Publication: Performance-based Financing in the Health Sector of the Democratic Republic of Congo: Impact Evaluation Report
Loading...
Published
2022-10
ISSN
Date
2022-10-11
Author(s)
Editor(s)
Abstract
The Democratic Republic of Congo (DRC) is the largest country in sub-Saharan Africa, by area. The country has a long history of conflict, political upheaval, and instability and has a very high poverty rate despite its abundance of natural resources. Mortality and fertility rates in DRC are among the highest in the world. The Health System Strengthening for Better Maternal and Child Health Result Project (PDSS – Le Projet de Développement du Système de Santé) was launched in 2015 with the objective of improving utilization and quality of maternal and child health services in eleven provinces of out of the provinces in the Democratic Republic of Congo (DRC). The main component of the project is the implementation of a provider payment system reform through Performance-Based Financing (PBF), launched in the end of 2016. Contracted health facilities receive quarterly payments conditional on the volumes of targeted services provided and on quality of care. The objective of this impact evaluation is to assess whether the PBF approach impacts utilization and quality of primary health services, in comparison to equivalent amounts of unconditional financing. The rational for comparing outcomes produced by facilities implementing PBF to those produced by facilities who receive equivalent amounts of unconditional financing is to isolate the impact of the PBF incentive mechanisms from the direct impact of the additional resources received through the program.
Link to Data Set
Citation
“World Bank Group. 2022. Performance-based Financing in the Health Sector of the Democratic Republic of Congo: Impact Evaluation Report. © World Bank. http://hdl.handle.net/10986/38132 License: CC BY 3.0 IGO.”
Digital Object Identifier
Associated URLs
Associated content
Other publications in this report series
Journal
Journal Volume
Journal Issue
Related items
Showing items related by metadata.
Publication Impacts of Performance‑Based Financing on Health System Performance(BMC Medicine, 2023-10-10)Health 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. We 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. The 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. The 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.Publication Alignment of Performance-Based Financing in Health with the Government Budget(World Bank, Washington, DC, 2021-08)Performance-based financing (PBF) is the transfer of funds to health facilities so they can provide a pre-agreed set of services according to appropriate standards of quality and administration. These initiatives have introduced a wide set of reforms, including in provider autonomy, access to financial services, flexibility on the utilization of funds, a performance orientation on the budget allocation, and rigorous verification protocols. This tends to set PBF apart from the prevailing public financial management (PFM) systems that often remain input-based and thereby create a sustainability challenge. If the prevailing PFM system remains in parallel to the PBF, countries are likely to return to the legacy PFM system once PBF donor resources dry up. This paper unpacks this problem. It develops a conceptual framework about how to think about aligning PBF principles with PFM structures; offers a set of diagnostic questions for an assessment; and helps guide an analyst through the process of developing a reform roadmap, considering country context. The paper also proposes a reform roadmap to be centered around the following four facility financing pillars: (i) provider autonomy, (ii) financial management capacity, (iii) output-oriented budget provisions, and (iv) a unified payment system. As a discussion paper, this work aims to solicit feedback on the proposed approach from the PBF and PFM community.Publication Performance-Based Financing Toolkit(Washington, DC: World Bank, 2014-02-26)Performance-based financing (PBF) approaches have expanded rapidly in lower-and middle income countries, and especially in Africa. The number of countries has grown from three in 2006 to 32 in 2013. PBF schemes are flourishing and cause considerable demand for technical assistance in executing these health reforms in a rational and accountable manner. Currently there is a lack of knowledge among many health reformers of how to implement performance-based financing pilot projects, and scale them up intelligently. In a context of tremendous demand for solid design and implementation experience and given the rapid expansion of results-based financing (RBF) programs, there is an urgent need to build capacity in designing and implementing PBF programs. As yet there has been little attempt to gather the learning from these experiences together in one volume and, moreover, in a form that serves as a guide to implementers. This toolkit answers the most pressing issues related to the supply-side RBF programs of which PBF forms part.Publication Impact of Implementing Performance-Based Financing on Childhood Malnutrition in Rwanda(BioMed Central, 2014-11-04)Malnutrition remains a serious concern in Rwanda, particularly