Abstract
BackgroundPerformance based financing (PBF) has been increasingly implemented across low and middle-income countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn.MethodsOur comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities.ResultsOur analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called ‘PBF principles’ that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes.ConclusionsOur study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.
Highlights
Performance based financing (PBF) has been increasingly implemented across low and middleincome countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme
Such programmes have been increasingly implemented across low and middle income countries in the past decade with considerable external financing from multilateral, bilateral and global health initiatives [2]. It is clear from the early studies that PBF is unlikely to be a homogenous intervention and that its modalities and effects will be dependent on context [3], the literature on PBF has been surprisingly thin in its discussion of how different contexts may influence PBF programmes [4]
In this paper, using case studies from three humanitarian settings – northern Nigeria, the Central African Republic (CAR) and South Kivu in the Democratic Republic of Congo (DRC) - we examine why and how PBF has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn
Summary
Performance based financing (PBF) has been increasingly implemented across low and middleincome countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. Performance based financing (PBF) schemes aim to improve health service delivery by providing bonuses to service providers (usually facilities, but often with a portion paid to individual staff) based on verified quantity of outputs produced, modified by quality indicators [1] Such programmes have been increasingly implemented across low and middle income countries in the past decade with considerable external financing from multilateral, bilateral and global health initiatives [2]. The review found that evidence on the interaction between PBF and context is still limited and pointed to some critical issues that deserve further attention It highlighted that, contrary to expectation, PBF design was relatively homogenous across FCAS settings, with the notable exception that in humanitarian settings some adaptations were emerging. As these adaptations are only partially described in the grey literature and not analysed in published studies, they were deemed to merit indepth exploration, which is the objective of this paper
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