Summary box
As implementers of Performance Based Financing (PBF) in various countries in Africa,
we have seen first-hand its benefits—but we acknowledge that there are challenges
that require ongoing improvements, and that debates and critical analyses are opportunities
to both question and strengthen the PBF approach.
However, constructive debates must be based on facts, value the large set of experiences
and require that all parties listen attentively and objectively to the arguments of
stakeholders, especially those with local knowledge and diversified institutional
affiliations.
Notably, PBF was initiated in Rwanda, jointly by African and European experts—but
we acknowledge that in our countries, PBF benefits from financial and technical leadership
by the World Bank and other exogenous actors, and while exogeneity can raise problems,
this is far from axiomatic.
PBF is an evolving strategy, with innovation and amendments by national actors based
on their context—in Democratic Republic of Congo (a tool for a fair sharing of bonuses),
Rwanda (community verification), Cameroon (urban PBF), Burundi (exemption of user
fees), Burkina Faso (focus on indigents), Nigeria (coupling PBF with demand-side financing
approaches) and Zimbabwe (risk-based verification to reduce administrative costs).
We see the value of PBF in its system-wide effects, such as improving coordination,
decentralisation accountability and overall governance in the health system (including
community engagement in health system governance), and completeness and timeliness
of health information system data.
Introduction
Performance Based Financing (PBF) is a health systems reform approach with an orientation
on results defined in terms of the quantity and quality of services. PBF has rapidly
gained popularity in many low/middle-income countries (LMIC), in Africa especially,
as a strategy towards better health outcomes, strengthened health systems and progress
towards Universal Health Coverage (UHC). The World Bank’s Performance Based Financing
Toolkit reports that in 2015 there were 34 PBF schemes, at either pilot or national
level, among the 51 countries of sub-Saharan Africa.1
The speed of PBF development raises concerns; recently Paul and colleagues2 took a
critical position towards its implementation in LMICs and the results that it promises.
The main areas of criticism include the availability of empirical evidence, the administrative
costs of implementing a PBF programme and the sustainability of PBF programmes in
the long run.
As experts directly involved in the implementation of PBF across Africa, we are keen
to share our perspectives and experience and critically review the various contributions
of PBF. We aim in this commentary to: (1) reflect on how the PBF approach has developed
in Africa, particularly in the countries where we work—Burkina Faso, Burundi, Benin,
Democratic Republic of Congo (DRC), Republic of Congo (Brazza) and Nigeria, (2) highlight
how the PBF approach has benefited our health systems and informed transformations
in the health sector, and (3) consider the challenges of and propose guidance for
reforming PBF implementation.
Our observations on PBF as a knowledge and policy process
Our experiences as implementers of PBF show that every context and case is different.
We alert the global health community against hasty conclusions drawn from a limited
set of experiences or a biased review of the vast scientific and grey literature.
We recognise that our perspectives are always partial and we value that many stakeholders
have intimate knowledge of health systems strengthening issues. As such, we take different
steps to overcome our knowledge gaps— for example, through sharing experiences within
the PBF Community of Practice (CoP). We have contributed to the body of knowledge
by sharing our experience through blogs, online discussions, trainings, workshops
and sometimes as coauthors of research papers. As practitioners, we value greatly
the knowledge generated by researchers, in its richness and possible contradictions.
At the country level, we try to create the most welcoming conditions for rigorous
studies and independent assessments of the PBF approach. We also do our best to follow
the body of evidence and value lessons emerging from scientific work.
In their criticism of PBF in LMICs, Paul and colleagues framed its development as
the work of some PBF champions motivated by direct and personal benefits, rather than
as stemming from real national political will.2 We find this framing paternalistic.
They emphasise the role of high-income country experts and obscure the contribution
of LMIC experts, especially from Africa. Through their focus on the role played by
international policy entrepreneurs, they overlook the national dynamics, the intricacies
within the government apparatuses and the contributions of national actors. However,
it is these national actors who are responsible for policy development, who seek to
influence the process and implementation, who follow and correct it and ultimately
benefit from PBF.3 PBF was theoretically and practically initiated in Rwanda, jointly
by African and European experts.4 In more than 15 years of existence, the actual form
of PBF in LMICs can be viewed as a cumulative process of experiences that took place
in our different local contexts across sub-Saharan Africa.
