Performance-based financing in three humanitarian settings: principles and pragmatism

Abstract

BackgroundPerformance based financing (PBF) has been increasingly implemented across low and middle-income countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn.MethodsOur comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities.ResultsOur analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called ‘PBF principles’ that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes.ConclusionsOur study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.Electronic supplementary materialThe online version of this article (10.1186/s13031-018-0166-9) contains supplementary material, which is available to authorized users.

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].…”

Towards constructive rethinking of PBF: perspectives of implementers in sub-Saharan Africa

“…Such a transition has led to a reduction in verification costs in Zimbabwe by 47%. 15 PBF programmes are not static but continue through action research 30 to seek the best possible strategy towards improving the health system.…”

Implementing performance-based financing in peripheral health centres in Mali: what can we learn from it?

“…Some research has shown that analysing the PBF implementation process provides a better understanding of the outcomes achieved [21]. Recent studies have paid more attention to the impacts of PBF on the relationships among actors in the health system and to the contexts and processes that explain whether or not these outcomes are achieved [18,[22][23][24][25][26]. To understand the processes, the contextual characteristics of implementation are essential elements and warrant in-depth analysis [27].…”