Implementation Research: Taking Results Based Financing from scheme to system

Challenges of integrating an innovative health financing scheme into the health system: lessons from Performance-Based-Financing (PBF) in Cameroon (2006 - 2015)

Research report

Cameroon

Isidore Sieleunou, Jean-Claude Taptue Fotso, Estelle Kouokam, Denise Magne Tamga, Habakkuk Azinyui Yumo, Anne-Marie Turcotte-Tremblay, Valéry Ridde

Acknowledgements

We would like to thank the Alliance for Health Policy and Systems Research for the funding and the Institute of Tropical Medicine for the technical support for the implementation of this project. We are most grateful to Mr Enandjoum Bwanga, the National Coordinator of the Cameroon Health Sector Support Investment Project, and Dr Paul Jacob Robyn, the World Bank’s Task Team Leader in Yaoundé, for their kind support. We also thank all the research assistants at R4D International, particularly Ajeh Rogers Awoh, Mark Nbenwi, Blonde Ngo Mbo, Léonard Ndongo, Albert Le Grand Amba and Marlène Tchoffo, for their great commitment for field activities for this study, and finally all the key informants whose availability and candid insights made this research possible. We are much indebted to many people who reviewed the first or second draft of this report and provided valuable comments.

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Table of Contents

I. INTRODUCTION...... 10 II. BACKGROUND ...... 12 III. OBJECTIVES ...... 13 IV. METHODOLOGY ...... 14

A. STUDY DESIGN ...... 14 B. CONCEPTUAL FRAMEWORKS ...... 14 Description of how PBF developed over time ...... 14 Analytical work ...... 15 Factors enabling or hindering the development of PBF program in Cameroon (agenda setting, formulation, and implementation) ...... 16 Assessing the transfer of the purchasing role from international NGOs to National agents in two regions (North- West and South-West regions) ...... 17 C. INSTRUMENTS, SAMPLE AND DATA COLLECTION ...... 18 Documents review ...... 18 Individual in-depth interviews ...... 18 D. ADDRESSING VALIDITY AND RELIABILITY OF COLLECTED DATA ...... 19 E. DATA MANAGEMENT AND ANALYSIS...... 20 F. ETHICAL CONSIDERATION ...... 21 G. LIMITATIONS ...... 21 V. RESULTS ...... 22

A. PROGRESS OF THE PBF SCHEME ...... 22 The CORDAID project (21) ...... 22 The Ministry of Public Health’s project supported by the World Bank ...... 24 a. History ...... 24 b. Key features of the project ...... 25 C. Coordination, monitoring and evaluation activities ...... 25 Scaling-up process ...... 27 Population coverage ...... 27 Service coverage ...... 27 Health system integration...... 27 Country ownership ...... 27 Society, idea and knowledge ...... 28 VI. FACTORS ENABLING OR HINDERING THE DEVELOPMENT OF THE PBF PROGRAM ...... 30

A. AGENDA SETTING ...... 30 Problem Stream ...... 30 Orientation stream ...... 32 Policy entrepreneurs ...... 33 Windows of opportunity ...... 34 B. FORMULATION OF PBF CAMEROON ...... 35 Orientation stream ...... 35 Policy Stream ...... 36 Policy entrepreneurs ...... 39 Windows of opportunities ...... 40 C. IMPLEMENTATION PBF CAMEROON ...... 40 Problems stream...... 40

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Policies Stream ...... 42 Policy entrepreneurs ...... 44 Windows of opportunity ...... 45 Perceived changes ...... 46 VII. TRANSFER OF THE PERFORMANCE PURCHASING AGENCY (PPA) ...... 50

A. ENGAGING IN THE TRANSFER PROCESS ...... 50 B. ACTORS INVOLVED IN THE TRANSFER PROCESS ...... 51 C. THE PURPOSES OF THE TRANSFER ...... 51 D. THE SOURCES OF THE TRANSFER ...... 53 E. THE DIFFERENT COMPONENTS OF TRANSFER ...... 53 F. FACTORS THAT FACILITATED THE TRANSFER ...... 54 G. FACTORS THAT HINDERED THE TRANSFER ...... 55 H. APPRECIATION OF THE TRANSFER...... 58 VIII. CONCLUSION...... 59 IX. LIST OF REFERENCES ...... 60 X. ANNEXES...... 65

A. ANNEX 1: GUIDE FOR IN-DEPTH INTERVIEWS WITH KEY INFORMANTS...... 65 B. ANNEX 2 : LIST OF THE KEY INFORMANTS ...... 69 C. ANNEX 3 : LIST OF THE RESEARCH ASSISTANTS ...... 71 D. ANNEX 4 : NATIONAL ETHICAL APPROVAL ...... 72 E. ANNEX 5 : WHO ETHICAL APPROVAL ...... 72 F. ANNEX 6 : LIST OF THE QUANTITY INDICATORS ...... 74 G. ANNEX 7 : LIST OF THE DOCUMENTS REVIEWED ...... 76

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List of Tables

Table 1 : sample for interviews ...... 19

List of Figures

Figure 1 : Analytical framework ...... 16 Figure 2: Timeline ...... 29

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Acronyms

AEDES : Agence européenne pour le développement et la santé AHPSR : Alliance for health policy and systems research CBHI : Community-based health insurances CENAME : Centrale d'Achat des Médicaments Essentiels CNRECHH : Cameroon National Research Ethics Committee for Human Health CPA : Complementary package of activities CR-CHUM : Centre de Recherche du Centre Hospitalier de l’Université de Montréal DR : Document review FBO : Faith Based Organization FBP : Financement basé sur la performance HF : Health Facility HSSIP : Health sector support investment project IDI : In-depth interview MDG : Millennium Development Goals MoPH : Ministry of public health MPA : Minimum package of activities NGO : Non governmental organisation OMS : Organisation mondiale de la santé ONG : Organisation non gouvernementale PBF : Performance-based financing PPA : Performance Purchasing Agency R4D International : Research for development inernational RAB : Research advisory board RDPH : Regional delegation of health RFHP : Regional Funds for Health Promotion RSPC : Regional Supply Pharmaceuticals Centres SWAp : Sector wide approach SYNAME : Système National d’Approvisionnement en Médicaments Essentiels WB : World Bank WHO : World health organization

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Executive Summary

Background The performance-based financing (PBF) project in Cameroon is implemented in public, private and Faith Based Organization (FBO) facilities across 26 health districts in 4 out of 10 regions, covering a total population of approximately 3 million. The intervention is mainly a supply-side approach, providing incentives for the delivery of packages of basic health care services. Our research aims at analyzing the development (scaling up) process of PBF in Cameroon from 2004 to March 2015 and draw lessons for further scaling up and sustaining such initiative, nationally and internationally. We conducted a case study to : (1) Appraise the progress of the PBF scheme (how PBF developed over time and what is the situation today), (2) Describe the factors enabling or hindering the development of PBF program in Cameroon (context, actors, content and processes), and (3) Assess the transfer of the purchasing role from international organizations to national agents in two regions (North-West and South- West regions) during the scaling up phase.

Methodology We combined a few theoretical frameworks to meet the objectives of this research. For example, Kingdon’s model was useful to understand how public policies related to PBF emerged in Cameroon. We also used Dolowitz and Marxh's work on policy transfer to assess the transfer of the purchasing role from international NGOs to national agents during scaling up phase. The research method used an explanatory case study and involved two concurrent qualitative data collection methods: a document review and in-depth interviews with key informants (KI). A total of 34 documents were included such as the national health development plan, the MoH-International organizations contractual documents, PBF designs documents, PBF implementation guidelines, PBF strategic meetings reports, the road map for the PPA transfer, and evaluation documents. These documents have been instrumental to understand the framing of policies and to supplement primary data collected from KIs.

KIs were selected using purposive sampling, with the main criterion being their knowledge of the program. The selected respondents included 74 key stakeholders of the intervention at various levels: policy makers at central Ministry of Health (n=5), policy makers at regional level (n=4), implementers at regional (n=12), implementers at peripheral level (n=25), regional finance actors (n=3), technical and financial partners at national level (n=4), technical and financial partners at international level (n=7), beneficiaries at peripheral level (community based-organizations and health-committee representatives) (n=14). All interviews were recorded, transcribed and analyzed using the QDA miner Lite software. Our findings were analyzed using a hybrid deductive-inductive approach that allowed us to assign data to predefined themes and to derive new themes from the data. The study was approved by ethics review committees in Cameroon and at the World Health Organization.

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Key Findings and recommendations With high rates of morbidity and mortality, the Cameroon health system has consistently faced huge challenges to meet its most basic objectives. In 2004, several reports and events provided evidence on the state of the poor health outcomes and health financing, thereby raising awareness of the situation. As upshot, decision-makers identified the lack of a suitable health financing policy as an important issue that needed to be addressed.. In addition, the change in the political discourse toward more accountability also gave room to test new mechanisms. A group of policy entrepreneurs from the World Bank collaborated with senior government officials to develop the PBF program, place it on the agenda, assure its adoption, and conduct its formulation. While the pilot CORDAID project did not contribute to the emergence of the government and the World Bank project, it however influenced its design.

Overall, the assessment of PBF-related changes seemed to be positive. According to interviewees, data management and reporting improved significantly in the PBF facilities. By improving data quality, it also increased the potential to improve the health management information system and decision-making for other interventions. The drivers of success at the health facility level turned around clarifying roles and responsibilities, enhancing supervision from the regulation level, and the reliability of service delivery from the financing and verification agency. The PBF approach seems to have promoted the level of autonomy to allow service providers to be imaginative and creative in order to improve the quality of care in their facilities. Most of the benefits mentioned were related to the workplace. It also appeared from the interviews that there were some positive appreciation at the community level such as the improvement of the quality of care and accountability.

Despite the positive changes, there were some concerns about the sustainability of the program. Moreover, some abnormalities were reported such as the pursuit of incentivised activities compared to non-incentivised activities. Some participants reported that a number of care providers focused more on paid activities and neglected the quality of services to increase quantity. The analysis shows that the country has moved from the pilot project to a larger scheme (though not covering all the regions), and is currently attempting to progress to a national policy with the integration of the scheme into the national health care financing. The purchasing role was in the process of being transferred from international organizations, a private consulting company (AEDES) and a non-governmental organization (CORDAID), to national organizations in two regions (North-West and South-West). This process included transferring the hard and soft dimensions of the purchasing role as well as the decision making power. The management of the transition process required a very high level of investment from various stakeholders. Recurrent meetings had to be organized between the staff of the international organizations and that of the national organizations. While respondents provided good reasons to conduct the transition, the process appeared somehow difficult. However, the timing of interviews conducted reflects only a certain specific period of the handover process which was ongoing at the time of the data collection.

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The key lessons learned regarding the transfer process include the following: - A high-level commitment from the different actors is important throughout the process; - A well-established transition plan with a clear timeline of activities should be prepared at the beginning of the implementation of the project; - Explicit guidance outlining the objectives, actors, sources, and forms of transfer should be developed at the central level with budgetary line as early as possible during the pre-transitional phase; - A communication plan involving all stakeholders, from the central level to the frontline staff, should be worked out; - A legal framework to conduct the transfer should be established before starting the active phase of the transfer; - A cohabitation period during which the outgoing team supports the new team would facilitate the transition process and ensure a greater continuity for PBF activities; - A formal post-transition support agreements should be clearly defined.

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I. INTRODUCTION

The deadline set for the Millennium Development Goals (MDGs) has been reached, meanwhile most low and middle income countries have not reached their targets (1). Some authors link this slow progress to the “know-do gap” issue : the gap between what is known and what gets implemented (2). The performance-based financing (PBF) approach has been described as a promising intervention for improving health services delivery (3–6). In view of the increasing adoption of the PBF strategy and its effects on the health care systemss, Meessen et al. suggest that this strategy can be a catalyst that can help transform deeply the health sector in low-income countries (7). On another hand, some studies found little evidence on the link between PBF and better health outcome (8), and weak evidence to draw general conclusions on this approach (9). Failure of the PBF program in Uganda highlighted the importance of understanding the factors that influence its implementation (10). Most PBF programs in low and middle income countries are still in the midst of the pilot phase. Pilot projects and other small-scale interventions which experiment with health innovations tend to demonstrate positive results. It is often unclear if scaling-up these interventions will produce the same processes and outcomes. In low and middle income countries, scaling up evidence-based innovation could substantially narrow the “know-do gap” and reduce the burden of disease. Calls for scaling up successfully tested innovative health interventions have multiplied over the past several years. Many acknowledged that pilot or experimental projects are of limited value unless they have larger policy and programme impact (11). For example, up to 70% of deaths of children under 5 years, could be prevented through the large-scale implementation of evidence-based interventions (12,13). Scaling up an intervention is not an isolated process and may require some reforms within the health system in order to achieve the desired impact. While there is a wealth of evidence on the efficacy of improving population outcomes with scaling up of evidenced-based interventions, there has been much less attention paid to the reforms induced by the integration of innovative strategies into the health system during the scale up phase (14). Whitworth and colleagues propose that “strong health research systems and research programmes that address bottlenecks to upscaling effective interventions should be developed without delay” (15). Several authors point out the low profile of implementation science in research (16,17). In Cameroon, a small pilot PBF project was implemented by CORDAID in the East Region from 2004 to 2012. With a World Bank funding, the Cameroon Government decided to start in 2008 a PBF program in several health districts located in four out of ten regions in the country (Littoral, North West, South West and East). Currently, Cameroon is moving toward the scaling up of the PBF program. One important part of the scaling up process is related to the drugs supply system. With the support of the German Cooperation, a pilot model involving the community with the aim to improve drugs management at the regional level was initiated by the Cameroon Government in the North West Region in 1987. Based on the success of the approach, the model was expanded to two other regions later on; South West (1989) and Littoral (1991). This model known as

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"Essential drugs program" and initially grounded on associative framework, became the Regional Funds for Health Promotion (RFHP) in December 2010, with a public interest group status thanks to a law. The RFHP are regional dialogue structures and consist of representatives of the beneficiary communities, the Ministry of Health and donors and thus constitute participatory governance bodies in the health system. Despite widespread agreement on the importance of scaling up, corresponding efforts to inform practice and share lessons learnt have been limited (14). While there is a growing body of research around the PBF program in Cameroon, much of it is directed at the content of interventions. Far less research has focussed on the integration of the program in the health system. We contributed to bridge this evidence gap by conducting a case study, as part of a multi- country research initiative supported by the AHPSR, to examine how PBF in Cameroon has been developed (scaled up) and assess the challenges of its integration into the health system during the scaling up phase. Below, we briefly present the context and objectives of the research. The next section provides information on the methods and sources of data. The results that follow are presented in three sub-sections: First, we present a timeline reporting the different key steps in the scale up and the phenomena that triggered them. Second, we describe the dynamics (agenda, formulation and implementation) that enabled or hindered the scaling up of the PBF. Third, we present results on the transfer process of the purchasing role from international organizations to national agents during scaling up phase.

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II. BACKGROUND

The challenges faced by the Cameroon health system can be summarized in five points: (i) the high level of out-of-pocket payments, (ii) the low quality of care, (iii) the difficult regulation of a growing private for profit sector, (iv) the lack of qualified human resources, and (v) the lack of accountability (18,19). For some important health indicators, Cameroon is performing worse than the average in sub-Saharan Africa and other countries that are economically comparable, leading the country to be off-track for MDGs 4 and 5. For example, Cameroon has one of the highest under five mortality rate in the world (122 deaths per 1000 live births) (20). Similarly, the maternal mortality rate is also higher than the average for sub-Saharan Africa and has increased significantly over the last decade from 782 women per 100,000 live births in 2012 to 669 in 2004 and 430 in 1998 (20). This rate is slightly higher than those recorded in countries such as Central African Republic, Chad, Liberia and Sudan (20). In late 2004 (Phase I) and late 2008 (Phase II), CORDAID started a small pilot PBF project in Catholic health centers in 3 dioceses (Batouri for Phase I as well as Bertoua and Yokadouma for phase II) in the East Region of Cameroon. The project ended in 2012 and analysis of the program in one Diocese (Batouri), although it was very limited, suggested some promising results in terms of enhancing accountability and governance at the level of the health facility (21). The World Bank and the Government of Cameroon decided in 2008 to launch a PBF Project in four out of ten regions in Cameroon, to improve the quality and quantity of health care delivery to the population. The project started in February 2011 in the Littoral Region and was extended in the three other regions (East, North-West and South-west) in 2012. The PBF project in Cameroon is implemented in public, private and Faith Based Organization (FBO) facilities across 26 health districts in the Littoral, North-West, South-West and East regions of Cameroon, covering a total population of approximately 3 million. Alongside the implementation of this PBF project, the World Bank is conducting an impact evaluation in 3 of the 4 regions (East, North-West and South-West). The impact evaluation focuses mainly on the program's outcomes and less on the implementation process. The process of strategic and/or operational system reforms carried out when integrating PBF into the health system during the scaling up phase needs to be understood. This is particularly important if the country wants to promote the program’s sustainability. In addition, the World Bank has recently conducted a qualitative study that focussed on two primary objectives: (1) Understand the experiences in the piloting of PBF at the central, regional and district level: perspectives of decision-makers and policymakers, and (2) Analyze the experiential elements of health service delivery at the operational level: perspectives of patients and providers. Results are not available yet. Our study is complementary to the World Bank’s impact evaluation and qualitative study.

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III. OBJECTIVES

The goal of this study is to analyze the integration of the PBF program into the health system during the scale up of PBF program in Cameroon. Specifically, the research intends to:

1- Appraise the progress of the PBF scheme (how PBF developed over time and what is the situation today). 2- Describe the factors enabling or hindering the development of PBF program in Cameroon (context, actors, content and processes). 3- Assess the transfer of the purchasing role from international organizations to national organizations in two regions (North-West and South-West regions) during scaling up phase.

For the first two objectives, we documented and analyzed the development (scaling up) process of PBF in Cameroon from late 2004 to March 2015 and drew lessons for further scaling up and sustaining such initiative, nationally and internationally. The documentation review hinged on descriptive work focused on scaling up as a policy process. A time line reporting the different key steps in the scale up and the phenomena which triggered them was produced. We then investigated the dynamics (agenda, formulation and implementation) that enabled or hindered the scaling up of the PBF. For the third objective, we deepened our understanding on the handover process of the purchasing role from international organizations to national agents in two regions (North- West and South-West regions) during the scaling up phase.

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IV. METHODOLOGY

A. Study design PBF is a complex health care financing intervention that may have the potential to catalyze a comprehensive reform and to help address structural problems related to health services in Africa (7). The WHO and experts recommend the use of case studies to study complexe health interventions (22,23). Our study relied on explanatory case study design (24). The case was defined as the PBF program in Cameroon, from late 2004 to March 2015. The levels of analysis were related to the conceptual framework described in the section below.

