International Journal of Science Academic Research

Vol. 02, Issue 06, pp.1662-1666, June, 2021

Available online at http://www.scienceijsar.com ISSN: 2582-6425

Research Article
SHORT TERM EFFECTS OF PERFORMANCE BASED FINANCING ON IMMUNIZATION DATA IN
THE DSCHANG HEALTH DISTRICT
*Djam Chefor Alain, Earnest Njih Tabah, Bekolo Calvin Epie and Tawase Rodrique
Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Cameroon

Received 20th April 2021; Accepted 16th May 2021; Published online 17th June 2021
Abstract
Background: Performance Based Financing (PBF) has been widely adopted in low and middle income countries with the aim to boast their
health system performance. However, very little is been known about the effects of PBF on the health information system (HIS). Objective: To
evaluate the short term effects of PBF on the quantity and quality of immunization data in the Dschang Health District. Method: A cross-
sectional time series study was carried out in 23 health facilities under PBF in the DHD. Our sample size was exhaustive with inclusion criteria,
health facilities that have existed for at least three years (2017 to 2018 before PBF and 2019 with PBF), and have been vaccinating for this period
of time and disposes all their vaccination data collection tools for this period of time. Our sample size was exhaustive. Sources of data included
the vaccination registers, monthly activity report and the district health information system. Results: The enrolment of pentavalent1 had a
decrease of 11,2% between 2017 to 2018 and 11,6% between 2018 and 2019. For pentavalent3, the number of enrolment had a decrease of
10,6% between 2017 to 2018 and 14,3% from 2018 to 2019. The timeliness of EPI data witnessed a 7,5% increase between 2017 and 2018, and
a drop of 73,7% between 2018 and 2019. The completeness of EPI data for the DHD from 98% to 96,6% in 2018 to 99,2% in across the three
years. Using the verification factor number of health facilities with consistent data ranges from 13% to 52% and 70% and 13% to 43,5% and
70% for 2017, 2018 and 2019 for pentavalent1 and pentavalent3 respectively. Health facilities with improved PBF score across 2019 increased
from 12 to 15 with PBF score ≥ 75% between the First trimester and the fourth trimester with no major change in data indicators. Conclusion:
the quality and precision of EPI data have improved most especially in 2019 across the years from 2017 to 2019 with PBF. However, timeliness
remains relatively low and should be improved.
Keywords: Immunization, Performance base financing, Timeliness, Completeness, Consistency.

INTRODUCTION The Republic of Cameroon has an estimated population of

26,545,863 million inhabitants (Cameroon population, 2020).
High quality data and effective data quality assessment are The health system in Cameroon can be described as a
required for accurately evaluating the impact of public health pluralistic system, characterized by multiple sources of
interventions and measuring public health outcomes (Chen et financing and health care providers. The main financing bodies
al., 2014). Data, data use, and data collection process, as the include government, public enterprises, foreign aid donors,
three dimensions of data quality, all need to be assessed for private enterprises, households, faith-based missions, and non-
overall data quality assessment. Public health has as an governmental organizations; whereas providers are mostly
ultimate goal to improve the health status at the population government, independent private and faith-based hospitals
level, and this can only be achieved through a collective (Kengne et al., 2009). The coordination of health care services
mechanisms and actions of public health authorities within the is centralized in the capital, with the Ministry of Health at the
government context (Winslow, 1920; Walker, 2008). Public helm, represented by Regional Delegates of Health in the ten
health agencies have three defined functions which include: administrative Regions. In the early 90s, the Cameroon
assessment of health status and health needs, policy Ministry of Health implemented a National Health Information
development to serve the public interest and assurance that System (NHIS) based on a bottom-up approach of manually
necessary service are provided (Medicine). In other to properly collecting and reporting health data (Ngwakongnwi et al.,
carryout this functions, the use of data, information and 2014). Like most African countries, Cameroon lacks an
knowledge is indispensable thus making public health a data organized health information system at all levels of care (BLN
intensive domain (Andresen, 2010). In the current information Webinar, 2020). An evaluation of Cameroon health
age, the use of data has become essential for decision making information system in 2008 using the Health Metrics Network
in public health at the local, national, and global level but (HMN) tool out line multiple challenges centred on six factors
despite a global commitment to the use and sharing of public notably; resources, indicators, sources, management of data,
health data, this can be quiet challenging in reality. At the local production of information, dissemination and used of results.
level, data are used to monitor population health and to target This evaluation was orientated towards the composition and
interventions; at the national level, data are used for resource functionality of the health information system. Major problems
allocation, prioritization, and planning; and at the global level identified was based on the absence of quality and quantity
for estimates on the global burden of disease, to measure personnel to ensure the functionality and management, poor
progress in health and development, and to contain emerging storing of data at all levels of the health system, managers of
global health threats (Chan et al., 2010; Heymann and Rodier, health facilities, care givers at all levels do not use the data
2001). they produce for management, follow up and periodic
evaluation (Global Routine Vaccination Coverage, 2012).
*Corresponding Author: Djam Chefor Alain, Another evaluation carried out in 2014 on the challenges to
Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences,
University of Dschang, Cameroon. implementing a national health information system (NHIS) in
1663 International Journal of Science Academic Research, Vol. 02, Issue 06, pp.1662-1666, June, 2021

