Performance-based Financing Program Research Articles

Effect of integrated supportive supervision on availability of resources for health care service delivery and uptake of services in Ekiti State, Southwest Nigeria, evidence from the Saving One Million Lives program for result supported facilities.

a world bank performance-based financing program. The Saving One Million Lives program for results supported integrated supportive supervision (ISS) in selected primary health facilities (PHF) in Ekiti State, Nigeria. The study assessed the impact of ISS on health service outputs and outcomes such as infrastructure, basic equipment, human resources for health (HRH), essential drugs, number of children receiving immunization, number of mothers who gave birth in the facility, number of new and continuing users of modern family planning and the number of pregnant women screened for HIV (human immunodeficiency virus). a cross-sectional survey of 70 SOME-supported facilities was used for the study. Parametric and non-parametric method of analysis was employed to compare the mean values of study indicators gathered over the 4 rounds of ISS visits from January 2018 to August 2020. the study demonstrated that ISS approach has a positive effect on PHC service outputs and outcomes such as infrastructure, basic equipment, health human resources (HRH), essential drugs, contraceptives prevalence rate, skilled birth attendant as well as postnatal care. However, there was no significant impact on HIV screening for pregnant women. integrated supportive supervision approach has a positive effect on the quality of health care delivery in PHCs in Ekiti State, Nigeria. It is therefore recommended that periodic ISS visits should be routinely carried out in all PHCs across the State in the country and can be further extended to secondary and tertiary facilities.

Impacts of performance-based financing on health system performance: evidence from the Democratic Republic of Congo

BackgroundHealth systems’ weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such programs introduced in LMICs to date.MethodsWe used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021–2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers’ satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain.ResultsThe PBF program improved the structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01–0.08), technical process quality by 5 ppts (0.03–0.07), and non-technical process by 2 ppts (0–0.04). PBF also increased coverage of priority health services by 3 ppts (0.02–0.04). Improvements were also observed for facility management (9 ppts, 0.04–0.15), service fee policies, and users’ satisfaction with service affordability (14 ppts, 0.07–0.20). Service fees and health workers’ satisfaction were not affected by the program.ConclusionsThe results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals.Trial registrationAmerican Economics Association Trial registry AEARCTR-0002880.

Nutritional status of children under five years and associated factors in 24 districts of Burkina Faso.

Malnutrition in children is a serious health problem, especially in Sub-Saharan Africa, with heavy socioeconomic burdens. The prevalence of stunting remains high in Burkina Faso. There is a need to further investigate undernutrition and identify the major factors contributing to its persistence. We aimed to assess the nutritional status of children aged under five years and the associated factors of undernutrition in Burkina Faso. We conducted a second study using a baseline household survey of the impact assessment of a performance-based financing program. The analysis focused on data of 10,032 children aged 0-59 months collected from households in 537 villages. Anthropometric indicators were assessed using the World Health Organization standards, and their association with children, mothers, and households' characteristics were assessed using logistic regression. Stunting occurred in 40.1% of children, wasting in 25.1%, and underweight in 34%. Children having both stunting, wasting, and underweight were 7.3%. Stunting and underweight was associated with the sex. Stunting was associated with ethnic groups: Fulani with AdjOR = 1.20 (95%CI: 1.01-1.42), household economic level: poorest AdjOR = 1.25 (95%CI: 1.10-1.43), two and more children aged under five years in households: AdjOR = 1.16 (95%CI: 1.05-1.27), distance more than 5km from household to health facility: with Adj OR = 1.21 (95%CI: 1.10-1.35) and household food insecurity. This study identified the modifiable factors that determine the high prevalence of undernutrition in Burkina Faso. Strategies and interventions to improve the health and economic status of the community are needed to reduce the occurrence of undernutrition.

An in-depth qualitative study of health care providers' experiences of performance-based financing program as a nation-wide adopted policy in Cameroon: A principal-agent perspective.

The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability. The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system. PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).

To What Extent Do Free Healthcare Policies and Performance-Based Financing Reduce Out-of-Pocket Expenditures for Outpatient services? Evidence From a Quasi-experimental Study in Burkina Faso.

