You are here

Article Text

Article menu

Download PDFPDF

Analysis
Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink?
  1. Elisabeth Paul1,2,
  2. Lucien Albert3,
  3. Badibanga N’Sambuka Bisala4,
  4. Oriane Bodson2,
  5. Emmanuel Bonnet5,
  6. Paul Bossyns6,
  7. Sandro Colombo7,
  8. Vincent De Brouwere8,
  9. Alexandre Dumont9,
  10. Dieudonné Sèdjro Eclou10,
  11. Karel Gyselinck6,
  12. Fatoumata Hane11,
  13. Bruno Marchal8,
  14. Remo Meloni12,
  15. Mathieu Noirhomme13,
  16. Jean-Pierre Noterman14,
  17. Gorik Ooms15,
  18. Oumar Mallé Samb16,
  19. Freddie Ssengooba17,
  20. Laurence Touré18,
  21. Anne-Marie Turcotte-Tremblay19,
  22. Sara Van Belle8,
  23. Philippe Vinard20,
  24. Valéry Ridde9
  1. 1 Tax Institute, Université de Liège, Liège, Belgium
  2. 2 Faculty of Social Sciences, Université de Liège, Liège, Belgium
  3. 3 International Health Unit, University of Montreal, Montreal, Quebec, Canada
  4. 4 Expert in district health systems based on primary healthcare, Groupe d’Appui à la Recherche et Enseignement en Santé Publique, Mbuji-Mayi, Democratic Republic of the Congo
  5. 5 Résiliences, Research Institute for Development (IRD), Bondy, France
  6. 6 Health Sector Thematic Unit, Belgian Development Agency (ENABEL), Brussels, Belgium
  7. 7 Independent Consultant, Madrid, Spain
  8. 8 Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
  9. 9 CEPED, Research Institute for Development (IRD), Paris Descartes University, INSERM, Paris, France
  10. 10 LADYD, Université d’Abomey-Calavi, Abomey-Calavi, Benin
  11. 11 Department of Sociology, Université Assane Seck, Ziguinchor, Senegal
  12. 12 Independent Consultant, Kigali, Rwanda
  13. 13 Independent Consultant, Brussels, Belgium
  14. 14 Independent Consultant, Bunia, Democratic Republic of the Congo
  15. 15 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
  16. 16 Global Health, Department of Health Sciences, Université du Québec en Abitibi-Témiscamingue, Quebec City, Quebec, Canada
  17. 17 Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
  18. 18 Anthropologist, Research Association Miseli, Bamako, Mali
  19. 19 University of Montreal Public Health Research Institute, Montreal, Quebec, Canada
  20. 20 Alter Santé Internationale, Montpellier, France
  1. Correspondence to Dr Elisabeth Paul; E.Paul{at}ulg.ac.be

Abstract

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

  • health policy
  • health systems

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000664

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Key questions

    What is already known about this topic?

    • Evidence regarding performance-based financing (PBF) effectiveness is mixed, and there is no evidence about its efficiency and equity.

    • Empirical evidence from different settings and disciplines indicates the risks, cost and perverse effects of PBF in LMICs.

    • Despite insufficient supportive evidence, PBF is increasingly promoted by donors and implemented.

    What are the new findings?

    • Consultants and international agencies increasingly play a brokerage role in PBF dissemination, at the expense of domestic initiative and ownership.

    • Based on our experience in the field in a wide array of countries, we have observed that the way PBF is actually implemented departs markedly from the ideal of an open approach enabling system reforms in LMICs.

    • Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems.

    Recommendations for policy

    • We plead in favour of abandoning the indiscriminate dissemination of a mainstream PBF model in the way it has been implemented so far.

    • Time, attention and resources should be devoted to strengthening key health system components to enable them to perform well.

    Introduction

    Ten years after the launch of the Health Results Innovation Trust Fund (HRITF), which aims to promote performance-based financing (PBF) in the health sector in low-income and middle-income countries (LMICs), and 6 years after publication of the paper ‘Performance-based financing: just a donor fad or a catalyst towards comprehensive health care reform?’,1 in which the authors argue that ‘performance-based financing can catalyse comprehensive reforms and help address structural problems of public health services [… and that] it may contribute to profoundly transforming the public sectors of low-income countries,’ we think it is time to question the mainstream view that PBF is an effective, efficient and equitable approach to improving the performance of health systems.