B. Conceptual frameworks Description of how PBF developed over time For the descriptive part of our study, we examined the scaling up process of PBF from its initiation in late 2004 to its current status in March 2015. The scale up process is the result of the combination of mainly two elements: progress on some key dimensions and time. As the scale-up of a health policy or program is multidimensional (ref: conceptual paper by ITM), we elaborated the broad dimensions in the box below. Each key dimension can be analysed according to its magnitude (primary outcomes) or stage (early, intermediary or advanced stage).

Dimensions of the scaling-up (ref: conceptual paper by ITM)  Population coverage which can be increased by expanding geographical or administrative coverage, covering more socio-economic groups, demographic (age, gender) groups, entitlement status (e.g. member of a specific voucher program…), and finally number of population.  Service coverage which can be increased by covering more number, level and type (public vs. private) health facilities, and more number and type of services (e.g. from family planning to all reproductive health services or all types of services, including chronic non communicable diseases).  Health system integration or institutionalization which refers to: increase in political support among health system stakeholders (staff, NGO, partners…), integration in health policy (goals, strategic plan…), extension from one to other components of the health system, type of personnel eligible for the bonus, integration or synergies with HIS, adoption by different aid agencies – amounts, commitment and instruments (budget support > SWAp > project), integration with other health care financing schemes, standardization of institutional arrangements (written in national guidelines/manual), learning of new tools & organizational culture (data mining, strategic purchasing, impact evaluation…).  Country ownership which is determined by increasing technical leadership by the country actors, especially high level policy makers, integration in public finance & arrangements, officialization with legal texts, enforcement by administration & courts, extension of the RBF logic to other sectors (education…).  Society, ideas & knowledge: evidence base, recognition and support from politicians / political parties, visibility at citizen level, ideology (from need-based equality to more meritocracy & stress upon individual responsibility), institutionalization of relationships & transaction under a state of “rule of law” & good governance.

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As for the time assessment, our key instrument was the timeline. We used an Excel sheet to situate key progresses of the PBF scale up process.

Analytical work Sabatier and Jenkins-Smith (25) argued that a common approach to understanding policy processes is to use the ‘stages heuristic’, breaking down the policy process into a series of four stages : (i) Emergence or agenda setting explores how issues get on to the policy agenda, why some issues do not even get discussed, (ii) Policy formulation explores who is involved in formulating policy, how policies are arrived at, agreed upon, and how they are communicated, (iii) Policy implementation seeks to see if the policy is put into effect, and (iv) Policy evaluation identifies what happens once a policy is put into effect – how it is monitored, whether it achieves its objectives and whether it has unintended consequences (26). Policies process are usually viewed as being a process for regulating situations where there are problems in resource distribution (27). However, it is a "swirly" process where these stages are interdependent and concurrent, not simply composed of distinct steps (28). Kingdon has proposed to look at this process as a dynamic of three streams: problems, policies, and politics (29). The problem stream refers to the perceptions of problems as public matters requiring government action and is influenced by previous efforts of government to respond to them (26). The policy stream consists of the ongoing analyses of problems and their proposed solutions together with debates surrounding these problems and possible responses (26). The politics stream operates quite separately of the other two streams and is comprised of events such as swings of national mood, changes of government and campaigns by interest groups (26). In a nutshell, for a policy to exist the following are needed: i) the recognition that a problem should be addressed, ii) a solution that is scalable into a policy, and iii) stakeholders supporting the policy. According to Kingdon, public policies emerge when policy entrepreneurs get hold of windows of opportunity to couple a problem stream with an orientation stream. The convergence of the three streams is initiated by a policy entrepreneur who decides to use these resources to promote convergence at a point where a window of opportunity appears. Entrepreneurs may emerge from any of the streams, depending on the situation and the degree to which a certain stream predominates (27).

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Factors enabling or hindering the development of PBF program in Cameroon (agenda setting, formulation, and implementation)

To describe the development of the PBF program in Cameroon, we relied on Ridde's framework (31), adapted from Gilson's (32), Kingdon's (29), Lemieux' (33), Olivier de Sardan's (34) and Walt's (30) work.

EMERGENCE ACTORS Polici Proble CONTEXT Orientatio Elected officials Geographic FORMULATION

Economic Polici Proble Appointed Individual Orientatio officials citizens Political

Cultural IMPLEMENTATION Members of interest groups Polici Organizational Proble Orientatio Entrepreneurs EFFECTS

Expected Unexpected Figure 1 : Analytical framework Based on this framwork, we formulated three assumptions. A1: For the emergence of the PBF program, a window of opportunity opened because of a convergence between the problems stream (poor maternal and child health outcomes : 669 deaths per 100 000 live births, 144 deaths per 1000 live births (35)) and the orientations stream (perspective to implement health sector reforms in order to achieve MDG). The convergence was initiated by the World Bank (political entrepreneur) by exploiting a window of opportunity (Adoption of the SWAP within the health sector). The solutions stream was present with the result based financing approach within the broad Sector Wide Approach project. A2: The formulation of the program was made possible by the convergence between the solutions stream (a brand new solution labelled as result-based financing) and the orientations stream (health sector reform) that coincide with the political preferences of policy makers and stakeholders. The convergence of the different streams was initiated by the political entrepreneurs (Ministry of Public Health with WB support) by exploiting a window of opportunities (implementation of the SWAP). A3: The implementation was done by coupling solutions streams (Performance-based financing) and the problems stream (poor supervision, lack of resources in health facilities, lack of autonomy of health facilities, no clear definition of the role assigned to health personnel). This coupling was initiated by several actors (entrepreneurs): the Ministry of Public Health, the RFHP, AEDES and CORDAID. The implementation of the PBF program faces many challenges among that of the autonomy of the health facilities to recruit health personnel as well as the liberalization of the essential drugs market in order to include private

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sector in the supply chain system. These challenges are partly due to the fact that the legislation in the health sector in Cameroon is not best adapted to the PBF approach.

Assessing the transfer of the purchasing role from international NGOs to National agents in two regions (North-West and South-West regions)

Reform is rarely a linear process. It tends to evolve through an interactive process and usually involves a wide range of actors. Health sector reforms can be seen as : (i) a movement aimed at reconfiguring health services and (ii) changing the rules of the game and the balance of power within the health sector (36). Examining the transfer of the purchasing role from international organizations to a national agencies in a PBF program leads to understand the process by which knowledge related to the previous system are used in the new one. Therefore, the approach of "institutional transfer" can be used to translate these dynamics. The expression of "institutional transfer" was first coined by David Apter in the 1950's (37). Institutions are the rules of the game in a society or more formally, are the humanly devised constraints that shape human interaction (38). They can be formal (laws, constitutions, contracts) as well as informal (custom, traditions, ways of conduct). The main role of an institution is to reduce uncertainty by establishing a stable structure to human interaction (38). We adapted our framework from Dolowitz and Marxh's (39) work on policy transfer to assess the transfer of the purchasing role from international NGO to National agents in two regions (North-West and South-West Regions) during scaling up phase. Drawing on this framework, the concept of institutional transfer can then be broken down into several key dimensions that can feed analysis and formulated in term of questions by Dolowitz and Marxh: i) Why do actors engage in institutional transfer? ii) Who are the actors involved in this process? iii) What are the purposes of the transfer? iv) What are the sources of transfers? v) What are the different forms of transfers? vi) What are the factors that promote or restrict transfers? vii) Finally, in the last version of their model, they add the question of whether and to what extent the observed transfers resulted in a success or a failure? From our view, the benefits of this approach was double: it provided an analytical framework for multi-level games that characterize public action and it offered opportunity to synthesize several concepts or assumptions attached to the transfer and reforms. The transfer cannot be simply emphasized as a "copy and paste" process (40). It is necessary to explore more deeply the role of the actors during transformation and observe if some resistance and path-dependencies can be noticed (41). Therefore, we relied on this framework to understand the sequential pattern of the handing over of the purchasing role by an international NGO to a national agency.

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C. Instruments, sample and data collection The research involved two concurrent qualitative data collection methods.

Documents review A document review was important for this study in order to understand the PBF policy, design and implementation in the Cameroonian context. Documents provided background and context, additional questions to be asked, supplementary data, a means of tracking change and development, and triangulation of findings from KIs. Moreover, documents were useful to gather data on events that could no longer be observed or on information that has been forgotten (46). A total of 34 documents were included in this study. These documents included: the national health development plan (19), MoH-International organizations contractual documents (47), PBF design documents (48,49), PBF implementation guidelines (18), PBF strategic meetings reports (50–52), road map for the PPA transfer (53,54), and evaluation documents (20,21,55– 62). These documents have been instrumental in understanding the policies frames and in supplementing primary data collected from KIs. See annex #7 for the full list of the documents reviewed.

Individual in-depth interviews The use of interviews provided information that could not be directly observed or studied in documents. Interviews can illuminate feelings, thoughts, perceptions, and interpretations of the surrounding world as well as the intentions of individual actions (42,43). Following our framework, we interviewed three categories of actors : the legitimizers (who formalize decisions), the actants (those who operationalize decisions), and the beneficiaries (those who benefit from decisions) (44). The purpose of the interviews was to elicit the emic view (45) of the PBF scale up. These KI were selected using approaches that provided contrasting views in terms of stage (agenda setting, formulation, implementation) and length (from the beginning, newly in the program, no longer in the program) of the implication, area (urban/rural) and sector (public/private) of the work, level of activity (central/regional/peripheral) and categories of actors conceived around the triangle of the decision (legitimizers/actant/beneficiaries) (44). Interviews outside the health sector (i.e Ministry of Finance) and funding agencies supplemented the information obtained from the central, regional and peripheral level of the health system. Using the timeline of key events, institutions that were involved in the policy process were identified. Key informants (KI) were selected using purposive sampling, with the main criterion being their involvement in the agenda setting, formulation, or implementation of the PBF program. From each of the key institutions, the focal persons involved in the policy process were selected and employed the snowballing technique to identify other key respondents until saturation. Some of the identified respondents had since moved on to other employment or retired and were categorized under the institutions they worked for at the time of the policy change. The selected respondents included donor representatives, policy makers, international organization, and researchers. Managers of health services at the district level, health care

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providers from the public and private not-for-profit as well as for-profit health facilities, and managers from the national and regional drug supply system were also interviewed. For the anonymity of the interviews we used: i) the level of the activity that included the following categories; international (NB), central (NC), intermediary (NI), and peripheral (NP), and ii) the categories of actors; partner, policy maker, implementer, and beneficiaries. As an example, we coded NP_Implementer3 for the third KI involved in the implementation of the PBF that we interviewed at peripheral level. This typology was valid for KI working in the health system. For other sector, we distinguished only by the level of the activity (For example, NI_other sector2 was coded for the second interviewed KI working at the intermediary level in other sector than health sector). In total, in-depth interviews were conducted with 74 purposively sampled key stakeholders of the intervention at various levels: policy makers at central Ministry of Health (n=5), policy makers at regional level (n=4), implementers at regional (n=12), implementers at peripheral level (n=25), regional finance actors (n=3), technical and financial partners at national level (n=4), technical and financial partners at international level (n=7), beneficiaries at peripheral level (community based- organizations and health committees representatives) (n=14). Details of the selected respondents are shown in Table 1. All interviews were recorded and notes were taken systematically to facilitate the analysis. When recording was not considered appropriated because of the sensitivity of the subject discussed or the informality of the conversation, notes were taken immediately after the interview. The sensitivity or informality of the conversation was determined by the interviewee and this part of the interview was not included as part of the data, as requested by one of the ethical committee.

Table 1 : sample for interviews Number of informants

interviewed Policy makers central level 5 Ministry of Public Policy makers regional level 4 Health Implementers regional level 12 Implementers peripheral level 25

Ministry of Finance Regional actors 3

Technical and National level actors 4 financial partners International level actors 7

Beneficiaries at Community based-organizations and 14 peripheral level health committees representatives Total 74

D. Addressing Validity and Reliability of Collected Data Lee (63) emphasizes that an important aspect of qualitative research is the use multiple data collection methods, thus creating a hybrid or combination of methods within a single study (64–66). To increase the validity of this research, we used different data sources and different data collection methods (documents, interviews). In addition, we sent our preliminary findings to a set of 20 KI (4 partners, 5 policy makers, 5 implementers and 6 beneficiaries) to collect their feedback. These KI were selected because they had provided us their email

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address and thus were accessible online. After 2 emails follow-up, we received feedback from 11 of them (3 partners, 2 policy makers, 3 implementers and 2 beneficiaries). We used this feedback to validate our findings. Marshall and Rossman (67) suggest that the "truth value" of qualitative research can be evaluated based on credibility/believability, transferability, replicability, and confirmability. The credibility of a qualitative study is the accurate and complete identification of the studied phenomenon. We enhanced the study's credibility by discussing major definitions and comprehension of the main themes with key stakeholders. Our research questions were jointly identified with the senior official in charge of the PBF program in Cameroon and the Task Team Leader (TTL) of the World Bank in Cameroon. The study protocol was shared with some key stakeholders, including the two cited above, to provide their comments on the different concepts. Their feedback was integrated in the final version of the protocol. Further, when developing data collection tools and the list of the key informants to be interviewed, we sought recommendations from the same stakeholders. Merriam (43) recommends the clarification of investigators' positions through the identification of the basic assumptions and theories that inform the study and also the context from which data is collected. We concurred with Marshall and Rossman's (67) assertion that research can be credible only within the boundaries of the particular setting and concepts of that research because participants and researchers construct that reality. The study used an iterative and cumulative process of data collection. The process resulted in the continual development of the topic guide for in-depth interviews. New data were continually compared to data already collected through a process of triangulation. This process continued until reaching a point of saturation (i.e. when no more new information emerged from the data).

Documentary review Time line development Key informant interviews

E. Data management and analysis With qualitative research, data collection and analysis is a simultaneous process carried out in an open-ended way (42,64,67–69). Therefore, our data analysis practically started in the field, forming an iterative relationship with document analysis and interviews. By beginning this interpretation and analysis during the field research, we were able to constantly compare the value of emerging categories for sorting the collected data. At the same time, it provided an opportunity to share and confirm our findings and subsequent interpretations with participants as advised by Hartley (68) and Miles and Huberman (64). Marshall and Rossman (67), and Miles and Huberman (64) also suggest combining the initial transcription of collected data with ongoing or early analysis. This helps the researcher to gain insights and plan strategies for collecting new, often better, or more relevant data. Patterns and categories that emerge from previously studied literature or collected data can help plan further data collection to fill gaps existing in the more preliminary research. We used this

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technique to increase the efficiency of our data analysis and to avoid being overwhelmed by data in the later stages of the research (64). Our findings were analyzed using a thematic approach (64) guided by our conceptual frameworks and our knowledge of the PBF. We organized a one-week workshop to train the research team to use QDA Miner Lite, a qualitative data analysis software, and to ensure a common understanding of the themes. We conducted thematic analysis to extract the main themes from the documentation and the in-depth interviews. All interviews were transcribed and analyzed using QDA Miner Lite. The coding of data was oriented by organizing the data around conceptual categories. A hybrid deductive-inductive approach allowed us to assign data to predefined themes and to derive new themes from the data. The analyses was conducted through a stepwise process. First, the research assistants analysed the in-depths interviews (and submitted a report). Then, a researcher conducted synthesis of the findings. Out of the 74 interviews, 35 were conducted in French. Therefore, the research team translated the citations in English for the results section below.

F. Ethical consideration The study protocol was reviewed and approved by the Cameroon National Ethics Committee for Human Health Research – as protocol N0 2015/02/549/CE/CNERSH/SP – and the WHO Research Ethics Review Committee – as protocol ID : RBF2014-395. Administrative authorization was granted by the Cameroonian Ministry of Health - as authorization No D30- 298L/MINSANTE/SG/DROS/CRSPE/CEA2 - prior to data collection. All respondents provided verbal or written informed consent before being interviewed.

G. Limitations Among the limits of this study is a potential recall bias. Interviews were conducted a long time after some policies were developed . However, the potential recall bias was reduced by combining multiple sources of data. Secondly, some members of the research team have been or are currently involved in the implementation of PBF. This could lead to a potential conflict of interest. To deal with this issue, the research team included independent researchers that have never been involved in the implementation of PBF. In addition most interviews were conducted by trained research assistants, who have never been involved in a PBF program. Third, a social desirability bias may arise if participants want to portray the PBF program in a positive image. Some stakeholders man have vested interests in promoting PBF in a possible way, especially due to the financial incentives associated with this intervention. Finally, the handover process of the purchasing role from an international organizations to local agencies was still ongoing at the time of the data collection. Therefore, the data collected may reflect only part of the reality, leading to a potential bias in our conclusion.

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V. RESULTS

We integrated the results from the review of relevant documents and from the interviews with KIs. These findings are presented in three sections, namely, (i) progress of the PBF scheme, (ii) factors enabling or hindering the development of PBF program, and (iii) transfer of the purchasing role from international NGOs to national agencies. A. Progress of the PBF scheme We identified two different projects in the development of the PBF program in Cameroon.

