Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach

Abstract

Background: Performance-based financing (PBF) is often proposed as a way to improve health system performance. In Benin, PBF was launched in 2012 through a World Bank-supported project. The Belgian Development Agency (BTC) followed suit through a health system strengthening (HSS) project. This paper analyses and draws lessons from the experience of BTC-supported PBF alternative approach – especially with regards to institutional aspects, the role of demand-side actors, ownership, and cost-effectiveness – and explores the mechanisms at stake so as to better understand how the "PBF package" functions and produces effects Methods: An exploratory, theory-driven evaluation approach was adopted. Causal mechanisms through which PBF is hypothesised to impact on results were singled out and explored. This paper stems from the co-authors’ capitalisation of experiences; mixed methods were used to collect, triangulate and analyse information. Results are structured along Witter et al framework. Results: Influence of context is strong over PBF in Benin; the policy is donor-driven. BTC did not adopt the World Bank’s mainstream PBF model, but developed an alternative approach in line with its HSS support programme, which is grounded on existing domestic institutions. The main features of this approach are described (decentralised governance, peer review verification, counter-verification entrusted to health service users’ platforms), as well as its adaptive process. PBF has contributed to strengthen various aspects of the health system and led to modest progress in utilisation of health services, but noticeable improvements in healthcare quality. Three mechanisms explaining observed outcomes within the context are described: comprehensive HSS at district level; acting on health workers’ motivation through a complex package of incentives; and increased accountability by reinforcing dialogue with demand-side actors. Cost-effectiveness and sustainability issues are also discussed. Conclusion: BTC’s alternative PBF approach is both promising in terms of effects, ownership and sustainability, and less resource consuming. This experience testifies that PBF is not a uniform or rigid model, and opens the policy ground for recipient governments to put their own emphasis and priorities and design ad hoc models adapted to their context specificities. However, integrating PBF within the normal functioning of local health systems, in line with other reforms, is a big challenge.

Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink?

“…Ultimately, money may be the force driving recipient countries’ adoption of the PBF agenda, but donors also use political pressure and other methods (eg, promises of funding and study tours to ‘success story’ countries) to persuade countries to ‘buy’ PBF. 9 55 58 59 This is especially perverse in distressed contexts: ‘as observed in Haiti, lack of positive evidence is not enough for a powerless [Ministry of Health] to reject a strongly-advocated and generously-funded approach.’ 60…”

“…We therefore exhort: Recipient countries: (1) not to believe blindly that PBF—under whatever new label might be applied—can solve problems caused by weaknesses of their health systems (see Naudet for a historical perspective on this) 68 ; (2) to dare to speak of problems they encounter with the way PBF is implemented and to make donors accountable for their mistakes; and (3) to first ensure that the basics are right (see below) before buying in to more elaborate mechanisms. Bilateral and multilateral donors who still have not embarked on the PBF approach: (1) to not blindly follow the lead of the World Bank and like-minded donors in disseminating the mainstream PBF model, and (2) to remember that ‘the real driver of change will come from national stakeholders such as health workers [and community groups] demanding the right to health and pressuring governments to find the mechanisms to deliver this goal.’ 69 Recipient countries and donors: to give greater consideration to foundational, systemic, sustainable and country-specific approaches to solving health system problems, such as: improved working conditions (functioning infrastructure and equipment, and so on); wage reforms (raising wages to a decent level aligned with position held) and balanced rewards and sanction strategies 70 ; human resources management to reinforce health staff self-esteem; financial premiums and respect for working in remote areas 71 ; strengthening dialogue arenas with and supporting the initiatives of communities 9 ; use of performance information for local decision-making 72 ; integration and strengthening of monitoring and evaluation institutions and related (local) accountability mechanisms 65 ; support to demand-side empowerment 9 ; reduction of financial and non-financial barriers to healthcare 73 ; development of integrated medical records; and financial reforms to reduce fragmentation of financing for health service providers, to integrate their budgeting, cash management and financial reporting processes, to ensure fair allocation of resources and to provide sufficient—and sufficiently flexible—monies to the operational level. Independent researchers (since PBF programmes are not likely to stop overnight): (1) to continue studying what is happening in the field, while minimising the risk of producing biased results 74 ; and (2) to focus especially on how stakeholders transform the model in practice, how PBF changes their behaviour, and on PBF’s complex long-term effects on motivation, including the effects of its interruption following donors’ withdrawal.…”

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

“…As in several recent contributions [46][47][48][49], our study adopted a broad view on the ToC of PBF. Our case shows that the intervention itself (PBF-N) interplayed with at least three other pre-existing interventions, each having its own ToC: delivery of nutrition services at the HC level, supervision by the district team and PBF-FHC.…”

Evidence gap map of performance measurement and management in primary care delivery systems in low- and middle-income countries – Study protocol

“…Proximal health effects could include the adoption of improved clinical behaviors by providers; quality improvement and safety outcomes at the patient- and facility-levels; increased service utilization and effective coverage; positive and negative equity effects; and, adverse or unintended effects. Examples of negative or unintended effects of performance management interventions have been reported in the literature, including gaming, shirking and cream-skimming 25 82 85 .…”