The PBF approach has been improved by several African countries, with innovations
coming from the DRC (a tool for a fair and transparent sharing of performance bonuses),
Rwanda (community verification),5 Cameroon (household visits according to protocol
and urban PBF),6 Burundi (coupling PBF with exemption of user fees),7–9 Burkina Faso
(PBF with special focus on indigents, PBF with mutual health insurance), Nigeria (coupling
PBF with demand-side financing approaches) and most recently Zimbabwe (risk-based
verification to reduce administrative costs). Notably, DRC actors have also pioneered
the application of the PBF approach to the education sector.10 To ignore all these
African intellectual and programmatic contributions is just another variation of the
mechanisms of misappropriation that is so often applied to Africa.
Research on the development of PBF at country level should follow rigorous methodologies
to identify these dynamics. For instance, using a health policy framework, such as
Kingdon’s multiple streams framework,11 and collecting primary data would have been
beneficial for Paul et al’s analysis of the conditions of emergence in our countries.2
They would have appreciated the part that the ‘problem stream’ (the crises or failures
observed in our health systems) played in this development at country level. There
were windows of opportunity (in Kingdon’s language), which helped advance the PBF
policy. Even without primary data, a greater attention to the existing scientific
literature12–14 would have usefully informed their analysis. Health policy analysis
cannot be a practice of incorporation of convenient narrative elements and ‘story
telling’: a comprehensive understanding of the complex realities of our countries
is key; the donor-government relationship is only part of the story.
In some countries, such as Zimbabwe, Burundi and Cameroon, PBF is viewed by national
actors as complementing already existing policies. In Zimbabwe, for instance, PBF
is used as a tool to implement the Government’s long-standing Results Based Management
and Results Based Budgeting approach.15 The design of PBF in Zimbabwe was protracted
because the Government placed a lot of emphasis on contextualising PBF principles
within its health system and country context. The actors developed a PBF institutionalisation
plan which laid out a road map for long-term implementation and governance arrangements
while envisaging reduction in administrative and verification costs. This milestone
saw an increase in budgetary allocation of US$5 million each year (2013–2017) to US$10.2
million with US$58.1 million complemented by the Health Development Fund (2016–2020).
The Health Development Fund was launched by the Government of Zimbabwe in partnership
with the United Nations and other development partners, built on the achievements
of two previous health sector programmes—the Health Transition Fund and Integrated
Support Program—which aimed to strengthen the health system and scale up the implementation
of high-impact health and nutrition interventions. PBF has evolved from a focus on
different vertical programmes into the Zimbabwe Health Strategy of (2016−2020) and
the UHC agenda. Integration into national processes also occurred in academia—the
University of Zimbabwe now runs an international PBF course, which is practically
designed for African contexts.16
However, we do not deny that PBF expansion benefited from the financial and technical
leadership developed by the World Bank and other global health actors.17 But PBF is
not the only strategy with such a partially exogenous origin—the Millennium Development
Goals, the Sustainable Development Goals and the UHC agenda are all initiatives designed
and promoted by external influences before they flourish in Africa. This does not
make them inappropriate.18 We agree that any exogeneity can raise problems in terms
of sustainability, but this is far from axiomatic.
Implementation challenges
The implementation of PBF, as with any other health reform strategy, is not without
its challenges; more so in some countries than others.19–23 We therefore fully endorse
the agenda of improving PBF and its implementation. When PBF evidence appears ‘mixed’,
implementation research can be helpful in understanding the intricacies of these findings.
A recent study conducted by Ogundeji et al
24 looked at how contextual and implementation factors influence the results of PBF
in Nigeria.24 The study found that within scheme variation in performance can be explained
by health worker’s understanding of PBF, effective communication between the regulator
and the provider and uncertainty in earning the incentive. We must try to understand
heterogeneity in results with the aim of improving both design and implementation.