The CORDAID project (21) The PBF was introduced for the first time in Cameroon in 2004 by CORDAID, a Holland based NGO, in 4 health centers (Batouri, Djouth, Mindourou and Ndélélé) in the Diocese of Batouri, East Region of Cameroon, in the context of their “Redynamisation des Soins de Santé dans la Région de l’Est Cameroun (RESSEC)” project. In fact, Cordaid was pivotal in the implementation of PBF in Rwanda, Burundi and Democratic Republic of Congo. It is one of the few NGOs which decided to include PBF as a central component of its programs. Since 1995, this organization and the Catholic Relief Service (CRS) had been implementing a project on the Reorientation of Primary Health Care in the ecclesiastic province of Bertoua in Cameroon, based on the "input" approaches (e.g. providing drugs, paying salaries). The evaluation of this project in 2004 did not provide conclusive results. At the same time, the Netherland government, that funded the majority of CORDAID's projects, was reforming its financing support mechanism toward a more results-oriented system. CORDAID seized this opportunity to modify its intervention strategy and introduced the PBF project in the diocese of Batouri, which was called the “RESSEC” project. The health facilities of the other dioceses which were supported by CORDAID continued to receive financial support. This project started with a baseline survey in 2004. Its objective was to improve the health of population served by the catholic health centers (CHCs) in the East Region. The first phase of the project (RESSEC1) started its activities during the 3rd quarter of 2004 and covered an estimated population of 16,914 inhabitants. The intervention package included 14 quantitative indicators purchased at the level of the health centers. This project had a relatively modest budget, estimated at US$36,000. An evaluation of this first phase, conducted in May 2007, showed an overall positive effect on (i) the organization of Catholic health centers included in the project and (ii) participatory management. However, the report indicated that the level of institutional organization reached was not able to ensure the sustainability of the results. Nevertheless, the main recommendation was to progressively extend the project in other Dioceses in the east region. The first phase of the project was completed in October 2007, the second phase of the project followed in November 2007. The second phase (RESSEC2), which continued until June 2012, retained the same design as RESSEC1, except that it covered 24 health centers, representing a total population of 120,000 inhabitants and an annual budget of approximately $ 900,000 US. Initially, this budget was approximately $ 1.4 million US per year, but due to financial crisis, one of the partners (the

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Catholic Relief Services (CRS)) was forced to reduce its contribution, thereby causing a 36% decrease in the overall budget. Only CHCs were integrated in the project. The role of the Contracting and Verification Agency was fulfilled by a project team recruited by CORDAID. The evaluation of the technical quality (regulation) was done by regulators and evaluation at community level was done by local associations. Performance contracts were signed between the project team and CHCs on a quarterly basis at the beginning, and half-yearly basis from 2008. At the end of each month, all the contracted CHCs sent their monthly report activities to the Diocesan Health Coordination, where the reports were synthesized and transmitted to the project team, who verified the accuracy of data in CHCs registers and calculated the funds generated. The evaluation of the technical quality was done quarterly (and then every six months from 2008) using a grid with criteria related to the organization of care, hospital hygiene, the modalities of conducting consultations, the laboratory organization, the management of the Expanded Program on Immunization (EPI), the management of resources and the organization of the referral system. The community evaluation was done quarterly (and six monthly from 2008) by community based organisations on a sample of patients who visited the CHC during a specified period. This community evaluation consisted of verifying the health care services provided and the satisfaction of the beneficiaries. The performance payment of CHCs consisted of; 1) the quantity of services provided; 2) an equity bonus of 12% based on the level of poverty and the population density, and 3) a 10% bonus for isolation (quantitative output) based on the following criteria: dispersion of the population, the state of the roads, the distance between the CHC and the center of the diocese, the availability of telephone line and connection to electricity. The identification of health facilities eligible for the equity (Djouth CHC and Mindourou CHC) and isolation (Djouth CHC) bonus was done at the beginning of the project. The CHC received 80% of its funds at the beginning and the remaining 20% was paid to the health facility as a quality premium if the technical and community quality objective was attained. The health facility received the technical quality bonus if it had an average score greater than or equal to 50/100 in the two scales. On a quarterly and six-month basis from 2008, each CHC developed a business plan for the quarter following quality quantitative production evaluations. This document had to include a clear description of the sources of revenue (e.g., cost recovery, PBF, gifts) and the expenditures. It also had to propose solutions to the problems identified during the control, the supervision or the community survey. The business plan was reviewed and approved by the Board of CHC management, composed of five members: the Head of the CHC, the representative of CHC staff, the Parish Priest, the representative of village chiefs and the representative of the Community Health Agents (Bertoua Ecclesiastical Province, Cameroon, 2009). The business plan developed by the CHC described amongst others, the objectives, activities to be undertaken and sources of funding. This business plan was approved by the

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project team which then signed a new six-month performance contract (initially quarterly) with CHC (Bertoua Ecclesiastical Province of Cameroon, 2010). Apart from wages, the personnel received premiums representing 10% of the profits generated. The modalities to distribute the funds depend on the CHC. The management of denominational staff was decentralized from the central level of the church to the diocese and to the health facility which recruited and managed its staff. Evaluation of the project in 2011 (21) showed that PBF emerged as a potential lever to strengthen and improve the functioning of dialogue structures (management committee and health committee). In addition, the program increased the quality of care and utilization of some health services. An illustration is the 38% annual average increase in the number of curative consultations between 2004 and 2007. Similarly, the evaluation noted an improvement in the health information system. However, the program did not have any effect on the allocation of medicines and medical equipment, nor on the improvement of the financial access to care.

The Ministry of Public Health’s project supported by the World Bank a. History In the years that preceded the adoption of PBF, health indicators in Cameroon were getting worse instead of improving. The Ministry of Public Health and the World Bank hired an independent consultant to help Cameroon move forward with the project. In the conclusions of his report (62), he recommended that the East Region which had already started the pilot project with CORDAID should be integrated into the project and that only the Littoral region could implement the project using a local organization, the Regional Funds for Health Promotion (RFHP), as the performance purchasing agency. For the East, North West and South West regions, the consultant recommended that international organizations be recruited to start the project during the first 3 years and reinforce the capacity of the RFHP to take over implementation of the project later. The MoPH and the World Bank followed these recommendations. In 2009, the project was restructured accordingly, and the credit agreement was revised. The restructuration of the project was completed in July 2010t (71). Twenty-six health districts (HD) were integrated into the project, that is, 4 in the Littoral (Cité des palmiers, d’Edéa, Loum, Yabassi), 4 in the North West (Ndop; Kumbo East ; Fudong; Nkambe), 4 in the South West, and 14 in the East (all the HDs in the East). The population covered at the beginning of the project was estimated to be 630,000 people in the Littoral, 620,993 people in North West, 587,968 people in South West, and 949,000 people in the East. The structure that played the PPA role at the beginning of the project was the RFHP in Littoral, AEDES in the North West and South West, and CORDAID in the East. In Littoral, recruitment of the RFHP was conducted through mutual agreement, while in the three other regions, it was done through an international call for tender.

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b. Key features of the project The beneficiary health facilities are public, private for-profit and faith-based facilities. Performance contracts are signed between a Performance Purchasing Agency (PPA) and health facilities. They focus on the complementary package of activities (CPA) for hospitals, and the minimum package of activities (MPA) for health centers. These performance contracts govern results-based payments to facilities, and performance bonuses from facilities to their health workers. A quarterly contract is signed between the PPA and the health district to evaluate the technical quality of health centers, and with the Regional Delegation of Public Health to (i) organize peer evaluation of hospitals, (ii) inspect pharmaceutical wholesalers, and (iii) carry-out counter verification of the health districts activities. Moreover, quarterly contracts are signed between the PPA and community-based organizations to conduct evaluations at the community level. The purchased outputs from health facilities include service output indicators for priority services. Facilities have the management autonomy to use PBF payments, based on priorities identified in their business plans, including the offering of performance or retention bonuses to health workers and the purchase of inputs. Facilities also have the management autonomy to hire and fire staff employed with PBF revenues. They can procure medication from government-approved distributors and retail outlets. They are not obliged to purchase their medication from any single source. Alongside the implementation of this PBF project, the World Bank is conducting an impact evaluation in 14 HDs from 3 of the 4 regions: North West (4 HDs: Ndop, Kumbo East, Fudong, Nkambe), the South West (4 HDs: Buéa, Kumba, Limbé, Manfé), and East (6 HDs: Abong-Mbang, Doumé, Kette, Lomié, Messamena and Nguelemendouka). The study has a pre-post with comparison design, relying primarily on experimental control. Individual health facilities in health districts included in the project in each region have been randomized to one of the 4 study groups (T: PBF with health worker performance bonuses; C1: Same per capita financial resources as PBF but not linked to performance; C2: No additional resources but same supervision and monitoring as PBF arms and T and C1; C3: Status quo).

C. Coordination, monitoring and evaluation activities In this section, we will describe several workshops and missions that led to the adoption of recommendations for a successful implementation of the PBF project. These missions and workshops included: the mission of the World Bank and the PAISS, workshops for exchanges between officials of the PPA, workshops for staff capacity building, mid-term evaluations. PAISS and World Bank’s mission from 23 August to 14 September 2012 (55) The objective of this mission was to technically support the implementation of the PBF in the four regions. This mission was composed of a workshop on September 12, 2012, during which the preliminary results of baseline impact assessment was presented. A PBF forum open door day was organised on September 13, 2012. Another workshop on the PBF was organized for the UNFPA staff by the World Bank in September 11, 2012. The objective was to brief the UNFPA staff on PBF, and to assess the possibilities of collaboration between the World Bank and UNFPA in the PBF project. They considered the contribution of the UNFPA to better define some reproductive health indicators, the possibility for UNFPA to finance some specific indicators, the potential integration of PBF with some UNFPA initiatives such as obstetric kits in the East Region.

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Technical support mission to the 4 PBF regions from 25th August to 14th September 2012 (56) The conclusions of the mission were that the results achieved by the PBF project in the Littoral Region were well above average in less than 2 years. These results related to the improvement of the quality of care in health facilities and the reduction in the cost of health care by the health facilities. The most important result was that the heads of health facilities had the feeling that they own their structures, and could influence its improvement rather than wait for the hierarchy to resolve their problems. The regions of the North West and South West had just started a few months ago while the East some weeks back. It was felt that they could benefit from the lessons learned in the Littoral. The issue of the political will required at national level to make the PBF sustainable was mentioned several times during the mission. Peer learning workshop of the Performance Purchasing Agencies: December 17th - 19th , 2012 in Douala (57) The main recommendation of the workshop focused on the harmonization of the practices of the different PPAs. Mid-term evaluation of the Littoral Project (58) The evaluation showed a significant impact of the project on quality of care and the use of services in the implementation districts compared to control districts after 2 years of implementation. Mid-term review of the entire PAISS project for May 6 - 17 (54) The main recommendations of this review were among others: to put in place a PBF technical unit by December 2013, to include PBF financing in the Ministry of Health’s 2014 budget, to ensure that the PBF runs in the 3 regions according to best practices, to integrate PBF in the implementation strategy of new RFHP, to put in place a web-based platform for management of the PBF project data, and to look for Trust Funds for the implementation of the PBF in targeted districts in the three regions of the north. Peer learning workshop of the Performance Purchasing Agencies in Bertoua, 17 - 18 of July 2013 (59) The conclusions and recommendations of this meeting were that the project should organize a national workshop on the harmonization of PBF indicators and costing of bonuses, harmonize the approach for the implementation of the home visit indicator, harmonize the approach for the implementation of the vulnerable / poor indicator, ensure that the proportion of the poorest treated represents 20% of the population of the targeted zone, associate the different stakeholders in the development of business plans of health facilities (health facility managers, controllers, management committee, PPA, ...). During the workshop, a UNICEF expert gave a presentation on the malnutrition trends in Cameroon. He pleaded the support of the PBF program for the inclusion of some malnutrition indicators. Consequently, two indicators at MPA and two indicators at the CPA level were retained. Discussions also focused on the difficulty in preparing the RFHP for the transfer to take over the PPA.

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Scaling-up process Based on the fact that the PBF program in Cameroon has moved from a pilot project to a national scheme (though not covering all the regions) on one hand, and is currently attempting to progress to a national policy with the integration of the scheme into the national health care financing on other hand, we situated this scaling-up process in-between the adoption and the institutionalisation phases. The initial Cameroon Health Sector Support Investment Project was a five-year US$25 million project. The project underwent a restructuring on June 2011 and again in March 2014. The project received an IDA Additional Financing of US$20 million to support the scale-up of performance-based financing to additional target populations in the poorest regions of Cameroon, and a US$20 million allocation from the Health Results Innovation Multi Donor Trust Fund (HRITF) to be used in the initial project areas to scale-up the activities of the project in the 26 districts currently implementing PBF by extending PBF to the impact evaluation group facilities.

Population coverage PBF was introduced in Cameroon by CORDAID in 2004 in the East region through the RESSEC 1 project. It started in four Catholic health facilities in the Batouri Diocese, covering an estimated population of 16,914 inhabitants. In 2008, Cordaid extended the PBF project in 24 catholic health facilities through the new RESSEC2 project, for a total population of 120 000 inhabitants. In 2011, the government PBF project started in 4 health district in the littoral region. This project was progressively extended to the North-West region at the beginning of year 2012 (4 health districts), to the South-West region 3 months later (4 health districts), and to the East region 6 month later (all the 14 health districts of the region), for a total population of 3 million inhabitants. The previous project supported by Cordaid in east region ended in 2010.

Service coverage In 2004, Cordaid started its PBF project with 14 output indicators. The government project started in 2011 with 23 MPA indicators and 24 CPA indicators. Five months later, these indicators were reduced to 15 MPA and 16 CPA but was increased again to 23 MPA and 25 CPA 6 months later by the Ministry of Health. These indicators were used by all region until June 2015. The revised process to introduce new indicators and community indicators for the PBF community started in the 2015 and was still going on.

Health system integration From the beginning of the project in the Littoral region, the government decided to use a national structure to carry out the role of the performance purchasing Agency (PPA): the Regional Funds for health promotion. In the three other regions (North-West, South West, and East region), international organizations were recruited to play the PPA role during 3 years. In late 2014 and beginning 2015, the PPA role was transferred from the international organizations to the RFHP in the 3 above mentioned regions. In 2015, the RFHP was also created in the 7 other regions in other to prepare the national scaling up of the PBF.

Country ownership The government changed its legal framework in other to allow the RFHP to fully play its role in the implementation of PBF and other health activities at the regional level. This new legal framework provided them with managerial autonomy. A national PBF steering committee that includes different ministerial departments and other ministries directly or indirectly involved in the implementation of the PBF in Cameroon was created to guide the development of the

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program. In addition, the MoPH decided to create a PBF Technical Unit in 2014. As part of the sustainability vision, the government invested Fcfa 670 million and its financial procedure for the implementation of the PBF project in the littoral region during the year 2014.

Society, idea and knowledge Several evaluations have been done since the beginning of the PBF in 2004. These include for instance the baseline study in December 2010 and the mid-term evaluation in March 2013 in the littoral region. Baseline evaluation in East, North-West and South-West regions was carried on in 2012, and the endline took place in June 2015. Many staff at operational and at central level were trained in PBF during several international 2-weeks courses.

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Figure 2: Timeline

Contract signed between MoH and AEDES to implement Decision to extend the PBF to 15 health districts of Introduction of PBF in 3 Catholic health facilities of the Extension of the project in 24 health facilities in the East a PBF pilot project in 4 health Districts in the North West Adamawa, North and Far North Regions with the World Batouri Diocese, funded by CORDAID (RESSEC 1 Project ) region with CORDAID financing support (RESSEC2 project) Region and 4 Health Districts in the South West Region Bank support with the World Bank support Population coverage Contract signed between the Ministry of Public Health Starting the PBF Project in 4 health districts of the Littoral and the CORDAID NGO to implement a PBF pilot project in Region with the World Bank support all the 14 HDs in the East Region with the World Bank support

Signing of the subsidiary agreement between MoH and the Littoral RFHP f Creation of RFHP Transfer of PPA from AEDES to the or the implementation of the PBF Projectin 6 other regions South West and the North-West RFHP Health system integration UNICEF shows interest to join the PBF program Starting of the PBF Project with 14 MPA indicators in the Starting of the PBF Project with 23 MPA Review and adoption of Discussion to add community PBF in the Catholic health facilities of the Batouri Diocese (RESSEC 1 and 22 CPA indicators in the Littoral Region Project ) a new list of indicators Littoral, North-west and South-west Service coverage Starting of the PBF Project with 23 MPA and 22 CPA 1st revision of indicators including 2 relating to community PBF in the the indicators East Region

14-Jan-2004 28-May-2005 10-Oct-2006 22-Feb-2008 6-Jul-2009 18-Nov-2010 1-Apr-2012 14-Aug-2013 27-Dec-2014 10-May-2016 6-month extension of the CORDAID Adoption of the 2007/2008 Law reforming Signing of the loan agreement between Creating a nationalOfficial launching of the PBF project Decision of the MoH to contract in the East Region to allow public financing in Cameroon the State of Cameroon and the World Bank PBF committee in the North & South west region create a PBF Technical Unit the transfer of the PPA Country Ownership Signing of the loan agreement between the government MoU between the Government and Signing of a 2nd loan agreement betweenSetting up of the regional Funding of the of Cameroon and the WB for the implementation of a the North-West & South-west RFHP the State of Cameroon and the WB PBF committees PBF project in PBF project the Littoral Region The Board of Directors with state resources approved the 5 years PBF

Baseline study Evaluation of the project Development of the procedure Mid-term evaluation of the PBF of thePBF project RESSEC 1 Project evaluation operationalization conditions manuals of the North & South Westproject in the Littoral Region Society, idea and Knowledge in the Littoral region PBF training for the East, Baseline study Development of the Mid-term evaluation Endline study of the PBF project in the Littoral, North-West and of the PBF project Cameroon PBF portal web of the PBF project East, North-west and South-west regions South-West regions staff in the East, North-west in Cameroon during an international and South-west regions 2-weeks course

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VI. FACTORS ENABLING OR HINDERING THE DEVELOPMENT OF THE PBF PROGRAM

For the remaining part of this report, we will focus on the Cameroon Government-World Bank PBF program – referred to as the PBF program. We decided to exclude the pilot CORDAID project because it was limited in size and activities. The development of the PBF took place in an environment where an organizational culture, a mode of functioning and the actors’ own logic already existed. These factors sometimes played as obstacles and other times as drivers to the development of the PBF program. The development of the program can be divided in three phases based on Ridde's conceptual framework, an extended version of the Kingdon model, namely agenda setting, formulation and implementation. For each phase, we focused on the actors, on the context, and to some extent on the effects.

A. Agenda setting

The data revealed that the PBF program emerged in the agenda of policy makers following the coupling of the problems stream (i.e., weak health outcomes, especially for maternal and child health, and inefficiency regarding financial resources) and the orientations stream (i.e., national mandates to improve population health, with an important reform of the health sector to achieve the health-related MDGs). This coupling was initiated by the actors from the World Bank in cooperation with a network of policy makers (i.e., political entrepreneurs) from the Ministry of Public Health.

Problem Stream The problems regarding the poor maternal and child health outcomes had been recognized by the state before the 2000s. Approximately ten years ago, Cameroon was confronted with high rates of maternal and child mortality. The rates increased from 454 deaths per 100 000 live births in 1996 to 669 deaths per 100 000 live births in 2004 (35). In 2005, the former Ministry of Health, Mr. Urbain Olanguena Awono, acknowledged that the maternal mortality rate was unacceptable and that it was necessary for the government of Cameroon to react by drawing up its action plan based on the principles of Equity, Social Justice and National Solidarity (72). We traced back around the end of the 1990s an important event that contributed to understanding the issue of poor maternal health outcomes as an important problem. During the National Symposium on the Reproductive health held in Yaoundé from the 14th to the 17th December 1999, many national experts and policy makers expressed their concerns regarding the worsening of maternal and child outcomes. This lead the country to define eight priorities sectors taking into account its own national specificities (73).

