AFRICAN

also be linked to the large growth margins
of most health indicators which were
originally very low in Chad (increasing
marginal returns). Indeed, in many health
facilities, consultations were extremely
low because patients were dissatisfied; so
there was room for greater workloads,
especially when there was a financial
motivation. Peaks observed between
July and October for “new cases of
curative consultations for under five”
were consistent with the rainy season, and
its set of endemic and epidemic diseases
(malaria, gastroenteritis, acute respiratory
infections etc.), while those observed
between January and April for “third
antenatal visit” correlated with the end
of farm activities, meaning women were
much freer to come to health facilities.
However, what is most interesting to
note are the vast performance disparities
between regions (and sometimes between
health centres in the same district even if
we didn’t show disaggregated data).
The first issue (disparities between
regions) highlights an initial important
lesson of our study, which is that
context matters a great deal. The
same intervention implemented in two
different contexts (geographic, climatic,
socioeconomic and cultural etc.) will
not have the same consequences with
regard to health outcomes. Secondly,
disparities between PHCs located in the
same district could be mostly explained,
based on our direct observations, by
differences in staffing, in health workers’
qualification and in lack of leadership
from managers. Indeed, generally, PBF
in Chad worked better in faith-based
facilities and where heads were actually
qualified and demonstrated strong
leadership.
Our results also highlighted the pilot’s
effect on better governance and
management of health institutions. But
despite these positive signs, more effort is
needed to make decision making happen
on a more empirical and rational basis.
We noted that in a large number of health
facilities, development of business plans
was neither rigorous nor actually effective,
owing to weak management capacity,
overall lack of human resources and low
levels of community participation. But
in health facilities with some potential
in relation to these elements, PBF easily
revived local initiatives even though
there is still a long way to go to establish
effective autonomy. Overall, management
of the local health information systems
also improved even though registers were
not always tailored to both health facility
and community verification requirements.
Thus, more appropriate tools need to
be devised, under the national health
information system, in order to facilitate
these verification activities while avoiding
duplication. Another issue that requires
close attention is better linking of
PBF with other financing mechanisms,
especially fee exemptions for emergency
care in hospitals (decreed since 2007 and
ongoing at the time of the study). A
decision (that was not yet effective) had
also been made to extend comprehensive
free care to all pregnant women and
children under five. The implementation
of these policies consists only in the
provision of drugs to health facilities,
without any effort to take into account
real needs in drug supply and changes at
other levels (increased workload, loss of
revenues for staff etc.), which obviously
raises major management challenges.
Some of the difficulties highlighted in this
article are structural and require systemwide
actions. However, it seems clear
from our study that the introduction of
the PBF scheme in health facilities, even if
at pilot stage and poorly regulated, creates
almost instantly a positive momentum
as well as enthusiasm and buy-in from
most local players, highlighted by our
qualitative results. It is precisely this that
makes PBF so innovative.
Conclusion
As currently occurring in numerous sub-
Saharan African countries, a PBF scheme
for health facilities was introduced in
Chad as a pilot project. Our analysis,
based on data collected through the PBF
system, as well as interviews and focus
group discussions, show that the PBF
scheme began to bear fruit after only 18
months of implementation. It induced
some strengthening of the health system
and good practices quickly took root.
Moreover, early results show improving
trends for some of the indicators observed.
However, results remain disparate across
regions and districts and between health
facilities. This confirms that PBF does
not operate mechanically and similarly in
all contexts, but rather acts as a catalyst to
address issues when some key conditions
are met. Our study presents some
limitations, but the changes highlighted
stress, more than ever, the need for
rigorous impact evaluations and for open
and evidence-based discussion in order
to tailor the design of PBF schemes to
specific contexts and policy needs, and to
better inform policy-making decisions on
PBF schemes, both at pilot stage and when
considering their rollout countrywide. p
Acknowledgements
Feedback was provided by Allison Gamble Kelley (health
economist) and Maria Paola Bertone (health policy, planning
and financing specialist). We thank key informants for
their participation, especially the head of the Direction
de l’Organisation des Services de Santé (DOSS) (Dr Dadjim
BLAGUE) and his staff, who were in charge of PBF at the MoH,
as well as the four health region managers. We also thank
Agence Européenne pour le Développement et la Santé
(AEDES) and Centre de Support en Santé Internationale
(CSSI) for their technical and logistical support. Funding was
received from the World Bank, through Projet Population et
Lutte contre le SIDA phase 2 (PPLS2). We thank its coordinator
(Mahamat Saleh) and his staff for their multifaceted support
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