Cameroon revealed an inefficient and stalled NHIS, the largest districts in the West region of Cameroon covering a
characterised by general lack of personnel, a labour intensive surface area of about 1.060KM² and a population ofover
process, delay in reporting data, much reliance on field staff 226964 habitats with people from all the ten regions of
and lack of incentives (Ngwakongnwi et al., 2014). As the Cameroon but a greater part of the population is made up of
Government of Cameroon set new, ambitious targets, it the Bamileke. In terms of religion, a great majority of the
became a critical priority to strengthen Cameroon’s monitoring population is made up of Christians, some are Muslims and
and evaluation system to enable health managers at every level others are animist. The DHD has a tropical climate with two
to access high-quality data and use this information to assess seasons; the rainy and the dry season, mostly mountains as
gaps in the health care delivery system, guide decision-making, relief. The DHD is bordered to the South by The Health
and measure progress toward the ultimate goal of universal District of Santchou, to the East by Health District of Penka
health coverage (UTAP-2Atlanta, 2020). Performance Based Michel, to the West by Fontem Health District and to the North
Financing( PBF) is a reform approach in the health sector as east by Batcham Health Districts. The DHD comprise 22
well as other sectors such as education where health care Health Areas and 82 health facilities. It should be noted that
providers receives direct incentives based on the quantity and each health area has an Integrated Health Centre (IHC) which
quality of services they render. This approach has been widely is charged with providing the Minimum packet of Activities
implemented by most low income countries who seek to boast (MPA).
the performance of their health system. This approach has also
been largely adopted and supported by most local Data collection and analysis
Governments as well as international partners such as the
World Bank (WB), Global fund (GF), World Health Data collection tool was a standardised form design to respond
Organisation (WHO) among others. Once payment has been to the different objectives of the study. It was modified after
done by PBF, the health facility has complete autonomy on the the pre-test. Sources of data included the vaccination registers,
income and uses it to; recruit more quality and quantity staffs, the monthly activity reports and the DVDMT/DHIS2 data base
attract qualified staff in remote areas, motivate management from 2017 to 2019. Data analysis was done based on key
and staff to organise outreach, motivate management and staff indicator in each objective. The enrolment of antigens was
to be open 24/7 (during night/weekend), motivate management defined as the number of children vaccinated for each of the
and staff to be creative and use resources in a more efficient antigens per year from 2017 to 2019 as declared in the
way, motivate management and staff to pay attention to DVDMT/DHIS2 system, the timeliness was calculated by
technical quality, motivate community workers to improve comparing the number of months with timely immunization
provision of information to clients. PBF is intended to reports sent to the Dschang district health services to the
contribute to improvement of health provider performance, and number of months with untimely immunization report send for
ultimately to improved quality of health service delivery at the each year from 2017 to 2019 and lastly, the timeliness was
operational level. At the same time, it means a fundamental measured by calculating the percentage of complete reports of
change in the way the health sector is financed with a shift the dschang health district for each year, the consistency of
from input to output funding. This requires changes in immunization data was measured by calculating the
accountability structures and concomitant redistribution of verification factor ( number of counted antigens administered
tasks and responsibilities between the different actors. Findings in the vaccination registers divided by the number of antigens
have shown that PBF influences the institutional architect in declared in the DVDMT/DHIS2 system (Consistent data: VF
the health sector as structures are needed at the operational between 0.85 to 1.15, Moderate over reporting: VF between
level for fund holding, mechanisms for accountability and 0.7 to 0.84, Over reporting: VF <0.7, Moderate under
transparency, and agencies to carry out the verification efforts, reporting: VF between 1,16 to 1,29, Under reporting: VF
inclusive of community level (Sieleunou et al., 2017). >1,29) (Ronveaux et al., 2016). The quantitative findings were
presented using charts and tables.
METHODS Ethical consideration
It is a cross sectional time series study carried out in health We obtained consent from all facility heads before accessing
facilities under PBF in the Dschang health district using a their registers and other data recording tools. A research
quantitative approach to evaluate the trend in some authorization was also obtained from the Dschang district
immunisation data quality indicators with time in the said health services and the National Ethical committee for
health facilities. The data quality indicators evaluated Research in Human Health before carrying out this research.
involved; the quantity of data produced in terms of number of
children vaccinated with the pentavalent1 and pentavalent3
RESULTS
antigen, its timeliness, completeness and consistency of the
later across different data collection tools. Data collection was
A total number of 27 health facilities were accessed using our
done with the help of a design grid. Our sources of data
standardised design form after which 4 health facilities where
involved; the vaccination register of health facilities selected
been eliminated due to missing data for certain years leaving
for our study, the monthly activity report for each health
us with 23 health facilities included in our study. There were
facility and the DHIS2 for the Dschang health district for a
distributed as one District hospital, four sub divisional health
period of three years (two years before the implementation of
facilities, ten public integrated health facilities and eight
PBF and one year in PBF). Another source of data was the
private health facilities.
PBF trimestral evaluation grid for each health facility.
Enrolment time series for pentavalent1 and pentavalent
Study area
This study was carried out in the Dschang Health District, A general decrease in the enrolment rate for pentavalent1 and
located in the West region of Cameroon. The DHD is one of pentavalent3 was observed across the years from 2017 to 2019.
1664 International Journal of Science Academic Research, Vol. 02, Issue 06, pp.1662-1666, June, 2021

