<mark>In 2008,</mark> the World Bank approved a US$25 million loan to the Government of Cameroon through the Bank’s Health Sector Support Investment Project (HSSIP). In 2011, through support from the HSSIP, a PBF pilot began in the Littoral region covering four health districts. The program began in July 2012 in the North West and South West regions, with four districts included in each region. In October 2012, the program expanded to the East region, covering all 14 health districts in the region.

Of the 26 health districts throughout Cameroon implementing PBF, 14 districts were included in the impact evaluation (see Figure 1 and Appendix Figures A2 – A4). The other 12 (four in Littoral and eight in the East) had already begun implementing some form of PBF before the impact evaluation baseline survey was conducted, or were added after the baseline survey was conducted.

# DESCRIPTION OF THE PBF PROGRAM DESIGN IN CAMEROON

# PROGRAM OVERVIEW

<mark>The administrative and technical aspects of the PBF program in Cameroon were managed at the regional level by Performance Purchasing Agencies (PPAs). PPAs are autonomous entities that have a contractual relationship with the Government of Cameroon who entrusts the agencies with contracting the health facilities, verification of the data declared by the health facility and management of funding intended for health care providers through PBF. All PBF health facilities signed a Performance Contract issued by the PPA which described conditions required to obtain PBF subsidies. These requirements included efforts to improve management, minimum quality levels, governance and financial inclusion, and clauses for termination of the contract. Additionally, PBF facilities prepared quarterly business plans and used frameworks for the health administration linked to performance payments. All facilities were trained to use the indice tool; however, use of the indice tool varied among Cameroon PBF facilities.</mark> PBF contracts were signed for a period of three months. Health facilities with performance contracts were responsible for completing registers and a monthly activity report/declaration form. This report and registers were used to document reported health service provision and were used as the primary basis for service verification. A list of the health services subsidized by the program, and the subsidy amounts is located in Appendix Table A1. A copy of this report was sent to the PPA each month. After the verification of the quantity of services provided and declared in the monthly report was completed by reviewing health facility records, the bill of the health facility was established and paid monthly. The declarations form verified and validated was used to justify the payment subsidies provided to the health facility.

# SERVICE VERIFICATION

Health service verification was completed on a monthly basis by the PPA verification agents. The verification agents used the facility register and tally sheets to verify that the number of services reported by the health facility in the payment request form was consistent with the facility documentation. If the supervisor encountered any errors, these problems were corrected in the presence of the facility staff, and any fraudulent cases were tracked and documented. As an added means of quantity verification, a sample of patients for a set of health services targeted by the program was contacted either by phone or in person by local PPA staff to confirm that they received the health service reported by the health facility and to assess patient satisfaction. If error rates for a certain indicator surpassed 10-15% (varying slightly by region), the service was not 5