Burkina Faso has been implementing financing reforms towards universal health coverage (UHC) since 2006. Recently, the country introduced a performance-based financing (PBF) program as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under 5. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPEs) for outpatient services. Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program's impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under 5 and individuals above 5 to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM). The proportion of children under 5 incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our difference in differences estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude. User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supply-side intervention, PBF appears to have limited effects on reducing financial burden.

Supply-side contribution to the lack of PBF impact on unmet need for family planning in Burkina Faso

Abstract Background In 2020, about one in four women in Burkina Faso faced an unmet need for family planning (FP). Between 2013 and 2017, Burkina Faso implemented a performance-based financing (PBF) program to improve primary health care service provision (including FP) at rural health centers. Our prior work revealed that PBF did not lead to a reduction in unmet need for FP, in spite of FP being an explicitly targeted service. Our current study assesses supply-side factors that have likely contributed towards this lack of effect at population level, by examining changes in facility-based indicators relevant to the provision of FP induced by PBF. Methods We used facility-based survey data from 406 PBF and 117 control facilities collected before and after the PBF implementation. To compare changes in FP service provision, we examined changes in a number of relevant indicators including: a. the types of FP methods offered by facilities; b. trainings received by different FP providers; and c. available stocks of modern contraceptives. We relied on a difference-in-differences (DID) regression model to estimate the impact of PBF on these indicators. Results We observed a significant positive impact on the number of staff qualified to provide injectables, implants and IUDs (effect size 0.47, p 0.003) as well as the number of facilities offering IUDs (effect size 0.28, p 0.016) and a significant reduction in the number of facilities experiencing stock-outs of female condoms (effect size -0.09, p 0.007) and implants (effect size -0.03, p 0.042). Conclusions Given the significant positive impacts on the number of qualified staff, facilities providing IUDs and a reduction in stock-outs of female condoms and implants attributable to the PBF intervention without showing signs of negative effects on the indicators measured supply-side factors might not have been the main reason for the lack of effect of the PBF program on unmet need for FP. Key messages • Supply-side factors might not have been the main reason for the lack of effect of the PBF program on unmet need for FP. • Further research is needed to explore other potential underlying reasons.

Factors associated with mothers’ health care-seeking behaviours for childhood fever in Burkina Faso: findings from repeated cross-sectional household surveys

IntroductionFever is one of the most frequent reasons for paediatric consultations in Burkina Faso, but health care-seeking behaviours and the factors associated with health care-seeking in the event of childhood fever are poorly documented. This study aims to analyse the health care-seeking behaviours and the factors associated with health care-seeking for childhood fever in Burkina Faso.MethodsThis study used the data from the baseline and endline surveys conducted to evaluate the impact of the Performance-Based Financing program in Burkina Faso. Univariate and multivariate binary logistic regression analyses were used to identify the factors associated with appropriate healthcare-seeking for childhood fever. Odds ratios were estimated to assess the strength of associations and 95% confidence intervals (CIs) were used for significance tests. Data were cleaned, coded and analysed using Stata software version 16.1.ResultsAmong the children under five who had a fever, 75.19% and 79.76% sought appropriate health care in 2013 and 2017, respectively. Being 24–59 months old (AOR: 0.344, 95% CI 0.182–0.649 in 2013 and AOR: 0. 208, 95% CI 0.115–0.376 in 2017), living in a very wealthy household (AOR: 2.014, 95% CI 1.149–3.531 in 2013 and AOR: 2.165, 95% CI 1.223–3.834 in 2017), having a mother with a secondary or higher level of education or having made at least four antenatal care visits were significantly associated with seeking appropriate health care for childhood fever. Living in an area where the health facility is safe was also significantly associated with seeking appropriate care for childhood fevers.ConclusionsThe findings underscore the need to concentrate efforts aiming at sensitizing the population (especially women of childbearing age) to improve sanitation and the use of family planning (household composition), skilled antenatal care and postnatal care to help reduce the prevalence of fever in children under five and improve the use of medical healthcare for childhood fever.

