. In each of be formulated in terms of questions: (1) What are the pur- the key groups, we interviewed specifically the focal persons poses of the transfer? (2) Why do actors engage in institu- involved in the transfer process and used a snowballing tech- tional transfer? (3) Who are the actors involved in this nique to identify others, until data saturation was reached. process? (4) What are the sources of transfers? (5) What are the different forms of transfers? (6) What are the factors that promote or restrict transfers? and (7) Whether and to what Data Management and Analysis extent the observed transfers resulted in success or failure. Patterns and categories emerging from the literature were These questions allow us to understand the dynamics of insti- used to develop predefined themes. We organized a one- tutional transfer, by focusing on the process by which knowl- week workshop to train the research team and to ensure a edge tied to institutions in the former organization is used for common understanding of the themes. All interviews were the development of institutional and administrative arrange- transcribed and analyzed using QDA Miner Lite (Provalis ments in the new organization. By analyzing the influences Research, Montreal). The coding of data was oriented by and interactions that characterize the actors involved in the organizing the data around conceptual categories. We con- transfer process, the framework makes it possible to isolate ducted thematic analysis,38 guided by our conceptual frame- the sources of the observed changes.35 work and our knowledge of PBF, to extract the main themes from the documentation and the in-depth interviews. A hybrid deductive–inductive approach allowed us to assign Instruments, Sample and Data Collection data to predefined themes and to derive new themes from the The study involved two concurrent qualitative data collection data. Data analysis started in the field, forming an iterative methods. relationship with document analysis and interviews.38-42 94 Health Systems & Reform, Vol. 3 (2017), No. 2 Therefore, we were able to constantly compare the value of of two years and a contingent one of one year. However, due emerging categories for sorting the collected data. At the to budgetary constraints, the contingent period was reduced same time, it provided an opportunity to share and confirm to six months (January–July 2014) and later extended by our findings and subsequent interpretations with participants another six months due to the ineffectiveness of the transfer as advised by Hartley and Miles and Huberman.38 Moreover, process, as observed by the end of July 2014. combining the initial transcription of collected data with In July 2014, several actions were implemented to accel- early analysis helps to gain insights and plan strategies for erate the process of the transfer including a visit of RFHPs’ collecting new data as suggested by Marshall and Ross- teams from the Northwest and the Southwest to the Littoral man.41 The analysis was conducted through a stepwise pro- Region, where the PBF program was already using the RFHP cess. First, the research assistants analyzed the in-depth as performance purchasing agency, as well as a meeting for interviews. Then, the principal investigator conducted syn- the development of a road map and tools to facilitate the thesis of the findings and all discrepancies were discussed transfer. At this time, the transfer process began to get up to among the team of researchers. speed. By the end of December 2014, the transition was com- pleted in the Northwest and Southwest Regions, although the consortium of NGOs in the East negotiated a six-month con- Ethical Considerations tractual extension up to June 2015. The study protocol was reviewed and approved by The analysis of this series of events allow us to divide the Cameroon’s National Ethics Committee for Human Health transfer process into three phases: (1) a preintensive phase Research and the World Health Organization’s Research (before July 2014), (2) an intensive phase (July–December Ethics Review Committee. All respondents provided verbal 2014), and (3) a posttransfer phase (after January 2015). or written informed consent. What Did the Transfer Consist of? RESULTS The first element of the transfer is labeled “soft.” It concerns Discussions on the transfer of the purchasing role started early transmitting to the national organizations ideas, expertise, in 2012 at the time the PBF project was launched in the three and even what some called “the PBF spirit.” This form of regions. The process aimed to transfer the performance pur- transfer was essentially performed through meetings, chasing role from international organizations to regional exchanges, and trainings. organizations (i.e., the RFHPs). At the beginning of the proj- The second element of the transfer, the “hard” one, con- ect, two staff members from the RFHP in each region partici- sisted of the handover of equipment, logistics, and all technical pated in a seven-day regional training for PBF trainers. tools—for example, computers, vehicles, procedures, manuals, Training RFHP staff was part of a capacity building plan, and