Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems

Abstract

Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.

Results-based financing as a strategic purchasing intervention: some progress but much further to go in Zimbabwe?

“…Keywords: Results-based financing, Strategic purchasing, Zimbabwe, Maternal and child health care, Performancebased financing Background Over the last decade, the model of RBF in which funds to health facilities are made conditional on agreed outputs or outcomes, often with quality adjustments (sometimes also called performance based financing or PBF) [1], has been increasingly implemented in fragile and conflict-affected states (FCAS). While research and evidence on RBF has grown since the first systematic review of its application in low and middle income countries [2], there remain some very significant gaps in our understanding of it, in particular in FCAS, where there is a need to understand the programmes' proliferation and how they may operate differently in these contexts [3], but also to examine their integration and wider system effects. RBF has been presented by some authors as a health system intervention with the potential to drive a more strategic approach to purchasing [4].…”

“…Some clinics in towns were included after the start of RBF in order to stop the flow of clients from towns to RHCs, however most urban areas and the two main cities, Harare and Bulawayo, are excluded. (There was a voucher programme piloted in these two areas 3 but this was small-scale and limited in terms of services covered.) This is problematic for the deprived areas within them.…”

Effects in spite of tough constraints - A theory of change based investigation of contextual and implementation factors affecting the results of a performance based financing scheme extended to malnutrition in Burundi

“…Context has played an important role in the story of PBF-N. This observation is not atypical for an intervention in a FCAS and has been documented in other studies on PBF in such settings [16,[63][64][65].…”

“…Alongside evaluations focused on the impact of PBF [11][12][13], we have now studies investigating the actual theories of change, with a plurality of situations and practices which prevail. One can highlight, for instance, the recent work by the ReBUILD team on how PBF works in Fragile and post-Conflict Affected Settings (FCAS) [14][15][16], the comprehensive analysis of the RBF scheme in Malawi by De Allegri and colleagues [17] or the research program carried out by Borghi and colleagues, mainly in Tanzania [18].…”

25 Anos de Política Nacional de Saúde na República da Guiné-Bissau: Memórias do seu Planeamento Estratégico em Saúde

“…Na opinião unânime dos entrevistados, o PES surge como resposta à exigência dos diferentes financiadores, afastando-se não raras vezes do PNDS, divergindo os planos regionais e os programas nacionais deste documento que determina as prioridades nacionais em matéria de saúde e que teoricamente deveria legitimar o governo da RGB para orientar os seus parceiros na ação e no financiamento deste sector. A literatura refere que o financiamento externo baseado no desempenho, realizado por parceiros bilaterais, multilaterais e globais, nos países de média e baixa renda, e particularmente no contexto de EF, é frequente, não estando os seus efeitos nos sistemas de saúde estudados (Bertone et al, 2018). No entanto, os mesmos autores referem que os atores externos e financiadores assumem um papel de grande destaque nestes contextos e que a fraca confiança entre estes, o sistema público e os governos levam à adoção de programas baseados em abordagens contratuais em detrimento de um alinhamento com as políticas dos países.…”