Looking into the performance-based financing black box: evidence from an impact evaluation in the health sector in Cameroon

Abstract

Performance-based financing (PBF) is a complex health systems intervention aimed at improving the coverage and quality of care. Several studies have shown a positive impact of PBF on health service coverage, often coupled with improvements in quality, but relatively little is known about the mechanisms driving those results. This article presents results of a randomized impact evaluation in Cameroon designed to isolate the role of specific components of the PBF approach with four study groups: (i) PBF with explicit financial incentives linked to results, (ii) direct financing with additional resources available for health providers not linked to performance, (iii) enhanced supervision and monitoring without additional resources and (iv) a control group. Overall, results indicate that, when compared with the pure control group, PBF in Cameroon led to significant increases in utilization for several services (child and maternal vaccinations, use of modern family planning), but not for others like antenatal care visits and facility-based deliveries. In terms of quality, PBF increased the availability of inputs and equipment, qualified health workers, led to a reduction in formal and informal user fees but did not affect the content of care. However, for many positively impacted outcomes, the differences between the PBF group and the group receiving additional financing not linked to performance are not significant, suggesting that additional funding rather than the explicit incentives might be driving improvements. In contrast, the intervention group offering enhanced supervision, coaching and monitoring without additional funding did not experience significant impacts compared to the control group.

Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis

“…In Zambia, P4P was found to have no significant effect on the availability of inputs (facility infrastructure, drugs, or equipment), process quality of care (antenatal and child health care exit interviews), and client satisfaction [ 43 ]. In Cameroon, there was no evidence of an effect of P4P on process quality of care measured using direct observation of antenatal and childcare consultations [ 44 ]. Finally, in Benin, P4P had a significant effect on various aspects of clinical care, including a 5.5 percentage point, 2.7 percentage point, and 8.8 percentage point increase in checklists for history taking, physical examinations and advice during antenatal care consultations [ 45 ].…”

Outcomes following SARS-CoV-2 infection in individuals with and without solid organ transplantation—A Danish nationwide cohort study

“…the availability of inputs (facility infrastructure, drugs, or equipment), process quality of care (antenatal and child health care exit interviews), and client satisfaction [43]. In Cameroon, there was no evidence of an effect of P4P on process quality of care measured using direct observation of antenatal and childcare consultations [44]. Finally, in Benin, P4P had a significant effect on various aspects of clinical care, including a 5.5 percentage point, 2.7 percentage point, and 8.8 percentage point increase in checklists for history taking, physical examinations and advice during antenatal care consultations [45].…”

Reviewing the evidence on health financing for effective coverage: do financial incentives work?

“…22 Several evaluations of PBF programmes have found that a comparison group that maintains resource neutrality and includes decentralisation can lead to equivalent gains in coverage although with differential impacts on quality of care. [23][24][25] While PBF interventions provide an unconditional core budget and additional financial incentives conditional on performance, DFF interventions only provide additional unconditional financing. Often the financing is accompanied by autonomy, community engagement and supportive supervision.…”