    PBF was conceptualised by its promoters—nearly all European or American—as an approach enabling health system reform in countries where past reforms had presumably failed.1–3 However, one can question in the first place whether other system-wide reforms, such as ambitious decentralisation or human resources reforms: (1) have actually failed; (2) have ever received sufficient financial support over the years; and (3) have effectively provided adequate funding to the operational level—which could actually be the critical issue to be solved. Indeed, for instance, the randomised controlled trial of PBF in Cameroon showed that, for most of the positive outcomes, there was no statistically significant difference between health facilities with the standard PBF package and a control group receiving all elements of PBF except the direct link between individual facility performance and additional financing.4

    PBF was conceived as an open approach adapted to specific country needs, even in fragile contexts; it is framed as ‘a tool for helping create better, more inclusive, and more accessible health services’2 and a “systems reform approach, which offers an answer to the ‘how’ of achieving Universal Health Coverage and the Sustainable Development Goals.”3 In theory, the approach has the potential to foster system-wide reforms in relation to human resources (increased motivation), financial management (autonomy of health structures, management tools), health information and other aspects of governance.1–3 However, as with many policies, strategies and tools, there is a gap between what was planned and what is actually implemented.5 In fact, we argue that PBF as it is currently implemented in many contexts—under the mainstream, unsustainable, donor-funded and donor-driven approach—does not satisfy the promises and can actually damage health services and systems.

    In this analysis paper, we present a critical perspective on how PBF is actually implemented. The coauthors of this paper are researchers, academics and public health experts from Europe, North America and Africa, working with recipient governments, in research centres and donor organisations, or as individual experts. We all share a strong knowledge and field experience and are concerned by what we have observed during the implementation of PBF programmes. Indeed, there is evidence that the open, reform-promoting ideal model of PBF is often implemented as a rigid blueprint or a ‘travelling’ model.6 Mostly financed by donors, implementation is often dissociated from existing health system institutions and does not foster effective system-wide reforms.7–9 We argue that PBF implementation was rushed despite insufficient evidence of its effectiveness, that there is a lack of ownership and that too little care is given to system-wide and long-term effects. We end by proposing entry points for alternative approaches.

    PBF implementation has been rushed

    PBF, as currently promoted in LMICs by the HRITF and other donors, was mainly designed by academics and professionals from wealthier countries as an innovative approach to improve health sector performance, without taking stock of the experience gathered by similar practices in high-income countries.10 This raises concerns, because PBF has not been particularly popular in wealthier countries; evidence regarding its effectiveness is mixed, and its efficiency could not be credibly demonstrated.11–17 Particular caution should be taken when introducing a reform in a system as complex as the health sector,18 and acting upon something as multidimensional and changing as actor motivation19 20 which may lead to unforeseen (or negative) consequences in the long term. Perverse effects are well known from the economics and management literature and include gaming, adverse selection, tunnel vision, distortion, crowding out of intrinsic motivation and of professionalism.19–24

    Since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects.25–27 Presented as a flagship by PBF promoters, the success story of Rwanda was questioned early.28 29 Nearly a decade later, evidence is still sparse and mixed:

    • The jury is still out as to whether there is credible and reproducible evidence that PBF is effective.30 A recent Cochrane review concluded that ‘the effects of provider incentives are uncertain (very low-certainty evidence), including […] the effects of pay-for-performance on provider performance, the utilisation of services, patient outcomes, or resource use in low-income countries.’31

    • PBF has been shown to be expensive. In Tanzania, PBF economic cost was twice as much as financial cost; in a low-income setting, the costs of managing the programme and generating and verifying performance data were substantial.32 Under the World Bank-promoted PBF model in Benin, for each US$1 paid to providers, about US$0.50 is used for verification, of which 39% goes to the implementing agency and 61% to the community-based organisations in charge of the community verification; this includes only the financial costs—for example, financial transactions that are a result of the verification activities introduced by PBF—and does not include economic costs, such as the time spent by district health management teams and implementing agency staff on verification, nor capital costs.33 In Burkina Faso, over the period 2014–2015, operating costs (in the broad sense) amounted to 30% of the total cost of PBF.34 Yet there is no evidence that PBF is efficient.35

    • In Rwanda, PBF has proved not to be equitable.36

    • Distortions and perverse effects predicted by several authors10 26 37 38 have emerged in field conditions. These include inducing oversupply of unnecessary services, gaming and data manipulation (including by controllers), cherry-picking of purchased services by PBF agencies, hiding stock-outs of essential medicines, respecting norms only during PBF supervisions, inducing work overload, uncertainty and undue penalisation of certain health workers, leading to dissatisfaction among health staff.8 25 29 39–43

    • The supposedly motivational effect of PBF on health workers may be reversed if the latter perceive it as unfair.44 45

    • The consequences of poorly designed PBF schemes, as well as those of suddenly stopping the PBF programme (as occurred in Benin, Chad and Mali, for instance), include negative effects on both motivation and service delivery.46 47