The publication of a report (74) by the World Bank in June 2003 drew consideration for this issue. It advocated that the time had come to pay greater attention to the poor maternal and child health status. In fact, the publication of the report titled “Cameroon country status report: Reversing the Decline in Health Outcomes", was a key element that supported the recognition of the poor health status as a real problem that deserved an attention. The

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importance of this report was highlighted during our interviews and respondents indicated that this was a very important document that largely influenced the comprehension of the health sectors' problems in the context of Cameroon. "There was stagnation, ok, the government was aware of the poor health indicators. Health indicators had been stagnating in the country especially getting toward reaching the millennium development goals. Reaching the millennium development goals, it's hell, especially in maternal and child health. Emm, Cameroon has over the years had an increase in the mortality rate which is a problem [ok]. Infants and maternal mortality rates have been on the rise [ok]" NI_Policy maker4 "Maternal mortality was just climbing. It caused a bit a shame for the country to see a critical situation like that. In fact, the State started from the year 2000 to try to find solution for the unacceptable poor condition of maternal and child health" NI_Implementer1 "OK. Uh there was a report on the health system - Country study support - that the Bank released; the Bank makes the sectoral report and must do every five years for each sector. It's more or less a descriptive analysis of the sector, what are the weaknesses, strengths, challenges, etc. and there was one that was made in 2003-4 something like that, that was not very good. But this report guided the CMU -the Country Management Unit- of IDA grant financing source for financing the health sector" NB_Partner1

The report revealed a difficult paradox to interpret: the disconnection between socioeconomic indicators and those of health. Indeed, the results of this study showed that health indicators were not proportionate with the level of wealth of the countries, measured by gross domestic product (GDP). Above all, it was striking to notice that some countries (e.g. Lesotho ) with socioeconomic levels well below that of Cameroon had much better health outcomes. There were allocative efficiency issues, in that, the majority of public funds for health care were allocated to the central and provincial levels of the health care system, and peripheral level with the greatest need were receiving the least funds. "The infant mortality rate was very high compared to some countries in the same or even lower level of wealth as Cameroon. And we also know that many women and children were dying due to the lack of adequate care" NC_Policymaker2 "..... we were trying to figure out a paradox in this country. If you look at the health indicators for Cameroon, look at the basic indicators and you look at the socioeconomic status of Cameroon on the other axis, there was a complete disconnect. Cameroon was a bit of an outlier. It wasn't attaining its potential" NB_Partner3

The data analysis also revealed two other political/strategic disconnections: the highly centralized management of the health system and a real disjunction in health program implementation between the peripheral and the central level. Indeed, it was striking to see that at the central level, high-level discussions were taking place, but that nothing concrete was translating to the operational level. In this regard, one respondent confided that: "The one thing that always struck me was the level of sophistication and the quality of the policy debates and policy discussions. And then, when you look at the implementation on the ground -and I visited many hospitals and health centers and so forth-, there was a disconnect again" NB_Partner3

The publication of the World Bank report provided evidence on the state of health outcomes

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and health financing, and raised awareness on the situation. As a result, the decision-making level conceptualized the lack of a suitable health financing policy to produce good outcomes as an important issue (in the problem stream) that was to be addressed by the government.

Orientation stream Within the orientation stream of the Cameroon PBF program, a series of background mandates and reforms allowed the introduction and adoption of the program. First of all, most of the key informants evoked primarily, the close deadline to the MDGs and the government priority to achieve these MDGs. Despite huge investments in health by many funders, the health indicators in Cameroon were stagnating especially in the domain of mother and child health. There was therefore a need for an innovative approach that could improve the health of the population. “I think that the main idea for the World Bank was that already so many years, so many donors put so much money in the health system and, despite all that, the changes are not that big, eg the mother and child mortality rate which even went worst here in Cameroon” NB_Partner3 "I had an opportunity to go to Sierra Leone where I represented Cameroon in a meeting on the MDGs uh ... so we were about twenty-five, fifteen countries and realized that those who had started with the PBF had quickly improved their MDGs " NC_Policy maker3

Secondly, the fight against corruption came in as a mandate of high priority for the government. Indeed, in the late 90s, the ranking of Transparency International reported twice that Cameroon had the greatest perceived corruption index (75). "My recollection is that there were frustrations that were very typical of Cameroon eh, corruption, mismanagement, etc" NB_Partner2 "So much money has been pumped into the system through GAVI, through the Global Fund, through bilateral partners, through WHO, UNICEF. A lot of money went into that sector. I can tell you that the per capita health financing in Cameroon, I think it was around or more than $ 60! But it still gave nothing! The indicators ... if you see Cameroon's MDG eh! Maternal mortality keeps increasing. Governance was not at the top." NI_Implementer10

In 2004, the government launched the Sparrowhawk operation1 in order to put the management of public funds in order. On October 5th, 2004 at Monatélé, the Cameroonian President firmly stressed in an election campaign speech that the fight against corruption will be a priority for his government if he is re-elected. After his re-election, actions were taken to fulfil this promises. In 2005, the Cameroonian President declared: "... I have given instructions to the Government to put the battle up a notch ... We cannot fight against poverty by letting people divert public funds". (76)

Then in 2006, following Cameroon’s achievement of the completion point of the heavily indebted poor country initiative (HIPC), it gives a measure of its determination to improve the governance of the country, by intensifying and densifying the tone of his speech: "those who

1 Name given to the vast judicial operation for the fight against corruption in Cameroon

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have enriched themselves at the expense of the public fortune must disgorge ... white collar offenders had better watch out" (76)

In this context, any initiative or program that supported the fight against corruption tented to be well received. For example, there was the creation of the National Anti-Corruption Commission in 2006 (NACC). "In short, there's been some reluctance and I think the results show ... anyway ... There has been commitment from the government that made it such that from the prime minister down to the Ministry of Public Health, it had to advance. What must be said is that our presentation aimed at framing the PBF to show that it could be used for the fight against corruption and for efficient financial management of the health system’s resources. So there was commitment from the State, the government through the Minister of Health, the first minister, to implement this project ..." NC_Policy maker3

The political changes, including the cabinet reshuffle in December 2007, let to a new Minister of Public Health in an environment where the government was committed to the fight against corruption and for which several senior officials including several ministers (for example the former ministers of public health and finance) and directors general suspected of embezzlement and illegal enrichment were prosecuted, gave an additional impetus to the reflections. In the following months, officials with great political and technical reputation, as well as considerable experience, were appointed at the administrative inspection services of the Ministry of Public Health, with a mandate to instil reforms that were underway in the health system. One of these officials was given, later on, the coordination of the PBF project management unit at the time of its implementation. Endorsement of the PBF program by the newly appointed Ministry of Public Health was then fundamental to push the policy into the agenda setting. "It was also a political commitment, the personal commitment of the Minister of Health was a necessary condition" NI_Implementer1 "So I think that, in all fairness, the Ministry of Public Health was very inspired and motivated, you know, to do something in this area. I think we have to give them credit" NB_Partner3

All political discourse was converging towards greater accountability to the population, and also to a more efficient health system. The changes in the orientation stream supported the emergence of a policy initiative (politics) that favoured the introduction of new political ideas (policies) on PBF.

Policy entrepreneurs The data suggests that it is the World Bank that carried the idea of developing PBF. The PBF program in Cameroon included several prominent policy entrepreneurs who played important roles in agenda-setting, as emphasized by the Kingdon model. These included officials from the World Bank and the Ministry of Health. Some senior officials from the World Bank were working on both the situation in Rwanda and in Cameroon. They saw, through the early and encouraging results from Rwanda (77), an opportunity to introduce the same strategy in Cameroon. Therefore, these players from the World Bank initiated a policy dialogue with decision makers from the Ministry of Public Public Health, through meetings and presentations of evidence from Rwanda, to consider how Cameroon could adopt such an approach.

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"And then working on Cameroon, you know, I began... and I think once I did a presentation you know at the Ministry of Public Health in Yaoundé about the Rwanda experience, and there were various other things that the World Bank was recognizing is part of this global movement. So when we put the health project together, we thought that this, you know, testing out this approach will be really a good thing in the Cameroonian context" NB_Partner3

Although there were recognised problems, as mentioned above, as well as policies mandates / directives, the PBF program was not on the agenda of policy makers until the end of 2007, when the World Bank initiated and supported the participation of a delegation of officials from Cameroon’s Ministry of Public Health in a PBF study tour in Rwanda. Thanks to promising results that were showcased during the study tour, these officials, who can be seen as political entrepreneurs, came back very motivated and acted as catalysts for change. They succeeded in coupling the two streams of problems and policies. "Already when we came back I think in 2007 from Rwanda, we made a presentation to all the officials in the Ministry. What they said was that we were enthusiastic and that it was not sure that what Rwanda was doing would succeed in Cameroon" NB_Policy maker3

The network of experts from the World Bank and officials from the MoPH played a crucial role to persuade, through lobbying, the government to consider the PBF as a program of high priority and importance. These policy entrepreneurs used evidence from Rwanda to claim that the current health financing mechanism in place was not effective. They tried to convince high-level authorities at both the Ministry of Health and the Ministry of Finance. These people, who were determined to place PBF on the agenda of policy makers, had good communication, lobbying and networking skills and also had important political connections. They used their skills to persuade all influential officials to join the development of the PBF program. The presence of political entrepreneurs was an important factor in opening windows of opportunity towards political innovation by linking the three streams of problems, orientation and solutions.

Windows of opportunity A series of meetings and international workshops contributed to push PBF in the agenda. The adoption of the PBF program coincided with the reform of public finance laws. Largely driven by the government, the reform was a public symbol of the presidents' commitment to transparency. This was marked by a shift from an input-based budget to a results-based budget. Some players recognized this as an element that weighed considerably for the emergence of the PBF approach in Cameroon. "Public finances were governed by the law of 1962 that evolved, and then in 2007, there is the 2007/2008 law of December 26th, 2007 that reforms public finances in Cameroon, changing the budget from a means-based to a results-based budget " NC_Policy maker1

The idea was also fertilized by the context of institutional reforms within the health system, with the adoption of the sector wide approach (SWAP), where we also noted the involvement of high-level players. There was the implementation of a health sector support investment project (HSSIP), under the SWAP. This opened a window of opportunity and prompted the Ministry of Public Health to make the PBF project a high priority within the HSSIP framework.

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Moreover, a contracting approach between the public and the private sector was already proposed as a solution in order to improve the performance of health systems. In this respect, the MoPH was engaged in a contractual relationship with the confessional health system. To support the State in its mission of public service delivery, the choice made was henceforth to apply the market rules in the management of health services through the implementation of tools that allow real time measure of the health structures' performance. The process of contracting within the health sector actually started from 2000s where conditions were progressively put in place for the development of this policy: a collaboration framework (2001), a health sector strategy (2001-2010 ), the appointment of a sub-director in charge of national partnership (2002), and the gradual convergence of several partners around the Division of Cooperation (DCOOP) of the MoPH on the need to develop a global partnership approach (78). The process was accelerated by the coming of the debt relief contract project, that provided a mandate to support the private not-for-profit sector, through contracting. The work of drafting a partnership strategy was engaged in 2003 and ended in 2006 (78).

The results above suggest that the PBF program benefited from a series of national and international meetings, study tours in other countries, and an ongoing health system as well as public finance reforms to become embedded in the agenda of policy makers.

B. Formulation of PBF Cameroon

When the Minister of Public Health and most importantly his finance colleague were convinced of the benefits of the new health financing approach, it was then time to couple the solution and the orientation streams for the formulation of the PBF program. Our analyses suggest that the formulation of the PBF program was made possible by the convergence between the result-based financing solution (solution stream) and the Government’s mandate to improve the health status of populations and above all improve the management of public resources (orientation stream), which coincided with the political preferences of policymakers and stakeholders. The convergence of various flux was initiated by political entrepreneurs (Ministry of Public Health with support from the World Bank) by exploiting a window of opportunity (several meetings focussing on health financing reforms).

Orientation stream The GoC was prompt in embarking in the formulation process of the PBF project because of some existing political agenda at the country level, namely the commitment to conduct the ongoing health financing reform. Most importantly, another circumstance where policy and politics collided in favor of the formulation of PBF was the law on public finance reforms (politics) passed in December 2007. This law shifted the Cameroon finance law to the result-based budgeting scheme and served as the legal framework that enable the smooth penetration and formulation of the PBF in the health sector in this country.

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"Public finances were governed by the law of 1962 that evolved, and then in 2007, there is the 2007/008 law of 26 December 2007 that reforms public finances in Cameroon, changing the budget from a means based to a results based budget " NC_Policy maker1

The idea was also fertilized by the context of institutional reforms within the health system, with the adoption of the sector wide approach (SWAP), where we also noted the involvement of high-level players. There was the implementation of a health sector support investment project (HSSIP), under the SWAP. This opened a window of opportunity and prompted the Ministry of Public Health to make the PBF project a high priority within the HSSIP framework.

Policy Stream According to the respondents, the Government of Cameroon through the MoPH approached the World Bank for financial and technical support. The outcome of the negotiations from these partners paved the way for the formulation of the PBF project in Cameroon. "...For the formulation of the PBF project like I said, Cameroon wanted to borrow money to improve the health of its people.... Then a consultant came, and did a mission to see if it was feasible, and then there were missions in 2007, 2008, 2009, to evaluate the situation and see how a PBF project could be designed ". NC_Policy marker4

The original Cameroon Health Sector Support Investment Project was a five-year US$25 million project (US$20 million District Service Delivery + US$5 Institutional Strengthening). It received the World Bank Board approval on May 29th, 2008, and became effective in March 2009. The project underwent a Level-2 restructuring on June 13th, 2011 and again in March 2014, with a revised closing date of January 31st, 2016 (79). Moreover, readily available funding from the World Bank was a monitory window of opportunity for the formulation of this project. Actually, a loan of 25 million dollars served as a catalyst for the political impetus in the formulation of the project in Cameroon. "It has to be said first of all that this project has been the signing of a credit agreement No. 4478CM of a sum of 28 ... 20 million dollars ... sorry 25 million dollars, that's $ 25 million to support this form of innovative financing strategy" NC_Policy marker2 This loan came within the context of the concessional rate loans programs of the International Development Association (IDA) at first, then later in the Trust Funds program. "Like I said, Cameroon was a little advanced. Cameroon had a credit in place before the Trust Funds was set up. That is to say that for many countries, the Trust Funds served as lever. In Cameroon, it is the credit that served as lever "NB_Partner4

The Government’s commitment to the PBF project led to the establishment of a steering committee comprised of representatives of various ministries. This steering committee, which was under the leadership of a senior official of the Ministry of Public Health, very close to the Minister of Public Health, legitimates the priority given by the government in this project. Although this inter-ministerial committee was created, the data shows that a key issue in the formulation of the PBF program was the weak participation of sectors other than health, such as the Ministry of Labour and Social Welfare and the Ministry of Finance. In addition, some key directions of the MoPH such as the human resources department, that of pharmacy and

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medicine, were not significantly included in the project formulation. Their views were sought from time to time without being structured within regular and planned interactions. "If people understand by central level the central technical departments, yes, they have not been heavily involved" NC_Policy marker2

The data also shows that the initial project implemented by CORDAID in the East of the country contributed a little to the formulation of PBF program in Cameroon. The understanding of the CORDAID project by officials of the MoPH was that it was a very localized intervention that probably deserved support from the government. However, the political entrepreneurs did not consider it as a pertinent experience on which it was possible to capitalize to help the start of the government PBF project. The interviews with some respondents who played key roles in formulating the program give us more insight: "Well frankly I think the project [CORDAID project] has come along in some way ... there was not even an analysis at CORDAID for a claim to inspire others. All that was not clear. First, it was very localized. It was not known. Even to the ministry people did not know what was happening in the East" NB_Patner4 "The fact that we added the East2 is because CORDAID was already piloting a similar project there. So we just needed to extend the CORDAID project to the 14 districts...... So technically, we did not base ourselves on the experience of CORDAID in the East to formulate the project, but rather added the East because of CORDAID" NB_Patner1

The design of the project was conducted by international consultants contracted by the World Bank. This followed the signature of the loan agreement between the World Bank and the GoC. The consultants came, did a feasibility study and designed the project. The consultants transferred the design of the great lake model and adapted it to Cameroon. They also brought the PBF ideology and rhetoric which were important for the process. Moreover, one of the consultants designed the Cameroon international PBF course that became a mainstream strategy to diffuse the PBF approach within the francophone African countries. The approach was not very participatory and did not involve significant discussions with different stakeholders. "...For the formulation of the PBF project, like I said, a consultant came, and conducted several missions in 2007, 2008, 2009, to evaluate the situation and see how a PBF project could be designed. The approach was not a participatory approach where everyone sits down and discusses. Consultants came, evaluated the situation and proposed things that the Ministry and the World Bank validated together. So this is how the design of the project was done ..." NC_Policy marker4

Globally, the Cameroon PBF model was based on the Great Lakes experiences, and most especially that of Rwanda. Indeed, contracted consultants had built their experience in the country that already showed initial positive results (77). It should be noted that, in addition to the model proposed by international consultants, the World Bank team added an impact evaluation of the PBF program that was implemented. Four out of ten Regions of Cameroon were selected for the implementation of the "PBF pilot project". These were the East, Littoral, North-West and South West Region. The East Region was selected because the PBF was already implemented there since 2004 by the Catholic Church, with the support of CORDAID.

2 the eastern region was added as a fourth region for the implementation of the project

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On the other hand, the selection of the 3 other regions (Nord-Ouest, Sud-Ouest and Littoral) was triggered by the presence in these regions of the Special Fund for Health Promotion, a community-based entity put in place by German Technical Cooperation Agency (GIZ) to promote the availability and accessibility of essential drugs and other health products at the community level. "...... The regions concerned were the Litoral with 4 health districts, 4 health districts in the North West, 4 health districts in the South West and 14 health districts in the East. I think I should explain a little here. In fact, when we assessed the project, we realized that there was a structure that was developed with the support of GIZ at the time GTZ. .... So, given all that I have said, when we evaluated the project, we said ah! If there are structures that were able to operate even in the informal sector in order to improve health services, we saw that there were no drug stock outs, that drugs were available, and they had even began to invest because they had a small warehouses for the medicines they distributed, they had even begun the construction of their drug stores. So they were functional until the project was evaluated. And so we said: we will use these structures as well to try to implement the PBF. So, it was the Littoral, the North West and the South West Regions that were endowed with such structures. These are the three regions that were presented from the beginning and that’s how they therefore were included among the selected regions to support this project in its pilot phase ..." NC_Policy marker2 "You know we wanted to work in areas where there was either capacity and/or interest to do this kind of work. So South-West, North-West and Littoral were seen as good candidates because there were already funds there [RFHP]" NB_Patner3

At the regional level, the criteria used to select the health districts for the pilot test were mainly the performance indicators. In the North West Region, for example, 4 health districts namely Ndop, Fundong, Kambe and Kumbo were selected on this basis. "…In fact, I was there when the Health Districts were selected and I played a big role in selecting the Health Districts because the health parameters were low and we selected these four in order to see what difference it will make because they were even lower than the others in the health performance districts..." NI_Policy marker2

The population size of the districts was another criteria. Health districts with larger population were prioritized. This was the case in the South West Region where Buea, Kumba, Limbe and Manfé were selected. "Yes, there were many criteria for choosing the districts for the project: i) the size of the population; ii) the performance of the district. So in South-West we have Limbé health district, Buéa health district, Kumba and Manfé which were the district that were chosen and which were involved in PBF in the region...." NI_Policy marker3

Moreover, in the Littoral region, geographical distribution (i.e., urban versus rural) was used as a selection criteria for health districts. In this region, one urban, one semi-urban and two rural health districts were included the project. "So for this approach in our region, four pilot districts were selected. There is one district in the city which is the urban, it is the Cité des Palmiers district; a semi-urban district, the Edea district; a district that is almost rural, that of Loum and a rural which is the Yabassi health District. So then these districts were selected on certain basis. Understand that the basis were: urban, semi-urban" NI_Policy marker1