so on. It was performed in accordance with the ministerial before any transfer process. In addition, the RFHPs were, note of December 2014 concerning the transfer, which stated from the beginning, part of the regional regulatory teams in in paragraph 2 of Article 2 that the transfer would be preceded charge of conducting the PBF quality assessment in hospitals. by an open inventory with a report signed by both parties and During the project evaluation, the World Bank organized under the supervision of the Regional Delegate of Health.47 two national events. In September 2012, a workshop was The third element refers to the transfer of decision-making convened to discuss progress, challenges encountered, and power. By acquiring all of the rights to make decisions,48 the the way forward for the implementation of PBF by the four RFHPs gained their new role as PPAs. Their decision-mak- PPAs.43,44 During this workshop, participants discussed the ing power focused on the content of the PBF program and fact that the transfer process of purchasing to national organi- included dimensions such as leadership and strategic pur- zations was not yet underway. In May 2013, at the second chasing. Strategic purchasing entails using financial resour- event, the PBF national meeting,45 findings and solutions ces effectively and efficiently to align incentives to health were discussed to improve the implementation of the pro- priorities to improve the health status of the population. It gram, including the transfer of the PPA role. includes selecting providers and signing contracts, defining Despite these events and discussions, the transfer process the services to be funded and attaching payment rates, put- did not progress until April 2014, when the minister of health ting in place a verification and enforcement system, transfer- sent a correspondence to international organizations, men- ring funds to facilities, and using information systems to tioning the need to begin the transition.46 Indeed, the PBF improve the accountability and the effectiveness and of program had been envisaged to last three years: a firm period provider payments. Although the cooperation agreement Sieleunou et al.: Transferring Performance-Based Financing 95 between the Ministry of Public Health (MoPH) and the that these two organizations had offices far from the RFHP was slow to be put in place, the right of decision mak- buildings for health services and used vehicles that bore ing was granted de facto because it was guaranteed at the end no sign of the MoPH. As one informant put it: of the transfer. It materialized through the Ministerial note of December 2014 and was enforceable from January 1, 2015, The PBF program is still viewed as a vertical program in the Northwest and Southwest.47 One informant because it is implemented by a vertical structure. It is important to replace the international NGO by a national highlighted the transfer of the decision-making power with structure that was already carrying out other health activi- the following quote: “They transferred all their power to the ties. (Implementer, Southwest Region) special funds. Because special funds became like the bosses of PPAs. . . . I think that when we say transfer, it is at all lev- els” (Implementer, Northwest Region). Engaging in and the Source of the Transfer From the start, the RFHPs were identified as potential entities to take up the PPA role. In the Littoral Region, where the The Purposes of the Transfer RFHP played this role since the beginning of PBF implemen- The sustainability and ownership of the PBF program tation, the model showed some apparent success, in terms of were identified as main reasons for the transfer. Actors at clarifying the roles and responsibilities of staff in health the decision-making level as well as partners had raised facilities, enhancing supervision from the regulation level, the issue of ownership, determining who has decision increasing the reliability of service delivery,30 and quality rights over the project. It was felt that in order for the improvement at health facilities.49 In the three other regions, PBF approach to have a chance of being scaled up, it international actors played the PPA role, and it was planned needed to be integrated within the existing structure of that the role would be transferred to the RFHPs after a certain the health system. This would increase its legitimacy for period of implementation. The contract50 between the PPAs the partners and make it easier to defend the gov- run by the international organizations and the government ernment’s budgetary decisions. The objective of sustain- stated: “. . . the Ministry’s vision is to ensure that the perfor- ability was also partly linked to this ownership mance purchasing agency role be progressively assumed by dimension. There was no doubt that the concerns of sus- the RFHP.” tainability and scalability of PBF were already part of the Furthermore, the ministerial decision giving guidance for issues that arose at the central level of the MoPH. On the the transfer process noted that the responsibility of AEDES other hand, the World Bank’s main interest in the transfer and