Does performance-based financing increase value for money in low- and middle- income countries? A systematic review

Abstract

Governments of low- and middle-income countries (LMICs) are widely implementing performance-based financing (PBF) to improve healthcare services. However, it is unclear whether PBF provides good value for money compared to status quo or other interventions aimed at strengthening the healthcare system in LMICs. The objective of this systematic review is to identify and synthesize the existing literature that examines whether PBF represents an efficient manner of investing resources. We considered PBF to be efficient when improved care quality or quantity was achieved with equal or lower costs, or alternatively, when the same quality of care was achieved using less financial resources. A manual search of the reference lists of two recent systematic reviews on economic evaluations of PBF was conducted to identify articles that met our inclusion and exclusion criteria. Subsequently, a search strategy was developed with the help of a librarian. The following databases and search engines were used: PubMed, EconLit, Google Scholar and Google. Experts on economic evaluations were consulted for validation of the selected studies. A total of seven articles from five LMICs were selected for this review. We found the overall strength of the evidence to be weak. None of the articles were full economic evaluations; they did not make clear connections between the costs and effects of PBF. Only one study reported using a randomized controlled trial, but issues with the randomization procedure were reported. Important alternative interventions to strengthen the capacities of the healthcare system have not been considered. Few studies examined the costs and consequences of PBF in the long term. Important costs and consequences were omitted from the evaluations. Few LMICs are represented in the literature, despite wide implementation. Lastly, most articles had at least one author employed by an organization involved in the implementation of PBF, thereby resulting in potential conflicts of interest. Stronger empirical evidence on whether PBF represents good value for money in LMICs is needed.

Twelve months of implementation of health care performance‐based financing in Burkina Faso: A qualitative multiple case study

“…We might therefore wonder whether the underlying theoretical rationale is not simply a pretext, which some might consider valid, to provide additional resources to the operational level of the health system, which in fact needs them. But is this incentive‐based logic worth the price, when other options to solve the health system's problems have not all been tested and PBF efficiency remains to be proven? The current state of knowledge is not yet adequate to answer this question in Africa.…”

“…Some even point to a trend in the PBF literature of a “well‐known publication bias in favour of success stories.” Nevertheless, it is essential that we enter into the “black box” of PBF and gain a deeper understanding of the functioning of this complex intervention . Studies that are not funded by the agencies organizing PBF are still very rare in Africa, as are studies on the implementation of such interventions …”

Performance-based financing contributes to the resilience of health services affected by the Liberian Ebola outbreak

“…We can find no other published studies on the effect of the Ebola outbreak or a similar health emergency on PBF schemes. While a recent systematic review focusing on low-and middle-income countries came to the conclusion that stronger empirical evidence is needed on whether or not PBF is cost-effective, 21 there are reports of PBF schemes benefiting health service delivery in hard-to-reach areas in Rwanda and Burundi and the conflict setting of the Democratic Republic of Congo. 3,[22][23][24] This being said, we do not really know why Bong County performed better than Margibi County and whether this had anything to do with PBF.…”

Performance‐based financing in the heath sector in low‐ and middle‐income countries: Is there anything whereof it may be said, see, this is new?

“…At this respect, it is worth insisting on the lack of evidence as for the cost-effectiveness (or value-for-money) of PBF. 10 This question should be investigated by looking at the costs of monitoring, the performance premiums, and the transaction costs because of increased administrative burdens and possible other economic or opportunity costs, 6,27 while at the same time, accounting for the relative effects of all ongoing reforms in a package of incentives. Thus, a thorough cost-benefit analysis may be an important tool to compare the efficiency of a PBF with other strategies that aim to improve health sector performance.…”

“…Although there has been recent advancement, more research is needed on the relevance, efficiency, impact, and the context-related enablers of PBF in LMICs as the results in general remain mixed. [6][7][8][9][10] Causes of disagreement notably stem from not only the lack of a clear and thorough analytical framework and robust scientific research but also the underutilisation of findings and lessons from other fields of study, other theories, and similar programmes. 2,11,12 Indeed, surprisingly, PBF in the health sector in LMICs has developed as an innovative, independent approach.…”