Effects Of Performance-based Financing Research Articles

Effects of Performance-Based Financing on Availability, Quality, and Use of Family Planning Services in the Democratic Republic of Congo: An Impact Evaluation.

Access to high-quality family planning services remains limited in many low- and middle-income countries, resulting in a high burden of unintended pregnancies and adverse health outcomes. We used data from a large randomized controlled trial in the Democratic Republic of Congo to test whether performance-based financing (PBF) can increase the availability, quality, and use of family planning services. Starting at the end of 2016, 30 health zones were randomly assigned to a PBF program, in which health facilities received financing conditional on the quantity and quality of offered services. Twenty-eight health zones were assigned to a control group in which health facilities received unconditional financing of a similar magnitude. Follow-up data collection took place in 2021-2022 and included 346 health facility assessments, 476 direct clinical observations of family planning consultations, and 9,585 household surveys. Findings from multivariable regression models show that the PBF program had strong positive impacts on the availability and quality of family planning services. Specifically, the program increased the likelihood that health facilities offered any family planning services by 20 percentage points and increased the likelihood that health facilities had contraceptive pills, injectables, and implants available by 23, 24, and 20 percentage points, respectively. The program also improved the process quality of family planning consultations by 0.59 standard deviations. Despite these improvements, and in addition to reductions in service fees, the program had a modest impact on contraceptive use, increasing the modern method use among sexually active women of reproductive age by 4 percentage points (equivalent to a 37 percent increase), with no significant impact on adolescent contraceptive use. These results suggest that although PBF can be an effective approach for improving the supply of family planning services, complementary demand-side interventions are likely needed in a setting with very low baseline utilization.

The effects of performance-based financing on neonatal health outcomes in Burundi, Lesotho, Senegal, Zambia and Zimbabwe.

Maternal and newborn care has been a primary focus of performance-based financing (PBF) projects, which have been piloted or implemented in 21 countries in sub-Saharan Africa since 2007. Several evaluations of PBF have demonstrated improvements to facility delivery or quality of care. However, no studies have measured the impact of PBF programmes directly on neonatal health outcomes in Africa, nor compared PBF programmes against another. We assess the impact of PBF on early neonatal health outcomes and associated health care utilization and quality in Burundi, Lesotho, Senegal, Zambia and Zimbabwe. We pooled Demographic and Health Surveys and Multiple Indicator Cluster Surveys and apply difference-in-differences analysis to estimate the effect of PBF projects supported by the World Bank on early neonatal mortality and low birthweight. We also assessed the effect of PBF on intermediate outputs that are frequently explicitly incentivized in PBF projects, including facility delivery and antenatal care utilization and quality, and caesarean section. Finally, we examined the impact among births to poor or high-risk women. We found no statistically significant impact of PBF on neonatal health outcomes, health care utilization or quality in a pooled sample. PBF was also not associated with better health outcomes in each country individually, though in some countries and among poor women PBF improved facility delivery, antenatal care utilization or antenatal care quality. There was no improvement on the health outcomes among poor or high-risk women in the five countries. PBF had no impact on early neonatal health outcomes in the five African countries studied and had limited and variable effects on the utilization and quality of neonatal health care. These findings suggest that there is a need for both a deeper assessment of PBF and for other strategies to make meaningful improvements to neonatal health outcomes.

Incentives to change: effects of performance-based financing on health workers in Zambia

BackgroundPerformance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers’ job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before–after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group.MethodsMixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program.ResultsEconometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity.ConclusionsIn Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.

The effects of performance-based financing on the use and quality of health care in Burundi: an impact evaluation

BackgroundPerformance-based financing (PBF) has attracted considerable interest from governments and aid agencies in low-income countries as a means to increase productivity and quality of health-care providers. In Africa alone, more than 35 countries are in the process of introducing payment methods that reward performance. The Burundi Government has gradually rolled out PBF across all provinces between 2006 and 2010. Our aim was to evaluate whether this has led to changes in the quantity and quality of health-care services provided. MethodsWe exploited the staggered rollout of PBF to apply a difference-in-differences approach using data from 2006 (baseline), 2008, and 2010. Cross-sectional data were collected among a random sample of 3200 households and panel data among 75 randomly selected health-care facilities across intervention and control provinces. FindingsWe found that PBF increased the probability of women delivering in an institution by 21 percentage points (p=0·0001), the probability of using antenatal care by 7 percentage points (p=0·067), and the use of modern family planning services by 5 percentage points (p=0·002). The overall facility quality score as constructed by external audits increased by 46%, but no effect of PBF was found on the quality of care as reported by patients. We also found no effects of PBF on vaccination rates, and the satisfaction with waiting times decreased. There is no strong evidence for unequal effects of PBF across socioeconomic groups. InterpretationThe introduction of PBF in Burundi has led to significant increases in mother and child care utilisation and in the quality scores of health-care facilities. Given the rising popularity of this financing strategy, more robust evidence on its effects is warranted. FundingWe thank the BMG Innovation fund, the Rotterdam Global Health Initiative, and Cordaid Netherlands for funding this research. EvdP is a Postdoctoral Fellow of the Netherlands Organisation for Scientific Research—Innovational Research Incentives Scheme—Veni project 451-11-03.

Looking at the effects of performance-based financing through a complex adaptive systems lens

The debate on PBF is misdirected. As is too often the case in international aid financing, agencies try to prove the effectiveness of their contribution by isolating it as the main reason for success.1 In reaction, opponents will often use the same approach in an attempt to prove that another factor is actually the cause of an observed change. We argue that this endless and futile debate, often present among experts in health systems strengthening, will not contribute to improving public health in low-income countries. Rather than searching for the impossible proof of whether PBF works or not, we should instead try to learn useful lessons from experiences. We agree with Ireland et al. that the focus of PBF assessment should be on “why” and “how” the intervention works.2 Comprehensive evaluation of PBF is needed as part of complete health system reform. We think that, to respond to some of these key questions, health systems should be analysed using a complex adaptive systems lens, as others have advocated in the past.3,4 A complex adaptive system is a collection of interacting components, each of which has its own rules and responsibilities. The behaviour of this kind of system is different to the sum of the behaviour of each of its components. Examples of complex adaptive systems include the human brain, ecosystems and manufacturing businesses. Health system “behaviour” and particularly counterintuitive behaviour (unexpected changes or lack of change) can be analysed using a complex adaptive systems lens when PBF is introduced, often with a mix of other interventions such as in a context of system reform. The purpose of this analysis is not to isolate causal factors but rather to identify “macro” characteristics of the system that may explain behaviour change. Although it has often been ignored in health system evaluation, social simulation can be useful for this approach. The most frequently used technique, agent-based modelling, uses computer simulation centred on a collection of autonomous agents whose interactions are based on a set of rules. These simulations can integrate empirical data or existing knowledge or opinions.5 One of the powerful features of agent-based modelling lies in its capacity to study complex phenomena in a simple and flexible way. Indeed, this approach does not require a high level of mathematical or programming skills, making it accessible to many researchers. Furthermore, it allows for an iterative learning process that is easy to set up compared to long and costly data collection processes. While this methodological approach may not “prove” the effectiveness of an intervention, it could provide insight into the reason a health system behaves in a given way (whether it changes or remains in a steady-state) when PBF is introduced. We believe that this type of information, although maybe less appealing to the usual stakeholders in development aid debates, is much more useful in evaluating PBF.