We appreciate the recent attempts to understand the specific context that may enable
or hinder the PBF implementation and effectiveness.25 26
PBF practitioners are, for instance, well aware that verification costs are too high
in some programmes: they were directly involved in the documentation of the problem.27
Experts affiliated to the PBF CoP have set up a working group and are assisting countries
to learn from each other28 and move forward this agenda.29 Through this deliberative
process, good practices are emerging, notably, the need to gradually transition from
intensified verifications during first years of implementation to risk-based verification
mechanisms in later years. 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
research30 to seek the best possible strategy towards improving the health system.
Another critical assumption is that health facilities become dependent on financial
incentives and may cease to function if there are any delays to these payments. Although
we acknowledge that this has occurred in some instances, we find that the fact that
PBF introduces decentralisation, challenges input monopolies and gives autonomy at
the level of the health facility is often incentive enough to improve health facility
performance. For example, in Cameroon there have been regular delays in payments to
health facilities of up to 6 months at times. However, even without this regular financial
incentivisation, the results of the health facilities improved greatly; the facilities
did not stop work, implying that there are other forces that play a role in incentivising
the facilities.31
One of the major challenges mentioned in many papers that discuss PBF is the lack
of sustainability of programmes in the long run. As implementers, we have faced challenges
regarding the sustainability of PBF in some countries, particularly as it moves from
project to programme mode. Solutions to ensure that PBF transcends from a project
to a programme-based system are context bound and therefore differ from country to
country.12 However, they are similar in observing the importance of key financing
mechanisms and establishing sustainable machinery to operationalise the approach.
For example, in Zimbabwe, the coordination framework of PBF is built on existing structures
at the district and national level to promote multistakeholder collaboration of District
Health executive, local government, facility representatives and local purchasing
units from Cordaid.15
In our experience, positioning of the PBF Unit is vital to the sustainability and
government ownership of PBF and ultimately systemic change in the health sector and
beyond. In countries such as the Central African Republic (CAR), Cameroon, Burundi,
Zimbabwe and Rwanda where the PBF Unit is positioned at a level where it is able to
effectively coordinate the health sector activities, there has not been an issue of
government participation and ownership, and often there has been a full move towards
national policy for PBF. To some extent, the experience of Benin cited by Paul and
colleagues2 is an example of what not to do: that is, postpone the creation of such
a national unit and allow two projects to coexist and undermine each other.
In short, we see PBF as a flexible approach that has evolved over time. PBF programmes
are evaluated through impact and qualitative studies as well as action research, which
have led to a corpus of good practices. It is a constant evolution. For example, a
recent mid-term review of PBF in Nigeria has led to the identification of implementation
bottlenecks, once again resulting in changes to the PBF design. This transformational
mode is the name of the game.
PBF and the strengthening of health systems
As health system actors, we observe and value several important systemic effects which
are observable in the health systems dynamics, and at different levels of the system.
We will illustrate this by looking at four of those effects on health system governance.
First, the establishment of national PBF steering committees has brought together
decision-makers at the national level, technical and financial partners and various
sectoral managers. These PBF steering committees have increased the sharing of information
and strengthened the culture of decision-making based on evidence at the central level.
Almost all countries adopting PBF are moving in this direction to improve stakeholder
engagement for better information sharing on implementation.
Second, at the intermediate level: provincial/regional management teams and district
management teams are contracted to provide supervision and monitoring of implementation,
which further empowers these regulatory actors.32 By introducing district validation
committees, who play a key role in the validation of the monthly/quarterly invoices,
district-level actors regularly coordinate health activities at the local level.
Third, at the level of the healthcare provider, the introduction of tools such as
the business plan and the indices management tools has increased transparency in management
and accountability among health workers of a health facility,1 and now even among
the various stakeholders in the PBF programme (regulatory authorities, contract development
and verification agencies).