Impact of Performance-Based Financing (PBF) Program on Utilization and Completeness of Partographs in Jimma

One of the most important quality thematic areas incentivized in PBF is maternity services which among other aspects include the use and completion of partographs when monitoring women in labor. Use f partographs during labor is a key intervention but it is not widely used due to various factors. Thus, the PBF program in Jimma sought to strengthen its use and completion since Q4 2019. A quasi-experimental design was used to review 7,260 mothers’ records from 2018, 2019 and 2021 from both Buno-Bedele (control) and Jimma (intervention) zones. Impact of the PBF program on partograph utilization and completeness was estimated using difference-in-differences (DiD) models in STATA 15. In 2019, partograph utilization was estimated to be 29.2% (CI: 26.6% - 31.8%) in Jimma and 23.5% (CI: 21.1% - 25.9%) in Buno-Bedele. In 2021, utilization increased to 87.2% (CI: 85.3% - 89.2%) in Jimma and 41.4% (CI: 38.7% - 44.2%) in Buno-Bedele. Out of the labor cases monitored with partographs, the completeness was 60.2% (CI: 58.1% - 62.4%) in Jimma and 51.6% (CI: 49.5% - 53.6%) in Buno-Bedele in 2019. In 2021, the completeness increased to 83.2% (CI: 82.3% - 84.2%) in Jimma and but remained the same in Buno-Bedele, 51.3% (CI: 49.7% - 52.8%). PBF accelerated the rate of improvement for both utilization (DiD: 30.8%, p-value < 0.001) and completion (DiD: 24.9%, p-value < 0.001) of partographs. Incentivizing facilities to improve quality of care coupled with coaching and mentorship of health workers is effective in improving quality of service for pregnant women in labor and delivery.

Cost-effectiveness analysis of the decentralized facility financing and performance-based financing program in Nigeria

Background: Nigeria piloted decentralized facility financing (DFF) and performance-based financing (PBF) programs under the Nigeria State Health Investment Project (NSHIP), funded by the World Bank. It aimed to increase the utilization and quality of maternal and child health (MCH) services. Although many low- and middle-income countries have launched or piloted DFF and/or PBF like programs and conducted impact evaluation, very few studies related DFF or PBF’s impact to its cost. This study evaluates the incremental cost-effectiveness ratios (ICERs) of facilities with DFF or PBF compared to comparably funded health facilities without it.

Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence

ABSTRACT Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF “works”—that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank’s repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region—either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.

Impact of Performance-Based Financing on effective coverage for curative child health services in Burkina Faso: Evidence from a quasi-experimental design.

To evaluate the impact of Performance-Based Financing (PBF) on effective coverage of child curative health services in primary healthcare facilities in Burkina Faso. An impact evaluation of a PBF pilot programme, using an experiment nested within a quasi-experimental design, was carried out in 12 intervention and 12 comparison districts in six regions of Burkina Faso. Across the 24 districts, primary healthcare facilities (537 both at baseline and endline) and households (baseline=7978 endline=7898) were surveyed. Within these households, 12350 and 15021 under-five-year-olds caretakers were interviewed at baseline and endline respectively. Linking service quality to service utilisation, we used difference-in-differences to estimate the impact of PBF on effective coverage of curative child health services. Our study failed to detect any effect of PBF on effective coverage. Looking specifically into quality of care indicators, we detected a positive effect of PBF on structural elements of quality of care related to general service readiness, but not on the overall facility quality score, capturing both service readiness and the content of childcare. The current study makes a unique contribution to PBF literature, as this is the first study assessing PBF impact on effective coverage for curative child health services in low-income settings. The absence of any significant effects of PBF on effective coverage suggests that PBF programmes require a stronger design focus on quality of care elements especially when implemented in a context of free healthcare policy.

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.