CORDAID in the management of the PPA would be fin- process, as the main technical and financial partner, ished once the transfer was complete, indicating unambigu- seemed to be cost reduction. The transfer to national ously that the transfer process was to occur from the structures was seen as a strategy to minimize costs (as international organizations to national entities.47 Finally, it international organizations were more expensive) and as was envisaged that the MoPH would sign a protocol of col- an excellent strategy to anticipate constraints during the laboration with the RFHPs for the implementation of the scaling up, as one official expressed: project.47 Main Actors Involved in the Transfer The PBF is an importation. When we import, we must first bring know-how into the country. Foreign expertise must Several actors with varying levels of interest and influence not stay forever. It must be transmitted to the nationals were involved in the transfer process (Figure 1). because it is more sustainable and cheaper like I said ear- Firstly, there were actors from the central and regional lier. So, it is more likely to remain when it is nationals levels of the Ministry of Public Health. At the central who are in control and it’s evidently much cheaper than importing work force. (Policy maker, Ministry of Public level, there were officials of the PBF project management Health) unit; that is, the department in charge of coordinating the PBF activities. The PBF project management unit was the For actors at the operational level, the purpose of the main body in charge of overseeing the transfer process. transfer was related to the “horizontalization” of the Actors from the central level worked with experts from health system. In Cameroon, vertical programs are often the World Bank, especially those at the sub-regional attributed to donors or NGOs. Therefore, local actors office in Yaound e, to plan the transfer process. At the often perceived the PBF project as an AEDES or COR- regional level, the delegates to whom the powers of the DAID project. This impression was reinforced by the fact MoPH were delegated ensured that the guidelines from 96 Health Systems & Reform, Vol. 3 (2017), No. 2 FIGURE 1. Main Actors Involved in the Transfer the central level were respected. They greatly influenced dual role in the transfer process. It acted as (1) a regula- the transfer process according to their level of tor by virtue of powers delegated by the minister of commitment. health and (2) the chairman of the RFHP’s management The technical assistants from the international organiza- committee. The German Cooperation, which technically tions in charge of the purchasing role (AEDES and and financially supported the RFHPs, was also involved CORDAID) were also at the heart of the transfer process. In in the transfer process. Although in the beginning this most cases, they initiated contacts and meetings with other important partner was not in favor of the RFHPs also stakeholders at the regional level to help the transition. One playing the role of purchasing agency for the PBF proj- of their main activities was to mentor and coach key RFHP ect, it contributed to the intensive phase of the process in staff right from the beginning of the project to gradually a consultative role. Interviews with some respondents build their capacities during the transition period and ensure who played key roles in formulating the program give us an effective takeover. more insight: The RFHPs and its managers were key elements in the process because they had to take the new function of No . . . well I think since it was GIZ who supported the PPA. These agencies were preexisting entities in each of Funds [RFHPs], of course there was this discussion with the regions. They had been created by the GIZ (Gesell- GIZ to use the Funds for the PBF and as you well know, GIZ was against PBF in the beginning, uh maybe specifi- schaft fu€r Internationale Zusammenarbeit, or German cally because of the PBF approach that lies on market the- Cooperation) as regional dialogue structures, consisting of ory, but at the end of the day, they were great advisors for representatives of the communities (one third of the mem- the transition. (Official, international organization). bers), the MoPH and public administration (one third), and donors (one third). Thus, they constitute participatory Finally, our data indicate that the conversation on the tran- governance bodies at the local level in the health system. sition framework was not extended to include the The state, through the regional delegates of health had a community. Sieleunou et al.: Transferring Performance-Based Financing 97 Factors that Enabled the Transfer managing drugs and other health products. Since October The majority of respondents promptly stated that the most 2013, they developed a new organizational structure that important factor that positively influenced the transfer was includes a support department for health promotion activities the fact that this transition was planned from the start. In and partnership. This new section hosts the PPA, as one addition, it was not something new in the strategic debate