Strengthening health system delivery and quality: Mechanisms and Effects of Performance Based Financing in the Sub-Saharan context

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Public Health and Policy

Abstract

Health care providers can be paid in a variety of ways. They can be given an annual budget for agreeing to provide a service or be paid on the basis of the size of the population covered. Payment according to achievement of specific standards or patient outcomes has been widely applied in the health sector. Such schemes are called Performance Based Financing. These schemes aim to focus health workers and their managers on specific outcomes and to change the way they behave to improve the quality of health care services and population health. Over 40 low and middle-income countries are currently implementing performance based financing schemes in the health sector. However, to date the focus of researchers and practitioners has been mainly on assessing the short term impact of performance based financing schemes on the performance targets. We understand little about how performance based financing affects health workers and the organisations they work in and how this translates into improvements in service delivery and health outcomes. We also do not know if the effects are sustained over time. The design of performance based financing schemes also varies from place to place and we have limited understanding of the factors that influence this variation nor how this affects the way performance based financing is implemented and its subsequent results. Most evaluations collect data specifically for each project, which limits the range of health outcomes that are considered and makes it difficult to compare across studies.
This research project will engage stakeholders involved in running performance based financing schemes and evaluating them in two countries: Mozambique and Zimbabwe. We will work together to clarify how performance based financing has been conceptualised and implemented in each setting. We will also identify how performance based financing is expected to affect health workers and their work environment to bring about better care, and what elements of performance based financing are most critical. We will use national level data on health system inputs to examine the effects of performance based financing on the health system over time. We will use data from household Demographic and Health Surveys to examine the effects on health outcomes and on the delivery of services that were not targeted by performance based financing. Finally we will seek to understand how performance based financing brings about changes to service delivery by identifying how and which changes in health system inputs are related to improvements in care delivery. We will also examine how the effects of performance based financing vary according to population and health facility characteristics. Performance based financing is sometimes accompanied by separate efforts to increase access to care and we will examine if this matters. Finally, we will look across the two countries to examine if the way in which the performance based financing scheme is designed affects the results.
The project will support knowledge sharing and learning across institutions in the United Kingdom, Mozambique, Zimbabwe and the wider Sub-Saharan African region.

Technical Summary

This project aims to understand to what extent incentive payments to health care providers (performance based financing) contribute to improved service delivery (increased coverage of quality health services) and health and behavioural outcomes through health system strengthening, or enhancements to health system inputs in Sub-Saharan African settings. Specific attention will be given to understanding how PBF works in low and middle income countries (LMICs) over time, by extending evaluations of PBF schemes in Mozambique and Zimbabwe, and exploring the contextual factors that shape this.
The research has six specific objectives.
1. To map key differences in PBF scheme design and context in each of the two countries and develop a theory of change for how PBF affects service delivery and health outcomes through changes to health system inputs;
2. To evaluate the short and longer term impact of PBF on health system inputs in each of the countries.
3. To evaluate the short and longer term impact of PBF on service delivery and health outcomes in each of the two countries.
4. To identify the specific causal pathway(s) through which performance based financing results in service delivery and health outcome effects;
5. To evaluate whether PBF effects on health system inputs, service delivery and health outcomes differ according to: scheme design; contextual factors; population characteristics; concurrent interventions, and the extent to which the design process projected and integrated measures to manage effects.
6. To develop a framework of conceptual links between PBF design, its effects on the health system, and ultimately on health outcomes that can be adapted to other countries as well as inform regional and global policy.

Planned Impact

This research will benefit three main groups: a) national and regional stakeholders; b) international stakeholders financing and supporting the implementation and/or evaluation of performance based financing in LMICs; and c) the academic community.

a) National and regional stakeholders
The study will be of interest to policy makers implementing performance based financing schemes in low and middle income countries (LMICs) as it will provide recommendations to optimise the design of performance based financing to strengthen health systems and achieve sustainable service delivery and health impact and minimise unintended effects. This project will also shed light on how context shapes the design of performance based financing programmes and their subsequent implementation, which will be useful in determining where performance based financing can be most effectively implemented. The findings will be of direct relevance to the study countries to implementers and funders, as well as to those managing and analysing secondary data (Health Management Information Systems officers at the Ministry of Health, and national statistics offices). The study will also be of interest to countries in the region scaling up PBF (e.g. Tanzania) and introducing PBF (e.g. Kenya). The study will also be of interest to non-governmental organisations and civil society groups in each country who are keen to hold systems to account via independent evidence and may be involved in programme evaluation.

b) International stakeholders
The research will benefit international agencies currently financing performance-based financing schemes in LMICs (including the United Kingdom, Department for International Development, the World Bank, USAID, The Norwegian Ministry of Foreign Affairs, and the Global Fund), as well as those supporting implementation (Cordaid, Clinton Health Access Initiative; Elizabeth Glaser Paediatric AIDS Foundation (EGPAF). Specifically, the research will add to the limited evidence base on the effects of PBF on health systems, and how these schemes work, which will inform more efficient investment decisions, and contribute to discussions on appropriate scheme design in different settings. The use of innovative methods will also be of interest to those doin evaluations and may be added to the World Bank PBF Impact Evaluation Toolkit and integrated into other evaluations that are World Bank supported.

c) The academic community
The study will inform discussions on evaluation of complex health systems interventions and provide an empirical basis on which others can draw, as described under academic beneficiaries. The project will also benefit those directly involved in this research collaboration, by fostering multi-disciplinary collaboration and partnership between three Universities in the United Kingdom with experience in evaluating performance based financing schemes in LMICs and in the UK. The project will facilitate knowledge sharing and learning among partners. This will facilitate greater capacity to support government decision making in relation to health system strengthening and enable ongoing monitoring and evaluation of health systems interventions using existing secondary data.

