Publication: Performance-Based Financing as a Health System Reform: Mapping the Key Dimensions for Monitoring and Evaluation
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2013-09-29
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2015-11-30
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Performance-based financing is increasingly being applied in a variety of contexts, with the expectation that it can improve the performance of health systems. However, while there is a growing literature on implementation issues and effects on outputs, there has been relatively little focus on interactions between PBF and health systems and how these should be studied. This paper aims to contribute to filling that gap by developing a framework for assessing the interactions between PBF and health systems, focusing on low and middle income countries. In doing so, it elaborates a general framework for monitoring and evaluating health system reforms in general.
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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 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 Looking into the Performance-Based Financing Black Box(World Bank, Washington, DC, 2017-08)Performance-based financing is a complex health system intervention aimed at improving coverage and quality of care. This paper presents the results of an impact evaluation in Cameroon that seeks to isolate the role of specific components of the performance-based financing approach on outcomes of interest, such as explicit financial incentives linked to results, additional resources available at the point of service delivery (not linked to performance), and enhanced supervision, coaching, and monitoring. Four evaluation groups were established to measure the effects of each component that was studied. In general, the results indicate that performance-based financing in Cameroon is an efficient mechanism to channel payments and funding to the provider level, leading to significant increases in utilization in the performance-based financing arm for several services (child and maternal vaccinations and use of modern family planning), but not for others, such as antenatal care visits and facility-based deliveries. However, for many of those outcomes, the differences between the performance-based financing group and the additional financing group are not significant. In terms of quality, performance-based financing was found to have a significant impact on the availability of essential inputs and equipment, qualified health workers, reduction in formal and informal user fees, and increased satisfaction among patients and providers. However, there was a clear effect of additional financing, irrespective of whether it was linked to incentives, in combination with reinforced supervision through performance-based financing. This result suggests that enhanced supervision and monitoring on their own are not sufficient to improve maternal and child health outcomes.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 in the Health Sector of the Democratic Republic of Congo(World Bank, Washington, DC, 2022-10)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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