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      Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems

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          Abstract

          Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.

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          Most cited references43

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          Interlocking Interactions, the Diffusion of Innovations in Health Care

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            Performance-based payment: some reflections on the discourse, evidence and unanswered questions.

            Performance-based payment (PBP) is increasingly advocated as a way to improve the performance of health systems in low-income countries. This study conducted a systematic review of the current literature on this topic and found that while it is a popular term, there was little consensus about the meaning or the use of the concept of PBP. Significant weaknesses in the current evidence base on the success of PBP initiatives were also found. The literature would be strengthened by multi-disciplinary case studies that present both the advantages and disadvantages of PBP, influential factors for success, and more details about the projects from which this evidence is drawn. Where possible, data from control facilities where PBP is not being implemented would be an important addition. This paper suggests a further agenda for research, including assessing optimal conditions for implementation of PBP schemes in less developed health systems, the impact of adopting measures of performance as targets, and the requirements for monitoring PBP adequately.
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              Why performance-based contracting failed in Uganda--an "open-box" evaluation of a complex health system intervention.

              Performance-based contracting (PBC) is a tool that links rewards to attainment of measurable performance targets. Significant problems remain in the methods used to evaluate this tool. The primary focus of evaluations on the effects of PBC (black-box) and less attention to how these effects arise (open-box) generates suboptimal policy learning. A black-box impact evaluation of PBC pilot by the Development Research Group of the World Bank (DRG) and the Ministry of Health (MOH) concluded that PBC was ineffective. This paper reports a theory-based case study intended to clarify how and why PBC failed to achieve its objectives. To explain the observed PBC implementation and responses of participants, this case study employed two related theories i.e. complex adaptive system and expectancy theory respectively. A prospective study trailed the implementation of PBC (2003-2006) while collecting experiences of participants at district and hospital levels. Significant problems were encountered in the implementation of PBC that reflected its inadequate design. As problems were encountered, hasty adaptations resulted in a de facto intervention distinct from the one implied at the design stage. For example, inadequate time was allowed for the selection of service targets by the health centres yet they got 'locked-in' to these poor choices. The learning curve and workload among performance auditors weakened the validity of audit results. Above all, financial shortfalls led to delays, short-cuts and uncertainty about the size and payment of bonuses. The lesson for those intending to implement similar interventions is that PBC should not be attempted 'on the cheap'. It requires a plan to boost local institutional and technical capacities of implementers. It also requires careful consideration of the responses of multiple actors - both insiders and outsiders to the intended change process. Given the costs and complexity of PBC implementation, strengthening conventional approaches that are better attuned to low income contexts (financing resource inputs and systems management) remains a viable policy option towards improving health service delivery. Copyright © 2012 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                3 April 2018
                2018
                : 13
                : 4
                Affiliations
                [1 ] ReBUILD & Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
                [2 ] Centre of African Studies, University of Edinburgh, Edinburgh, United Kingdom
                [3 ] Centre for Primary Care and Public Health, Queen Mary University, London, United Kingdom
                University of Virginia, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-17-25998
                10.1371/journal.pone.0195301
                5882151
                29614115
                6db32f12-ff3b-46af-80af-31901e69cb19
                © 2018 Bertone et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 6, Tables: 2, Pages: 27
                Product
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100000278, Department for International Development;
                Award ID: ReBUILD
                The time of two of the study authors (SW and MB) was funded through the ReBUILD grant from UK AID, https://www.gov.uk/government/organisations/department-for-international-development.
                Categories
                Research Article
                Social Sciences
                Economics
                Finance
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Health Systems Strengthening
                People and Places
                Geographical Locations
                Africa
                Burundi
                People and Places
                Geographical Locations
                Africa
                Rwanda
                Medicine and Health Sciences
                Public and Occupational Health
                Global Health
                Medicine and Health Sciences
                Health Care
                Socioeconomic Aspects of Health
                Medicine and Health Sciences
                Public and Occupational Health
                Socioeconomic Aspects of Health
                Social Sciences
                Political Science
                Political Aspects of Health
                Social Sciences
                Economics
                Finance
                Public Finance
                Money Supply and Banking
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

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