    In 2014, the Independent Evaluation Group of the World Bank raised a red flag. It found that multiple PBF pilots had failed and that ‘decisions were made to scale up regardless of weak, inconclusive, or incomplete pilot results.’ It stated that the World Bank had supported PBF with insufficient evidence that the approach is effective.48 Nevertheless, donors intensified support to PBF. Between 2007 and June 2016, the HRITF disbursed US$281.7 million, 68% of which was disbursed over the last 3 years, when the majority of HRITF-funded PBF programmes were initiated (https://www.rbfhealth.org/mission). The number of bilateral and multilateral donors that fund PBF has increased in the past 3 years. In 2017, the World Bank recognised that ‘[m]ore research is needed to assess the effectiveness of [performance-based] schemes, and their impact may depend on existing conditions.’49

    PBF is a donor-driven solution

    The PBF approach was pioneered in very specific contexts (postconflict or failed states: Cambodia, Haiti, Rwanda, Burundi) by a close circle of consultants and researchers.2 From small-scale pilot projects, PBF was first scaled up in the atypical context of Rwanda. The first reported results suggested it was successful,50 although this conclusion was later questioned, regarding both effectiveness51 and equity.36 From there, PBF was quickly and widely disseminated with intense donor support; the HRITF has so far supported 35 PBF programmes in 29 countries (https://www.rbfhealth.org/mission). In contrast, with the exception of Burundi and Rwanda, recipient countries hardly devote any domestic funds to PBF.

    In no LMIC has PBF been a home-grown strategy; all PBF programmes have been initiated and developed with donor support. Considering its lack of domestic ownership, the amounts of time and money it now absorbs and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Although some fads eventually prove to be long-lasting innovations, the prototypical fad is wildly popular but short lived, abandoned and readily replaced by new schemes.52

    How do we explain this donor fad? The ‘results-based management agenda’ is tempting for donors,53 especially in a climate of global financial recession. Moreover, just as was observed with the dissemination of New Public Management, ‘[a] new cottage industry of consultants has been spawned by this results-oriented […] strategy.’54 Indeed, consultants and international agencies increasingly play a brokerage role in global health governance, and especially in PBF dissemination, at the expense of domestic initiative and ownership.55 As Pavignani and colleagues56 pointed out, PBF has been disseminated from the start in an ‘evangelistic’ way. Currently, two closely interlinked networks promote PBF: SINA Health, which organised 62 PBF courses (http://www.sina-health.com/), and the PBF community of practice (CoP) (http://www.healthfinancingafrica.org/). The PBF conceptualisers co-opted and trained a growing number of ‘PBF champions’, who in turn were sent to neighbouring countries to spread PBF. While the CoP was set up to encourage open debate, the underlying personal and institutional interests allow for little controversy.

    As Barnes and colleagues pointed out, the RBF Health blog “is revealing in the positive bias attributed to performance approaches to health system reform. None of the 38 blog entries published as of July 2014 were overtly critical or specific about potential limitations of PBF. […] challenges were weighed against an extensive list of the advantages to PBF in each of these entries and, in some cases, stories of successes from PBF flagship countries […]. Such a positive bias is unsurprising given the amount of money the World Bank has invested in these programmes as flagships of its Health, Nutrition, and Population section and some of the positive gains arising from the project. However, the use of PBF-friendly bloggers—implementing partner NGOs such as Cordaid, World Bank consultants, and representatives from ‘success story’ country health ministries—and the lack of representation of some of the limitations of or potential alternatives to PBF—and of those who are more hesitant about its transformative power – reinforce the positive bias.”55

    The enthusiasm emanating from the CoP is not supported by solid evidence that PBF is an effective and efficient approach, despite the circular argument that its adoption by LMICs is an indicator of its success. Many professionals seemingly just follow suit because they would lose top-ups or opportunities for work or consultancy if they did not adhere to PBF. This may be especially the case for African researchers, who have fewer research grant opportunities and tend to rely a great deal on consultancy.57 Even more worryingly, this is also the case for researchers in general: publication bias and conflicts of interest seem particularly prevalent in relation to this subject.7 35 Several coauthors of this paper have endured moral pressure and even threats for daring to express concerns about PBF programmes in countries and/or for trying to find out what is actually happening during programme implementation.

    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

    PBF may actually weaken health systems

    Based on our experience in the field in a wide array of countries including Benin, Burkina Faso, Cameroon, Democratic Republic of the Congo (DRC), Haiti, Mali, Niger, Nigeria, Rwanda, Senegal, Uganda and Zimbabwe, we have observed that the way PBF is actually implemented under donor pressure departs markedly from the ideal of an open approach enabling system reforms in LMICs. It seems many countries adopt PBF because donors have convinced ‘PBF champions’ to buy it. Some champions do so because they see direct, personal benefits in the management of its machinery; in Benin, for instance, the acronym FBR—French for PBF—is popularly known as ‘financements bien ramassés’ (‘easy money’). Beneficiaries are not informed and do not entirely understand how and why they get certain PBF bonuses.42 61 As a consequence, in many countries, ownership of PBF is limited to a very small circle.62 This means, for instance, that the ministries in charge of finance and civil service are not really involved in its design and evaluation and consequently are unable to promote the necessary comprehensive reforms, such as increased financial autonomy for health districts and facilities, which supposedly is an essential component of the ‘PBF package’.63 PBF is thus not integrated into routine health systems processes, but instead is subject to separate evaluation missions, budgets and data collection tools.8 9 42

