Like skilled delivery, the percentage of women receiving four or more antenatal care visits, another health service with the potential to decrease maternal and child mortality, remained unchanged over the last decade. In 2004, 59.1% of women had received four antenatal visits, the number recommended by the World Health Organization, compared to 58.8% in 2014 (Institut National de la Statistique, 2015). Even when women obtain antenatal services, they still may not receive important service components due to low quality of care. Previous studies have shown that fewer than half of women are informed about the danger signs to look for during pregnancy, over 40% did not have the recommended number of tetanus vaccinations during their last pregnancy (ICF International, 2012), and 25% did not provide a urine sample to test for protein, a required procedure to test for preeclampsia (The World Bank, 2013).

Child mortality declined in Cameroon by approximately 21% between 1991 and 2014 (ICF International, 2012; Institut National de la Statistique, 2015; Institut National de la Statistique (INS) et ICF International, 2012); nonetheless, according to the most recent data approximately 1 in 10 children still dies before their fifth birthday (Alkema et al., 2015; The United Nations Children's Fund, 2015).

# HEALTH FINANCING CHALLENGES IN CAMEROON

Several aspects of the health care financing landscape in Cameroon contribute to the low quality of primary health care service provision, and sub-optimal coverage of essential maternal and child health care services. Cameroon spends $10 dollars more than the average for Sub-Saharan Africa (excluding South Africa) and has similarly high health spending as Senegal and Nigeria (Bove, Basile., Robyn, & Singh, 2013). However, despite this relatively high level of overall spending, the share of government spending on health is low and has not reached above 9 percent of the total budget in the previous 10 years (Bove et al., 2013). Due to these low levels, in 2012 the share of per capita total health spending paid for by the government was only US $14 (i.e. 21.7 percent). Much of the remaining 70.4% of health spending is paid for through out-of-pocket users fees (Ministere de la Sante Publique, 2016). Another important part of the problem is that the operational level receives a small fraction of the health budget. Although the health sector budget has more than doubled in recent years, the majority of these resources have been allocated for administration and infrastructure. The public budget favors central-level administration and tertiary care, with less than 10% of the budget being allocated to service providers and deconcentrated levels of the Ministry of Public Health nationwide at the regional, district and health facility level (The World Bank, 2017). This has resulted in a scarcity of funds to meet operating expenses incurred in the day-to-day business of a district health system (e.g., consumables, drugs, regular maintenance, community outreach, etc.) (Ministere de la Sante Publique, 2016).

# PBF TIMELINE IN CAMEROON

Cameroon’s first experience with PBF began with the Redynamisation des Soins de Sante à l’Est du Cameroun (REDSSEC) project. In 2006, REDSSEC implemented a pilot PBF program in Faith Based Organization (FBO) facilities in the East region with support from Cordaid and Catholic Relief Services. The project began with four FBO facilities in Batouri district, and then expanded to FBO facilities in Bertoua, Doume and Yokadouma districts through 2011 (Appendix Figure A1).

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