This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.
Background: Performance-based financing (PBF) is often proposed as a way to improve health system performance. In Benin, PBF was launched in 2012 through a World Bank-supported project. The Belgian Development Agency (BTC) followed suit through a health system strengthening (HSS) project. This paper analyses and draws lessons from the experience of BTC-supported PBF alternative approach – especially with regards to institutional aspects, the role of demand-side actors, ownership, and cost-effectiveness – and explores the mechanisms at stake so as to better understand how the "PBF package" functions and produces effects Methods: An exploratory, theory-driven evaluation approach was adopted. Causal mechanisms through which PBF is hypothesised to impact on results were singled out and explored. This paper stems from the co-authors’ capitalisation of experiences; mixed methods were used to collect, triangulate and analyse information. Results are structured along Witter et al framework. Results: Influence of context is strong over PBF in Benin; the policy is donor-driven. BTC did not adopt the World Bank’s mainstream PBF model, but developed an alternative approach in line with its HSS support programme, which is grounded on existing domestic institutions. The main features of this approach are described (decentralised governance, peer review verification, counter-verification entrusted to health service users’ platforms), as well as its adaptive process. PBF has contributed to strengthen various aspects of the health system and led to modest progress in utilisation of health services, but noticeable improvements in healthcare quality. Three mechanisms explaining observed outcomes within the context are described: comprehensive HSS at district level; acting on health workers’ motivation through a complex package of incentives; and increased accountability by reinforcing dialogue with demand-side actors. Cost-effectiveness and sustainability issues are also discussed. Conclusion: BTC’s alternative PBF approach is both promising in terms of effects, ownership and sustainability, and less resource consuming. This experience testifies that PBF is not a uniform or rigid model, and opens the policy ground for recipient governments to put their own emphasis and priorities and design ad hoc models adapted to their context specificities. However, integrating PBF within the normal functioning of local health systems, in line with other reforms, is a big challenge.
Objective: The aim of this work was to determine the prevalence, associated factors and quality of high blood pressure (HBP) management in three regions of Benin in 2015. Methodology: This was a cross-sectional study, with two components. The first component included adults aged from 18 to 69 years, selected using a three-stage random sampling within the households. Data were collected thanks to the French version of the WHO STEPS instrument. Anthropometric data, including blood pressure, capillary fasting glucose and total cholesterol were measured according to standard procedures. The second component included Public Health Centers (PHC) selected by a random stratified multi-stage sampling. Data were collected on the structures and the processes of HBP management using the standardized tool for assessing the capacities of management of non-communicable diseases in peripheral health centers provided by the World Health Organization. Results: A total of 4816 participants were included in the first component. The mean age was 35.8 ± 12.7 years. The weighted prevalence of HBP was 27.9% (95% Confidence Interval (CI) [25.6 -30.2]). It was higher in the 60 -69 years compared to the lower age groups (Adjusted Odd-ratio (ORa) = 5; 95% CI [3.9 -6.5)]). HBP was positively associated with urban residence (ORa = 1.26; 95% CI [1.24 -1.28]), obesity (ORa = 1.46; 95% CI [1.43 -1.50]), hyperglycemia (ORa = 1.13; 95% CI [1.10 -1.15)]) and hypercholesterolemia (ORa = 1.64; 95% CI [1.59 -1.70)]). A total of 27 PHC were included in the second component. Taking blood pressure and other anthropometric measurements was not routine in PHC. Several essential medicines were not available in the PHC. A low How to cite this paper: Dramé, M.L.,
Aims: Diabetes is a major public health problem in low and middle-income countries. This study 1) estimated prevalence and factors associated with hyperglycemia in Benin, and 2) assessed the treatment quality of diabetes. Methodology: A cross-sectional research was conducted with two components. The First component has included 4954 subjects aged (18-69) randomly selected in Mono/Couffo and Donga regions. Data were collected according to WHO's STEPS approach. Capillary blood glucose was measured using the automat Cardiocheck PA. The Second component considered Public Health Centers (PHCs) within the study regions. Health system established for diabetes control, healthcare practices and the level of involvement of the Public Healthcare Providers and community actors in the management of diabetes have been explored. Findings: A total of 4775 subjects participated in the first component with a predominance of women (56.8%), rural residence and aged (<45 years). Prevalence of hyperglycemia was 9.2%. Age ≥ 30 years, Fon ethnic groups and related, obesity, hypercholesterolemia, and inadequate intake of fruits and vegetables were positively associated with hyperglycemia. The second component has underscored a mismatch of facilities, processes and quality healthcare. Conclusion: Diabetes prevalence goes increasingly in Benin when its management is inadequate in PHCs. Prevention and control actions should be strengthened.
Introduction: In 2012, Belgian Development Agency (BTC), at the request of Benin Authorities, introduced a Results-Based Financing (RBF) mechanism in two Regions to improve health system performance. The purpose is to grant subsidies to providers and managers of care and services on a performance basis. Two regional steering committees (SC) chaired by mayors have been set up with health care and civil society representatives. Mayors were given the position of buyer of performances on behalf of beneficiaries. The aim is to study the institutional arrangements for the management of BTC's RBF at the decentralized level in relation to its effectiveness in the context of supply/demand dialogue, community empowerment, better coordination between local Governments and Health, and improving care quality. Methods: This is a cross-sectional study with retrospective and prospective data collection. The study population is made up of players involved in the RBF. Data collection was carried out through the documentary review of the RBF experiences in Benin. The analysis was conducted by identifying the strengths, weaknesses, opportunities and threats of the SC at the decentralized level. Results: Regular meetings of the SC focuses henceforth on the resolution of concrete problems through a constructive dialogue between supply and demand; Community participation has shifted from information to co-decision making; Enhanced accountability: providers and managers report on their performance to the reporting line, mayors and the Civil Society; The presence of the Civil Society and the mayors ensures compliance with the principle of performance-based payment and contributes to the fight against fraud and impunity; Complaints management data and community verification feed into the supervision of the Health zone management team; Progressive financing of the SC functioning by the municipalities and; Improving satisfaction of health services users. Conclusions: SC at the decentralized level promotes stakeholder engagement for people's access to health care; It shows the need for a permanent framework of exchanges among players at the decentralized level to improve the provision of care; Involvement of mayors in a process of improving care quality and at a decision-making level is a guarantee of responsibility and community involvement.
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