Table 1. Trend in the consistency of pentavalent1 and pentavalent3 using the verification factor
Mild under reporting Moderate under reporting Consistent data Moderate under reporting Mild overreporting
Year
(vf >1,29 (vf 1,16 -1,29) (vf 0,85 -1,15) (vf 1,16-1,29) (<0,7)
Penta 1 Penta 3 Penta 1 Penta 3 Penta 1 Penta 3 Penta 1 Penta 3 Penta 1 Penta 3
2017 3(13%) 2(8,7%) 2(8,7%) 2(8,7%) 3(13%) 3(13%) 3(13%) 2(8,7%) 12(52,2%) 14(60,9%)
2018 2(8,7%) 1(4,5%) 0(0%) 1(4,5%) 12(52,2%) 10(43,5%) 7(30,4%) 9(39,1%) 2(8,7%) 2(8,7%)
2019 2(8,7%) 0(0%) 1(4,5%) 2(8,7%) 16(69,6%) 16(69,6%) 3(13%) 2(8,7%) 2(8,7%) 3(13%)

This decrease ranges between 6766 as recorded in 2017 to The trend in the completeness of healthcare reports in the DHD
6011 in 2018 (11,2% decrease) and then to 5316 in 2019 varied from 98% in 2017 down to 96,6% in 2018 and again
(11,6% decrease) for pentavalent1 antigen while the decrease increases to 99,2% in 2019 (Figure 5).
in pentavalent3 ranges from 6511 in 2017 to 5820 in 2018
(10,6% decrease) and finally to 4987 in 2019 (14,3% decrease)
(Figure 1). The greatest decrease was observed for public
integrated health facilities between 2018 and 2019 (30,2%
decrease) while the least decrease in enrolment was observed
in sub divisional health facilities (18,1% decrease) between
2018 and 2019 for pentavalent1. A slight increase in enrolment
of pentavalent1 is observed in the district hospital (13,2%)
between 2018 and 2019 and in private health facilities between
(9,3% increase) between 2017 and 2018 (Figure 2). Similarly
for pentavalent3 enrolment, the greatest decrease is observed
in public integrated health facilities (36,3%) between 2018 and
2019 while the least decrease was observed in private health
facilities (12,7%) between 2018 and 2019 (Figure 3).
Figure 3. Trend in the enrolment of pentavalent3 per category of
health facilities