informant noted: “The reorganization of the regional funds among the different stakeholders. Rather, most of these peo- for health promotion to a public utility institution made it a ple were keen to see the process done. To this effect, a com- good structure into which the PBF could fit” (Implementer, petence development plan, with specific objectives, expected Northwest Region). results, and time frame for the results, was to be produced by Finally, the experience in the Littoral Region was another international organizations and discussed with both the cen- enabling factor because its performance was inspiring and tral and regional levels of Ministry of Health.50 reassuring about the relevance of this choice and served as a As part of this early plan, key management staff from the proof of concept.30,51 RFHPs became members of the PBF regional steering com- mittees, which held quarterly meetings. These steering com- Factors that Hindered the Transfer mittee meetings were important opportunities to open space A major difficulty for the transfer was related to the legal for a conversation and experience-sharing among the regula- framework under which it was envisaged. Indeed, a legal tors, PPAs, and health units involved in PBF as well as repre- document providing such a framework was needed to kick- sentatives of the beneficiary committees. start the transfer, because bureaucrats of the RFHPs thought Another important factor was the expertise created by that they could not engage in the transfer process without an international training courses on PBF. A Dutch firm (SINA official administrative authorization from their hierarchy. HEALTH) collaborated with national actors to regularly pro- This official note, which was finally signed by the Minister vide a two-week course on PBF that usually attracts more of Public Health on December 24, 2014, stipulated that the than 25 participants from many Francophone African coun- transfer of the management of the PPA to the regional funds tries. Cameroonians usually represent half of the participants. was to be effective as of January 1, 2015. The need to wait The importance of this training course is pointed out by the for a legal framework to start the transfer process contributed following quote: “Now, we must have more than 200 people to delays, as highlighted by the following quote: trained in the 14-day PBF course, with all of the approaches, all of the philosophies. So there is the material, there are The contract remained somewhat vague with respect to resources in Cameroon” (Implementer, East Region). the transfer modalities. Hence, there was a need for a min- There was a gradual increase over time in the amount of isterial memorandum to clarify the conditions and con- tents of the transfer. But you know how things happen in staff training provided to help prepare for the transition. Fol- our country. It always takes time. The result is that the lowing the initial training, the RFHPs worked out a schedule note was signed at the time the transfer process was sup- for in-depth and refresher capacity building for the staff. In posed to be completed. (Implementer, Southwest Region) line with these efforts, managers of the RFHPs attended an international training on PBF, and other staff underwent con- Despite the intervention of the Health Sector Support tinuous training. Investment Project steering committee, which provided A third factor that facilitated the process was the modifica- some indications concerning the steps to follow for the tion of the RFHPs’ legal status. RFHPs initially held the status scaling-up phase, the shortcomings in legal arrangements of associations and it was legally impossible for them to still persisted. For example, there was no collaboration receive public funds and to manage them according to market agreement clarifying the responsibilities of each party; as mechanisms. This obstacle was removed when RFHPs became one official put it: “The MoU between the Funds [RFHP] public interest groups. The law was voted on in December and the MoH is not yet ready. So what is the benefit of 2010. This new legal status confirmed that RFHPs were dia- Funds if the MoU is still on the table?” (Policy maker, logue structures, exercising a public service mission. It also Northwest Region). established a partnership between the government, several The short timeline of the intensive phase of the transition technical and financial partners, as well as the community of also appears to have hindered good management practices. The the region represented by the members of dialogue structures. five-month period allowed for it was very tight and did not facil- Additionally, there have been changes in the RFHPs’ itate a gradual strengthening of relationships and learning, as organizational structure. RFHPs initially focused on well as the good planning of the implementation process. 