Performance-based Financing Schemes Research Articles

Discontinuation of performance-based financing in primary health care: impact on family planning and maternal and child health

Performance-based financing (PBF) is advocated as an effective means to improve the quality of care by changing healthcare providers’ behavior. However, there is limited evidence on its effectiveness in low- and middle-income countries and on its implementation in primary care settings. Evidence on the effect of discontinuing PBF is even more limited than that of introducing PBF schemes. We estimate the effects of discontinuing PBF in Egypt on family planning, maternal health, and child health outcomes. We use a difference-in-differences (DiD) model with fixed effects, exploiting a unique dataset of six waves of spatially constructed facility-level health outcomes. We find that discontinuing performance-based incentives to providers had a negative effect on the knowledge of contraceptive methods, iron supplementation during pregnancy, the prevalence of childhood acute respiratory infection, and, more importantly, under-five child mortality, all of which were indirectly targeted by the PBF scheme. No significant effects are reported for directly targeted outcomes. Our findings suggest that PBF can induce permanent changes in providers’ behavior, but this may come at the expense of non-contracted outcomes.

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.

Implementation of a performance-based financing scheme in Malawi and resulting externalities on the quality of care of non-incentivized services

BackgroundCountries in Africa progressively implement performance-based financing schemes to improve the quality of care provided by maternal, newborn and child health services. Beyond its direct effects on service provision, evidence suggests that performance-based financing can also generate positive externalities on service utilization, such as increased use of those services that reached higher quality standards after effective scheme implementation. Little, however, is known about externalities generated within non-incentivized health services, such as positive or negative effects on the quality of services within the continuum of maternal care.MethodsWe explored whether a performance-based financing scheme in Malawi designed to improve the quality of childbirth service provision resulted positive or negative externalities on the quality of non-targeted antenatal care provision. This non-randomized controlled pre-post-test study followed the phased enrolment of facilities into a performance-based financing scheme across four districts over a two-year period. Effects of the scheme were assessed by various composite scores measuring facilities’ readiness to provide quality antenatal care, as well as the quality of screening, prevention, and education processes offered during observed antenatal care consultations.ResultsOur study did not identify any statistically significant effects on the quality of ANC provision attributable to the implemented performance-based financing scheme. Our findings therefore suggest not only the absence of positive externalities, but also the absence of any negative externalities generated within antenatal care service provision as a result of the scheme implementation in Malawi.ConclusionsPrior research has shown that the Malawian performance-based financing scheme was sufficiently effective to improve the quality of incentivized childbirth service provision. Our findings further indicate that scheme implementation did not affect the quality of non-incentivized but clinically related antenatal care services. While no positive externalities could be identified, we also did not observe any negative externalities attributable to the scheme’s implementation. While performance-based incentives might be successful in improving targeted health care processes, they have limited potential in producing externalities – neither positive nor negative – on the provision quality of related non-incentivized services.

PCN199 Testing the Potential of Performance Based Financing As a Strategy for Sustainable Health Systems in Latin America: The Case of Colombia

Performance Based Financing (PBF) is a form of incentive where health providers are, at least partially, funded based on their performance to meet targets, being defined as fee-for-service-conditional-on-quality. Some PBF types include: Results Based Financing, Pay for Success or Health Impact Bonds. There have been some case studies in healthcare reported in developed and developing countries but none in Colombia. We conducted a rapid literature review in MEDLINE and grey literature, using a snowball technique. Our search query used PBF and its types limiting results to the last decade. Articles were selected and analyzed by 2 independent reviewers. In addition, a feasibility PBF study was conducted in Colombia to establish an operational, financial and legal framework aiming at benefiting vulnerable population by providing access to innovative oncology treatments. In total 89 articles were found in MEDLINE, identifying country case studies in all continents with predominance in Africa. PBF schemes were mainly related to public health interventions to reduce maternal mortality, increase immunization rates or address some prevalent non-communicable-diseases (e.g. Diabetes, CVD, Mental Health). The feasibility study involved 25 stakeholders from national and state governments, industry, insurers, providers, investors and civil society. The study concluded that there is willingness to invest, operating viability and a legal and regulatory pathway for implementation. Despite challenges associated with PBF, there is stakeholders’ receptivity to explore this funding option to ensure access to innovation in underserved populations, while maintaining healthcare sustainability. During the feasibility study diverse stakeholders’ interests were aligned, opening a window of opportunity to generate trust and operational synergies. A second phase is currently being deployed to detail and fully structure the mechanism, stakeholders’ roles, operation governance, metrics and funding.

