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?

Paul, Élisabeth; Renmans, Dimitri

doi:10.1002/hpm.2409

Cited by 29 publications

(32 citation statements)

References 46 publications

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“…A second causal mechanism identified in the process of this theory-driven evaluation is the fact that PBF appears to be acting on health workers’ motivation through a complex mechanism, all the more since beyond financial premiums, all contractual features and ancillary components of PBF are likely to impact on workers’ various sources of motivation. 21 Bertone and colleagues 22 have warned against the risk of looking at PBF payments in isolation, without reference to the overall remuneration of health workers. Their study confirms that the remuneration of health workers is complex and interrelated so that the different financial incentives cannot be examined independently.…”

Section: Resultsmentioning

confidence: 99%

Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach

Paul

Dramé

Kashala

et al. 2017

Int J Health Policy Manag

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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.

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Section: Resultsmentioning

confidence: 99%

Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach

Paul

Dramé

Kashala

et al. 2017

Int J Health Policy Manag

Self Cite

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“…We might therefore wonder whether the underlying theoretical rationale is not simply a pretext, which some might consider valid, to provide additional resources to the operational level of the health system, which in fact needs them. But is this incentive‐based logic worth the price, when other options to solve the health system's problems have not all been tested and PBF efficiency remains to be proven? The current state of knowledge is not yet adequate to answer this question in Africa.…”

Section: Discussionmentioning

confidence: 99%

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

Ridde

Yaogo²,

Zongo

et al. 2017

Health Planning & Management

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To improve health services' quantity and quality, African countries are increasingly engaging in performance‐based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post‐launch in late 2014.The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents.Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community‐based audits had yet been done. Distribution of bonuses varied from one centre to another.This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.

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“…However, elements of PBF may foster both extrinsic and intrinsic motivation. Evidence on the motivational mechanisms of PBF remains scarce, but some studies have found that PBF can stimulate intrinsic forms of motivation, such as transforming the work environment [ 4 , 9 , 12 , 16 , 17 ], giving health workers opportunities to improve skills, enhancing recognition from the community [ 4 , 19 ], and strengthening professional pride and responsibility [ 9 , 19 ]. It thus appears that PBF as a complex systems intervention has the potential to influence many different types of motivational determinants [ 20 – 22 ].…”

Section: Introductionmentioning

confidence: 99%

Performance-based financing kick-starts motivational “feedback loop”: findings from a process evaluation in Mozambique

Gergen¹,

Rajkotia²,

Lohmann

et al. 2018

Hum Resour Health

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BackgroundPerformance-based financing (PBF) reforms aim to directly influence health worker behavior through changes to institutional arrangements, accountability structures, and financial incentives based on performance. While there is still some debate about whether PBF influences extrinsic or intrinsic motivators, recent research finds that PBF affects both. Against this backdrop, our study presents findings from a process evaluation of a PBF program in Mozambique, exploring the perceived changes to both internal and external drivers of health worker motivation associated with PBF.MethodsWe used a qualitative research design with in-depth, semi-structured interviews with health workers, which included a rank order exercise and focus group discussions. Interviews were analyzed by two researchers using thematic analysis techniques. Rank order frequency was calculated using weighted average methodology.ResultsHealth workers reported that PBF, overall, positively influenced their motivation by introducing or reinforcing both internal and external motivational drivers. Internal drivers included enhanced self-efficacy driven by goal orientation, healthy competition among colleagues, and job satisfaction. External drivers included an organized work environment, enhanced access to equipment and supplies, financial incentives, teamwork, and regular consultations with verifiers (a type of supervision). PBF stimulates an interactive relationship between internal and external motivational drivers, creating a feedback loop involving responsibility, achievement, and recognition, which increased perceived motivation.ConclusionsThe PBF program helped workers feel that they had well-defined and achievable goals and that they received recognition from verification teams, management committees, and colleagues due to enhanced accountability and governance. Our paper shows that financial incentives could serve as the “driver” to kick-start the feedback loop, of responsibility, achievement, and recognition, in environments that lack other drivers. Understanding how PBF programs can be designed and refined to reinforce this feedback loop could be a powerful tool to further enhance and track positive motivational changes. For countries thinking about PBF, we recommend that policymakers assess the loop in their contexts, identify drivers, determine whether these drivers are sufficient, and consider PBF if they are not.Trial registrationWe obtained ethical approval for the study protocol, data collection instruments, and informed consent forms from the Ethics Review Committee of the Centers for Disease Control and Prevention (CDC) [IRB 2015–190] and the Ethics Review Committee of the Mozambique Ministry of Health.

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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?

Cited by 29 publications

References 46 publications

Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach

Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach

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

Performance-based financing kick-starts motivational “feedback loop”: findings from a process evaluation in Mozambique

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