98 Health Systems & Reform, Vol. 3 (2017), No. 2 In addition, there were no formal agreements in place Appreciation of the Transfer Results for posttransition support. Instead, the government’s During the first three months of 2015 (i.e., the posttransition guidelines simply defined a specific date when all of the period up to when our analysis was conducted), the transfer activities of the international organizations had to stop seemed effective in the sense that the consortium of interna- altogether. As a consequence, with the exception of the tional organizations had already withdrawn, giving room to East Region, the transfer process was conducted without the RFHPs, which were henceforth responsible for managing establishing a cohabitation period during which the outgo- the PPAs. All equipment acquired during the implementation ing team would support the new team and the new PPAs of the project by international organizations had been trans- were established after the former teams had already ferred to the RFHPs. In the process of shifting key decision stopped their operations. rights on how to use funds for health services, the RFHPs Another hindering factor was the lack of agreement took up the entire responsibility for the stewardship function between the international organizations and RFHPs in directing the PBF program. This was seen by many regarding the issue of managing human resources used by respondents as a major achievement toward the integration the PPAs. This was a gray zone in the ministerial direc- of the PBF program within the health system as well as an tives that gave room to different interpretations. Point 2 initial articulation of the country leadership. The exercise of of Article 3 of the ministerial note47 stipulated that “the recruiting staff and signing of contracts for the new national staffing plan will highlight the positions filled or to be PPAs started in January 2015, therefore legitimizing the filled in such that recruitment is launched within the best decision right dimension of the RFHPs on the PBF program. possible time, based on validated terms of reference and Data from key informants highlighted the positive apprecia- the profiles required by the post.” tion of effective implementation of the transfer; as some pol- The different interpretations of this directive created icy makers from regional and central levels put it: some tensions. The outgoing PPAs’ managers expected that their staff would automatically be transferred to the new PPAs, whereas the RFHPs’ managers considered that The Cameroonian experience clearly proves that the it was legitimate for them to constitute a new team for RFHP can be rendered capable and effective in taking up the new PPAs. the functions of national PPA in each of the ten regions of Cameroon within the framework of scaling up PBF. The Moreover, the variation in pay scales posed a challenge. RSFHP should be retained as model for every region. The government’s budget imposed lower wages for the new (Policy maker, Northwest Region) PPA staff compared to the wages offered by international organizations. This salary reduction of the managing staff Handling the implementation of the project through a (i.e., managers and assistant managers) led almost all of national organization is a matter of legitimacy and owner- them to drop out. The salary scales also varied from one PPA ship. Now that the RFHP is in charge of the PBF program, and given the fact that the Ministry of Public Health (the to another, raising the issue of salary harmonization across regulator) in Cameroon is now quite aware and knowl- the different PPAs. edgeable of the PBF principles, the future of PBF in A final hindering factor was the concern regarding the Cameroon is bright. (Policy maker, central level) ability and willingness of the RFHPs to implement PBF through the PPA role. Some of its members were openly However, a striking element during this first quarter was the reluctant. Some did not demonstrate that they wanted to pos- absence of a contract for PPA-recruited staff. Furthermore, sess PBF-related skills and blocked the process of giving activities related to the implementation of the PBF program drug management autonomy to health facilities, as shown by occurred quite slowly. For example, the performance con- the following extract: tracts with health institutions, regulators, and community- based organizations were not yet signed. Thus, there were no He [the manager of the RFHP] still refused to go for coaching activities, reporting/verification, and quality evalu- the training. How can someone manage PBF activities ations conducted in two regions (Northwest and Southwest) if he is not trained? He had to be removed! We cannot during this period. This was exacerbated by the fact that the entrust one billion six hundred thousand CFA francs Ministry of Public Health at the central level established con- (i.e., two million dollars) to someone who does not tracts with the RFHPs only many months after the with- know what is inside so, uh . . . that’s it, it is very important that the institution, the Management Com- drawal of the international NGOs in the Northwest and mittee of the RFHP accepts the PBF. (Implementer, Southwest Regions. The gap between the withdrawal of the Southwest Region) international organization and the takeover by the RFHPs Sieleunou et al.: Transferring Performance-Based Financing 99 also raised concerns among health facility staff about a