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Policy entrepreneurs The formulation of the PBF project in Cameroon was the fruit of the cooperation between the officials from the MoPH (central and regional level) and actors from the World Bank, most importantly consultants contracted by this institution. International consultants contracted by the World Bank played a pivotal role by convincing the MoH that the great lake model was the suitable PBF approach for the Cameroon context. In addition to the financial support, the World Bank played an important role in imbuing some central MoPH cadres with the PBF approach. This role contributed to the emergence of local officials with PBF-related skills. This pioneer local staff was then able to vouch for the formulation of the new PBF program across regions. This motivation and commitment at a higher level must have played an instrumental role in the formulation of PBF in Cameroon. "There were quite a few people who were trained in PBF, Regional Delegates of public health and some people who became the managers of the PPA" NB_Partner1

The management staff of the initial PBF project implemented by CORDAID in the East Region influenced to a certain extend the formulation of the PBF project in Cameroon. An advocacy spearheaded by this staff resulted in the enrollment of the East Region into the government PBF project. "It was in 2008 that we went to Yaoundé and finally met the people in the Ministry and also in the GIZ. But they were not aware of the project in the East. So we discussed with them, arguing that: listen, you want to start the PBF and we have already been doing this for three years in the East. We want to expand because the Catholic approach is only for Catholics, so we want to convert this to a broader approach but we lack the means. It was at that time that they finally agreed to insert the East in the project of the World Bank ..... That's how the East got into this project" NB_Partner5

It emerged from the data that the development process of the PBF in Cameroon faced opposition from some actors, mainly from other assistance or cooperation agencies. These actors in many cases were protecting the integrity of their interests and projects’ agenda. With the support of GIZ, the Cameroon Government initiated in 1987 a pilot model in the North West Region that involved the community to improve drug management at the regional level. Based on the success of the approach, the model was expanded to two other regions later on: South West (1989) and Littoral (1991). Known as the "Essential drugs program" and initially grounded on associative framework, this model became RFHP in December 2010, with a public interest group status thanks to a law. The RFHP are regional dialogue structures and consist of representatives of the beneficiary communities, the Ministry of Health and donors and thus constitute participatory governance bodies in the health system. The RFHP are more or less autonomous structures with no hierarchical or formal link with CENAME. Although at the end, GIZ appeared as a facilitator in the selection process of the 3 regions (Littoral, North-West and South-West), our data shows that in the beginning, this important partner was not favorable about using the RFHP as purchasing agencies for the PBF project. However, it was not that influential compared to the World Bank so their resistance did not dampen the formulation of the project. "No ... well I think since it was GIZ who supported the Funds [RFHP], of course there was this discussion with GIZ to use the Funds for the PBF and as you well know, GIZ was against

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PBF in the beginning uh maybe specifically because of the free drugs choice policy" NB_Partner1 Conversely, domestic players did not explicitly express opposing views regarding PBF. It seems this was due to the fact that the PBF approach was new and therefore probably unknown by policy makers and healthcare entrepreneurs. "Initially, there were very few people who supported at the partner level because it was changing the traditional way that people did things and therefore people were not so comfortable to do so. In terms of partners, there were very few who supported it. At the Ministry, the central departments did not feel concerned at all, they did not feel like it was their business" NB_Partner4 At regional level, the Regional Delegates for Public Health with the support of the district medical officers led the selection process for the pilot PBF health districts. Also at this level, the formulation process of the PBF project was challenged by the resistance of some members of the Regional Special Funds for Health who were afraid to lose control over these structures. Actually, the implementation of PBF using the Special Funds as Purchasing Agencies required the adjustment of the status of these entities to enable them receive public funds. "The obstacles were that members of the management committees of the RFHP thought they would lose their autonomy as members of the regional dialogue structures" (NC_Policy marker3)

Windows of opportunities Evidence shows that international and national meetings served as windows of opportunities, and contributed to advancing the PBF formulation agenda in Cameroon. A first event was the Africa flagship course on health sector reform held in Kigali (Rwanda) in June 2010. During this course, a World Bank official from Cameroon presented the formulation process of the PBF project in this country and received feedback from other participants mainly from the Great Lake countries where PBF was already being implemented (48). In addition, some consultants who were in charge of designing the Cameroon PBF program were also participating at this meeting and they used this opportunity to interact with two other participants from Cameroon who will later on be AAP managers during the implementation phase. The Results-Based Financing (RBF) Third Annual Impact Evaluation Workshop held in Bangkok in October 2011 was another forum where the formulation of the Cameroon PBF project was enriched. At this meeting, participants including high policy makers and World Bank officials from Cameroon were drilled on impact assessment of the Cameroon PBF projects. Most importantly, during this meeting, Cameroon featured as Country Case Study for the integration of Impact Evaluation into the PBF program design (49).

C. Implementation PBF Cameroon

At the end of the third quarter of 2009, the PBF project was formulated and had to move to the implementation stage.

Problems stream

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Our analysis pointed out the main problems faced by the health system that required a change. This included the legal environment of the country, with laws that dated back to the 1980s. Some of these laws were inconsistent with PBF’s best practices. In some places, certain people began PBF by putting these laws on hold, and others did not have the same courage and did not apply certain PBF principles. Some controllers and inspectors who arrived at health facilities understood that the PBF was a pilot project and thus tolerated non-compliance with the laws in force. On the other hand, others took this as a violation of the laws and as utter threats. This led mainly to the lack of financial management autonomy for some health facilities, sometimes causing tensions between hospital directors and the inspectors from the department of finance. Indeed, the finance laws required that hospitals deposit their incomes to the public treasury and to withdraw them later, after justifying the use of funds with a preliminary budget draft. In contrast, the PBF guidelines required that all revenues of health facilities be retained and be available immediately to improve the quality of care. "The finance law requires that money produced by the hospital must be deposited at the public treasury. You see? With the PBF, you need to retain the money; but with the finance rule, you do not have the right to retain the money. The finance law is against PBF. The proof is that the health centers, hospitals, must produce their money and deposit it at the public treasury. But this is absurd! I fight against this procedure. Someone has his money, instead of using it to produce more, you ask him to go and deposit it into the public treasury. Where does their money go? How do they get it? At the end of the day, you have to walk behind someone in the treasury office in order to receive part of your money, and this is after a commission of 10%, 20%". Reference NI_Implementer10

The lack of human resources management autonomy was also an issue. Despite the fact that some health facilities recruited local staff and paid them with their financial resources, staff management remained centralized. Sometimes health facilities influenced the posting of personnel in their structures by the MoPH while they were already overstaffed and, on the other side, best trained PBF personnel were snatched from other structures, leaving them to start all over with new people. This instability did not reassure the staff of health facilities to invest their revenue to improve the productivity of the health facility in order to benefit in future. They were not sure of being there later to reap the benefits of their sacrifice. "... So we have a centralized management of human resources. That's a big problem. How are we going to solve this? It is a difficulty. You see ... But if the state had a system let’s say for example that a health center must have 5 trained staff, and their wage is wired to the health center. The day that these staff do not work, they do not have their payment. You ...the head was supposed to have authority over your personal such that if you do not work, you do not even have salary and he recruits someone who is available to do the work. " NI_Implementer2 The late payment of health facilities and health services was a major challenge for the PBF in Cameroon. Delays of up to six months following submission of the payment constituted difficulties for the health facilities regarding the execution of their business plans. "Yes, the payment! Because what happens is that you are supposed to be paid at the end of each month when you declare what you have done. When you do your declaration it is paid but it is not regular sometimes for instance up to the end of year we were not paid from June". NP_Implementer25

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"The main problem with payments is that the payments were delayed and this makes our work difficult. For example, if the business plan shows that we are to purchase some articles at a particular point in time, the lack of these funds keep us helpless". NP_Implementer22

The abilities of some health facility managers to take responsibility for the transparent management of huge amounts of money given to them, using management procedures that they were not used to, was very challenging. "So, how can the personnel who was familiar with small amounts of money now manage such a huge funds? This is another problem. And we detected that many do not even know how to spend in a manner that respects public spending standards. They have to be trained on how to use these funds in a transparent manner because the aspect of good governance is very important in the PBF" NI_Implementer2 There were also risks of conflicts of interest for the RFHP, the organisation that held the monopoly of sales of essential medicines in public health facilities before the PBF program. The pharmacies of health facilities belonged to the RFHP, which kept the profits from the sale of drugs. With the coming of PBF, pharmacies of the health facilities were reassigned to health facilities, and in addition they had the freedom to buy their drugs elsewhere apart from the RFHP. The majority of health financing in Cameroon is allocated to the central level of the MoPH as well as the central and general hospitals. The operational level receives a small proportion of the funds. In 2005, only 34% of the budget of the Ministry of Health was allocated at the peripheral level compared to 61% at the central level, despite the fact that 80% of the population uses services at the peripheral level (80). Moreover, several key informants noted that only a very small part of the proportion that is allocated to the peripheral level actually reaches the health facilities, due to enormous administrative procedures and corruption. "But you know the input system? Eh, the ... the ... the management is centralized in Yaoundé. Before money leaves Yaoundé on paper, only 3 to 4% may be left. There are leaks throughout. And what are the consequences? The consequences are that health facilities are poorly equipped, they are old, the staff is demotivated, you see? Priorities are not those expressed by the facility itself; it is someone who is in Yaoundé who decides what to put in place in a health facility which he has never seen" NI_Implementer10

District Health Services do not do regular supervisions due to lack of financial resources. Some data indicates that the District Health Services imposed payments from health facilities equivalent to a certain percentage of their budget to enable them to conduct their supervision and coordination activities. In addition, the equipment purchased by the central level and sent to the peripheral structures do not always match their needs.

Policies Stream Once the formulation was done, the project had to find a suitable model to be implemented at the level of regions. In order to ensure the sustainability and ownership of the intervention, as well as to build on what already existed, policy makers identified, in each region, structures with some degree of autonomy that already played a key role in the health system. These structures were recruited to ensure the role of the Performance Purchasing Agency. The Regional Funds for Health Promotion (RFHP), which are dialog structures in the regions, consisting of technical and financial partners (1/3), members of the community (1/3) and

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members of the administration (1/3) existed already in three regions (Littoral, South West and North West). Their main mission was to supply of essential generic drugs in health facilities. They also had a certain level of credibility and autonomy in the way that they managed their financial resources. The policy makers decided to rely on RFHP for the implementation of the project. "It was giving some good results in these two interesting Funds [RFHP], North-West and Littoral. And we thought : there must be something that we can build on with these activities because first of all, all these things had several elements in common. One was: there was a sense of accountability, there was an important attachment to good governance, there was participation from several society. And most importantly, they were getting some good results from...like for the two funds, you know, the drugs were available, and the inputs" NB_Partner3 The East Region did not have a RFHP, it was initially proposed that the government would sign by mutual agreement a contract with CORDAID, which was already implementing a smaller PBF Project. The government committed to provide 2.5 million Euros to CORDAID for a 2-year period during the intervention. Negotiations were well advanced and activities were about to start when suddenly, the Government decided to stop the process, following a recommendation from a consultant hired to formulate the project. This interview abstract is from one of the key informant on this subject: "Back in 2008, at that time the MoPH told us to propose a project without a call for tender, and over time I even went to the Diocese of Batouri to develop a project document and I have it here in front of me, it’s a project from 2009 to 2012, on request of the MoPH. This project, we formulated it and negotiations dragged on ... and finally, I think in 2009 ....., the project was accepted, and we even started. We had an opening session with the governor to start this project in the East, and it was about to start in the Diocese of Batouri. It is the World Bank consultant who told the minister not to execute this project. So, there was a workshop to launch this project, but the official documents of agreement was not signed yet, and finally the activities of this project never started; it was in 2009" NB_Partner5

We further investigated the reason why the Government decided to stop the process of the mutual agreement with CORDAID. According to stakeholders, the main reason was the fact that the initial CORDAID project (RESSEC) on which the agreement was built was too closely linked to the Church authorities and could not be objective in playing the performance purchasing role. "In the East Region, there were major concerns notably the fact that RESSEC was linked to the Catholic diocese and may not be able to assume the performance purchasing role with public facilities. NC_Policymaker4

In the Littoral, North-West and South-West regions, although RFHP had already been identified to implement the project, there were no major advances. The difficulties were related to the ability of these RFHP to implement the interventions. Amongst these difficulties, there was the problem of qualified human resources, especially the managerial vision of these entities, which in their design and mandates were not accountable for performance. In addition, the regulations in place did not allow the RFHP, which were public interest groups, to receive public funds and to manage them according to market rules. "In fact, from the point of view of designing PBF … it was thought that what was there could do the job and that we could use the tools and structures that existed to do everything. None

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of these structures had a vision and understanding of what the project was". NI_Policymaker3 A re-assessment led to the conclusion that of the three RFHP, only that of Littoral had sufficient capacity to be able to implement the project. The alternative that was offered was to recruit international organizations with experience in the implementation of PBF to ensure the PPA role in the other three regions (East, North West and South West). These structures had to play the role of PPA and would in turn have a contractual performance relationship with the health services and health facilities, that allowed them to directly receive cash funds according to their performance and decide priorities to solve with these funds. "Special Funds already existed but they were working on drugs, they did not know PBF. Well, in evaluating the project, we said: It is them who will implement PBF. The Littoral was able because it had qualified personnel. What therefore happened to the other regions? So the Ministry and the Bank agreed to recruit international actors with proven experience in PBF, who had already implemented it in other countries, on the basis of an international open tender. Thus the European Agency for Health Development, that is AEDES won the contract for the North West and South West. They were therefore the ones to develop the performance purchasing agency in each of these regions" NC_Policy maker2

Policy entrepreneurs Several actors played various roles in the PBF implementation in Cameroon, namely policymakers from the central and regional levels, RFHP managers and technical assistants from international organizations. HSSIP ensures the management and coordination of the project at the national level and the Project Steering Committee provides strategic orientations. The project coordinator and the president of the steering committee played an important role in bringing the regional delegates of health to adhere to the project. Most importantly, they negotiated the participation of regional administrative authorities, especially during the launching of the project and they contributed to the randomisation process of groups for impact evaluation. These authorities from the central level of the Ministry of Health built alliances with actors from the regional level to couple the problems with the policy streams. With their good communication skills, lobbying abilities and political influence, they were able to persuade the majority of the peripheral actors to adhere to the implementation of the PBF program. The Bishop of the Diocese of Batouri and his team were also key actors in the implementation of the PBF program in the East Region of the country. They influenced the Minister of Health to extend the project to this region. "What is it all about my lord? CORDAID, are you the one experimenting? The Minister was not aware. CORDAID gave the floor to his lordship. His lordship returned the floor to us. I presented the project and its strategies .... when we presented this approach to the Ministry and the Bank, the Minister Olanguena said to the World Bank officials: I think you're right. I’m convinced by this approach. I think that the East should be included" NI_Implementer2

The Littoral RFHP was the first entity to start the implementation of the PBF Project in late 2011. It influenced the implementation of the project in the other three regions. At the Littoral RFHP, the following key actors succeeded in negotiating the autonomy of the PPA, despite the risks of conflicts of interest: the Littoral Regional Delegate of Public Health, who was the

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president of the Littoral RFHP management committee, the Manager of the Littoral RFHP and the PPA Manager. The technical assistants of AEDES and CORDAID also contributed to the coupling of the two streams. They drafted the project implementation procedure manuals in their respective zones of intervention, and were able to mobilize other actors, such as community-based organizations, to be part of the project. In the North West and South West Regions, these actors continuously negotiated with the FRPS to ensure their adhesion to the project and especially their ownership. The presence of all of these political entrepreneurs was an important success factor in the opening of the windows of opportunities during the implementation of the project by connecting the two streams of problems and policy. In contrast to the Littoral RFHP, the RFHP of the North West and South West were not very enthusiastic about joining the project. Although the actors of these regional entities did not explicitly express their opposition with respect to the PBF - this may be understandable due to the fact that directives came from the highest authority of the Ministry of Public Health -, their attitudes, however, suggests that their position was much more mitigated. "Because I'll tell you that the former manager of the Funds had been so resistant to the PBF. I think it's one of the reasons uh ... that led to its replacement" NI_Implementer10

Windows of opportunity The implementation of the PBF program benefited from a series of national, regional and district meetings in order to move forward. In the East, North-West and South-West regions, the official launching of the program was coupled with a two-day workshop. Participants were frontline managers, community representatives and regional health stakeholders. The PBF national coordination actors, the World Bank officials and the international implementing agencies used the opportunity to explain the underlying principle and the raison d'être of the program through several presentations, followed by discussions. The majority of implementing actors in health facilities were trained in cascades during one- week courses by the Performance Purchasing Agencies, health districts and regional health delegations. These training opportunities helped them understand the PBF project and apply its principles and best practices. "We had one week of training at the regional level. After the regional level training, we came back to the level of the Division where there was a one-week training. The first training was in Bamenda at the regional level, our second training was at the district level". NP_Implementer1

"We had a training on everything that concerns PBF: why a PBF program, how it will function. So the training here was to see how the PBF activities should be carried out. With training, people understand the project and then are motivated and there is an effort to implement the PBF principles and best practices, especially regarding the autonomy, which has given much zeal to others to be able to implement it, although there has always been some bottlenecks" NP_Implementer19

In each of the four regions, a quarterly 3-day meeting in each district that was implementing the program was scheduled to review the performance progress of each health facility. This coordination meeting was a real opportunity to improve the knowledge and practice of the

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front line managers. During the meeting, challenges related to the implementation of the program were discussed and solutions were sought. Moreover, it is during this meeting that the contracts between the PPA and the health facilities were renewed on the basis of a new quarterly business plan. "Each quarter, we have a restitution meeting in which we sit down, and we look at performance at the district level, performance at the facility level ok, the facilities are based on three different categories and … based on that they have subsidies which are paid to them. Everybody is challenged at the different levels; at the district level, the district medical officer is challenged, the director of the hospital is challenged and when we meet we identify factors that cause poor performances and look for solutions". NI_Policymaker4

Other important opportunities seized by the PBF stakeholders to improve the implementation of the program were the inter-PPA meetings. Under the coordination of the PBF national coordination unit, a quarterly rotating meeting was organised between the four PPAs, the PBF project management unit and the World Bank. Problems that could not be solved in situ during the quarterly district coordination meeting were reported and discussed during this national coordination meeting. For instance, the harmonization of the implementation of the program across the four regions was a major recurring theme of the meeting. Finally, two national focussing events were organized by the World Bank. On September 12th - 13th, 2012 following a supervision mission in the four regions, the World Bank convened a workshop in Yaoundé to discuss the progress, challenges and the way forward for the successful implementation of the PBF by the four PAA (55). An interesting point discussed during this workshop was the finding in bind with the imbalance in favour of curative services at the expense of preventive ones in the delivery package of PBF activities. The second event was the PBF national meeting on May 14th - 16th, 2013, that followed the mid-term evaluation of the program (56). Major findings and solutions were discussed in order to improve the implementation of the program.

