Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence

Abstract

Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF “works”—that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank’s repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region—either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.

Reviewing the evidence on health financing for effective coverage: do financial incentives work?

“…17 Crucially, an extensive literature grapples with the overarching role of political economy and local bureaucratic norms that drive and mediate all technical approaches such as PBF. [18][19][20] This literature suggests that technical approaches not integrated into the local political economic context and without addressing systemic constraints-as An empirical application of this decomposition of the constraints to quality further illustrates this point. This application shows that despite years of investments in physical infrastructure and medical training, the five sub-Saharan African countries included in figure 2 continue to have pervasive gaps in physical infrastructure and health worker knowledge.…”

“…There are several sources of worker motivation and non-pecuniary approaches may at least as effective at motivating staff 17. Crucially, an extensive literature grapples with the overarching role of political economy and local bureaucratic norms that drive and mediate all technical approaches such as PBF 18–20. This literature suggests that technical approaches not integrated into the local political economic context and without addressing systemic constraints—as critics have argued PBF does not—will fail, particularly in terms of sweeping improvements.…”

A qualitative evaluation of stakeholder perspectives on sustainable financing strategies for ‘priority’ adolescent sexual and reproductive health interventions in Ghana

“…Investors, development partners, and policymakers acting as principal financiers may be willing to provide financial support for priority ASRH service providers (agents) if they have reasons to believe there will be prudent use for their investments. Irrespective of how simple this financing strategy may seem, there could be setbacks in implementing new interventions that are yet to generate data to show evidence of effectiveness, requiring that other sustainable financing strategies should run parallel to performance-based financing [ 29 ]. Therefore, implementation-based financing strategies may not be the most suitable when implementing new priority ASRH interventions [ 30 , 31 ].…”

Making development assistance work for Africa: from aid-dependent disease control to the new public health order

“…Despite decades of statements of commitment to strengthening health systems in Africa, including by the WHO ( World Health Organization, 2007 ) and global financiers ( Global Fund to Fight AIDS, Tuberculosis, and Malaria, 2007 ; Kenney and Glassman, 2019 ; Waithaka et al. , 2022 ), there were widespread fears and acknowledgements that African countries did not have health system capacities to effectively respond to the COVID-19 pandemic ( Tessema et al.…”