Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

Local stakeholders' perceptions about the introduction of performance-based financing in Benin: a case study in two health districts

BACKGROUND

Performance-Based Financing (PBF) has been advanced as a solution to contribute to improving the performance of health systems in developing countries. This is the case in Benin. This study aims to analyse how two PBF approaches, piloted in Benin, behave during implementation and what effects they produce, through investigating how local stakeholders perceive the introduction of PBF, how they adapt the different approaches during implementation, and the behavioural interactions induced by PBF.

METHODS

The research rests on a socio-anthropological approach and qualitative methods. The design is a case study in two health districts selected on purpose. The selection of health facilities was also done on purpose, until we reached saturation of information. Information was collected through observation and semi-directive interviews supported by an interview guide. Data was analysed through contents and discourse analysis.

RESULTS

The Ministry of Health (MoH) strongly supports PBF, but it is not well integrated with other ongoing reforms and processes. Field actors welcome PBF but still do not have a sense of ownership about it. The two PBF approaches differ notably as for the organs in charge of verification. Performance premiums are granted according to a limited number of quantitative indicators plus an extensive qualitative checklist. PBF matrices and verification missions come in addition to routine monitoring. Local stakeholders accommodate theoretical approaches. Globally, staff is satisfied with PBF and welcomes additional supervision and training. Health providers reckon that PBF forces them to depart from routine, to be more professional and to respect national norms. A major issue is the perceived unfairness in premium distribution. Even if health staff often refer to financial premiums, actually the latter are probably too weak-and 'blurred'-to have a lasting inciting effect. It rather seems that PBF motivates health workers through other elements of its 'package', especially formative supervisions.

CONCLUSION

If the global picture is quite positive, several issues could jeopardise the success of PBF. It appears crucial to reduce the perceived unfairness in the system, notably through enhancing all facilities' capacities to ensure they are in line with national norms, as well as to ensure financial and institutional sustainability of the system.