"So during the assessment in May 2013, multidisciplinary teams visited the four regions. The teams consisted of people from several departments of the MoH, partners, etc. They went and evaluated how the PBF was running on the field. The evaluation intended to see if the implementation was going as planned, to address the challenges encountered and propose solutions". NC_Policymaker2

Perceived changes The assessment of changes recorded with the introduction of PBF was mostly positive. According to interviewees, data management and reporting improved significantly in the PBF facilities. Patient statistics that were not initially being collected were collected when PBF came. The emphasis on data and monitoring, which stimulated better reporting, benefitted both the health facilities and the districts. In addition, through improved data quality, it also increased the potential to improve the health management information system and decision- making for other interventions. "The PBF program has changed the system considerably. It has brought the improvement of completeness and timeliness of data. And not only PBF data per se, but of the overall system. Now, using data from health facilities, we are able to plan the best areas of intervention. This was not the case before the arrival of the PBF". NP_Implementer25 "Before PBF, when we were told to carry out vaccination, we used to go and sit under a tree, then check and fill the records. And few days or months after, there were measles outbreaks

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because no child was actually vaccinated. Now with PBF, you cannot do that because as soon as you check immediately, as soon as you come out, you send the report, two teams will go down. Guys from the PAA will come to check what has been done through direct observation and community survey by the local community based association. If those children are vaccinated, the community itself will testify". NP_Implementer16

The drivers of success at the health facility level were related to clarifying the roles and responsibilities of staff, enhancing supervision from the regulation level, and increasing the reliability of service delivery from the financing and verification agency. Facilities required support in planning and data management, as well as regularity in funding in order to demonstrate to communities that quality services would be available. The appreciation of the PBF program reveals that changes in work attitude occurred as workers became more committed and where challenged to produce good results.

"We observed a change in the provision of health care facilities. Our registries revealed that we gave consultations to many more people in a month than before. Moreover, today there is a better division of labour: some personnel consult, others take care of the registries, others take care of the pharmacy while others work in the laboratory. This prevents staff from being over worked, rendering them more efficient at their various tasks. This was not possible before". NP_Implementer22

The PBF approach pushes a level of autonomy to allow service providers to be imaginative and inventive in order to improve the quality of care in their facilities. One such way was for each health center and hospital to develop its own business plan stipulating activities to be achieved in each quarter. This was done by all staff in participatory way in order to create a sense of ownership. Informants in the in-depth interviews reported that they conducted their daily tasks without any business plan before the PBF program. After the PBF training, though challenging, things changed in some of the facilities as narrated by a chief of health center: "There are lots of changes with PBF because the staff is now awake, work is now running seven days per week, 24 hours / 24. And so, I think that's always the PBF vision which facilitated the promotion of that program and especially the development of the business plan. For example, the laboratory that used to be opened five days per week, now it works 7/7". NP_Implementer13

Most of the participants implementing the project indicated thatthere were no clear financial systems in their health facilities before the PBF program. With the PBF, all the staff sat together with the community representative to establish a financial system in their facilities. This improved the facility management. The PBF provided materials and equipment in the hospital. Improvement of the governance was also mentioned as a great achievement of the program. “Before the PBF came here, there was no placental pit, we dug the placental pits. Thanks to PBF, we have bought many beds, and that is a fridge there, a fridge which uses both electricity and gas bought with the PBF funds. Then these blankets we just bought with mosquito nets, all these things were not here” NP_Implementer20 "It's a magic pill [(laughs), magic pill], it's a magic pill. It is what we have to encourage. Decisions should be taken according to needs. It should not be taken from above because it has changed the face of hospital and between these months, between this period I can say the change that we have had in two years is greater than what we had in twenty years". NP_Implementer8

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Globally, informants mentioned that there were improvements in patients flow, community satisfaction, standards of care and health personnel motivation. "Yes, for example, the consultation rate has increased, the delivery rate has increased, quality of care has improved, operation with the presence of doctor and outreach activities have been put in place". NP_Implementer2 Most of the benefits mentioned were those related to the workplace. Nevertheless, the interviews revealed some positive appreciation at the community level. Beneficiaries of the PBF program mentioned that they appreciated the changes brought by the PBF program, especially in regards to the improvement of the quality of care. Moreover, they reckoned that the health personnel became more responsible and accountable. Interestingly, the vulnerable population seems to also profit from the program due to some innovative strategies that health facilities attempted to put in place in order to increase their utilization rate. "Now in the health center, orphans or vulnerable children, when they don't even have money they can have a consultation and they'll be still given drugs, and this is because of PBF". NP_Beneficiary3 "At first, all of us here, we were not even interested in the health facilities around because there was almost no staff, and even the services were expensive. And we used to hire vehicles to go to Njinikom (75 km). But now, everything has changed and all the people here now use the health facilities around. Even Bororos who used to deliver at home are using now the health center". NP_beneficiary7 Despite the above-mentioned positives changes, there were some concerns about the cost of such a strategy. The big concern focused on the sustainability of the PBF program. Many KIs raised concerns about the medium and long-term sustainability of such a program when external funding elapses. "The PBF is a very expensive way of reaching results, I mean we have to pay the health workers, medical doctors or nurses or I don't know who else to perform while they received already a salary. My question is certainly on the long term because now this initiative is heavily funded by the World Bank. What if the World Bank withdraws and there is no other financial or technical partner? For some years, as the World Bank invests in PBF, that same nurse will have not one hundred but one hundred and thirty thousand. Now if the World Bank withdraws she falls back to one hundred, will she continue to do what she did for one hundred and thirty thousand for one hundred thousand? The sustainability of the PBF is not certain after the World Bank will withdraw the PBF funds in Cameroon". NC_Partner4

Some abnormalities were noted on the field such as the selection of incentivized activities. Some care providers focused more on paid activities while neglecting the quality in order to increase quantity. "Other problems … is that the staff now tends to focus on indicators that produce more money at the expense of the others. And it is the population that suffers. Other things, they also tend to focus on the indicators with higher per unit cost and that are easy to achieve, so that they can quickly get money". NC_Policymaker2 "I can tell you that one day I went to supervise a health center in a remote health district. And when I arrived in the morning, I saw the security guard with a registry. Not knowing who I was, I asked him what he was doing and he answered: I am the watchman, I just finished work, I'm doing my home visit. You see ... it's the watchman, a security guard. who does not understand anything, who was carrying out the home visit. Is this a home visit? What advice

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is he giving? The only thing is that he fills out the registry in order to have money". NI_Implmenter10

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VII. TRANSFER OF THE PERFORMANCE PURCHASING AGENCY (PPA)

The handover of the purchasing role from an international operator to a national agency is analyzed following an adaptation of the Dolowitz framework on policy transfer. Drawing from this framework, we broke down the transfer process into several key dimensions: i) Engagement of the transfer ii) Actors involved in the process iii) Purposes of the transfer iv) Sources of transfers v) Different forms of transfers vi) Factors that promoted or restricted the transfer and vii) Appreciation of the transfer. We identified the dates that correspond to two key events in the transition phase. These dates allowed us to segment the transfer process in 3 phases: (i) a pre-intensive phase, (ii) an intensive phase, and (iii) a post-transfer phase. These two events are: 1) the PPA meeting that was held in September 2014 and 2) the end of the contracts of the international organizations (particularly AEDES) on December 31st, 2014. The period before September 2014 corresponds to the pre-intensive period. The months of September through December 2014 corresponded to the intensive phase. The post-transfer phase started in January 2015. During the inter-agency meeting of September 2014, the question regarding the level of preparedness for the transfer of the PPA management to the RFHP was raised. The discussions focused on : (a) the inventory of the PPA’s properties and equipment; (b) the PPA’s procedure manuals; (c) the number of personnel who were to be part of the PPA, their profile and their proposed wages; (d) the estimated budget of the PPA (operation and purchase of performance). Following the exchanges on these points, activities were proposed and timelines were set to continue the transfer. A. Engaging in the transfer process In 2009, it was determined that the three RFHP in the Littoral, South West and North West Regions could be eligible for a direct contract with the government, whereas the RESSEC could be eligible in the East Region. However, in 2009, a follow up mission found that the special funds in the South West and North West Regions were too weak and too involved in the monopolistic system of essential drugs. In the East Region, there were major concerns such as the fact that the RESSEC was too closely linked to the Church authorities and may not be sufficiently objective to play the performance purchasing role. Thus, it was decided that a mutual agreement would be given to the Littoral RFHP and that international organizations would be recruited to play the PPA role in the three other regions (East, NW, SW). AEDES was recruited for the South West and North West Regions while CORDAID was the PPA in the East Region. Thus, from the start, the RFHP was identified as a potential entity to perform the PPA role. It was planned that the PPA role would be transferred to the RFHP after a certain period of implementation in the three regions. In the meantime, this role was to be played by international actors. The vision of the transfer was established at the national level by the government of Cameroon, as specified in the contract (47) with the international NGOs that played the PPA role: "... the Ministry’s vision is to ensure that the performance purchasing agency role be progressively assumed by RFHP " "In their terms of reference, it was clear in the signing of contracts that the international organization was to implement the purchasing agencies and prepare the transition. It was

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necessary to prepare the transition and it was already clear at that moment that it was to be passed to the RFHP" NC_Policy maker2 B. Actors Involved in the transfer process Several actors with varying levels of interest and influence were involved in the transfer process. Firstly, there are actors from the central and regional level of the Ministry of Public Health. At the central level, there were mainly officials of the PBF project management unit (PMU). These actors were very influential in the transfer process, because it is primarily at this level that the guidelines and main orientations of the process were established. The transfer of the PPA to national entities was a very important step for the PMU. At the regional level, the regional delegates to whom the powers of the Minister of Public Health were delegated ensured that the directives and guidelines from the central level were respected. They had the ability to influence the implementation of the process and even the decisions at the central level. Thus, the regional delegates of health greatly influenced the transfer process and their level of commitment could facilitate or hinder the activities. The technical assistants from the international organizations (AEDES and CORDAID) were also at the heart of the transfer process. In most cases, they were the ones who initiated contacts and meetings with other stakeholders at the regional level in order to help the transition progress. It should be noted that the mandate of these international organizations clearly stated that they were responsible for preparing strategies to enable the RFHP to take over the project at the end of the contract. The managers of the RFHP were another group of important actors in this process. The RFHP, as the structure that had to take the new function of PPA, was of course a key element in the process. It should also be noted that the regional delegates of health had a dual role in the transfer process. More specifically, they acted 1) as regulator by virtue of powers delegated by the Minister of health and 2) as the chairman of the RFHP management committee. "Well of course the MoPH and the regional funds itself, the local governments, the people working for the purchasing agency currently and some technical experts. And they either came from Cordaid or they came from some...well locally, we have some local experts who have a lot of experiences establishing regional funds and had structure for it and also worked in the transfer". NB_Partner7 "Well, the key actors involved were staff from the RFHP, the PPA and the South West Regional Deligation of Public Health". NI_Implementer7

Finally, an actor, no doubt, less influential during the process, but very concerned about this transition was the GIZ. In fact, it was this German bilateral cooperation structure that supported the implantation of RFHP through technical and financial support. C. The purposes of the transfer Several reasons justifying the purpose of the transfer emerged from the data. Although the project’s contract documents did not mention any justification for the transfer, the objectives of this process seemed quite clear for some of the stakeholders. One of the first reasons for the transfer was the "horizontalization" of the health system. With a configuration where an international organization assured the PPA role, it gave the impression that the PBF project was one of numerous vertical programs that exists in the

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country. The particularity of these programs is related to their partially autonomous functioning in responding to one or a few specific areas of the health system and a lack of integration within existing structures to strengthen the system in its entirety. Moreover, in the context of Cameroon, a vertical program is often attributed to the donor or NGOs who provide financial or technical support to the program. Therefore, it was not unusual for many people in the community and even those within the health system to perceive the PBF project as an AEDES or CORDAID project. This impression was reinforced by the fact that these two organizations that assumed the PPA roles had their offices far from the buildings of health services, and used vehicles that bore no sign of the MoPH, but only the logos of these organizations. "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" NI_Policy maker4

If the point of view described above represents the vision of the operational level players, the understanding of actors at the central level seemed more focused on the aspects of sustainability and ownership of the project. The ownership of the project was an essential issue raised by actors at the decision-making level as well as the partners. In order for the PBF approach to have a chance of being scaled up, it needed to be integrated within the existing structures of the health system. This would increase its legitimacy for the partners and make it easier to defend the government’s budgetary decisions. The objective of sustainability was also partly linked to this ownership dimension. There was no doubt that the concerns of sustainability and scalability of PBF were already part of the issues that arose at the central level of the Ministry of Public Health. The transfer to the national structures was seen on one hand as a strategy to minimize costs (the international organizations were more expensive) and on the other hand as an excellent strategy to anticipate constraints during the scaling up. "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" NC_Policy maker4 "The goals of this transfer as I said, is first of all, the ownership. It’s necessary that the Cameroon government owns this approach more and more. And secondly, it aims... to facilitate the scaling up of the project in the coming years" NC_Partner2 Some policymakers also saw the transfer as a way to legitimize the political ideology of the. However, we were not able to dig further to know whether it was a political opinion supporting or criticizing the actions of the ruling party. "Handling the implementation of the project through a national organisation is a matter of legitimacy, to demonstrate that the government is keen to ensure that citizens are fully part of the project" NI_Policy maker2 The actors from the central level worked with experts from the World Bank, especially those at the sub-regional office in Yaoundé, in order to plan the activities of the transfer process. The World Bank’s main interest in the transfer process, as a technical and financial partner, seemed to be the cost-reduction.

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D. The sources of the transfer It was mentioned in the contractual documents that AEDES / CORDAID would contribute to the training of the RFHP. To this effect, a competence development plan, with specific objectives, expected results and time frame for the results was to be produced and discussed with both the Ministry of Health as well as the regional delegations of health [Item 8. Contractual document] (47). However, only CORDAID was able to provide us the plan. Furthermore, the ministerial decision giving precise guidance for the transfer process noted that the responsibility of AEDES / CORDAID in the management of the Performance Purchasing Agency will be finished when the transfer is complete, indicating unambiguously that the transfer process was to occur from the international organizations to national entities [Article 5. Ministerial decision] (54). Finally, it was planned that the MoPH had to sign a protocol of collaboration with RFHP for the implementation of the project [Article 4. Ministerial decision] (54).

E. The different components of transfer The first form of transfer which clearly emerged from our analysis was the transfer of equipment, logistics and all technical tools. This transfer category labeled as "hard", aimed at moving everything bought or developed by the old PPA to the new PPA to ensure the smooth operation of the project; e.g. computers, vehicles, procedures manuals and others. In accordance with the ministerial note of December 2014 on the transfer, it was stated in paragraph 2 of Article 2 that the transfer would be preceded by an open inventory, with a report signed by both parties. This would be conducted under the supervision of the Regional Delegate of Health (54). The deadline for this transfer was set for December 30th, 2014. "Good, all the equipment has been given to the RFHP, with minutes from the PPA because the contract linking the international actors to the state, says that all equipment acquired during the implementation of the project will be given back to the State at the end of the implementation of the project. So all the equipment was given to the delegates, as instructed by the central level, such that the delegates will in turn give it to the RFHP. So there were three signatories to the minutes: the PPA , the delegation and RFHP" NC_Policy maker2 The other form of transfer was labeled as the "soft". It was about transmitting ideas, expertise, and even what some called "the PBF spirit." This form of transfer was less measurable than the first. It was essentially carried out through meetings, exchanges and trainings. In the East, the common work period of six months was also a great opportunity to strengthen this form of transfer. The third form of transfer referred to the decision-making power. It was by acquiring all the rights to make decisions that the RFHP gained their new title as PPA entities. This decision- making power focused on the content of the PBF program. It included dimensions such as management contracts with the regulators, care providers, and community-based organizations. Although the cooperation agreement between the MoPH and the RFHP was slow to put in place, the right of decision-making was granted de facto since it was guaranteed at the end of the transfer. It materialized by the ministerial note of December 2014 and was enforceable from January 1st,2015 in the North-West and South-West (54). "they transferred.... not only documents. They transfer all their power to the special funds. Because special funds became like the bosses of PPAs ... actually I think that when we say transfer, it is at all levels . ... When there are furniture, logistics, they must transfer all of this to the special funds" NI_Implementer8

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Finally, there was the issue of whether or not human resources would be transferred. There was less unanimity between the technical assistants of the international organizations and RFHP managers regarding this issue. The ministerial directives appeared to leave some shadow areas that are open to interpretation. It was mentioned in point 1 of Article 2 of this note (54) "The present transfer involves human resources, logistics work, equipment and technical tools to ensure continuity in the functioning of the Performances Purchasing Agency". This was interpreted by some actors as meaning that the staff of the outgoing PPA would be transferred to the new PPA. "... The staff who was staff at AEDES will now become RFHP staff" NI_Implementer10 "I can’t really tell the components of the transfer as there is no memorandum for the transfer up to now [End of February 2015]. Eeehhhmm, I think the components to be transferred include: workers, assets, funds (some funds have been transferred representing the 4 months owed to the health facilities). Some workers of the PPA will work at the regional fund. There is no organisational chart or related documents" NI_Implementer7

F. Factors that facilitated the transfer The most important factor that influenced the success of the transfer was the fact that this transition was planned right from the start. Thus, before the project started, the consortium of international actors clearly knew that they would transfer the PPA to the RFHP at the end of their contract. Another main factor that favoured the transfer process was the existence of qualified national staff. Indeed, each year, Cameroon houses international francophone trainings on PBF. Organized by a Dutch firm (SINA HEALTH) in collaboration with some national actors, this intensive 2-week PBF course attracts more than 25 people coming from all francophone African countries. Cameroonians usually represents half of the participants. "We are currently organizing the 6th course, international course, in Douala. The first course was here. All the other managers were trained with CORDAID. 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. ... for example in the Littoral, they had no international organization. It's the people we trained who successfully implemented the PBF in the Littoral" NI_Implementer2 An important point that was at the center of the transfer had to do with the restructuring of the RFHPs. From their original status as associations, the RFHPs became Public Interest Groups, following a law voted on December 21st, 2010. This new legal status confirms that the RFHPs are dialogue structures, exercising a public service mission. It establishes a partnership between the Government, several technical and financial partners, as well as the community of the region represented by the members of dialogue structures. According to this agreement, the RFHP acquired a legal status and financial autonomy. In June 2012, the North- West, South West and Littoral each signed a Public Interest Group convention. Initially, it was legally impossible for the RFHP to receive public funds and to manage them according to market mechanisms. This transformation removes this obstacle. While it initially focused on managing drugs and other health products, the RFHPs have, since October 2013, developed a new organizational structure that includes a support

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department for health promotion activities and partnership. It is this new section which hosts the PPA. "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" NI_Implementer7 A level of commitment from the RFHP was also seen as an element of success in the process. Since the MoU between the MoPH and the RFHP was slow to develop, the RFHP had to take the risk, in some cases, by pre-financing certain activities pending reimbursement. "So we are the ones who pre-financed the activities, just to make the process move forward while waiting to sign the memorandum of understanding with the Ministry. I think what we have pre-financing today should be more than 10 million (F CFA) now" NI_Implementer11 Unlike the North West and South West, the consortium of NGOs in the East had a six months contractual extension to allow them to prepare for the transition. This was because the region did not have a RFHP and thus had to create one. This was somewhat beneficial because it seems that the difficulties observed in the first two regions allowed the latter to learn and be better prepared. For example, in the East, there was a period of joint work and a well- organized work plan with a clear deadline and budget. "... In the East, we were able to do it, because CORDAID negotiated an extension with the World Bank, so as to really give us the time to do the transfer ... we transferred correctly by training people, supervising them, and it has a cost. It certainly has a cost, but it's worth putting that cost and having a correct and structured transfer, than just giving the structures randomly and saying that each person should struggle" NB_Partner5 "For the East Region, a six month extension of the contract was proposed because the Regional Fund for Health Promotion was created in the East just in November 2014 and their first constituent general assembly was held on January 28th, 2015. So now CORDAID will stay for another six months to help them set up the agency for the first three months and then follow up with them for a while. When they fly on their own, they will then withdraw definitively" NC_Policy marker2

G. Factors that hindered the transfer During the active phase of the transition, there were limited possibilities to plan the implementation of the process due to the tight timeline (four months). This planning should have been done long before this active phase. However, during the pre-intensive period, a few actors were really concerned with the transition. Discussions often focused on how to effectively drive the process. The different stakeholders, in some cases, appeared to underestimate the level of effort, time and planning required for this transition. The lack of planning during the pre-transitional phase manifested itself in different ways. For example, it was not explicit whether there were clear guidance to carry out the process at the central level, thus, leaving it to each region to drive things in their own way. With the exception of the East, we did not find budgetary lines dedicated to the transition process. A major difficulty was related to the legal framework in which the transfer was conducted. There was supposed to be an official legal act in order to materialise the transfer. This act, which was finally signed on December 24th, 2014, stipulated that the transfer of the management of the Performance Purchasing Agency to the Regional Funds was to be effective from January 1st, 2015, in accordance with various contracts.