among children under-5 years. Performance-based financing (PBF), an innovative health systems financing strategy, has been implemented at the national level since 2008. This study aimed to assess the impact of PBF and other factors associated with the prevalence of three classifications of malnutrition (stunting, wasting and underweight) in children under-5 years in Rwanda. The study is a cross-sectional study comprising of 713 children under five years old from 557 households, whose anthropometric measurements (height, weight and age) had been obtained as part of the 2008 Rwanda General Health and HIV household survey. Z-scores for height-for-age, weight-for-age, weight-for-height, and body mass index-for-age were analyzed according to the World Health Organization 2006 Child Growth Standards. Random intercept logistic regression models were used to regress each anthropometric measure (WAZ, HAZ and WHZ) against child, maternal and household characteristics.Publication Tajikistan - Feasibility Study for Results-Based Financing (RBF) In the Health Sector(World Bank, 2010-03-31)The purpose of this study is to examine the feasibility of introducing Results-Based Financing (RBF) in Tajikistan's health sector. Several countries have experience with RBF in low-income settings, and lessons learned can be interesting for Tajikistan. Technically, RBF is a retrospective provider payment that can be designed to reimburse providers for contractually defined services and specific compliance targets, including for efficiency and quality targets. In Tajikistan RBF will be linked to ongoing provider payment reforms. Therefore, the chapter also provides a brief overview on provider payment mechanisms and experience with provider payment reforms and treatment patterns from middle- and higher-income countries. The objective of this feasibility study is to propose a sustainable RBF pilot program for two oblasts (Khatlon and Sughd), to cost-effectively improve maternal and child health (MCH) outcomes. The study aims to inform the health sector strategy and help the Government and partners to effectively design and use RBF mechanisms at three potential levels. First, the fiscal transfer from the central government to oblasts (regions) and rayons (districts) could be adjusted to include a bonus payment based on specific results achieved. Second, the provider payment method from oblast health fund pools to hospitals and outpatient facilities could reward providers based on results indicators. Third, a performance payment could be added to salaries paid to staff working in health facilities. It is expected that such a three-pronged approach could reinforce the financial incentive set through RBF to staff working in the administration and provision of care. If the staff responds to these incentives, then this could lead to better management in oblast and rayons, improved availability of financial resources and medical material in health facilities, and better treatment of patients. Combined, these behavioral changes will ultimately lead to better health results, including improved quality of care and in the longer-run improved health status.
Users also downloaded
Showing related downloaded files
Publication Poverty and Equity Assessment for El Salvador 2024(Washington, DC: World Bank, 2024-12-12)This report proposes an agenda for building on gains to re-accelerate poverty reduction among Salvadorans. The last World Bank Poverty Assessment for El Salvador, from 2015, proposed two key policy recommendations: (a) effective pro-poor spending and (b) reduction of crime and violence through better access to jobs and education. Nine years later, the authorities have managed to achieve a substantial reduction in crime and violence and have indicated an intent to build on such progress to establish a path toward an El Salvador where shared prosperity is achievable. In this report, we propose a three pillar structure to address poverty and inequality reduction: jobs, services, and social protection, with a cross-cutting set of primary conditions that articulates this structure.Publication Poverty, Prosperity, and Planet Report 2024(Washington, DC: World Bank, 2024-10-15)The Poverty, Prosperity, and Planet Report 2024 is the latest edition of the series formerly known as Poverty and Shared Prosperity. The report emphasizes that reducing poverty and increasing shared prosperity must be achieved in ways that do not come at unacceptably high costs to the environment. The current “polycrisis”—where the multiple crises of slow economic growth, increased fragility, climate risks, and heightened uncertainty have come together at the same time—makes national development strategies and international cooperation difficult. Offering the first post-Coronavirus (COVID)-19 pandemic assessment of global progress on this interlinked agenda, the report finds that global poverty reduction has resumed but at a pace slower than before the COVID-19 crisis. Nearly 700 million people worldwide live in extreme poverty with less than US$2.15 per person per day. Progress has essentially plateaued amid lower economic growth and the impacts of COVID-19 and other crises. Today, extreme poverty is concentrated mostly in Sub-Saharan Africa and fragile