    By presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms.53 We argue that the latter include a wide range of improvements to: working conditions; human resources management (disparities in health staff distribution; quality of initial and vocational training; low salaries and poor accountability; plethora of untrained health staff, as in the case of DRC)64; transparency in use of financial resources; quality of care; integration of programmes and their monitoring and evaluation65; accountability; performance of public financial management; engagement of communities (eg, as village health committees, traditional leaders and other community members) in governing the demand and supply of health services66; and so on. Paradoxically, all of these are structural determinants of PBF’s own performance.9 44 66

    In all, PBF has huge opportunity costs: millions of dollars have been spent on complicated management and verification mechanisms that are not fraud proof, without producing sustained positive results (even though some have been observed) or strengthening health systems in any sustainable way.

    What are the alternatives?

    In addition to individual country impact evaluations (see https://www.rbfhealth.org/impact), the HRITF itself is currently being evaluated and is slated for termination in 2022. HRITF acknowledges that, considering the ‘new evidence emerging from Impact Evaluations and strong experience on the ground, […it] is a good time to re-imagine [P]BF and gear-up for the future’ (https://www.rbfhealth.org/mission-history). Based on our field experience and scientific evidence, we plead in favour of abandoning the indiscriminate dissemination of a mainstream PBF model in the way it has been implemented so far, which does not take into account health systems’ complexity and sustainability. Instead, time, attention and resources should be devoted to strengthening key health system components to enable them to perform well. To paraphrase Stephen Kidd on another World Bank strategy that is ‘harming many of the world’s most vulnerable people’67: Isn’t it time for a rethink? 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 strategies70; human resources management to reinforce health staff self-esteem; financial premiums and respect for working in remote areas71; strengthening dialogue arenas with and supporting the initiatives of communities9; use of performance information for local decision-making72; integration and strengthening of monitoring and evaluation institutions and related (local) accountability mechanisms65; support to demand-side empowerment9; reduction of financial and non-financial barriers to healthcare73; 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 results74; 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.

    Acknowledgments

    We thank Donna Riley for editing assistance, as well as anonymous colleagues who have contributed to this paper but have not been in a position to sign it for private or institutional reasons.