Fourth, PBF strives to bring together groups of community representatives to strengthen
collaboration between healthcare providers and surrounding communities. Through community
satisfaction surveys conducted by local community-based organisations, patients of
the facilities have a voice to give honest feedback around the quality and affordability
of service that they receive; holding the facilities accountable for the service that
they provide.9
In addition to governance, PBF contributes to improving the completeness and timeliness
of health information system data. PBF quality checklists have generated a wealth
of data on their actual nature of the services delivered to the population. Today,
with the development of DHIS2, interoperability between DHIS2 and PBF databases is
realised or under development in many countries (DRC, Central African Republic, Congo,
Côte d’Ivoire, Burundi, Nigeria). This interoperability allows alignment of PBF indicator
definitions with national health information system definitions. Criticisms on this
aspect were valid a few years ago, but not anymore. This convergence between data
systems is an example of how actors identify shortcomings, progressively improve PBF
implementation and take advantage of new opportunities such as the huge development
of information and communication technologies. Indeed, PBF can be a major accelerator
of the digitalisation of our health systems.
The systemic effects of PBF can and does reach beyond the health system. PBF is also
a proposition to change practices in the aid and public sectors.33 One of the radical
propositions put forward by PBF is that funding should directly reach health facilities
(without intermediaries), thus guaranteeing their greater control on the delivery
of services to the population. We sincerely hope that this will be the future standard,
both for aid agencies and our governments. One potential effect of this principle
is to link this funding to the achievement of measurable and verifiable specific results.
This would be a systemic change in terms of accountability for our countries (which
are often overcentralised, with weak governance), and for the aid industry (as sometimes,
an unacceptable proportion of aid return to the donor country through its implementing
agencies).
Thanks to PBF, we have been able to highlight the central role of institutional arrangements
for the improved performance of our health systems.34 35 It has put issues such as
the importance of clarifying the mission of different components of the health system
squarely on the agenda, and of better aligning incentives to those missions, through
provider payment reforms.36
PBF is not an end in itself and is bound to evolve. It has set countries on new pathways
and will allow further transformation of our health systems, such as making the purchasing
for UHC more strategic.37 Certainly, there is still a lot to document, prove and discover
with respect to the multiple system effects of PBF, but from the evidence we see emerging
at the implementation level, PBF is bringing much needed positive change to our health
systems.
Rethinking PBF
Let’s be clear: as experts, we subscribe to the agenda of updating the PBF approach.
And this revision process is already taking place in some countries, with real control
by national actors.38 As shown by different collective dynamics, particularly within
the PBF CoP, but also at the level of the research community,39 the rethinking of
PBF is already under way. For instance, rethinking is already launched on the challenge
of measuring quality of care and the exact contribution of PBF in its improvement.
Experts from diverse backgrounds, African and non-African, some working on PBF and
others with an expertise in another domain (eg, family planning) are contributing
in this area.40 But we agree that more could be done in different aspects of the approach.25
We must move faster in this critical review. The growing body of empirical studies
can help question some ‘dogmas’. We must certainly also allow more variation in terms
of designs and implementation.27 Critical review by external observers can really
be helpful for this agenda, if the intention is constructive.
We believe that a synthesis is possible, if we make a common effort to better structure
convergences and divergences. Mayaka et al showed that a consensus was possible around
the consideration of PBF as a lever for change and a complementary strategy to other
strategies, for example, those focused on improving financial access to health services
(ie, vouchers for selective free healthcare).41 42 However, this synthesis will only
be possible if we do not force actors to position themselves as ‘proponents’ or ‘opponents’
of PBF. This polarisation, actually often exogenous to our countries, slows down the
synthesis which mobilises country experts. The worst thing for our countries would
be to be left in an ‘in-between situation’ which would create uncertainty and in fact
perpetuate an eternal dependence on the development aid fads denounced by Paul and
colleagues.2
Conclusion
As implementers, we have witnessed a range of effects of PBF in our health sectors,
some challenging, and some positive as highlighted in this paper. As a global health
community, we can help PBF to continue to evolve. This is what implementation is all
about: constantly balancing, constantly adapting to new circumstances. There is no
room for complacency: our prime concern should be the strengthening of our health
systems for the greater benefit of the population. We are committed to playing an
important role both at country and at global level to continually update the PBF approach
as we learn lessons from implementation.