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"There was supposed to be a legal act which materialized the transfer of the PPA. So, here on my desk I can show you the decisions that the Minister signed on the transfer of management from AEDES to regional funds in the South West and North West" NC_Policy maker2 "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" NI_Implementer10 Communication between the PPA managers and central and regional health authorities appeared to be generally very good during the transition, but the front line staff was less informed about the transition. The results of our analyses suggest that the participation of non- executive staff was virtually nil during the many meetings devoted to the transition. As mentioned above, the ministerial directive concerning human resources seems to have left some gray zones open to interpretation. Likewise, point 2 of Article 3 of the ministerial note (54) stipulated that: "The staffing plan will highlight the positions filled or to be filled in such that recruitment is launch within the best possible time, based on validated terms of reference and the profiles required by the post". This different understanding of the directives from the central level created some tensions between the outgoing PPA managers who expected that their staff would automatically be transferred to the new PAA and the RFHP managers who considered that it was legitimate for them to constitute a new team for the new PPA. Job offers were finally launched for the recruitment of new staff, but in reality, it was the same personnel from the old PPA who were selected, except those who, for various reasons, no longer wanted to be part of the project. Although significant efforts were made to develop the skills and align the individual objectives of the staff with those of the transfer, it was difficult to cope with the wider consequences of the transition on the staff, particularly the fact that the Government’s budget standards generally imposed lower wages for the new PPA staff compared to the wages offered by the international organizations. The salary scales varied from one PPA to another. PPA staff employed by international organizations were better paid (e.g., managers and assistant managers) with the exception of verificators, than the staff employed by the PPA of RFHPs. The transfer of the PPA to RFHP raised the issue of salary scale harmonization across the different PPAs. The salaries of the staff (e.g., managers and assistant managers) was reduced, leading to the drop out of almost all of this staff. "The working conditions that the state offers for example, is not necessarily the conditions of international organizations. Uhh, we have a little difficulty at this level because there are many who are in the process of leaving because they prefer ..Euhh, some went to Nigeria, some to Ethiopia because they already have the experienced, and then uhh .. We think it is legitimate. We cannot oblige someone to work somewhere when he can have better conditions elsewhere." NC_Policy maker1 "I do not know the salaries of the RFHP personnel, but what is certain is that the wages paid by the international organizations are significantly higher than what the RFHP will pay. ... What I regret the most is the staff that was trained under the PBF. I say nationals will not stay in the country. That's regrettable" NI_Implementer10 Another concern had to do with the ability and willingness of the RFHP in terms of competence and motivation to implement PBF through the PPA role. In July 2013, it appeared that the North West RFHP was not yet ready to take over the PPA activities. This was evident by the open reluctance of some of its actors. Some did not demonstrate that they wanted to

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possess the PBF-related skills and systematically blocked the process of giving the drug management autonomy to the health facilities. In the South West, we noted some resistance by the fund in handing over the management of drugs to health facilities and a weak exhibition of ownership in the approach. "You see, we made a first proposal for him [the manager of the RFHP] to go for training. He denied that he will not go for the training. Most recently, I learned that, there is currently a course expected for the Littoral and we asked him to attend. I think he still refused to go for the training. How can someone manage the PBF activities if he is not trained? He had to be removed! We cannot entrust one billion six hundred thousand dollars to someone who does not know what is inside so uh ... that's it, it is very important that the institution, the Management Committee of the fund accept the PBF" NI_Implementer1 The intervention of the HSSIP steering committee brought orientations regarding the different steps to follow in regards of the scaling-up phase: (1) use the existing and functional structures while waiting for the others to develop, (2) generalize the approach in other regions that have RFHP, (3) extend and further reinforce the RFHP to eventually extend its mandate to other projects of the Ministry of Health. Nevertheless, the shortcomings in the legislation still persisted. For example there was no collaboration agreement clarifying the expectations of each party between the RFHP and the MoPH. This was unlike the case between the international organizations and the state in which contracts were signed, until end of March 2015. “The Memorandum Of Understanding, MOU, between the Funds [RFHP] and the MoH is not yet ready. So what is the benefit of Funds if the MOU is still on the table?” NI_Policy maker2 In addition, there were no formal post-transition support agreements in place. Instead, the government’s guidelines defined a date when all of the activities of the international organizations had to stop. From our analysis, it appears that this issue was never discussed either before or during the implementation of the transition. This contributed in underpinning some confusion. For example, the human resources problem of whether RFHP had to recruit new staff or use the staff that worked for the international organizations. The management of the transition process required a very high level of investment by various stakeholders, necessitating repeated meetings between the staff of international organizations and that of RFHP. However, the opportunity to extend this framework to include other actors was missed. In practice, the efforts during the transition were limited between the incoming and outgoing PPA actors. Little attention was paid to other stakeholders such as implementers at the peripheral level. From another angle, with an exception of the East, the transfer process was conducted without establishing a cohabitation period during which the outgoing team would support the new team. Instead, the new PPA was set up after the former team had stopped operations. "In October, I asked the Funds to publish the job posting for managers ... so that we would be able to do the recruitment one month after, in November, according to the law of the country. It was also to take the months of November and December to guide the new managers, to train them and transmit the project. Unfortunately, the central level requested that we suspend the process" NI_Implementer10 "It is not a transfer only on paper, but all actors must really be involved in the business. And generally, I found that the national level does not sufficiently take into account this support. This should be organized, budgeted and having a correct and structured transfer, rather than having the structures one after the other, saying that everyone should try their way" NB_Partner5

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H. Appreciation of the transfer While there were plenty of good reasons to do the transition, the process seemed very difficult in the North West and the South West Regions, leading actors, especially those at the operational level, to have some bad opinions on the transfer process. "All the activities that we 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 or supervision despite the fact that, we at the district, we 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. You see, there is clearly a big gap. It is not moving the way it was moving". NI_Implementer12 During the first three months of 2015, the post-transition period on which our analyzes were done, the real achievement was the administrative effectiveness of the transfer, in the sense that the consortium of international organizations had already withdrawn, giving room to the RFHP, which was henceforth responsible for piloting the PPA. The striking thing during this first quarter was the absence of contract for the PPA staff. Furthermore, activities related to the implementation of the PBF program seemed to have been in slow motion, e.g. the performance contracts with health institutions, regulators and community-based organizations were not yet signed. Thus, there were no coaching activities, reporting / verification and quality evaluation conducted in the two regions mentioned above during this period. This was exacerbated by the fact that the central level had materialized contracts with RFHP many months after the transition process officially ended in North West and South West Regions. During our data collection period, the transition process was still ongoing in the East because there was a six months extension. "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 keept, 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 Lastly, the lack of immediate "gains" in the North-West and South-West regions seems to have been a significant obstacle for the whole transition program, but could also have contributed to better preparation of this process in the East.

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VIII. CONCLUSION

A group of policy entrepreneurs from the World Bank collaborated with senior government officials to develop the PBF program in Cameroon, place it on the agenda, assure its adoption, and conduct its formulation. While the pilot CORDAID project did not contribute to the emergence of this World Bank project, it however influenced its design. Currently, the scaling-up process is situated in-between the adoption and the institutionalisation phases. The program has moved from a pilot project to a national scheme (though not covering all the regions) and is currently attempting to progress to a national policy with the integration of the scheme into the national health care financing. Overall, the assessment of PBF-related changes seemed to be positive. Despite these positive changes, there were some concerns about the sustainability of the program. Moreover, some abnormalities were reported such as the pursuit of incentivised activities compared to non- incentivised activities. While the program may improve quality and health services' utilization, policy-makers must remain vigilant to prevent or lessen its potential undesirable effects by paying particular attention to deviant behaviours, more than ever during the scaling-up phase. The experience in Cameroon suggests that key components for a successful transfer may include: clear policy guidelines, an extended and sequenced timeframe for transition, a co- ownership and planning of transition by both parties, a detailed transition planning, an engagement of staff in the transition process, and the development of a post-transition support phase. Further researches need to encompass issues on health systems reforms that have to be carried out in order to guarantee a smooth integration of the PBF in the health system during the scaling-up.

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IX. LIST OF REFERENCES

1. The World Bank. HNP Millenium Development Goals [Internet]. [cited 2015 Sep 5]. Available from: http://databank.worldbank.org/data/views/reports/ReportWidgetCustom.aspx?Report_Name= HNP-MDG-country-tables- new&Id=74437051f7&ti=n&ds=n&dd=y&tb=y&sh=y&dw=y&pr=y&inf=y&zm=y&theme=darkGr ey&bdrClr=rgb(177,186,170)&bdrStyle=solid&bdrWidth=0px&exptypes=Excel,CSV,TAB,PDF

2. Pablos-Mendez A, Shademani R. Knowledge translation in global health. J Contin Educ Health Prof. 2006;26(1):81–6.

3. Basinga P, Gertler PJ, Binagwaho A, Soucat ALB, Sturdy J, Vermeersch CMJ. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet. 2011 Apr 23;377(9775):1421–8.

4. Eichler R. Can ‘Pay for Performace’ Increase Utilization by the Poor and Improve the Quality of Health Services? [Internet]. CGD; 2006. Available from: http://www.cgdev.org/doc/ghprn/PBI%20Background%20Paper.pdf

5. Meessen B, Kashala J-PI, Musango L. Output-based payment to boost staff productivity in public health centres: contracting in Kabutare district, Rwanda. Bull World Health Organ. 2007 Feb;85(2):108–15.

6. Soeters R., Vroeg P. Why there is so much enthusiasm for performance-based financing, particularly in developing countries. Bull World Health Organ [Internet]. 2011 [cited 2014 Mar 20]; Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=emed10&AN=2 011491661

7. Meessen B, Soucat A, Sekabaraga C. Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform? Bull World Health Organ. 2011 Feb 1;89(2):153–6.

8. Oxman AD, Fretheim A. Can paying for results help to achieve the Millennium Development Goals? Overview of the effectiveness of results-based financing. J Evid-Based Med. 2009 May 1;2(2):70–83.

9. Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev. 2012;2:CD007899.

10. Ssengooba F, McPake B, Palmer N. Why performance-based contracting failed in Uganda – An ‘open-box’ evaluation of a complex health system intervention. Soc Sci Med. 2012 Jul;75(2):377–83.

11. WHO-ExpandNet. Practical guidance for scaling up health service innovations. 2009.

12. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet. 2003 Jul 5;362(9377):65–71.

60 | P a g e

13. Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, et al. Systematic scaling up of neonatal care in countries. Lancet. 2005 Mar 19;365(9464):1087–98.

14. Simmons R, Fajans P, Ghiron L. Introduction. In: Scaling up health service delivery: from pilot innovations to policies and programmes. Geneva: World Health Organization; 2007.

15. Whitworth J, Sewankambo NK, Snewin VA. Improving Implementation: Building Research Capacity in Maternal, Neonatal, and Child Health in Africa. PLoS Med. 2010 Jul 6;7(7):e1000299.

16. Yamey G. What are the barriers to scaling up health interventions in low and middle income countries? A qualitative study of academic leaders in implementation science. Glob Health. 2012 May 29;8(1):11.

17. Ridde V, Turcotte-Tremblay A-M, Souares A, Lohmann J, Zombré D, Koulidiati JL, et al. Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso. Implement Sci. 2014 Oct 12;9(1):149.

18. AEDES. Performance Based-Financing implementation procedures manual. 2012.

19. Ministère de la Santé Publique. PLAN NATIONAL DE DEVELOPPEMENT SANITAIRE (PNDS 2011- 2013). 2011.

20. Banque Mondiale. Vers une plus grande équité. Cah Économique Cameroun. 2013 Jul;

21. Keugoung B, Tsafack JP, Ymele Fouelifack F, Sieleunou I, Ayissi Noubosse I. Expérience pilote de financement basé sur la performance dans le diocèse de Batouri au Cameroun: leçons pour l’extension du modèle. CoP PBF; 2011.

22. Gilson L. Health policy and systems research. A methodology reader [Internet]. AHPSR; 2012. Available from: http://www.who.int/alliance-hpsr/alliancehpsr_reader.pdf

23. Peters DH, Tran NT, Adam T. Implementation research in health. A practical guide [Internet]. AHPSR; 2013. Available from: http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf

24. Yin RK. Case Study Research: Design and Methods. 4th edition. Los Angeles, Calif: SAGE Publications, Inc; 2008. 240 p.

25. Sabatier P. Policy Change and Learning: An Advocacy Coalition Approach (Theoretical Lenses on Public Policy) [Internet]. {Westview Press}; [cited 2015 Sep 6]. Available from: http://www.amazon.ca/exec/obidos/redirect?tag=citeulike09-20&path=ASIN/0813316499

26. Buse K, Mays N, Walt G. Making Health Policy. 2 edition. Maidenhead, Berkshire, England; New York: Open University Press; 2012. 288 p.

27. Ridde V. ‘The problem of the worst-off is dealt with after all other issues’: the equity and health policy implementation gap in Burkina Faso. Soc Sci Med 1982. 2008 Mar;66(6):1368–78.

28. Ridde V, Olivier de Sardan J-P. Étudier les politiques publiques et les politiques de santé en Afrique de l’Ouest. Afr Contemp. 2013 Jan 9;243(3):98–9.

29. Kingdon JW. Agendas, Alternatives, and Public Policies, Update Edition, with an Epilogue on Health Care. 2 edition. Boston: Pearson; 2010. 304 p.

61 | P a g e

30. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. 1994 Jan 12;9(4):353–70.

31. Ridde V. Equity and health policy implementation in Burkina Faso. L’Harmattan. Paris; 2007;

32. Gilson L, Kalyalya D, Kuchler F, Lake S, Oranga H, Ouendo M. The equity impacts of community financing activities in three African countries. Int J Health Plann Manage. 2000 Oct 1;15(4):291– 317.

33. Lemieux V. L’étude des politiques publiques, les acteurs et leur pouvoir. Les Presses de l’Université Laval, Québec; 2002.

34. Olivier de Sardan J-P. Anthropology and development. Understanding contemporary social change. Zed Books. London; 2005.

35. l’Institut National de la Statistique. Enquête Démographique et de Santé. 2004.

36. Collins AE. Health ecology and environmental management in Mozambique. Health Place. 2002 Dec;8(4):263–72.

37. Larmour P. Foreign flowers: institutional transfer and good governance in the Pacific Islands. Honolulu: University of Hawai’i Press; 2005. 220 p.

38. North DC. Institutions, Institutional Change and Economic Performance. Cambridge University Press; 1990. 164 p.

39. Dolowitz DP, Marsh D. Learning from Abroad: The Role of Policy Transfer in Contemporary Policy-Making. Governance. 2000 Jan 1;13(1):5–23.

40. Bafoil F. Transfert institutionnel et européanisation. Une comparaison des cas est-allemand et est-européens. Rev Int Polit Comparée. 2006 Dec 18;13(2):213–38.

41. Saurugger S, Surel Y. L’européanisation comme processus de transfert de politique publique. Rev Int Polit Comparée. 2006 Dec 18;13(2):179–211.

42. Creswell JW. Qualitative inquiry and research design: choosing among five traditions. Thousand Oaks: Sage Publications; 1998.

43. Merriam SB. Case study research in education. Josey-Bass Publishers. San Francisco; 1991.

44. Ridde V, Diarra A. A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Serv Res. 2009;9:89.

45. Kottak CP. Cultural anthropology. Boston (Mass.): McGraw Hill; 2008.

46. Glenn A. Bowen. Document Analysis as a Qualitative Research Method. Qual Res J. 2009 Aug 3;9(2):27–40.

47. Ministère de la Santé Publique. Contrat de services No 0114/CS/MINSANTE/PAISS/12-2011 passé entre le ministère de la santé publique et l’Agence européenne pour le développement de la santé. 2012.

48. Sorgho G. Cameroon RBF Operation: Technical Design Matters! 2010 Jun 27; Kigali, Rwanda.

62 | P a g e

49. World Bank. Building Evidence on Results-Based-Financing (RBF) for Health: Third Annual Impact Evaluation Workshop. 2011 Oct 17; Bangkok, Thaìlande.

50. PAISS. Rapport de l’Atelier d’échanges entre les Agences d’Achat de Performance 17 au 19 décembre 2012 à Douala. 2012.

51. PAISS. Rapport atelier de Renforcement des Capacité des Personnels Fiduciaires des régions et production du Rapport de suivi Financier du deuxième Trimestre 2013 : Ebolowa (NKOLANDOM) du 02 au 07 Août 2013. 2013.

52. PAISS. Troisième rencontre trimestrielles des Responsables des Agences d’Achats des Performances. Bertoua les 17 et 18 Juillet 2013. 2013.

53. PAISS. Suite PBF Est Cameroun janvier -mars 2015. Proposition au Ministère de la Santé Publique Cameroun : CORDAID. 2013.

54. Ministre de la santé publique. Décision No 1483/D/MINSANTE/CAB/PAISS du 24 Dec 2014 portant transfert de la gestion de l’Agence d’Achat de Performance du Nord-Ouest au Fonds Régional pour la Promotion de la Santé du Nord-Ouest. 2014.