    References

    1. ↵
      2. Meessen B ,
      3. Soucat A ,
      4. Sekabaraga C
      . Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform? Bull World Health Organ 2011;89:153–6.doi:10.2471/BLT.10.077339
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      2. Fritsche GB ,
      3. Soeters R ,
      4. Meessen B
      . Performance-Based Financing Toolkit: The World Bank, 2014. http://documents.worldbank.org/curated/en/369941468325159289/pdf/854120PUB0978100Box382147B00PUBLIC0.pdf (cited 7 Nov 2017).
    3. ↵
      2. Soeters R
      . Performance-based financing in Action – Theory and Instruments – SINA-Health Course Guide with 17 modules. 8th edn: SINA-Health, 2017. http://www.sina-health.com/wp-content/uploads/PBFCourseBookSINATheoryActionEngVF100817.pdf (cited 7 Nov 2017).
    4. ↵
      2. de Walque D ,
      3. Robyn PJ ,
      4. Saidou H , et al
      . Looking into the performance-based financing black box: evidence from an impact evaluation in the health sector in cameroon [Internet]. Policy research working paper 8162. Washington, DC: The World Bank, 2017.
    5. ↵
      2. Pressman J ,
      3. Wildavsky A
      . How great expectations in Washington are dashed in Oakland. 3rd edn. Berkeley, Los Angeles, London: University of California Press, 1984.
    6. ↵
      2. Olivier de Sardan JP ,
      3. Diarra A ,
      4. Moha M
      . Travelling models and the challenge of pragmatic contexts and practical norms: the case of maternal health. Health Res Policy Syst 2017;15(Suppl 1):60.doi:10.1186/s12961-017-0213-9
      OpenUrl
    7. ↵
      2. Ssengooba F ,
      3. McPake B ,
      4. Palmer N
      . Why performance-based contracting failed in Uganda – An “open-box” evaluation of a complex health system intervention. Soc Sci Med 2012;75:377–83.doi:10.1016/j.socscimed.2012.02.050
      OpenUrlPubMed
    8. ↵
      2. Paul E ,
      3. Sossouhounto N ,
      4. Eclou DS
      . Local stakeholders’ perceptions about the introduction of performance-based financing in Benin: a case study in two health districts. Int J Health Policy Manag 2014;3:207–14.doi:10.15171/ijhpm.2014.93
      OpenUrl
    9. ↵
      2. Paul E ,
      3. Dramé ML ,
      4. Kashala J-P , et al
      . Performance-based financing to strengthen the health system in Benin: challenging the mainstream approach. Int J Health Policy Manag 2018;7:35–47.doi:10.15171/ijhpm.2017.42
      OpenUrl
    10. ↵
      2. Paul E ,
      3. Renmans D
      . Performance-based financing in the health sector in low- and middle-income countries: is there anything whereof it may be said, see, this is new? Int J Health Plann Manage 2017.doi:10.1002/hpm.2409
    11. ↵
      2. Van Herck P ,
      3. De Smedt D ,
      4. Annemans L , et al
      . Systematic review: Effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res 2010;10:247.doi:10.1186/1472-6963-10-247
      OpenUrlCrossRefPubMed
    12. ↵
      2. Emmert M ,
      3. Eijkenaar F ,
      4. Kemter H , et al
      . Economic evaluation of pay-for-performance in health care: a systematic review. Eur J Health Econ 2012;13:755–67.doi:10.1007/s10198-011-0329-8
      OpenUrlCrossRefPubMed
    13. ↵
      2. Eijkenaar F ,
      3. Emmert M ,
      4. Scheppach M , et al
      . Effects of pay for performance in health care: a systematic review of systematic reviews. Health Policy 2013;110:115–30.doi:10.1016/j.healthpol.2013.01.008
      OpenUrlCrossRefPubMedWeb of Science
    14. ↵
      2. Ryan AM ,
      3. Krinsky S ,
      4. Kontopantelis E , et al
      . Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study. Lancet 2016;388:268–74.doi:10.1016/S0140-6736(16)00276-2
      OpenUrlCrossRefPubMed
    15. ↵
      2. Doran T ,
      3. Maurer KA ,
      4. Ryan AM
      . Impact of provider incentives on quality and value of health care. Annu Rev Public Health 2017;38:449–65.doi:10.1146/annurev-publhealth-032315-021457
      OpenUrl
    16. ↵
      2. Forbes LJ ,
      3. Marchand C ,
      4. Doran T , et al
      . The role of the quality and outcomes framework in the care of long-term conditions: a systematic review. Br J Gen Pract 2017;67:e775–84.doi:10.3399/bjgp17X693077
      OpenUrlAbstract/FREE Full Text
    17. ↵
      2. Mendelson A ,
      3. Kondo K ,
      4. Damberg C , et al
      . The effects of pay-for-performance programs on health, health care use, and processes of care: a systematic review. Ann Intern Med 2017;166:341–53.doi:10.7326/M16-1881
      OpenUrl
    18. ↵
      2. de Savigny D ,
      3. Adam T
      . Systems thinking for health systems strengthening: Alliance for Health Policy and Systems Research and World Health Organization, 2009. http://www.who.int/alliance-hpsr/resources/9789241563895/en/
    19. ↵
      2. Adams O ,
      3. Hicks V
      . Pay and non-pay incentives, performance and motivation. Prepared for WHO’s December 2000 Global Health Workforce Strategy Group: World Health Organization, 2000. http://www.who.int/hrh/en/HRDJ_4_3_02.pdf (cited 9 Nov 2017).
