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Performance-based financing as a
way to build strategic purchasing in
FCAS: potential and pitfalls
Professor Sophie Witter
IGHD, Queen Margaret University &
ReBUILD
What is PBF?
• Many different forms and terminology within the RBF school
• PBF aims to improve health services by providing payments to service providers
(usually facilities, but often with a portion paid to individual staff) based on the verified
quantity of outputs produced, modified by quality indicators.
– In many cases there is a division of functions between regulation, purchasing,
fund-holding, and service delivery
• It has expanded rapidly across low and middle countries, over the last decade, and
especially in FCAS settings, but relatively little work on how context affects PBF
– Conflicting arguments: some argue that PBF is unlikely to be effective in fragile
settings while others point out that precisely in situations of weak institutions
there is more potential for PBF to re-align relationships and improve accountability
PBF in sub-Saharan Africa
Source: Fritsche et al., 2014
Patterns of PBF adoption in FCAS
– 23 (43%) out of 53 FCAS countries have/had at least one PBF programme
– 19 (56%) out of 34 PBF programmes in SSA are implemented in FCAS
Afghanistan Comoros Guinea Nigeria
Burundi Congo (Republic) Guinea Bissau Rwanda
Cambodia Cote d’Ivoire Haiti Sierra Leone
Cameroon Djibouti Lao PDR Tajikistan
Central African
Republic
DR Congo Liberia Zimbabwe
Chad The Gambia Mali
Bertone, M., Falisse, J-B., Russo, G., Witter, S. (2018) Context matters
(but how and why?) A hypothesis-led literature review of performance
based financing in fragile and conflict-affected health systems. PLOS
ONE, 13(4): e0195301.
PBF adoption over time
– All PBF programmes in SSA implemented before 2006 are in FCAS settings
(Rwanda, Burundi, DRC, Cameroon, Cote d’Ivoire)
– The first countries to have scaled-up PBF nationwide are also FCAS: Rwanda
(2008), Burundi (2010) and Sierra Leone (2011)
– Appears to have been a successor to PBC model supported earlier by donors in
FCAS (Cambodia, Haiti, Afghanistan and Liberia)
– Often multiple schemes – e.g. DRC (7) and Burundi (6) over past ten years
Some of the PBF controversies
1. Drivers
Adaptation to local needs or donor-
driven?
2. Fit to context
Flexible or copy/paste?
3. Implementation
Plan versus reality
4. Health system impact
HSS or vertical distraction/adding to
fragmentation?
5. Equity
Enhancing or undermining?
6. Efficiency
Increasing efficiency or costly
distraction?
7. Quality of care
Promoted or neglected?
8. Effectiveness
Especially in relation to health outcomes
9. Mechanisms of change
Money, incentives, clearer roles, local
autonomy, skills building, feedback on
performance – all or which of the above?
10. Spillover effects
System reformer versus gaming,
demotivation etc.
11. Tensions in the model
Autonomy versus control
12. Sustainability
Institutionalising capacity and funds
Overall questions for panel and
audience
In FCAS settings:
1. Has/can PBF improve the accountability and
functioning of purchasers?
2. Has/can PBF improve the engagement with and
responsiveness to populations of the purchasing
system?
3. Has/can PBF improve the effectiveness of
provider payments?
How? In which contexts? With which designs and at
what cost?