The medium-run and scale-up effects of performance-based financing: An extension of Rwanda’s 2006 trial using secondary data

Abstract Performance-based financing (PBF) programs have been introduced in numerous developing countries to increase the provision and quality of health services through financial incentives. Despite growing evidence about short-term impacts of PBF, less is known about medium-run impacts and scale-up effects, and about how PBF compares to other financing approaches. In this paper, we extend the initial evaluation of Rwanda’s PBF program to identify medium-run and scale-up effects of incentives and unconditional financing relative to a new “business as usual” counterfactual. We use data from the Demographic and Health Surveys from Rwanda and several Sub-Saharan African countries from 2001 to 2010, using two control group strategies: all available control regions, and a subset of regions that are similar to Rwanda based on pre-intervention trends in covariates and outcomes. We then use difference-in-differences regressions to measure the Rwandan program’s impacts on four indicators: institutional deliveries, antenatal tetanus prophylaxis, completion of any antenatal visits, and completion of four antenatal visits. The results are similar using the various control groups and in additional robustness checks. In the short-run and relative to no intervention, both performance-based and unconditional financing raised institutional delivery rates and completion of four antenatal visits. In the medium-run, relative to no intervention and in addition to the initial short-run impacts, performance-based incentives resulted in further improvements for institutional deliveries. Program scale-up was effective, with few differences between intervention arms after all areas received performance-based incentives. There were few effects on antenatal tetanus prophylaxis or on completion of any antenatal visits. Together, the results suggest that PBF can have persistent effects for some indicators, but unconditional financing can also be effective. Moreover, the analysis demonstrates how observational research methods and secondary data can generate new insights on completed trials.

The cost-effectiveness of using performance-based financing to deliver the basic package of health services in Afghanistan

Performance-based financing (PBF) is a mechanism to improve the quality and the utilisation of health benefit packages. There is a dearth of economic evaluations of PBF in the ‘real world’....

Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi

BackgroundSeveral performance-based financing (PBF) evaluations have been undertaken in low-income countries, yet few have examined community perspectives of care amid PBF programme implementation. We assessed community members’ perspectives of Support...

No effects of pilot performance-based intervention implementation and withdrawal on the coverage of maternal and child health services in the Koulikoro region, Mali: an interrupted time series analysis.

Performance-based financing (PBF) has been promoted and increasingly implemented across low- and middle-income countries to increase the utilization and quality of primary health care. However, the evidence of the impact of PBF is mixed and varies substantially across settings. Thus, further rigorous investigation is needed to be able to draw broader conclusions about the effects of this health financing reform. We examined the effects of the implementation and subsequent withdrawal of the PBF pilot programme in the Koulikoro region of Mali on a range of relevant maternal and child health indicators targeted by the programme. We relied on a control interrupted time series design to examine the trend in maternal and child health service utilization rates prior to the PBF intervention, during its implementation and after its withdrawal in 26 intervention health centres. The results for these 26 intervention centres were compared with those for 95 control health centres, with an observation window that covered 27 quarters. Using a mixed-effects negative binomial model combined with a linear spline regression model and covariates adjustment, we found that neither the introduction nor the withdrawal of the pilot PBF programme bore a significant impact in the trend of maternal and child health service use indicators in the Koulikoro region of Mali. The absence of significant effects in the health facilities could be explained by the context, by the weaknesses in the intervention design and by the causal hypothesis and implementation. Further inquiry is required in order to provide policymakers and practitioners with vital information about the lack of effects detected by our quantitative analysis.

How does performance-based financing affect the availability of essential medicines in Cameroon? A qualitative study.

Performance-based financing (PBF) is being implemented across low- and middle-income countries to improve the availability and quality of health services, including medicines. Although a few studies have examined the effects of PBF on the availability of essential medicines (EMs) in low- and middle-income countries, there is limited knowledge of the mechanisms underlying these effects. Our research aimed to explore how PBF in Cameroon influenced the availability of EMs, and to understand the pathways leading to the experiential dimension related with the observed changes. The design was an exploratory qualitative study. Data were collected through in-depth interviews, using semi-structured questionnaires. Key informants were selected using purposive sampling. The respondents (n = 55) included health services managers, healthcare providers, health authorities, regional drugs store managers and community members. All interviews were recorded, transcribed and analysed using qualitative data analysis software. Thematic analysis was performed. Our findings suggest that the PBF programme improved the perceived availability of EMs in three regions in Cameroon. The change in availability of EMs experienced by stakeholders resulted from several pathways, including the greater autonomy of facilities, the enforced regulation from the district medical team, the greater accountability of the pharmacy attendant and supply system liberalization. However, a sequence of challenges, including delays in PBF payments, limited autonomy, lack of leadership and contextual factors such as remoteness or difficulty in access, was perceived to hinder the capacity to yield optimal changes, resulting in heterogeneity in performance between health facilities. The participants raised concerns regarding the quality control of drugs, the inequalities between facilities and the fragmentation of the drug management system. The study highlights that some specific dimensions of PBF, such as pharmacy autonomy and the liberalization of drugs supply systems, need to be supported by equity interventions, reinforced regulation and measures to ensure the quality of drugs at all levels.