possi- from the start, (2) the presence of local expertise, (3) modifi- ble termination of the PBF program. Several informants cation of the RFHPs’ legal status, (4) modification of the recalled the difficulties that health facilities faced during the RFHPs’ organizational structure, and (5) the previous experi- phase immediately after the transfer: ence acquired in one region (Littoral Region). Despite these enabling features, multiple factors hindered the process, such All the activities that were supposed to be going on, they as the (1) lack of a legal framework clarifying the conditions are now frozen. The new PPA has not signed contracts of the transfer, (2) lack of posttransition support agreements, with the health units up till now. The Region has not (3) lack of agreement between international organizations come down for supervision despite the fact that we at the district are still going and trying to see how we can actu- and RFHPs regarding the management of human resources ally carry out our activities. Ironically, we have received a used for the PAAs, (4) short timeline of the intensive phase letter from the Regional delegate that we should continue of the transferal, (5) salary reduction for managing staff, and to carry out the activities as if the contracts were already (6) lack of participation of actors at the frontlines. Many par- signed. (Implementer, Northwest Region) ticipants criticized the transition process and reported the dis- continuation of numerous PBF activities, thereby questioning As soon as the RFHP took the control of the PPA, it caused some delays in the transfer of funds and it created the success of the transfer. a lot of problems in the health units, until some personnel Overall, the success of the transfer, defined as the achieve- had to leave. They resigned. They resigned because they ment of expected results, was relative. It was quite effective could not be paid. The reserves that were usually kept, for elements such as the transfer of decision-making rights were exhausted and some of the personnel left. Projects but remained problematic for some others; for example, for that were planned in the business plan were suspended transfer-related activities implemented (or not) in the imme- and so many things went wrong. (Implementer, Southwest Region) diate posttransfer phase. In addition, given that the transfer process continues to evolve over time, it is difficult to judge the success or lack thereof of transfer at a particular moment in time. DISCUSSION The most important factor that allowed the relative success This study assessed the transfer of the purchasing role from of the transfer was the fact that the transition was planned international organizations to national entities during the right from the beginning of the PBF implementation process. scaling up process of the PBF program in Cameroon. Results This finding supports past research suggesting that planning highlight that the main reasons behind the transfer were to and implementing transition strategies introduced at the time ensure the sustainability, ownership, and integration of the of program inception could contribute to reduce operational PBF intervention into the health system. However, the crite- challenges. For example, Gardner et al.52 argue that transition ria that guided the choice of the RFHPs as the only possible strategies should be integrated into all aspects of program- option for overseeing the implementation of the PBF after ming, program planning and design, implementation, as well the international withdrawal remained unclear.30 This option as monitoring and evaluation.52 This point has important pol- seems to have been guided by the fund holding role that was icy implications because, in fact, many global health interven- to be handled by RFHPs, in which the state is a great player. tions are implemented without sufficiently considering how Policy makers should stay vigilant with this model because they will be transferred to local entities later on. the fear is that the institutionalized monopoly of the RFHPs This study also highlights the “pollination” role of inter- could undermine the efficiency of the verification role in the national organizations during the transfer process through long run. In this sense, another possible option for the trans- knowledge and competence flows gained from previous fer, such as a national NGO assuming the PPA role that is experience of successful PBF programs. This is in line with limited to the service of verification, while the fund holding the findings of some authors who have pointed out the role of component lies within the responsibilities of the RFHPs, international organization in diffusion of innovation.53 In could have been a more relevant alternative. addition, the study underlines the value of good practice- The elements of transfer that we identified consisted of the sharing within the country, in the case from the Littoral decision-making power, the soft elements (e.g., ideas, exper- Region where the PPA function was already handled by a tise, spirit), and the hard elements (e.g., computers, vehicles, national organization. The presence of structures