An Exploration of the Unintended Consequences of Performance-Based Financing in 6 Primary Healthcare Facilities in Burkina Faso

Abstract

<jats:p> <jats:bold>Background:</jats:bold> Performance-based financing (PBF) is promoted to improve the quality and quantity of healthcare services in low-income countries. Despite the complexity of the intervention, little attention has been given to studying its unintended consequences. Our objective is to increase evidence on the unintended consequences of PBF in Burkina Faso. <jats:bold>Methods:</jats:bold> Using the diffusion of innovations theory, we conducted a multiple case study. The cases were 6 healthcare facilities in two districts. Between April 2015 and 2016, we collected data through 101 semi-structured interviews, discussions, observations, and documents. We conducted thematic analysis using a hybrid deductive-inductive approach. Secondary data was used to illustrate the evolution of reported services. We conducted a cross-case synthesis to identify the results arising independently from more than 1 case. <jats:bold>Results:</jats:bold> A desirable unintended consequence of PBF was that 3 facilities limited the sale of non-prescribed medication to encourage patients to consult. Undesirable unintended consequences were found in the majority of facilities including fixation on measures rather than on underlying objectives, the pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices. Providers in all facilities deliberately manipulated medical registers and documents, such that the reported quantity and quality of care differed from what was actually delivered. While most participants indicated that PBF was more advantageous than previous practices, the long payment delays were a source of dissatisfaction and demotivation across all facilities. Dissatisfaction also emerged in relation to the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered "unqualified" in guidelines. Results in many facilities revealed suboptimal planning, a perception of the intervention as "budgetivorous," as well as tensions related to the principle of managerial autonomy. <jats:bold>Conclusion:</jats:bold> PBF led to numerous unintended consequences that could undermine the intervention’s effectiveness. The findings contribute to a more comprehensive picture of the consequences of implementing PBF. Policy-makers can use the results of this study to devise effective strategies before, during and after the implementation of the intervention to minimize undesirable unintended consequences and promote desirable ones. </jats:p>

Impact of Performance-Based Financing (PBF) Program on Utilization and Completeness of Partographs in Jimma

“…Our study findings are in-line with a study in Uganda where partograph use was enhanced through training, coaching, and mentoring [67]. In Burkina Faso, PBF also contributed in better partograph utilization in the intervention sites compared to control sites [68]. Other reason for variation of results could be differences is study designs and years of studies [69].…”

The unintended consequences of COVID-19 mitigation measures matter: practical guidance for investigating them

“…Between 2014 and 2020, our team studied the unintended consequences of a complex health intervention in a low-income setting, from which we drew lessons. The results of the study have been published and are available online [48][49][50][51][52]. We began by reading some key literature on the assessment of unintended consequences [28,[53][54][55][56][57][58].…”

“…Our team used literature on the diffusion of innovations theory to help develop the framework illustrated in Fig. 1 [28,[48][49][50]86].…”

“…1 Framework for studying unintended consequences. Adapted from Rogers [28], Bloomrosen et al [86] and Turcotte-Tremblay et al [48][49][50] illustrative purposes, we refer again to the example of school closures to show how potential unintended consequences can be classified (see Table 3). Empirical research will be needed to test these consequences.…”

“…The level of desirability can vary when the perceptions of decision-makers are compared with those of street-level workers, who have different goals and needs. Operationalizing these concepts imposes difficult choices on research teams, but examples of how to do it are available in the literature [48][49][50]65].…”