Our panel
1. Maria Bertone, ReBUILD – reflections on adoption of PBF in FCAS and its impact
on relationships in the health system
2. Eelco Jacobs, KIT – lessons from adaptation of PBF in humanitarian settings
3. Manjiri Bhawalkar, Global Fund – funder’s perspective on PBF and evidence
needs
4. Jos Dusseljee, Cordaid – view from an implementer – designing and
implementing PBF in FCAS settings
5. Gwati Gwati, Ministry of Health, Zimbabwe – reflections from the MoH on
RBF/PBF, its past contribution and future potential
6. Isidore Sieleunou, PBF Community of Practice member and researcher -
reflections on PBF research and its contribution to practice
rebuildconsortium.com
@rebuildrpc #HSRFCAS
Visit us on Stand 21 in the Exhibition Hall

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Performance based financing as a way to build strategic purchasing in fragile and conflict affected settings - potential and pitfalls

  • 1. Performance-based financing as a way to build strategic purchasing in FCAS: potential and pitfalls Professor Sophie Witter IGHD, Queen Margaret University & ReBUILD
  • 2. What is PBF? • Many different forms and terminology within the RBF school • PBF aims to improve health services by providing payments to service providers (usually facilities, but often with a portion paid to individual staff) based on the verified quantity of outputs produced, modified by quality indicators. – In many cases there is a division of functions between regulation, purchasing, fund-holding, and service delivery • It has expanded rapidly across low and middle countries, over the last decade, and especially in FCAS settings, but relatively little work on how context affects PBF – Conflicting arguments: some argue that PBF is unlikely to be effective in fragile settings while others point out that precisely in situations of weak institutions there is more potential for PBF to re-align relationships and improve accountability
  • 3. PBF in sub-Saharan Africa Source: Fritsche et al., 2014
  • 4. Patterns of PBF adoption in FCAS – 23 (43%) out of 53 FCAS countries have/had at least one PBF programme – 19 (56%) out of 34 PBF programmes in SSA are implemented in FCAS Afghanistan Comoros Guinea Nigeria Burundi Congo (Republic) Guinea Bissau Rwanda Cambodia Cote d’Ivoire Haiti Sierra Leone Cameroon Djibouti Lao PDR Tajikistan Central African Republic DR Congo Liberia Zimbabwe Chad The Gambia Mali Bertone, M., Falisse, J-B., Russo, G., Witter, S. (2018) Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems. PLOS ONE, 13(4): e0195301.
  • 5. PBF adoption over time – All PBF programmes in SSA implemented before 2006 are in FCAS settings (Rwanda, Burundi, DRC, Cameroon, Cote d’Ivoire) – The first countries to have scaled-up PBF nationwide are also FCAS: Rwanda (2008), Burundi (2010) and Sierra Leone (2011) – Appears to have been a successor to PBC model supported earlier by donors in FCAS (Cambodia, Haiti, Afghanistan and Liberia) – Often multiple schemes – e.g. DRC (7) and Burundi (6) over past ten years
  • 6. Some of the PBF controversies 1. Drivers Adaptation to local needs or donor- driven? 2. Fit to context Flexible or copy/paste? 3. Implementation Plan versus reality 4. Health system impact HSS or vertical distraction/adding to fragmentation? 5. Equity Enhancing or undermining? 6. Efficiency Increasing efficiency or costly distraction? 7. Quality of care Promoted or neglected? 8. Effectiveness Especially in relation to health outcomes 9. Mechanisms of change Money, incentives, clearer roles, local autonomy, skills building, feedback on performance – all or which of the above? 10. Spillover effects System reformer versus gaming, demotivation etc. 11. Tensions in the model Autonomy versus control 12. Sustainability Institutionalising capacity and funds
  • 7. Overall questions for panel and audience In FCAS settings: 1. Has/can PBF improve the accountability and functioning of purchasers? 2. Has/can PBF improve the engagement with and responsiveness to populations of the purchasing system? 3. Has/can PBF improve the effectiveness of provider payments? How? In which contexts? With which designs and at what cost?
  • 8. Our panel 1. Maria Bertone, ReBUILD – reflections on adoption of PBF in FCAS and its impact on relationships in the health system 2. Eelco Jacobs, KIT – lessons from adaptation of PBF in humanitarian settings 3. Manjiri Bhawalkar, Global Fund – funder’s perspective on PBF and evidence needs 4. Jos Dusseljee, Cordaid – view from an implementer – designing and implementing PBF in FCAS settings 5. Gwati Gwati, Ministry of Health, Zimbabwe – reflections from the MoH on RBF/PBF, its past contribution and future potential 6. Isidore Sieleunou, PBF Community of Practice member and researcher - reflections on PBF research and its contribution to practice
  • 9. rebuildconsortium.com @rebuildrpc #HSRFCAS Visit us on Stand 21 in the Exhibition Hall