When information is not power: Community-elected health facility committees and health facility performance indicators.

Health Facility Committees (HFCs) made of elected community members are often presented as key for improving the delivery of services in primary health-care facilities. They are expected to help Health Facility (HF) staff make decisions that best serve the interests of the population. More recently, Performance-Based Financing (PBF) advocates have also put the HFC at the core of health reform, expecting it to hold HF staff into account for the HF performances and development. In Burundi, a country where PBF is implemented nationwide, a randomised control trial was implemented in 251 health facilities where the HFC had been largely inactive in recent years. A random sample of 168HFCs was trained on their roles and rights, with a subset also given information about the performance of their HF (using PBF indicators) and the PBF approach in general. The interventions, taking place in 2011-2013, made the HFCs better organised but largely failed to generate any effect on HF management and service delivery. Nested qualitative analysis reveals important tensions between nurses and HFC members that often prevent further change at the HF. In the HFs that received both the training and information interventions, this tension appeared exacerbated: the turnover of chief nurses was significantly higher as the HFCs exerted pressure to remove them. This situation was more likely to happen if the HFC had already received training before the interventions, thereby suggesting that repeated training empowers committees. Overall, the results provide rare rigorous evidence on HFCs, suggesting that more attention needs to be paid to the socio-economic and cultural contexts in which they operate. They also invite to caution when discussing the role of HFCs as a possible watchdog in PBF schemes.

A Rapid Review of Available Evidence to Inform Indicators for Routine Monitoring and Evaluation of Respectful Maternity Care.

Some opportunities to routinely capture and improve respectful maternity care (RMC) during facility-based childbirth include quality improvement (QI) initiatives, community-based monitoring efforts through community score cards (CSC), and performance-based financing (PBF) initiatives. But there is limited guidance on which types of RMC indicators are best suited for inclusion in these initiatives. We sought to provide practical evidence-based recommendations on indicators that may be used for routine measurement of RMC in programs. We used a rapid review approach, which included (1) reviewing existing documents and publications to extract RMC indicators and identify which have or can be used in facility-based QI, CSCs, and PBF schemes; (2) surveying RMC and maternal health experts to rank indicators, and (3) analyzing survey data to select the most recommended indicators. We identified 49 indicators spanning several domains of RMC and mistreatment including dignified/nondignified care, verbal and physical abuse, privacy/confidentiality, autonomy/loss of autonomy, supportive care/lack thereof, communication, stigma, discrimination, trust, facility environment/culture, responsiveness, and nonevidence-based care. Based on the analysis of the survey data, we recommend 33 indicators (between 2 and 6 indicators for each RMC domain) that may be suited for incorporation in both facility-based QI and CSC-related monitoring efforts. Integrating RMC indicators into QI and CSC initiatives, as well as in other maternal and neonatal health programs, could help improve RMC at the facility and community level. More research is needed into whether RMC can be integrated into PBF initiatives. Integration of RMC indicators into programs to improve quality of care and other health system outcomes will facilitate routine monitoring and accountability around experience of care. Measurement and improvement of women's experiences will increase maternal health service utilization and improve quality of care as a means of reducing maternal and neonatal morbidity and mortality.

What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo.

Background: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF.Methods: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF.Results: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community.Conclusion: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems.

Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.

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?

Whereas performance-based financing (PBF) is now developing fast in the health sector in low- and middle-income countries and is presented an innovative approach-concomitantly, subject to a separate research stream-it shares many features of the "managing for results" (MfR) and performance-based budgeting (PBB) currents that have existed for decades. In this paper, we first argue that PBF as currently developed in the health sector in low- and middle-income countries shares many features and thus can be viewed as an avatar of MfR and more precisely PBB. Secondly, we draw lessons from the literature on MfR and PBB so as to (1) better apprehend PBF conceptually and (2) avoid pitfalls and better design PBF schemes in practice. We argue that the lessons from the theoretical and empirical literature on MfR and PBB offer interesting insights to feed into a "theory of change" of PBF, enabling to analyse critical aspects and better design PBF schemes. Moreover, it is hoped that just like MfR processes have been demonstrated as having the potential to boost individual performance not only through links with financial incentives but also through acting on other sources of motivation, one can demonstrate more accurately by which mechanisms the various elements of the PBF package can help improve health sector results.

Physicians’ and nurses’ attitudes towards performance-based financial incentives in Burundi: a qualitative study in the province of Gitega

ABSTRACT Background: Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners. Objective: To elicit physicians’ and nurses’ experiences and views on how PBF influenced and helped them in healthcare delivery. Methods: A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data. Results: Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery. Conclusions: PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes.

Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing

Performance-based financing (PBF) is a common health system reform approach in low and middle income countries at present. Although increasing evidence on the effectiveness of PBF and knowledge of principles of good design are available, research is still lacking in regards to other aspects. Among these are a yet limited understanding of the complex role of health worker motivation in PBF and of potential side effects, for instance on intrinsic motivation. Our article aims to support meaningful future research by advancing the theoretical discussion around health worker motivation and PBF. We argue that an in-depth understanding of the motivational mechanisms and consequences of PBF at health worker level are of high practical relevance and should be at the heart of the PBF research agenda, and that predominant unidimensional conceptualizations of health worker motivation and descriptive rather than explanatory research approaches are insufficient to fully understand whether, how, and why PBF schemes alter health workers' motivational structures, mindsets, affect, and behavior. We introduce and apply Self-Determination Theory to the context of PBF as a valuable theoretical framework for future empirical exploration. From this, we conclude that PBF interventions are unlikely to have a generally adverse effect on intrinsic motivation as feared by parts of the PBF community. Rather, we posit that PBF can have positive and negative effects on both intrinsic and extrinsic motivation, to varying degrees depending on the specific design, implementation, and results of a particular intervention and on health workers’ perceptions and evaluations of it.

Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone.

BackgroundThere is growing interest on the impact of performance-based financing (PBF) on health workers’ motivation and performance. However, the literature so far tends to look at PBF payments in isolation, without reference to the overall remuneration of health workers. Taking the case of Sierra Leone, where PBF was introduced in 2011, this study investigates the absolute and relative contribution of PBF to health workers’ income and explores their views on PBF bonuses, in comparison to and interaction with other incomes.MethodsThe study is based on a mixed-methods research consisting in a survey and an 8-week longitudinal logbook collecting data on the incomes of primary health workers (n = 266) and 39 in-depth interviews with a subsample of the same workers, carried out in three districts of Sierra Leone (Bo, Kenema and Moyamba).ResultsOur results show that in this setting PBF contributes about 10 % of the total income of health workers. Despite this relatively low contribution, their views on the bonuses are positive, especially compared to the negative views on salary. We find that this is because PBF is seen as a complement, with less sense of entitlement compared to the official salary. Moreover, PBF has a specific role within the income utilization strategies enacted by health workers, as it provides extra money which can be used for emergencies or reinvested in income generating activities. However, implementation issues with the PBF scheme, such as delays in payment and difficulties in access, cause a series of problems that limit the motivational effects of the incentives. Overall, staff still favor salary increases over increases in PBF.ConclusionsThe study confirms that the remuneration of health workers is complex and interrelated so that the different financial incentives cannot be examined independently from one. It also shows that the implementation of PBF schemes has an impact on the way it does or does not motivate health workers, and must be thoroughly researched in order to assess the impact of PBF.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1546-8) contains supplementary material, which is available to authorized users.

Measuring and understanding the effects of a performance based financing scheme applied to nutrition services in Burundi-a mixed method impact evaluation design.

BackgroundMalnutrition is a huge problem in Burundi. In order to improve the provision of services at hospital, health centre and community levels, the Ministry of Health is piloting the introduction of malnutrition prevention and care indicators within its performance based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services, as PBF has done, in Burundi and elsewhere, for several other services.MethodsThis paper presents the protocol for the impact evaluation of the PBF scheme applied to malnutrition. The research design consists in a mixed methods model adopting a sequential explanatory design. The quantitative component is a cluster-randomized controlled evaluation design: among the 90 health centres selected for the study, half receive payment related to their results in malnutrition activities, while the other half get a budget allocation. Qualitative research will be carried out both during the intervention period and at the end of the quantitative evaluation. Data are collected from 1) baseline and follow-up surveys of 90 health centres and 6,480 households with children aged 6 to 23 months, 2) logbooks filled in weekly in health centres, and 3) in-depth interviews and focus group discussions. The evaluation aims to provide the best estimate of the impact of the project on malnutrition outcomes in the community as well as outputs at the health centre level (malnutrition care outputs) and to describe quantitatively and qualitatively the changes that took place (or did not take place) within health centres as a result of the program.DiscussionAlthough PBF schemes are blooming in low in-come countries, there is still a need for evidence, especially on the impact of revising the list of remunerated indicators. It is expected that this impact evaluation will be helpful for the national policy dialogue in Burundi, but it will also provide key evidence for countries with an existing PBF scheme and confronted with malnutrition problems on the appropriateness to extend the strategy to nutrition services.Trial registrationClinicalTrials.gov PRS Identifier: NCT02721160; registered March 2016