Figure 1. The trend in the enrolment of pentavalent1 and

pentavalent3

Figure 4. Trend in the timeliness of immunization reports

Figure 2. Trend in the enrolment of pentavalent1 antigen per

category of health facilities Figure 5. Trend in the completeness of health facility reports as
recorded in the DVDMT/DHIS2 system
Trend in timeliness and completeness
Trend in the consistency of immunization data
The proportion of health facilities reports send on time
increased from 241 to 259 (7, 5% increase) between 2017 and For penta1 antigen, the number of health facilities has
2018. Between 2018 and 2019, a sharp decrease from 259 to increased from 3(13%) in 2017 to 12(52%) in 2018 and to
68 (73.7% decrease) was observed (Figure 4). 16(70%) in 2019. For penta3 antigen, the number of health
1665 International Journal of Science Academic Research, Vol. 02, Issue 06, pp.1662-1666, June, 2021

facilities has also increased from 3 (13%) in 2017 to 10 from 2017 to 2019 has improved. This can be seen in the
(43,5%) in 2018 and then to 16(70%) in 2019. The number of increase in the number of health facilities with consistent data
health facilities with moderate over reporting varies from 3 across the years. It can also be seen in the decrease in the
(13%) for penta1 in 2017 to 7(30,4%) in 2018 and down to number of health facilities with mild over reporting and mild
3(13%) in 2019. The number of health facilities with moderate under reporting. This show an improvement in recording and
over reporting for penta3 antigen ranges from 2(8,7%) in 2017 reporting in health facilities carrying immunization services
to 9 (39%) in 2018 and to 2 (8,7%) in 2019. The number of and are under PBF in the DHD. This is so because all health
health facilities with mild over reporting for pent1 ranges from facilities now have an obligation to register all the clients
12(52,2%) in 2017 to 2 (8,7%) in 2018 and remains the same vaccinated during each vaccination session in the vaccination
for 2019. The number of health facilities with mild over registers because all payments from PBF are based on the
reporting for penta3 decreases from 14(60,9%) in 2017 to 3 number of antigens administered and registered in the register.
(13,0%) in 2018 and then to 2(8,7%) in 2019. Number of This therefore turns to reduce the rate of over reporting in
health facilities with moderate under reporting ranges from 2 health facilities (Figure 5).
(8,7%) to 0 to 1(4,3%) for penta1 and 2 to 1 to 2 penta3 for the
respective years; 2017, 2018 and 2019. The number of health However, the relationship between PBF verification and
facilities with mild under reporting varies from 3(13,0%) to 2 decrease in over reporting is not really clear. This is because a
(8,7%) to 2(8,7%) for penta1 and from 2(8,7%) to 1(4%) to 0 great decrease in the number of health facilities with mild over
for penta3 for the year 2017, 2018 and 2019 respectively. reporting was seen between 2017 and 2018; 12 (52,2%) to 2
(8,7%) respectively for pentavalent1 and 14 (60,9%) to 2
DISCUSSION (8,7%) for pentavalent3 respectively. It should be noted that
PBF was adopted in the DHD in the last trimester of 2018 but
From the results above, the enrolment of pentavalent1 and took its effective course in 2019. This implies that the decrease
pentavalent3 across the year 2017, 2018 and 2019 as recorded in the number of health facilities with mild over reporting seen
in the DVDMT (2017 and 2018) and the DHIS2 (2019) data between 2017 and 2018 might have been course by a different
base have decrease. This results are similar to the WHO factor not evaluated in this study. This is further explained by
UNICEF estimates time series for Cameroon which shows that the fact that between 2018 and 2019, the number of health
the vaccination coverage for pentavalen1 in Cameroon has facilities with mild over reporting had no change for
decrease from 83% in 2017 to 76% in 2018 to 75% in 2019 pentavalent1 while for pentavalent3; the number has increased