that facili- procedures manuals). We also found that several factors tate learning and sharing have been found to positively enabled the transfer, including (1) the fact that it was planned encourage adoption and diffusion of innovations.54 100 Health Systems & Reform, Vol. 3 (2017), No. 2 However, the transfer cannot be simply seen as a 1 Start discussing and planning the transition early on 2 Set up inclusive policy dialogue to seek high-level commitment “copy and paste” process,55 and the lack of tailored and and participation from different actors active planning during the preintensive phase manifested 3 Consistently build country capacity (e.g., training on the itself in different ways. For example, there was no clear intervention to be transferred) guidance to carry out the process at the central level, thus 4 A well-established transition plan with a clear timeline of leaving it to each Region to drive changes in their own activities should be prepared at the beginning way. Though more coordination and follow-up from the 5 Explicit guidance outlining the objectives, actors, sources, and central level would have allowed a smoother transition, forms of transfer should be developed at the central level with budgetary line these differences also emphasize the critical importance 6 A communication plan involving all stakeholders, from the of the environment for successful transition and suggest central level to frontline staff, should be worked out that management strategies will likely need to be adapted 7 A legal framework to conduct the transfer should be established to reflect different circumstances on the ground.52,56 before starting the intensive phase of the transfer This study also emphasizes that international organiza- 8 An overlap period during which the outgoing team supports the tions that implement health interventions in LMICs need new team should be implemented to facilitate the transition to adopt pay scales that are compatible with local govern- process and ensure a greater continuity for PBF activities ment budgets to facilitate transfers and long-term sustain- 9 A formal posttransition support agreement should be clearly defined ability of health interventions. Donors should work with 10 Transition plans should include explicit procedures for governments to understand how national and donor poli- absorbing human resources and harmonizing pay scales early cies could impact program integration to avoid distortions on so that staff do not have to take lower salaries or are early on.57 This is illustrated by the fact that many PBF motivated to leave during the transition experts used by the international organizations in Came- roon migrated to other countries that needed PBF expertise TABLE 1. Recommendations to Transfer the Performance Purchas- once the intervention was transferred to national entities ing Agency Role due to the significant pay reduction. The finding is consis- tent with arguments by others, namely, that the coordina- Limitations tion and harmonization of salaries and incentives may be One limitation of this study is recall bias. Interviews were required to get the commitment of key actors to specific conducted a long time after some of the activities described development programs and to address brain drain.58,59 were held. However, the potential recall bias was reduced by Governments in less-developed countries also have to combining multiple sources of data. Furthermore, a social learn to channel the potential of their own people by pro- desirability bias may have arisen if participants wanted to viding adequate incentives for them to stay and excel.60 portray the transfer program in a positive way, because some Regardless of the reasons behind the transition, the transi- stakeholders may have had vested interests in such a positive tion process itself proved to be challenging, with a risk of picture. Moreover, the transfer process of the purchasing disruptions to services and, in the most extreme instances, role was still ongoing at the time of data collection, and their discontinuation.56 In turn, if the health system is to be some elements that emerged later may not have been cap- understood as a complex adaptive system,24 the transfer of a tured. However, the most up-to-date information available program, which was also seen by various stakeholders as its to the authors on the transition of the PBF program in Came- integration, will foster interactions between the program and roon confirms our findings and identifies delays in the pay- the wider system within which it is rooted. This complex ment of subsidies and in the signing of new performance interaction can be understood to be an essential aspect of sus- contracts with health facilities as the main causes of the tainability that can possibly generate system-wide changes slowdown of activities during the immediate posttransition over time.61 period.62 At the same time, these challenges seem to have Drawing on the findings of this study, we developed a been successfully managed and to have had limited conse- list of ten recommendations for decision makers who are quences on the program.62 This is consistent with a study