Impact of a public–private performance-based financing partnership on the proportion of caesarean section deliveries: a cross-sectional study

BackgroundChiranjeevi Yojana (CY) is a performance-based financing (PBF) programme in the Indian state of Gujarat that aims to increase access to free delivery care for poor women. The state makes a fixed payment to accredited private hospitals per 100 deliveries performed, regardless of vaginal and caesarean section delivery proportions. CY has been operational for 6 years with over 600 000 women having benefited from the programme. In Gujarat, caesarean sections are higher among private facilities (18%) compared with public facilities (14%). Other PBF programmes report an increase in caesarean sections with improved access to delivery care. The present study compares the proportion of caesarean section deliveries among CY beneficiaries and non-beneficiaries in private facilities to study the impact of the programme on the proportion of caesarean section deliveries in the Sabarkantha district of Gujarat, especially among women who need caesarean section deliveries. MethodsA cross-sectional survey of mothers delivering in 66 high-load (>30 deliveries per 3 months) private facilities (CY and non-CY) was done in the Sabarkantha district of Gujarat, India in 2012. Demographic and delivery care information was collected in the facilities. Findings224 mothers from 23 CY-accredited facilities and 372 from 43 non-CY facilities were interviewed. Caesarean section rates among CY beneficiaries were 6% (six of 97), compared with 18% (14 of 79) among non-beneficiaries in CY facilities. Non-CY programme mothers were three times more likely to have a caesarean section than were CY mothers, even after controlling for maternal age and antenatal and intranatal complications (odds ratio 3·02, 95% CI 1·06–8·57) in a logistic regression model. InterpretationCaesarean sections among CY beneficiaries were significantly lower than were those among non-beneficiaries in private facilities, contrary to reports from other PBF schemes and proportions in state-run hospitals. The non-differential financing mechanism had an embedded disincentive to prevent the overuse of caesarean section deliveries. Low caesarean section proportions could also possibly be due to the selection of clients by the accredited facilities. Given the size of the programme, it is important to explore if all women with necessary indications receive caesarean sections in the programme. FundingGrant EU FP 7 MATIND from Karolinska Institutet, Sweden.

Performance Based Financing and Uptake of Maternal and Child Health Services in Yobe Sate, Northern Nigeria

Reported maternal and child health (MCH) outcomes in Nigeria are amongst the worst in the world, with Nigeria second only to India in the number of maternal deaths. At the national level, maternal mortality ratios (MMRs) are estimated at 630 deaths per 100,000 live births (LBs) but vary from as low as 370 deaths per 100,000 LBs in the southern states to over 1,000 deaths per 100,000 LBs in the northern states. We report findings from a performance based financing (PBF) pilot study in Yobe State, northern Nigeria aimed at improving MCH outcomes as part of efforts to find strategies aimed at accelerating attainment of Millennium Development Goals for MCH. Results show that the demand-side PBF led to increased utilization of key MCH services (antenatal care and skilled delivery) but had no significant effect on completion of child immunization using measles as a proxy indicator. We discuss these results within the context of PBF schemes and the need for a careful consideration of all the critical processes and risks associated with demand-side PBF schemes in improving MCH outcomes in the study area and similar settings.

Studying the link between institutions and health system performance: a framework and an illustration with the analysis of two performance-based financing schemes in Burundi

Institutional arrangements of health systems and the incentives they set are increasingly recognized as critical to promote or hinder performance in the health sector. Looking at complex health system interventions from an institutional perspective may contribute to better understanding what are the paths and processes that lead to the results of such interventions. In this article, we propose an analytical framework drawing from new institutional economics. This framework suggests seven dimensions to look at: institutions, enforcement mechanisms, property rights, incentives, interactions between extrinsic and intrinsic sources of motivation, behavioural changes and organizational performance. For illustrative purposes, we then apply the framework to the analysis of the institutional (re)arrangements of two performance-based financing (PBF) schemes in Burundi by carrying out an empirical comparison of case studies. We use mainly qualitative data from primary and secondary sources and analyse them with focus on the seven dimensions of the framework. The analysis of the case studies provides a comparative narrative of the two PBF schemes and highlights the differences in their operational design, the challenges faced during implementation and the adaptations made. From a methodological perspective, this article proposes a tool to analyse complex health system interventions, looking beyond the evaluation of the final effects to focus on the processes through which institutional (re)arrangements affected those results. Its application indicates, at an empirical level, that such analysis could help identify lessons regarding the design of health systems interventions, such as PBF schemes, and the process of reforming institutional arrangements.