Creating a pathway for public hospital accreditation in Rwanda: progress, challenges and lessons learned.

Quality problemWeaknesses in the quality of care delivered at hospitals translates into patient safety challenges and causes unnecessary harm. Low-and-middle-income countries disproportionately shoulder the burden of poor quality of hospital care.Initial assessmentIn the early 2000s, Rwanda implemented a performance-based financing (PBF) system to improve quality and increase the quantity of care delivered at its public hospitals. PBF evaluations identified quality gaps that prompted a movement to pursue an accreditation process for public hospitals.Choice of solutionSince it was prohibitively costly to implement an accreditation program overseen by an external entity to all of Rwanda’s public hospitals, the Ministry of Health developed a set of standards for a national 3-Level accreditation program.ImplementationIn 2012, Rwanda launched the first phase of the national accreditation system at five public hospitals. The program was then expected to expand across the remainder of the public hospitals throughout the country.EvaluationOut of Rwanda’s 43 public hospitals, a total of 24 hospitals have achieved Level 1 status of the accreditation process and 4 have achieved Level 2 status of the accreditation process.Lessons learnedLinking the program to the country’s existing PBF program increased compliance and motivation for participation, especially for those who were unfamiliar with accreditation principles. Furthermore, identifying dedicated quality improvement officers at each hospital has been important for improving engagement in the program. Lastly, to improve upon this process, there are ongoing efforts to develop a non-governmental accreditation entity to oversee this process for Rwanda’s health system moving forward.

Stakeholder Perceptions and Context of the Implementation of Performance-Based Financing in District Hospitals in Mali.

Background: To improve the performance of the healthcare system, Mali’s government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa. Methods: This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle’s members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR). Results: Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership. Conclusion: The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention.

The Extent to Which Performance-Based Financing Programs' Operations Manuals Reflect Rights-Based Principles: Implications for Family Planning Services.

Recognition is growing that development programs need to be guided by rights as well as to promote, protect, and fulfill them. Drawing from a content analysis of performance-based financing (PBF) implementation manuals, we quantify the extent to which these manuals use a rights perspective to frame family planning services. PBF is an adaptable service purchasing strategy that aims to improve equity and quality of health service provision. PBF can contribute toward achieving global family planning goals and has institutional support from multiple development partners including the Global Financing Facility in support of Every Woman Every Child. A review of 23 PBF implementation manuals finds that all documents are focused largely on the implementation of quality and accountability mechanisms, but few address issues of accessibility, availability, informed choice, acceptability, and/or nondiscrimination and equity. Notably, operational inclusion of agency, autonomy, empowerment, and/or voluntarism of health care clients is absent. Based on these findings, we argue that current PBF programs incorporate some mention of rights but are not systematically aligned with a rights-based approach. If PBF programs better reflected the importance of client-centered, rights-based programming, program performance could be improved and risk of infringing rights could be reduced. Given the mixed evidence for PBF benefits and the risk of perverse incentives in earlier PBF programs that were not aligned with rights-based approaches, we argue that greater attention to the rights principles of acceptability, accessibility, availability, and quality; accountability; agency and empowerment; equity and nondiscrimination; informed choice and decision making; participation; and privacy and confidentiality would improve health service delivery and health system performance for all stakeholders with clients at the center. Based on this review, we recommend making the rights-based approach explicit in PBF; progressively operationalizing rights, drawing from local experience; validating rights-based metrics to address measurement gaps; and recognizing the economic value of aligning PBF with rights principles. Such recommendations anchor an aspirational rights agenda with a practical PBF strategy on the need and opportunity for validated metrics.