Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation

Abstract

BackgroundPerformance-based financing is increasingly being applied in a variety of contexts, with the expectation that it can improve the performance of health systems. However, while there is a growing literature on implementation issues and effects on outputs, there has been relatively little focus on interactions between PBF and health systems and how these should be studied. This paper aims to contribute to filling that gap by developing a framework for assessing the interactions between PBF and health systems, focusing on low and middle income countries. In doing so, it elaborates a general framework for monitoring and evaluating health system reforms in general.MethodsThis paper is based on an exploratory literature review and on the work of a group of academics and PBF practitioners. The group developed ideas for the monitoring and evaluation framework through exchange of emails and working documents. Ideas were further refined through discussion at the Health Systems Research symposium in Beijing in October 2012, through comments from members of the online PBF Community of Practice and Beijing participants, and through discussion with PBF experts in Bergen in June 2013.ResultsThe paper starts with a discussion of definitions, to clarify the core concept of PBF and how the different terms are used. It then develops a framework for monitoring its interactions with the health system, structured around five domains of context, the development process, design, implementation and effects. Some of the key questions for monitoring and evaluation are highlighted, and a systematic approach to monitoring effects proposed, structured according to the health system pillars, but also according to inputs, processes and outputs.ConclusionsThe paper lays out a broad framework within which indicators can be prioritised for monitoring and evaluation of PBF or other health system reforms. It highlights the dynamic linkages between the domains and the different pillars. All of these are also framed within inter-sectoral and wider societal contexts. It highlights the importance of differentiating short term and long term effects, and also effects (intended and unintended) at different levels of the health system, and for different sectors and areas of the country. Outstanding work will include using and refining the framework and agreeing on the most important hypotheses to test using it, in relation to PBF but also other purchasing and provider payment reforms, as well as appropriate research methods to use for this task.

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?

“…First, as unquestioned in social science, “systems thinking” and realist evaluation, context matters in determining whether and how an intervention will or has produce(d) effects. This is obviously the case of PBF . A number of contextual factors influence the way PBF schemes are “designed” (eg, national policies, pressure from stakeholders to incorporate their priorities) that may get them depart from the otherwise “optimal contract” predicted by theory.…”

Performance-based financing for improving HIV/AIDS service delivery: a systematic review

“…To prevent this, some publicly financed PBF initiatives include indicators for many diseases [20]. This approach would make PBF a wider health financing reform and may lead to improved institutionalisation and larger returns on health investments [42]. Consideration could also be made to evaluate use of PBF across different ministries as overall government reform.…”

Evidence gap map of performance measurement and management in primary care delivery systems in low- and middle-income countries – Study protocol

“…Proximal health effects could include the adoption of improved clinical behaviors by providers; quality improvement and safety outcomes at the patient- and facility-levels; increased service utilization and effective coverage; positive and negative equity effects; and, adverse or unintended effects. Examples of negative or unintended effects of performance management interventions have been reported in the literature, including gaming, shirking and cream-skimming 25 82 85 .…”

“…System antecedents, such as experiences with previous institutional reforms, and the readiness for change in the primary care system, have also been shown to have effects on the acceptance and assimilation of performance improvements 107 108 . Finally, ancillary components like technical assistance, monitoring and evaluation, and training, among others, should also be considered as relevant factors that can contribute or create obstacles in the generation of performance improvements 25 37 82 . Given operational limitations, contextual factors and ancillary components will not be included in the scope for this EGM.…”