This article is a collaboration between researchers, academics and public health experts from Europe, North America and Africa, working with recipient governments, in research centres and donor organisations, or as individual experts. It presents a critical perspective on how performance-based financing (PBF) is actually implemented and questions the view that 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. It was published in january 2018 in BMJ Global Health.
Elisabeth Paul, Lucien Albert, Badibanga N’Sambuka Bisala, Oriane Bodson, Emmanuel Bonnet, Paul Bossyns, Sandro Colombo, Vincent De Brouwere, Alexandre Dumont, Dieudonné Sèdjro Eclou, Karel Gyselinck, Fatoumata Hane, Bruno Marchal, Remo Meloni, Mathieu Noirhomme, Jean-Pierre Noterman, Gorik Ooms, Oumar Mallé Samb, Freddie Ssengooba, Laurence Touré, Anne-Marie Turcotte-Tremblay, Sara Van Belle, Philippe Vinard, Valéry Ridde.
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.
What is already known about this topic?
Evidence regarding performance-based financing (PBF) effectiveness is mixed, and there is no evidence about its efficiency and equity.
Empirical evidence from different settings and disciplines indicates the risks, cost and perverse effects of PBF in LMICs.
Despite insufficient supportive evidence, PBF is increasingly promoted by donors and implemented.
What are the new findings?
Consultants and international agencies increasingly play a brokerage role in PBF dissemination, at the expense of domestic initiative and ownership.
Based on our experience in the field in a wide array of countries, we have observed that the way PBF is actually implemented departs markedly from the ideal of an open approach enabling system reforms in LMICs.
Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems.
Recommendations for policy:
We plead in favour of abandoning the indiscriminate dissemination of a mainstream PBF model in the way it has been implemented so far.
Time, attention and resources should be devoted to strengthening key health system components to enable them to perform well.
Paul E, Albert L, Bisala BN’S, et al. Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink? BMJ Glob Health 2018 ;3:e000664. doi:10.1136/ bmjgh-2017-000664