and the vaccination coverage for pentavalen3 has also decrease by 1, which is 2 in 2018 and 3 in 2019. This number is lower
from 74% in 2017 to 67% in 2018 which remains constant in than the decrease witnessed between 2017 and 2018 when
67% in 2019. This decrease in enrolment can be looked upon there was no PBF. However, the number of health facilities
in two dimensions; an improvement in the quality of data with moderates over reporting witnesses a great decrease
available for estimates at the national and international level between 2018 and 2019 with the implementation of PBF. This
following over reporting in previous years and on the second is also similar with the number of health facilities with
part due to a decrease in the performance of the EPI. However, consistent data for both antigens whose greatest increase was
it should be noted that a decrease in vaccination coverage seen between 2018 and 2019 with the implementation of PBF.
exposes the population to vaccine preventable diseases. This Data inconsistency however remains a great problem in most
can be seen in a study conducted by David Sinclair et al. 2019 low and middle income countries resulting in poor decision
which showed that a 5% decrease in the vaccination rate is making as well as poor orientation of resources (Seemeeh et
associated with 40% 4000% increase in potential outbreak size al., 2017).
based on the metropolitan area (Sinclair et al., 2019). In this
Limits of the study
study, the former dimension is very likely to be true. A study
carried out by Simon Forcha in Douala Cameroon (2016) on Our study design was a great limit to our study as it does not
the effects of PBF on data from the EPI showed a more permit us to conclude with certitude if the changes observed
précised and quality data from health facilities under PBF are due to PBF or not. Also, our sample size cannot permit our
compared to those which were not in the PBF program (Simon, study to be applied on a large scale.
2016). We observed that the greatest decreased was seen
between 2018 and 2019 (11,6% for Pentavalent1 and 14,3% Conclusion
for Pentavalent3 which was the period in which PBF was
implemented in the DHD. The enrolment in pentavalent1 and pentavalent3 has decreased
across the years from 2017 to 2019 with the greatest decreased
The trend in the effective of monthly timely reports for EPI witnessed in 2019 with the implementation of PBF as recorded
showed a slight increase between 2017 and 2018 (4%) but in the DVDMT/DHIS2 data base of the DHD. The timeliness
drops drastically in2019 (74,4%) with the implementation of of monthly activity reports has decrease between 2018 and
PBF. This decrease can be attributed the introduction of the 2019 with the implementation of PBF and this decrease can be
DHIS2 data base in this district during this period. Adaptation attributed to the introduction of the DHIS2 software in the year
to technology, lack of adequate human and material resources, 2019 in this said district. The completeness has also witness a
week internet infrastructure and frequent power failure are 2,6% increase between 2018 and 2019 following the
some of the challenges that hinders the effectiveness of the implementation of PBF. The precision and quality of EPI data
DHIS2 system in sub-Saharan countries such as Cameroon. has also increased across the year from 2017 to 2019. Despite
However, maximum use of PBF resources by health facilities great improvement in the precision and the quality of
can go a long way to improving on the timeliness of EPI data. immunization data across the years, these achievements cannot
The completeness of data showed a slight increase between be fully attributed to PBF. More studies especially analytic
2018 and 2019 (2,6%) with the implementation of PBF. The studies would go a long way to fully establish the relationship
precision and quality of immunization data across the year between data quality and PBF.
1666 International Journal of Science Academic Research, Vol. 02, Issue 06, pp.1662-1666, June, 2021

