Studying the link between institutions and health system performance: a framework and an illustration with the analysis of two performance-based financing schemes in Burundi

Abstract

Institutional arrangements of health systems and the incentives they set are increasingly recognized as critical to promote or hinder performance in the health sector. Looking at complex health system interventions from an institutional perspective may contribute to better understanding what are the paths and processes that lead to the results of such interventions. In this article, we propose an analytical framework drawing from new institutional economics. This framework suggests seven dimensions to look at: institutions, enforcement mechanisms, property rights, incentives, interactions between extrinsic and intrinsic sources of motivation, behavioural changes and organizational performance. For illustrative purposes, we then apply the framework to the analysis of the institutional (re)arrangements of two performance-based financing (PBF) schemes in Burundi by carrying out an empirical comparison of case studies. We use mainly qualitative data from primary and secondary sources and analyse them with focus on the seven dimensions of the framework. The analysis of the case studies provides a comparative narrative of the two PBF schemes and highlights the differences in their operational design, the challenges faced during implementation and the adaptations made. From a methodological perspective, this article proposes a tool to analyse complex health system interventions, looking beyond the evaluation of the final effects to focus on the processes through which institutional (re)arrangements affected those results. Its application indicates, at an empirical level, that such analysis could help identify lessons regarding the design of health systems interventions, such as PBF schemes, and the process of reforming institutional arrangements.

Motivating health workers up to a limit: partial effects of performance-based financing on working environments in Nigeria

“…Other theories such as Cognitive Evaluation Theory and SelfDetermination Theory (deCharms 1968;Deci and Ryan 1985), caution that while PBF could enhance extrinsic motivation it can also reduce intrinsic rewards which are in the form of satisfaction from the content of the job itself (deCharms 1968). In line with these theories and existing empirical evidence, the 'PBF package' indeed appeared to improve perceived extrinsic motivation of health workers in Wamba, Nigeria (deCharms 1968; Gagné and Deci 2005;Soeters et al 2006;Kalk et al 2010;Bertone and Meesen 2013;Population Council 2013).…”

“…They were also motivated by the recognition received from the community and improved working conditions. In addition, a few studies also noted importance of performance feedback or 'coaching' introduced through PBF to have motivating influences on health workers (Kalk et al 2010;Bertone and Meesen 2013;Population Council 2013).…”

Implementation of the free maternity services policy and its implications for health system governance in Kenya

“…22 In this study, two types of motivation are discussed: intrinsic motivation (the health workers comply with the new policy arrangement as s/ he values the goal of the policy) and extrinsic motivation (the health workers expect to benefit by complying with the new policy). 9 Formal and informal rules and their enforcement mechanisms define 'property rights' of individuals. 'Property rights' include decision-making rights and earning rights which the individuals hold on different assets (eg, patent, trademark, a piece of land).…”

“…8 The application of institutional economics as a theoretical basis for health systems research is not new: Bertone and Meessen developed a framework to evaluate the implementation of performance-based financing in Burundi. 9 Abimbola et al adapted the multilevel framework developed by Ostrom 10 to assess governance of primary healthcare in Nigeria. [10][11][12][13] Furthermore, Abimbola et al used the concept of transaction costs originally developed by Williamson (1979) to explore the barriers to accessing tuberculosis services in Nigeria.…”

The effects of performance incentives on the utilization and quality of maternal and child care in Burundi

“…Based on quantity and quality of services provided, facilities receive performance related funding (Bertone and Meessen, 2012) which on average makes up 40 percent of the total facility budget (The World Bank Health Results Innovation Trust Fund, 2013). Quantity is measured using various output indicators including ANC, vaccinations, family planning, and HIV care (Minist ere de la sant e publique Republique du Burundi, 2010).…”