55. PAISS. Aide mémoire mission banque PAISS du 23 août au 14 septembre 2012. 2012.

56. Sorgho G. Aide mémoire mission de revue à mi-parcours du PAISS - 06 au 17 mai 2013.

57. Célestin Kimanuka, Taptue JC. Rapport de l’enquête Ménage et de l’enquête qualité de base pour le programme achat des Performances dans 4 districts de santé : Cité des palmiers, Edéa, Loum et Yabassi, 2011-2014, en comparaison avec les districts témoins : Nylon, Mbanga, Melong, Logbaba, Nkongsamba, Manjo : Janvier –Février 2011.

58. Soeters R. Support Mission for the Performance Based Financing program PAISS in Cameroon from 25 August to 14 September 2012. 2012.

59. Le Mentec R, Mettling C. Fonds régionanaux pour la promotion de la santé : fonctionnement – Forces – Défis. GIZ; 2014.

60. CORDAID. Evaluation interne du projet de financement base sur la performance dans la région de l’Est-Cameroun. 2014.

61. l’Institut National de la Statistique (Prénom). Enquête Démographique et de Santé et à Indicateurs Multiples EDS-MICS 2011. 2011.

62. Soeters R, Enadjoum B. Rapport de Mission Banque Mondiale. Projet PAISS Performance Based Financing. Du 19 au 31 octobre 2009. 2009.

63. Lee TW. Using qualitative methods in organizational research. Sage Publications; 1999.

64. Miles M, Huberman AM. Qualitative data analysis: An expanded sourcebook. Thousand Oaks: Sage Publications; 1994.

65. Patton MQ. Two Decades of Developments in Qualitative Inquiry A Personal, Experiential Perspective. Qual Soc Work. 2002 Jan 9;1(3):261–83.

66. Yin R. Case study research. Design and methods. Thousand Oaks: Sage Publications; 2003.

63 | P a g e

67. Marshall C, Rossman GB. Designing qualitative research. Thousand Oaks: Sage Publications; 2006.

68. Hartley J. Case study research. Sage Publications; 2004.

69. Maxwell JA. Qualitative research design. An interpretive approach. Thousand Oaks: Sage Publications; 2005.

70. Sekaganda E, Habaguhirwa JB, Habineza C. Santé et performance au Rwanda. Expérience et leçons au niveau opérationnel dans la mise en oeuvre de l’approche PBF [Internet]. KIT Development Policy & Practice; 2010. Available from: http://www.kit.nl/health/wp- content/uploads/publications/1668_Sante%20et%20performance%20au%20Rwanda_text%20. pdf

71. PAISS. Termes de Référence de la Revue à mi-parcours du Proiet PAISS ; Cameroun du 6 au 17 mai. 2013. 2013.

72. Ministère de la Santé Publique. Feuille de route pour la réduction de la mortalité maternelle et néonatale au Cameroun 2006-2015. 2005.

73. UNFPA. Why invest in reproductive health in Cameroon? 2012.

74. The World Bank. Cameroon Country Status Report: Reversing the Decline in Health Outcomes. 2003.

75. Transparency International. Corruption perceptions index [Internet]. [cited 2015 Sep 16]. Available from: http://www.transparency.org/research/cpi/overview

76. Commission Nationale Anti-Corruption. Rapport sur l’état de la lutte contre la corruption au Cameroun [Internet]. 2011. Available from: https://www.acauthorities.org/sites/aca/files/countrydoc/Introduction%20Generale.pdf

77. Soeters R, Habineza C, Peerenboom PB. Performance-based financing and changing the district health system: experience from Rwanda. Bull World Health Organ. 2006 Nov;84(11):884–9.

78. Boulenger D, Keugoung B, Bart C. La contractualisation entre secteur confessionnel et secteur public de la santé: un processus en crise ? Les cas du Cameroun, de la Tanzanie, du Tchad et de l’Ouganda. 2009.

79. The World Bank. World Bank Report No: PAD923. International development association project paper on a proposed additional funds. 2014.

80. Ministère de la Santé Publique. Contribution du MINSANTE au développement du Cameroun - Rapport de programmation 2009-2013. 2008.

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X. ANNEXES

A. Annex 1: Guide for in-depth interviews with key informants

Description of PBF

1) How was the PBF project initiated in the country?

A. CORDAID project: (starting, ending, beneficiaries, actors, funding sources, setting, design, budget, content, monitoring and evaluation, results, modifications, events ...)

B. Government project (starting, actors, beneficiaries, setting, design, funding sources, budget, content, monitoring and evaluation, results, modifications, events, phases, ....)

2) What pushed the government to engage in piloting the PBF project?

(Health Problems in the country at that moment, public health priorities, what were the solutions developed by the government to resolve these priorities, why was PBF adopted, who were the actors who contributed to the adoption of PBF, what were the obstacles, what were the factors promoting, probe for: country macroeconomic picture, donors aid conditionality, national leadership, ongoing reforms, opinion leaders, health system performance, salary levels, available evidence on PBF, expectations of the PBF, etc.) ....

Formulation

3) How the government project was designed (method)?

(the project formulation (use evidence, experiences ...), why this design (the choice of regions, districts, .....), who influenced the process, who were the actors who contributed to the formulation of PBF, what were the obstacles observed in PBF formulation, the favouring factors, what was the contents, its definition, the budget, the sources of finance,) ....

4) How was the government project implemented?

(Implementation (contents, problems and reactions of actors toward these problems, adaptation strategies...), the results, the changes (positive or negative) observed in the health system, existence of institutional archives, problems that PBF has permitted us to resolve)

5). what are the factors (context, and actors) that favoured?

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(Promoting (competences, the prices, policy ...), restricting (very low salary, non adapted legislations, lack of state leadership, absence of technical unity of PBF at the central level ...)

5) What are the factors (context and actors) that hindered the implementation?

(Promoting (competences, the prices, policy ...), restricting (very low salary, non adapted legislations, lack of state leadership, and absence of technical unity of PBF at the central level ...).

6) How do you appreciate the project?

7) What are the strategies put in place by the government to scale up the PBF?

Assess the transfer of the purchasing role from international NGOs to National agents in two regions (North-West and South-West regions) during scaling up phase;

8) Why did actors engaged in institutional transfer?

(Sustainability, existence of national competences, visible policy: ownership ...). Why the choice of RHPF: Regional Fund for Health Promotion (RFHP) to insure the role of PPA (Performance purchasing agency).

9) Who are the actors involved in this process?

10) What are the purposes of the transfer?

(Sustainability: utilisation of national institutions, cheaper...),

11) What are the sources of transfers? (From International NGO (AEDES) to a national institution (grouping of public interest: FRPS NW and SW) (look organigrams of the different entities).

12) What are the different forms of transfers? (functions (contents, strategies, activities, responsabilities ...), equipments, human resources

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13) What are the factors that promote or restrict transfers?

(Promoting (competences, the prices, policy ...), restricting (very low salary, non adapted legislations, lack of state leadership, and absence of technical unity of PBF at the central level ...).

14) To what extent do the observed transfers resulted in a success or a failure?

( was it a complete transfer (only the new agency lead the activities) or partial (the two agencies lead the activities), signature of contract by the new agency, existence of resources (human, logistics, financial) in the new agency, are there still activities carried out by the old agency?, appreciation of primary results (contracts signature, coaching, payment of subsidies, coordination meetings, ....),was the transfer done according to the calendar or there were some deviations?, does the new agency have some specific difficulties?, how was the transfer process done (degree of communication between the two sources of transfer, how often they work together, exchange of documents, training of personnel,..).

Effect of PBF induced drug supply system liberalization on drug accessibility

A. How was the drug supply system before the implementation of PBF? (availability /stock out, price, quality control, suppliers, quantity, stakeholders, policies in place, public and private partnership, sources and mechanisms of supply, judicial framework, management tools) satisfaction of beneficiary, (appreciation of actors (positive/negative), satisfaction of health personnel in health facilities, wholesalers, difficulties encountered and solutions proposed, strategies developed (adjustment, alternatives, etc.),

B. How is the drug supply system after the implementation of PBF? (Availability, price, quality control, suppliers, quantity, stakeholders, major changes, management tools), changes in practices from the procedural perspective), satisfaction of beneficiaries) satisfaction of beneficiary, (appreciation of actors (positive/negative), satisfaction of health personnel in health facilities, wholesalers, difficulties encountered and solutions proposed, strategies developed (adjustment, alternatives, etc.),

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What are the effects of the liberalization of drug supply system on accessibility to drugs? (COSA, CBO, community, availability, price, quality control, suppliers, quantity, stakeholders, major changes, etc.)

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B. Annex 2 : List of the key informants

Num Code Num Code

1 NP_Implementer1 38 NI_Implementer6

2 NP_Beneficiary1 39 NP_Implementer12

3 NI_Implementer1 40 NP_Beneficiary13

4 NC_Policy marker1 41 NI_Implementer7

5 NI_Implementer2 42 NP_Implemeter13

6 NP_Implementer2 43 NP_Implementer14

7 NP_Beneficiary2 44 NC_Policy marker2

8 NI_Other sector1 45 NP_Implementer15

9 NI_Implementer3 46 NB_Partner1

10 NI_Other sector2 47 NI_Implementer8

11 NP_Beneficiary3 48 NP_Implemeter16

12 NI_Implementer4 49 NC_Policy marker3

13 NI_Policy marker1 50 NP_Implementer17

14 NP_Implementer3 51 NB_Partner2

15 NP_Beneficiary4 52 NB_Partner3

16 NP_Beneficiary5 53 NB_Partner4

17 NI_Implementer5 54 NB_Partner5

18 NP_Implementer4 55 NI_Implementer9

19 NP_Implementer5 56 NB_Partner7

20 NP_Implementer6 57 NI_Implementer10

21 NP_Implementer7 58 NB_Partner6

22 NP_Beneficiary6 59 NP_Implementer19

23 NC_Policy marker4 60 NP_Implementer20

24 NC_Partner1 61 NC_Partner3

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25 NP_Implementer8 62 NP_Implementer21

26 NP_Benecifiary7 63 NP_Implementer22

27 NP_Implementer9 64 NC_Partner4

28 NP_Beneficiary8 65 NP_Implementer23

29 NP_Beneficiary9 66 NI_Policy marker2

30 NP_Implementer18 67 NI_Implementer11

31 NC_Partner2 68 NI_Other sector3

32 NP_Beneficiary10 69 NP_Beneficiary14

33 NP_Implementer10 70 NP_Implementer24

34 NP_Beneficiary11 71 NI_Policy maker4

35 NI_Policy marker3 72 NI_Implementer12

36 NP_Beneficiary12 73 NP_Implementer25

37 NP_Implemeter11 74 NP_Implementer25

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C. Annex 3 : List of the research assistants

1. Marlène Tchoffo 2. Ajeh Rogers Awoh 3. Brice Soung 4. Blonde Ngobo 5. Albert Le Grand Mballa 6. Yves Pierre Nzomo 7. Léonard Ndongo 8. Mark Benwi 9. Marlène Sipping 10. Louise Kengne 11. Hilton Nchotou 12. Forbuzo Valery Achu 13. Justice Abinuyi

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D. Annex 4 : National Ethical Approval

E. Annex 5 : WHO Ethical approval

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F. Annex 6 : List of the quantity indicators

Indicators of the minimum package of activities

N° Indicators (number)

1 Out Patient Consultations (new cases): Nurse 2 Out Patient Consultations (new cases): Doctor 3 Out Patient Consultations of the poor and vulnerable (new cases): Doctor or nurse (free) 4 Hospital bed days (observation/Hospitalization) 5 Hospital bed days (observation/Hospitalization) for the poor and vulnerable 6 Minor surgery cases 7 Referral received in the hospital 8 Children Completely Vaccinated 9 VAT2 or VAT3 or VAT4 or VAT 5 10 Home visits 11 Vitamin A supplementation (distribution) 12 HIV positive Pregnant Women put on ARV prophylactic treatment 13 Newborn management of a baby born of an HIV positive mother. 14 Voluntary Counseling and Testing for HIV/AIDS 15 Cases of STIs treated 16 Cases of TB diagnosed positive by Microscopy 17 Cases of TB treated and healed 18 Normal Assisted Delivery 19 FP : New or old acceptants on oral pills of injections 20 FP : Implants and IUD 21 Post abortive Curettage (spontaneous or induced) 22 ANC1 or ANC2 or ANC3 or ANC4 23 IPT1 or IPT2 or IPT3

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Indicators of the complementary package of activities

N° Indicators

1 Out Patient Consultations (new cases): Doctor 2 Out Patient Consultations of the poor and vulnerable (new cases): Doctor or nurse (free) 3 Hospital bed days Hospitalization (no longer than 14 days / case)

4 Hospital bed days (Hospitalization) for the poor and vulnerable (no longer than 14 days / case) 5 Counter Referral received in the Health center 6 Cases of STIs treated 7 Cases of TB diagnosed positive by Microscopy 8 Cases of TB treated and healed 9 Major Surgery (Excluded CS) 10 Minor surgery cases 11 Blood Transfusion 12 Normal Assisted Delivery 13 Cesarean Surgery 14 Difficult (Dystocique) Delivery 15 FP : Implants and IUD 16 FP : New or old acceptant on oral pills of injections 17 FP: Permanent methods (Vasectomy, Tubal Ligation) 18 Post abortive Curettage (spontaneous or induced)

19 ANC1 or ANC2 or ANC3 or ANC4

20 IPT1 or IPT2 or IPT3

21 Voluntary Counseling and Testing for HIV/AIDS including pregnant women

22 HIV positive Pregnant Women put on ARV prophylactic treatment

23 Newborn management of a baby born of an HIV positive mother

24 New HIV/AIDS cases placed on ARV Therapy

25 Old patients on ARV followed up within six months

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G. Annex 7 : List of the documents reviewed

1. PAISS. Aide mémoire mission banque PAISS du 23 août au 14 septembre 2012. 2012. 2. Sorgho G. Aide mémoire mission de revue à mi-parcours du PAISS - 06 au 17 mai 2013. 3. PAISS. Rapport de l’Atelier d’échanges entre les Agences d’Achat de Performance 17 au 19 décembre 2012 à Douala. 2012. 4. PAISS. Rapport atelier de Renforcement des Capacité des Personnels Fiduciaires des régions et production du Rapport de suivi Financier du deuxième Trimestre 2013 : Ebolowa (NKOLANDOM) du 02 au 07 Août 2013. 2013. 5. Célestin Kimanuka, Taptue JC. Rapport de l’enquête Ménage et de l’enquête qualité de base pour le programme achat des Performances dans 4 districts de santé : Cité des palmiers, Edéa, Loum et Yabassi, 2011-2014, en comparaison avec les districts témoins : Nylon, Mbanga, Melong, Logbaba, Nkongsamba, Manjo : Janvier –Février 2011. 6. Soeters R.et Enandjoun B. Rapport de Mission Banque Mondiale. Projet PAISS - Performance Based Financing. Du 19 au 31 octobre 2009 7. Soeters R. Support Mission for the Performance Based Financing program PAISS in Cameroon from 25 August to 14 September 2012. 2012. 8. PAISS. Troisième rencontre trimestrielles des Responsables des Agences d’Achats des Performances. Bertoua les 17 et 18 Juillet 2013. 2013. 9. Banque Mondiale. Vers une plus grande équité. Cah Économique Cameroun. 2013 Jul; 10. PAISS. Suite PBF Est Cameroun janvier -mars 2015. Proposition au Ministère de la Santé Publique Cameroun : CORDAID. 2013. 11. AEDES. Performance Based-Financing implementation procedures manual. 2012. 12. Keugoung B, Tsafack JP, Ymele Fouelifack F, Sieleunou I, Ayissi Noubosse I. Expérience pilote de financement basé sur la performance dans le diocèse de Batouri au Cameroun: leçons pour l’extension du modèle. CoP PBF; 2011. 13. Le Mentec R, Mettling C. Fonds régionanaux pour la promotion de la santé : fonctionnement – Forces – Défis. GIZ; 2014. 14. CORDAID. Evaluation interne du projet de financement base sur la performance dans la région de l’Est-Cameroun. 2014. 15. PAISS. Evaluation d’Impact de deux années de PBF sur la qualité et l’utilisation des services de santé dans la région du littoral- Cameroun. 2013. 16. Ministre de la santé publique. Décision No 1483/D/MINSANTE/CAB/PAISS du 24 Dec 2014 portant transfert de la gestion de l’Agence d’Achat de Performance du Nord-Ouest au Fonds Régional pour la Promotion de la Santé du Nord-Ouest. 2014. 17. Ministère de la Santé Publique. Décision No: 0032/MINSANTE/CAB/du 24 janvier 2011 portant sur les procédures de gratuité. 2011. 18. Ministère de la Santé Publique. Décision No : 0118/D/MINSANTE/CAB du 13 mars 2011 portant sur la consultation et le kit de traitement. 2012.

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19. Ministère de la Santé Publique. Contrat de services No 0114/CS/MINSANTE/PAISS/12-2011 passé entre le ministère de la santé publique et l’Agence européenne pour le développement de la santé. 2012. 20. l’Institut National de la Statistique (Prénom). Enquête Démographique et de Santé et à Indicateurs Multiples EDS-MICS 2011. 2011. 21. Sorgho G. Cameroon RBF Operation: Technical Design Matters! 2010 Jun 27; Kigali, Rwanda. 22. World Bank. Building Evidence on Results-Based-Financing (RBF) for Health: Third Annual Impact Evaluation Workshop. 2011 Oct 17; Bangkok, Thaìlande. 23. The World Bank. Cameroon economic update. Towards better service delivery an economic update on Cameroon. July 2011. Issue No.2 24. Fonds régional pour la promotion de la santé du Littoral. Manuel de procédures administratives, financiers et comptables du fonds spécial pour la promotion de la sante du littoral pour la mise en œuvre du projet de financement base sur la performance dans la région du littoral. Novembre 2011 25. Messen B. et Antony M. Rapport de mission appui a la recherche, au suivi technique et stratégique. Mission réalisée en juillet 2012 26. Brenzel L and Schneidman M. Results-based financing at the world bank - Cameroon country snapshot 54082 27. The World Bank. Cameroon Economic Update Towards Greater Equity A Special Focus on Health. July 2013 28. The World Bank. Cameroon Country Status Report Reversing the Decline in Health Outcomes. June 2013 29. The World Bank. Cameroon Country Status Report on Health. December 2013 30. The World Bank. Implementation Status & Results. Cameroon Health Sector Support Investment (SWAP) (P104525). June 2013 30. The World Bank. Implementation Status & Results. Cameroon Health Sector Support Investment (SWAP) (P104525). December 2013 30. The World Bank. Implementation Status & Results. Cameroon Health Sector Support Investment (SWAP) (P104525). May 2014 31. Integrated Safeguards Data Sheet Additional Financing. Report No.: ISDSA7312. April 2014 32. Ministère de la Santé Publique. Feuille de route pour la réduction de la mortalité maternelle et néonatale au Cameroun 2006 - 2015 33. UNFPA. Why invest in reproductive health in Cameroon. 2012 34. Ministère de la Santé Publique. Contribution du MINSANTE au développement du Cameroun - Rapport de programmation 2009-2013

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