    20. ↵
      2. Paul E ,
      3. Robinson M
      . Performance budgeting, motivation and incentives In: Robinson M . Performance budgeting: linking funding and results: Basingstoke: International Monetary Fund & Palgrave/McMillan, 2007:330–375.
    21. ↵
      2. Frey BS ,
      3. Jegen R
      . Motivation crowding theory. J Econ Surv 2001;15:589–611.doi:10.1111/1467-6419.00150
      OpenUrlCrossRefWeb of Science
    22. ↵
      2. Shen Y
      . Selection incentives in a performance-based contracting system. Health Serv Res 2003;38:535–52.doi:10.1111/1475-6773.00132
      OpenUrlCrossRefPubMedWeb of Science
    23. ↵
      2. Petersen LA ,
      3. Woodard LD ,
      4. Urech T , et al
      . Does pay-for-performance improve the quality of health care? Ann Intern Med 2006;145:265–72.doi:10.7326/0003-4819-145-4-200608150-00006
      OpenUrlCrossRefPubMedWeb of Science
    24. ↵
      2. Sanderson AA
      . Pay-for-performance programs in the United Kingdom. N Engl J Med 2006;355:1832–3.doi:10.1056/NEJMc062305
      OpenUrlCrossRefPubMed
    25. ↵
      2. Oxman AD ,
      3. Fretheim A
      . Can paying for results help to achieve the Millennium Development Goals? A critical review of selected evaluations of results-based financing. J Evid Based Med 2009;2:184–95.doi:10.1111/j.1756-5391.2009.01024.x
      OpenUrlPubMed
    26. ↵
      2. Ireland M ,
      3. Paul E ,
      4. Dujardin B
      . Can performance-based financing be used to reform health systems in developing countries? Bull World Health Organ 2011;89:695–8.doi:10.2471/BLT.11.087379
      OpenUrlCrossRefPubMedWeb of Science
    27. ↵
      2. Witter S ,
      3. Fretheim A ,
      4. Kessy FL , et al
      . Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev 2012;2:CD007899.doi:10.1002/14651858.CD007899.pub2
      OpenUrlCrossRefPubMed
    28. ↵
      2. Rusa L ,
      3. Ngirabega JD ,
      4. Janssen W , et al
      . Performance-based financing for better quality of services in Rwandan health centres: 3-year experience. Trop Med Int Health 2009;14:830–7.doi:10.1111/j.1365-3156.2009.02292.x
      OpenUrlCrossRefPubMed
    29. ↵
      2. Kalk A ,
      3. Paul FA ,
      4. Grabosch E
      . ’Paying for performance' in Rwanda: does it pay off? Trop Med Int Health 2010;15:182–90.doi:10.1111/j.1365-3156.2009.02430.x
      OpenUrlCrossRefPubMed
    30. ↵
      2. Das A ,
      3. Gopalan SS ,
      4. Chandramohan D
      . Effect of pay for performance to improve quality of maternal and child care in low- and middle-income countries: a systematic review. BMC Public Health 2016;16:321.doi:10.1186/s12889-016-2982-4
      OpenUrl
    31. ↵
      2. Wiysonge CS ,
      3. Paulsen E ,
      4. Lewin S , et al
      . Financial arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017;9:CD011084.doi:10.1002/14651858.CD011084.pub2
      OpenUrl
    32. ↵
      2. Borghi J ,
      3. Little R ,
      4. Binyaruka P , et al
      . In Tanzania, the many costs of pay-for-performance leave open to debate whether the strategy is cost-effective. Health Aff 2015;34:406–14.doi:10.1377/hlthaff.2014.0608
      OpenUrlAbstract/FREE Full Text
    33. ↵
      2. Antony M ,
      3. Bertone MP ,
      4. Barthes O
      . Exploring implementation practices in results-based financing: the case of the verification in Benin. BMC Health Serv Res 2017;17:204.doi:10.1186/s12913-017-2148-9
      OpenUrl
    34. ↵
      2. Nonkani G ,
      3. Bakyono R ,
      4. Tapsoba B
      . Results-Based Financing (RBF) in the health sector in Burkina Faso: implementation and expenditure patterns (January 2014 to December 2015): mimeo, 2016.
    35. ↵
      2. Turcotte-Tremblay AM ,
      3. Spagnolo J ,
      4. De Allegri M , et al
      . Does performance-based financing increase value for money in low- and middle- income countries? A systematic review. Health Econ Rev 2016;6:30.doi:10.1186/s13561-016-0103-9
      OpenUrl
    36. ↵
      2. Lannes L ,
      3. Meessen B ,
      4. Soucat A , et al
      . Can performance-based financing help reaching the poor with maternal and child health services? The experience of rural Rwanda. Int J Health Plann Manage 2016;31:309–48.doi:10.1002/hpm.2297
      OpenUrl
    37. ↵
      2. Kalk A
      . The costs of performance-based financing. Bull World Health Organ 2011;89:319.doi:10.2471/BLT.11.087247
      OpenUrlCrossRefPubMedWeb of Science
    38. ↵
      2. Miller G ,
      3. Babiarz KS
      . Pay-for-Performance Incentives in Low- and Middle-Income Country Health Programs. NBER Working Paper No. 18932: National Bureau of Economic Research, 2013. http://www.nber.org/papers/w18932.pdf (cited 2017 Nov 9).
    39. ↵
      2. Mansourian H ,
      3. Ousley J
      . Final review – report results-based financing pilot project – district of Haut Katanga, Democratic Republic of Congo: International Rescue Committee, 2011.
    40. ↵
      2. Baird IG ,
      3. Hammer P