REFERENCES Perceptions and experiences with District Health Information

System software to collect and utilize health data in
A systematic review of barriers to data sharing in public health Bangladesh: A qualitative exploratory study. 2019.
| BMC Public Health | Full Text. https://bmcpublichealth. doi:10.21203/rs.2.12293/v1. doi: 10.100/jamanetwork.
biomedcentral.com/articles/10.1186/1471-2458-14-1144. 2019.9768
Accessed 6 Aug 2020. Performance based financing: an international review of the
Andresen E, Bouldin ED. Public Health Foundations: literature. KIT Royal Tropical Institute. https://www.kit.nl/
Concepts and Practices. John Wiley & Sons; 2010. publication/performance-based-financing-an-international-
BLN Webinar: Immunization Data Management Systems – review-of-the-literature/. Accessed 6 Aug 2020.
Challenges and Perspectives from Cameroon. Better Performance-Based Financing Strengthens Public-Private
Immunization Data Initiative. https://bidinitiative.org/ Partnerships in the Health Sector – a Case Study from the
resource-library/posts/bln-webinar-immunization-data- Littoral Region of Cameroon | RBF Health. https://www.
management-systems-challenges-and-perspectives-from- rbfhealth.org/resource/performance-based-financing-
cameroon/. Accessed 6 Aug 2020. strengthens-public-private-partnerships-health-sector-
Cameroon population, 2020. Worldometer; available at: %E2%80%93-case. Accessed 6 Aug 2020.
cameroon. Seemeeh A O., Menberu G T et al; A Pilot study of routine
Chan M, Kazatchkine M, Lob-Levyt J, Obaid T, Schweizer J, immunization data quality in Bunza Local Government
Sidibe M, et al. Meeting the Demand for Results and area: causes and possible remedies. African Journal. 2017;
Accountability: A Call for Action on Health Data from 27:239.
Eight Global Health Agencies. PLOS Medicine. Sieleunou I, Turcotte-Tremblay A-M, Fotso J-CT, Tamga DM,
2010;7:e1000223. Yumo HA, Kouokam E, et al. Setting performance-based
Chen H, Hailey D, Wang N, Yu P. A Review of Data Quality financing in the health sector agenda: a case study in
Assessment Methods for Public Health Information Cameroon. Globalization and Health, 2017;13:52.
Systems. International journal of environmental research Simon F; the effect of performance based financing on the
and public health, 2014;11:5170–207. quality of data from the expanded program on
Framework and Standards for Country Health Information immunization: the case of the Littoral Cameroon, may
Systems / Health Metrics Network, World Health 2016. available at https://www.texilajournal.com/public-
Organisation.2nd ed. Available at; www.who.int health/aticle/392-the-effect-of. doi: 10.21522/TIJPH.2013.
Global Routine Vaccination Coverage, 2012. https://www.cdc. 04.02.Art060
gov/mmwr/preview/mmwrhtml/mm6243a4.htm. Accessed Sinclair DR, Grefenstette JJ, Krauland MG, et al. Forecasted
6 Aug 2020. Size of Measles Outbreak Associated With Vaccination
Heymann DL, Rodier GR, WHO Operational Support Team to Exemptions for Schoolchildren.JAMA Netw Open.
the Global Outbreak Alert and Response Network. Hot 2019;2(8):e199768. published 2016 Aug 2.
spots in a wired world: WHO surveillance of emerging and UTAP-2Atlanta: Strengthening Cameroon's System for
re-emerging infectious diseases. Lancet Infect Dis., Monitoring and Evaluating Health services that prevent
2001;1:345–53. Mother to Child Transmission of HIV. Accessed 8 Jun
Kengne AP, Djouogo CFT, Dehayem MY, Fezeu L, Sobngwi 2020.
E, Lekoubou A, et al. Admission trends over 8 years for Walker R. Health Information and Public Health. Health Inf
diabetic foot ulceration in a specialized diabetes unit in Manag. 2008; 37:4–5.
cameroon. Int J Low Extrem Wounds, 2009;8:180–6. WHO UNICEF estimates time series for Cameroon, Review of
Medicine I of. The Future of Public Health. 1AD. national Immunization coverage pdf. available at
doi:10.17226/1091. https://apps.who.int/immunization_monitoring/globalsumm
Ngwakongnwi E, Atanga MBS, Quan H. Challenges to ary/estimates
Implementing a National Health Information System in Winslow, C. E. A. 1920. The Untilled Fields of Public Health.
Cameroon: Perspectives of Stakeholders. J Public Health Science, 51, 23-33. - References - Scientific Research
Africa, 2014; 5. doi:10.4081/jphia.2014.322. Publishing. https://www.scirp.org/(S(oyulxb452 alnt1aej
O.Ronveaux, D.Rickert, S. Hadler et Al: The immunization 1nfow45))/reference/ReferencesPapers.aspx?ReferenceID=
data quality audit: verifying the quality and consistency of 1862355. Accessed 6 Aug 2020.
immunisation monitoring systems. Bulleting of the World
Health Organisation/july 2005,83(7) Accessed 15 February
2016

*******