Publication: Performance-based Financing in the Health Sector of the Democratic Republic of Congo: Impact Evaluation Report
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2022-10
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2022-10
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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.
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“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.”
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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). 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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.
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