      . Contracting Illness: reassessing international donor-initiated health service experiments in Cambodia’s indigenous periphery. South East Asia Research 2013;21:457–73.doi:10.5367/sear.2013.0159
      OpenUrlCrossRef
    41. ↵
      2. Chimhutu V ,
      3. Lindkvist I ,
      4. Lange S
      . When incentives work too well: locally implemented pay for performance (P4P) and adverse sanctions towards home birth in Tanzania - a qualitative study. BMC Health Serv Res 2014;14:23.doi:10.1186/1472-6963-14-23
      OpenUrl
    42. ↵
      2. Ridde V ,
      3. Yaogo M ,
      4. Zongo S , et al
      . Twelve months of implementation of health care performance-based financing in Burkina Faso: a qualitative multiple case study. Int J Health Plann Manage 2017.doi:10.1002/hpm.2439
    43. ↵
      2. Feldacker C ,
      3. Bochner AF ,
      4. Herman-Roloff A , et al
      . Is it all about the money? A qualitative exploration of the effects of performance-based financial incentives on Zimbabwe’s voluntary male medical circumcision program. PLoS One 2017;12:e0174047.doi:10.1371/journal.pone.0174047
    44. ↵
      2. Mansourian H
      . Health workers’ perspectives on the influences of results based financing model on health worker motivation and performance in Katanga, D.R. Congo. Doctoral Project: Columbia University, Mailman School of Public Health, 2013.
    45. ↵
      2. Chimhutu V ,
      3. Songstad NG ,
      4. Tjomsland M , et al
      . The inescapable question of fairness in Pay-for-performance bonus distribution: a qualitative study of health workers' experiences in Tanzania. Global Health 2016;12:77.doi:10.1186/s12992-016-0213-5
      OpenUrl
    46. ↵
      2. Kandpal E
      . Completed impact evaluations and emerging lessons from the health results innovation trust fund learning Portfolio: World Bank, 2017. https://www.rbfhealth.org/sites/rbf/files/IE%20and%20emerging%20lessons_Eeshani%20Kandpal.pdf (cited 2017 Nov 9).
    47. ↵
      2. Alonge O ,
      3. Lin S ,
      4. Igusa T , et al
      . Improving health systems performance in low- and middle-income countries: a system dynamics model of the pay-for-performance initiative in Afghanistan. Health Policy Plan 2017;32:1417–26.doi:10.1093/heapol/czx122
      OpenUrl
    48. ↵
      Independent Evaluation Group (IEG). World Bank Group Support to Health Financing. 2014 http://ieg.worldbankgroup.org/sites/default/files/Data/reports/chapters/health_finance_evaluation_w_appendix_updated_0.pdf (cited 7 Nov 2017).
    49. ↵
      World Bank. World Development Report 2017: Governance and the Law: World Bank, 2017. http://www.worldbank.org/en/publication/wdr2017 (cited 10 Nov 2017).
    50. ↵
      2. Basinga P ,
      3. Gertler PJ ,
      4. Binagwaho A , et al
      . Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. The Lancet 2011;377:1421–8.doi:10.1016/S0140-6736(11)60177-3
      OpenUrlCrossRef
    51. ↵
      2. Skiles MP ,
      3. Curtis SL ,
      4. Basinga P , et al
      . The effect of performance-based financing on illness, care-seeking and treatment among children: an impact evaluation in Rwanda. BMC Health Serv Res 2015;15:375.doi:10.1186/s12913-015-1033-7
      OpenUrl
    52. ↵
      2. Best J
      . Flavor of the month: why smart people fall for fads. Berkeley:  University of California Press, 2006.
    53. ↵
      2. Valters C ,
      3. Whitty B
      . The politics of the results agenda in DFID 1997-2017: Overseas Development Institute (ODI) Report, 2017. https://www.odi.org/sites/odi.org.uk/files/resource-documents/11730.pdf (cited 7 Nov 2017).
    54. ↵
      2. Morgan D ,
      3. Robinson KS ,
      4. Strachota D , et al
      . Budgeting for local governments and communities. Routledge: Milton Park, 2014.
    55. ↵
      2. Barnes A ,
      3. Brown GW ,
      4. Harman S
      . Global politics of health reform in Africa. Basingstoke: Palgrave Macmillan, 2015.
    56. ↵
      2. Pavignani E ,
      3. Michael M ,
      4. Murru M , et al
      . Making sense of apparent chaos: health-care provision in six country case studies. International Review of the Red Cross 2013;95:41–60.doi:10.1017/S1816383113000726
      OpenUrlCrossRef
    57. ↵
      2. Olivier de Sardan J-P
      . Promouvoir la recherche face à la consultance. Autour de l’expérience du lasdel (Niger-Bénin). Cah D’études Afr 2011;202–203:511–28.
      OpenUrl
    58. ↵
      2. Barnes A ,
      3. Brown GW ,
      4. Harman S , et al
      . African participation and partnership in performance-based financing: A case study in global health policy. EQUINET Discussion Paper 102, 2014.
    59. ↵
      2. Chimhutu V ,
      3. Tjomsland M ,
      4. Songstad NG , et al
      . Introducing payment for performance in the health sector of Tanzania- the policy process. Global Health 2015;11:38.doi:10.1186/s12992-015-0125-9
      OpenUrl
    60. ↵
      2. Pavignani E ,
      3. Colombo S
