Looking into the Performance-Based Financing Black Box: Evidence from an Impact Evaluation in the Health Sector in Cameroon

Abstract

Performance-based financing is a complex health system intervention aimed at improving coverage and quality of care. This paper presents the results of an impact evaluation in Cameroon that seeks to isolate the role of specific components of the performance-based financing approach on outcomes of interest, such as explicit financial incentives linked to results, additional resources available at the point of service delivery (not linked to performance), and enhanced supervision, coaching, and monitoring. Four evaluation groups were established to measure the effects of each component that was studied. In general, the results indicate that performance-based financing in Cameroon is an efficient mechanism to channel payments and funding to the provider level, leading to significant increases in utilization in the performance-based financing arm for several services (child and maternal vaccinations and use of modern family planning), but not for others, such as antenatal care visits and facility-based deliveries. However, for many of those outcomes, the differences between the performance-based financing group and the additional financing group are not significant. In terms of quality, performance-based financing was found to have a significant impact on the availability of essential inputs and equipment, qualified health workers, reduction in formal and informal user fees, and increased satisfaction among patients and providers. However, there was a clear effect of additional financing, irrespective of whether it was linked to incentives, in combination with reinforced supervision through performance-based financing. This result suggests that enhanced supervision and monitoring on their own are not sufficient to improve maternal and child health outcomes.

High-quality health systems in the Sustainable Development Goals era: time for a revolution

“…improve unrewarded dimensions of quality, including patient satis faction. 314,316,319 Overall, performance-based financing does not appear to be highly cost-effective, especially vis-à-vis unconditional additional financing. 316,317 The HCPPR showed that interventions that include financial incentives have a median increase on quality of 7•6 percentage points.…”

“…314,316,319 Overall, performance-based financing does not appear to be highly cost-effective, especially vis-à-vis unconditional additional financing. 316,317 The HCPPR showed that interventions that include financial incentives have a median increase on quality of 7•6 percentage points. For financial incentives, including performance-based financing programmes, to be successful, economic theory and research suggest that rewards will have smaller effects than penalties because of the tendency to avoid losses, and incentives are most effective when closely linked to processes under the direct control of providers.…”

“…Performance-based financing might modestly improve quality compared with no intervention in some contexts, but does not always outperform unconditional financing; the effect appears to be driven not by the financing mechanism as much as the equipment and workforce interventions. [314][315][316][317] Compared with alternative interventions, performance-based financing incurs unique costs for performance verification that can account for 10% to 15% of operating costs, including the cost of staff time. 318 There can also be unintended consequences of performance-based financing programmes, including reports that providers have threatened patients to report positive outcomes, but these programmes can also…”

A Rapid Review of Available Evidence to Inform Indicators for Routine Monitoring and Evaluation of Respectful Maternity Care

“…[25][26][27] PBF, on the other hand, is generally a mechanism to measure and incentivize providers' and facilities' performance: facilities and providers earn incentives based on achievement of specific performance criteria. 21,28,29 For this review, we wanted to consider widely used approaches and platforms with potential to generate routine data for accountability on RMC in lower-resource settings. QI or assurance approaches have been used in LMICs for more than 30 years and are a major source of investment by major donors such as the United States Agency for International Development (USAID).…”

Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi

“…6 7 Evidence from PBF programmes across low-and middle-income countries is mixed in regard to its impact on service utilisation and quality. 8 9 PBF has been observed to yield a positive effect on maternal care services in Rwanda, 10 Burundi 11 and Tanzania, 12 but not in Afghanistan; 13 a positive effect on childhood immunisations in Cameroon 14 but not in Rwanda, 10 Afghanistan 13 or Burkina Faso; 15 and mixed effects on various indicators of quality of care. 9 Incentives have also been associated with drawbacks such as gaming by providers to maximise results 16 and perceptions of unfairness among providers in rewarding performance that negatively affects delivery of quality of care to clients.…”