settings. At a higher standard more typical of upper-middle-income countries—US$6.85 per person per day—almost one-half of the world is living in poverty. The report also provides evidence that the number of countries that have high levels of income inequality has declined considerably during the past two decades, but the pace of improvements in shared prosperity has slowed, and that inequality remains high in Latin America and the Caribbean and Sub-Saharan Africa. Worldwide, people’s incomes today would need to increase fivefold on average to reach a minimum prosperity threshold of US$25 per person per day. Where there has been progress in poverty reduction and shared prosperity, there is evidence of an increasing ability of countries to manage natural hazards, but climate risks are significantly higher in the poorest settings. Nearly one in five people globally is at risk of experiencing welfare losses due to an extreme weather event from which they will struggle to recover. The interconnected issues of climate change and poverty call for a united and inclusive effort from the global community. Development cooperation stakeholders—from governments, nongovernmental organizations, and the private sector to communities and citizens acting locally in every corner of the globe—hold pivotal roles in promoting fair and sustainable transitions. By emphasizing strategies that yield multiple benefits and diligently monitoring and addressing trade-offs, we can strive toward a future that is prosperous, equitable, and resilient.Publication Unlocking the Power of Healthy Longevity(Washington, DC: World Bank, 2024-09-12)Noncommunicable diseases (NCDs) are among the major health and development challenges of our time. Every year, about 41 million people die due to NCDs. This makes up about 74 percent of all deaths globally, the majority of which are in low- and middle-income countries (LMICs). Countless more people live with NCDs every day. Yet, NCDs are largely treatable and preventable. The risk of developing NCDs and deaths from them can both be lowered with appropriate attention to prevention and treatment. However, weak health systems and limited access to affordable care and information, especially in LMICs, contribute to lapses in seeking and receiving appropriate and timely care. This compendium is a compilation of 18 chapters, each exploring a different but related topic in the nexus of NCDs, human capital, and productivity. It is based on a series of analytical work taken up by the World Bank to support the Healthy Longevity Initiative (HLI) - a collaborative effort between the World Bank, the University of Toronto, and key academic and development partners including the Harvard University and the University of Washington. The HLI presents one of a growing set of efforts to increase the urgency of policy response to NCDs across the world.Publication The Changing Wealth of Nations(Washington, DC: World Bank, 2024-10-29)In this report, we update and extend the methodology developed for the previous CWON 2021 report to assess the economic value of non-wood ecosystem services from forests (Siikamäki et al. 2021). Like the earlier assessment, we develop a meta-analytic predictive model using regression and machine learning techniques to spatially estimate the value of the following three ecosystem services: (1) recreation, hunting, and fishing; (2) non-wood forest products; and (3) watershed protection (hereafter, “water services”). These values are produced using 0.1º by0.1º (approximately 10km by 10km) spatial resolution and then combined and spatially aggregated to estimate country-wealth from non-wood forest products. In addition, we develop an operational method to estimate the contribution of protected areas to the value of non-wood forest productions.Publication Digital Pathways for Education(Washington, DC: World Bank, 2024-11-08)This work aims to offer a strategic approach to policymakers when undertaking digital transformation reforms in education and skills development systems, with a focus on “how.” It builds on the World Bank education vision framework offered in realizing the future of Learning by unpacking the digital cross-cutting area of “Invest wisely in technology”, looking into how this may be done to maximize impact at scale for all. The authors promote cautious optimism and techno realism, clarifying how the education and skills sector can use digital technologies to its advantage by being proactive, strategic, and evidence-based, considering carefully why to use digital and in what conditions the existing and emerging technologies might be positively leveraged. It is widely recognized that one size does not fit all and that policymakers need to have a laser focus on learning, weighing in contextual needs, and purposefully using the next marginal investable dollar on digital solutions to fulfill education objectives equitably at scale for all. Along with policymakers in government who are the primary audience for this work, it is intended to enable dialogue and critical partnerships across industry, academia, researchers and multilateral, and World Bank staff to support and deepen our country engagements as countries increasingly expand the digital reach of public education services.