How performance targets can ingrain a culture of ‘performing out’: An ethnography of two Indian primary healthcare facilities

Das, Priya; Newton-Lewis, Tom; Khalil, Karima; Rajadhyaksha, Madhavi; Nagpal, Phalasha

doi:10.1016/j.socscimed.2021.114489

Cited by 7 publications

(1 citation statement)

References 28 publications

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“…Last, we acknowledge that reported performance on a checklist is not the same as strong facility operations and there is the risk that facilities were "performing out" rather than making fundamental improvements, which has been documented elsewhere. 31,32…”

Section: Discussionmentioning

confidence: 99%

The effects of decentralized financing and funding levels on the breadth and quality of services provided in primary health facilities in Nigeria

Hagedorn,

Cooper,

Loevinsohn

et al. 2024

Preprint

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Background To improve service delivery of Nigeria’s primary health care (PHC) system, the government tested two approaches for facility-level financing: performance-based financing (PBF) and decentralized facility financing (DFF). Facilities also had increased autonomy, supervision, and community oversight. We examine how the approach, funding level, and state context affected breadth of services and structural quality.Methods We use health facility surveys previously collected in 2014 and 2017, covering three years of implementation, in which districts were randomly assigned PBF or DFF and compared to matched districts in control states. We use log-linear regressions and non-parametric statistics to estimate the effect size of the financing approach and level of funding per capita.Results Service availability was highest in PBF facilities, while DFF also outperformed control on most measures. Results showed that structural readiness and service offerings both increased with more funding, especially under DFF. DFF and PBF facilities were better equipped to provide services that they claimed to offer, which was not the case for controls. Overall, PBF outperformed DFF, partially explained by funding levels. The rate of offering complimentary services followed a pattern of easiest-to-hardest to deliver.Conclusion PBF and DFF both improved the breadth and structural quality of services, although DFF performance was more sensitive to funding levels. Improvements were observed at relatively low levels of funding, but larger investments were associated with better performance. Most DFF facilities exceeded the performance of higher-funded controls, implying that funding was more valuable in the context of autonomy, increased supervision, and community oversight.

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Section: Discussionmentioning

confidence: 99%