Local stakeholders’ perceptions about the introduction of performance-based financing in Benin: a case study in two health districts

Abstract

Background: Performance-Based Financing (PBF) has been advanced as a solution to contribute to improving the performance of health systems in developing countries. This is the case in Benin. This study aims to analyse how two PBF approaches, piloted in Benin, behave during implementation and what effects they produce, through investigating how local stakeholders perceive the introduction of PBF, how they adapt the different approaches during implementation, and the behavioural interactions induced by PBF. Methods:The research rests on a socio-anthropological approach and qualitative methods. The design is a case study in two health districts selected on purpose. The selection of health facilities was also done on purpose, until we reached saturation of information. Information was collected through observation and semi-directive interviews supported by an interview guide. Data was analysed through contents and discourse analysis. Results: The Ministry of Health (MoH) strongly supports PBF, but it is not well integrated with other ongoing reforms and processes. Field actors welcome PBF but still do not have a sense of ownership about it. The two PBF approaches differ notably as for the organs in charge of verification. Performance premiums are granted according to a limited number of quantitative indicators plus an extensive qualitative checklist. PBF matrices and verification missions come in addition to routine monitoring. Local stakeholders accommodate theoretical approaches. Globally, staff is satisfied with PBF and welcomes additional supervision and training. Health providers reckon that PBF forces them to depart from routine, to be more professional and to respect national norms. A major issue is the perceived unfairness in premium distribution. Even if health staff often refer to financial premiums, actually the latter are probably too weak-and 'blurred'-to have a lasting inciting effect. It rather seems that PBF motivates health workers through other elements of its 'package' , especially formative supervisions. Conclusion:If the global picture is quite positive, several issues could jeopardise the success of PBF. It appears crucial to reduce the perceived unfairness in the system, notably through enhancing all facilities' capacities to ensure they are in line with national norms, as well as to ensure financial and institutional sustainability of the system.

Twelve months of implementation of health care performance‐based financing in Burkina Faso: A qualitative multiple case study

“…This study is the first in Burkina Faso to analyse PBF implementation and one of the very few published on the subject in francophone West Africa. It is a response to needs expressed by many researchers to understand the “why” and “how” of PBF …”

“…The delays in paying bonuses (similar to those experienced in Benin), when bonuses are at the heart of the theoretical and practical argument underpinning the intervention, are a prime example of the difficulties of organizing everything beforehand. Moreover, we saw that, as seen in Tanzania, Benin, and Sierra Leone, issues around the distribution of individual bonuses in health centres are crucial, raising notions of social justice and equity. Furthermore, PBF in Burkina Faso operates on a “carrot and carrot” approach, to paraphrase the experts, where no sanction appears possible or likely (and is perhaps not at all realistic in the West African context, in contrast to Rwanda, at least in the experts' opinions).…”

Performance‐based financing in the heath sector in low‐ and middle‐income countries: Is there anything whereof it may be said, see, this is new?

“…This is an important challenge for PBF because it will determine how financial performance premiums interact with other incentives in place and impact of health workers' motivation. For instance, in Cambodia, Khim reports that financial incentives under the PBF scheme account for a significant part of health workers' income (42% of the average total income) and are associated with higher job motivation; in Sierra Leone, Bertone et al find that PBF contributes about 10% of their total income but still are valued by health workers; by contrast, in Benin, Paul et al report that health workers perceived that PBF premiums are too low and “blurred” among many other allowances to have a “mechanical” incentive effect.…”

“…Other general lessons from MfR/PBB experience, which can inform on PBF schemes, point that (1) to ensure efficiency, it is important that PBF schemes are perfectly integrated within existing systems and avoid unnecessary duplications (eg, integrate supervision/monitoring/verification missions as much as possible without losing sight of their unique characteristics and needs; use national audit institution); (2) especially, PBF design must ensure coherence with other reforms such as decentralisation/devolution (avoid conflicts of interests; such an issue has been identified in Paul et al) and universal health coverage (for example, PBF may come in opposition to cost limitation mechanisms promoted in the context of Universal Health Coverage (UHC), possibly through capitation payment); (3) the choice of indicators should be carefully assessed; indicators should of course respect usual quality criteria (eg, being smart) but to avoid donor pushing priorities, their choice should be based on government's priority outcomes in the health sector—hence the importance of involving the Ministry of Finance and other government bodies; (4) the question of whether to fix quantitative indicators' “price” in relation to cost or not must be balanced; the first option rather incentivises technical efficiency, while the second rather acts to increase motivation to produce more outputs; moreover, it is important not to fix too high a price and overincentivise some activities—like it can be the case in some countries to C‐sections for instance; (5) as already argued, cost‐effectiveness of the whole system must be carefully balanced and before developing a complex PBF system, a first step may be to remove the factors that demotivate health workers—such as unfair pay or poor working conditions; (6) beyond being the basis for calculating financial premiums and enabling to clarify organisational priorities, various PBB experiences indicate that PBF could be “upgraded” so as to further use information on results as a basis for resource allocation: on the one hand in the context of budget negotiations with the Ministry of Finance and on the other hand as a basis for redistributing resources between health care providers; and (7) finally, successful implementation of MfR/PBB reforms has required careful planning and organisation, hence the importance of the sequencing and pace of the reforms …”

A friendly critical analysis of Kass’s ethics framework for public health

“…Growing data suggest that PBF may lead to unintended consequences. 8 The implementation of interventions with high burdens for the health system, workers or populations should be based, as much as possible, on rigorous evidence. We would like to add some nuance, however, to Kass's statement that PH programs should not be implemented if there are not at least "some data" demonstrating the validity of a program's assumptions.…”