in considering transferring the implementation of PBF pro- India where the lack of early “wins” does not appear to have grams to local actors (Table 1). Future research should been a significant barrier to the overall program of transi- empirically test these recommendations and further develop tion.56 A follow-up study would be useful to provide more overarching guidelines that can be adopted to facilitate such insights on how the transition process evolves over time. transitions. Though the benefit of using Dolowitz and Marsh’s Sieleunou et al.: Transferring Performance-Based Financing 101 conceptual framework was that it offered an opportunity authors have never been involved in implementation of a to synthesize several concepts related to the transfer, PBF program. allowing us to understand what causes and impacts the I.S., J.C.T.F., and D.M.T. can be described as insider process of transfer as well as how it leads to particular researchers because they served/serve as key implementa- outcomes,63 it did not offer insights into how organiza- tion actors. This may present certain concerns regarding tional structures affect learning processes. In addition, it the trustworthiness and objectivity of the judgments made remained unclear what performance and its dynamics by the research team. However, it should be noted that meant within the framework of the transfer process in concerns regarding the objectivity of the research findings this case study. Further research is needed to investigate reported are minimal, considering the scientific rigor of how the transfer from an external to a national agency the other members of the research team from the Catholic affects how performance is measured. Finally, though we University of Central Africa and from the University of draw some lessons from Cameroon’s PBF experience in Montreal. transitioning the PPA from international to national organizations, we recognize the limitations of a single case analysis and emphasize the need for comparative ACKNOWLEDGMENTS case studies to improve the generalizability of these les- We are most grateful to Enandjoum Bwanga, the National sons beyond the Cameroon case. Coordinator of the Cameroon Health Sector Support Investment Project, and Dr. Paul Jacob Robyn, the World Bank’s Task Team Leader in Yaound e, for their kind sup- CONCLUSION port. We also thank all the research assistants at R4D International organizations have supported the implemen- International, particularly Ajeh Rogers Awoh, Mark tation of PBF programs in many LMICs, such as Came- Nbenwi, Blonde Ngo Mbo, L eonard Ndongo, Albert Le roon, which were introduced with the aim of increasing Grand Amba, and Marl ene Tchoffo, for their great com- the quantity and quality of health care services. However, mitment for field activities for this study and all of the the performance purchasing role must be transferred from key informants whose availability and insights made this international organizations to national entities to enhance research possible. We are much indebted to Bruno Mees- ownership and sustainability in the long term. Ensuring a sen and Zubin Cyrus Shroff, who reviewed the first draft smooth transition process is crucial because it may of this article and provided valuable comments. The influence the proper functioning of the PBF program, its authors also acknowledge the work of the anonymous long-term development, and the delivery of health care reviewers who provided us with extremely helpful com- services for vulnerable populations. The experience in ments and feedback. Finally, we thank Maria Paola Ber- Cameroon suggests that key components of a successful tone for her careful editing work. transfer may include clear policy guidelines, an extended A.M.T.T. and I.S. received a training bursary from the and sequenced time frame, coownership and involvement Canadian Institutes of Health Research. V.R. holds a CIHR- in the planning of the transition by all parties, detailed funded Research Chair in Applied Public Health. transition planning, and engagement of staff and provision of posttransition support to promote exchanges between departing and incoming teams. Lastly, transition plans FUNDING should include explicit procedures for absorbing human resources and harmonizing pay scales early on, so that This research was supported by the Alliance for Health Pol- the staff’s motivation is not reduced by lower salaries icy and Systems Research with funding from Norad. posttransfer and that this does not lead to their ultimately leaving the agency’s employment during the transition. AUTHORS’ CONTRIBUTIONS I.S., E.K., J.C.T.F., D.M.T., and V.R. designed the study pro- DISCLOSURE OF POTENTIAL CONFLICTS OF tocol and coordinated the data collection process. A.M.T.T. INTEREST and I.S. helped analyze the data. I.S., A.M.T.T., and H.Y. I.S., J.C.T.F., and D.M.T. have been involved in the imple- wrote the first draft of the article. All authors read and mentation of the PBF program in Cameroon. The other approved the final article. 102 Health Systems & Reform, Vol. 3 (2017), No. 2 ORCID financing programme in northern Cameroon. 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