      . Strategizing in distressed health contexts. In: Schmets G , Rajan D , Kadandale S , eds. Strategizing national health in the 21st century: a handbook: World Health Organization (WHO), 2016.
    61. ↵
      2. Renmans D ,
      3. Holvoet N ,
      4. Criel B
      . Combining theory-driven evaluation and causal loop diagramming for opening the ‘Black Box’ of an Intervention in the health sector: a case of performance-based financing in Western Uganda. Int J Environ Res Public Health 2017;14:1007.doi:10.3390/ijerph14091007
      OpenUrl
    62. ↵
      2. Gautier L ,
      3. Ridde V
      . Health financing policies in Sub-Saharan Africa: government ownership or donors’ influence? A scoping review of policymaking processes. Glob Health Res Policy 2017;2:23.doi:10.1186/s41256-017-0043-x
      OpenUrl
    63. ↵
      2. Renmans D ,
      3. Holvoet N ,
      4. Orach CG , et al
      . Opening the ‘black box’ of performance-based financing in low- and lower middle-income countries: a review of the literature. Health Policy Plan 2016;31:1297–309.doi:10.1093/heapol/czw045
      OpenUrlCrossRefPubMed
    64. ↵
      2. Fox S ,
      3. Witter S ,
      4. Wylde E , et al
      . Paying health workers for performance in a fragmented, fragile state: reflections from Katanga Province, Democratic Republic of Congo. Health Policy Plan 2014;29:96–105.doi:10.1093/heapol/czs138
      OpenUrlCrossRefPubMed
    65. ↵
      World Health Organization. Monitoring, evaluation and review of national health strategies: a country-led platform for information and accountability: World Health Organization (WHO) with the International Health Partnership and related initiatives (IHP+).
    66. ↵
      2. Mabuchi S ,
      3. Sesan T ,
      4. Bennett SC
      . Pathways to high and low performance: factors differentiating primary care facilities under performance-based financing in Nigeria. Health Policy Plan 2017:czx146-czx146.doi:10.1093/heapol/czx146
    67. ↵
      2. Kidd S
      . Anti-Social Registries: How have they become so popular? [Internet]. PATHWAYS’ PERSPECTIVES on social policy in international development Issue No 24. 2017 http://www.developmentpathways.co.uk/resources/wp-content/uploads/2017/09/Anti-Social-Registries-FINAL.pdf (cited 7 Nov 2017).
    68. ↵
      2. Naudet J-D
      . Trouver des problèmes aux solutions – Vingt ans d’aide au Sahel. Paris: Organisation de Coopération et de Développement économiques, 1999.
    69. ↵
      2. Tichenor M ,
      3. Sridhar D
      . Universal health coverage, health systems strengthening, and the World Bank. BMJ 2017;358:j3347.doi:10.1136/bmj.j3347
      OpenUrlFREE Full Text
    70. ↵
      2. Zinnen V ,
      3. Paul E ,
      4. Mwisongo A , et al
      . Motivation of human resources for health: a case study at rural district level in Tanzania. Int J Health Plann Manage 2012;27:327–47.doi:10.1002/hpm.2117
      OpenUrlPubMed
    71. ↵
      2. Belaid L ,
      3. Dagenais C ,
      4. Moha M , et al
      . Understanding the factors affecting the attraction and retention of health professionals in rural and remote areas: a mixed-method study in Niger. Hum Resour Health 2017;15:60.doi:10.1186/s12960-017-0227-y
      OpenUrl
    72. ↵
      2. Levesque J-F ,
      3. Sutherland K
      . What role does performance information play in securing improvement in healthcare? a conceptual framework for levers of change. BMJ Open 2017;7:e014825.doi:10.1136/bmjopen-2016-014825
    73. ↵
      2. O’Connell TS ,
      3. Bedford KJA ,
      4. Thiede M , et al
      . Synthesizing qualitative and quantitative evidence on non-financial access barriers: implications for assessment at the district level. Int J Equity Health 2015;14:54.doi:10.1186/s12939-015-0181-z
      OpenUrl
    74. ↵
      2. Fretheim A ,
      3. Witter S ,
      4. Lindahl AK , et al
      . Performance-based financing in low- and middle-income countries: still more questions than answers. Bull World Health Organ 2012;90:559–559A.doi:10.2471/BLT.12.106468
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • Handling editor Seye Abimbola

    • Contributors EP and VR had the initial idea for this paper. They wrote the first draft and all authors contributed to the development of ideas, writing the manuscript, commenting on drafts and approved the final version.

    • Funding EP and OB are funded in part by the ARC grant for Concerted Research Actions, financed by the French Community of Belgium (Wallonia-Brussels Federation).

    • Disclaimer The views expressed are those of the authors, and not necessarily those of their respective institutions.

    • Competing interests Some authors have been involved in PBF programmes as a researcher and/or consultant and/or staff of a donor agency.

    • Provenance and peer review Commissioned; internally peer reviewed.

    • Correction notice Since original publication of this article a French translated version has been made available and can be viewed in the online supplementary material.

    Linked Articles