Publications

10 25 50
 
Description In Zimbabwe, additional funding provided through the RBF programme, as subsidy payments, benefited facilities in wealthier and less remote areas, and facilities which were generally better resourced and attended before the start of RBF (more staff, higher case load). The fact that distributional inequities did not improve over time suggests that disadvantaged facilities were not able to catch up, with RBF potentially enhancing pre-existing inequities across providers.
Institutional deliveries increased by 7 percentage points as a result of RBF. This increase was observed in primary care facilities. There was no positive effect of RBF on any of the other incentivized services. C-section rates reduced by 3 percentage points. This may be due to the fact that increased delivery uptake was at primary care facilities, which are not incentivized or able to offer c-section. There is also qualitative evidence that providers were more reluctant to refer to a higher level facility for c-section in order to benefit from the RBF subsidy. Under five mortality reduced by 2 percentage points when exposure was defined from the time of conception. There were no effects on other health outcome measures. Reductions in infant mortality and neonatal mortality were noted when exposure was defined from the time of delivery suggesting that services at or around the time of delivery may have been most effective. While the mortality reduction is encouraging, it is unclear from our analysis why this reduction occurred, as no improvements in service use were noted apart from institutional deliveries. The programme was generally pro-poor. The Positive effects of RBF were only observed initially but were not sustained over time.

In Mozambique, the PBF scheme increased HIV testing and knowledge about prevention of HIV mother-to-child transmission, particularly for less educated women, increased antenatal care visits for more educated women and, in Gaza only, increased the rate of institutional deliveries. Effects beyond the immediate catchment area of PBF facilities indicate outreach to non-targeted peripheral facilities. Structural supply factors and demand side constraints limited the effectiveness of facilities efforts to increase service use.

From the realist review, although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P.
Exploitation Route The findings from this work can be used to shape the future design of the P4P programme for maximum impact in LMIC.
Sectors Healthcare

 
Description The dissemination meetings in Zimbabwe raised issues that are being taken up in other policy forums and in the RBF programme steering committee on equity in health outcomes and distribution of subsidies. The meeting has resulted in stakeholders applying and using a theory of change framework in strategic performance review, and encouraging a review of options for addressing identified design gaps on demand side measures.
First Year Of Impact 2020
Sector Healthcare
 
Description Influence on Programme Implementation Manual of RBF
Geographic Reach National 
Policy Influence Type Participation in a national consultation
Impact The PEMBA results are feeding into a review and updating of the programme manual for the results based financing scheme, particularly in relation to equity targets and how to complement demand side gaps from the programme with other initiatives. The findings have helped to show the value of using a theory of change framework in strategic planning and have strengthened collaborative relations across stakeholders on evidence based policy design.
 
Description TARSC has been a member of the advisory working groups on the national financing strategy and on the national health strategy 2020-2025 and more recently on the working group on research and knowledge for the National Health Strategy.
Geographic Reach Africa 
Policy Influence Type Participation in a advisory committee
 
Description Global Impact Accelerator Account (GIAA) grant Workshop on mechanisms and health system effects of Performance Based Financing (PBF) schemes in the public health sector in Mozambique, Maputo 11th to 15th March 2019
Amount £29,329 (GBP)
Organisation United Kingdom Research and Innovation 
Department Global Challenges Research Fund
Sector Public
Country United Kingdom
Start 03/2019 
End 03/2019
 
Description UKRI Covid-19 Grant Extension Allocation
Amount £17,835 (GBP)
Organisation United Kingdom Research and Innovation 
Sector Public
Country United Kingdom
Start 01/2021 
End 06/2021
 
Title Policy document review guidelines 
Description Guidelines and data extraction forms for the policy document review. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact This tool guided the policy document review in Mozambique and Zimbabwe. 
 
Title Qualitative interview guide 
Description In-depth interview guide for qualitative interviews with key stakeholders in Zimbabwe. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact This tool was used to gather qualitative data in relation to the project. 
 
Title Data on bonus payments for Zimbabwe 
Description We have compiled facility level data on PBF bonus payments received over time. We have combined this with information about the health facility. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact We are doing analysis of the factors explaining variation in bonus payments across facilities in Zimbabwe. 
 
Title Data on service use and outcomes for Mozambique 
Description We have combined 2 rounds of DHS survey data for Mozambique with information about household exposure to PBF. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact The dataset has been analysed and a paper drafted and a conference presentation given. 
 
Title Dataset for Zimbabwe 
Description We have linked relevant variables from the following datasets and created a new dataset for our analysis of the effects of PBF and contextual moderators in Zimbabwe:Zimbabwe DHS -Demographic and Health Survey data from: 2015 and 2011 and Health facility data including name, level of care, ownership and geo-coordinates and data on PBF performance payments to facilities over time. 
Type Of Material Database/Collection of data 
Year Produced 2018 
Provided To Others? No  
Impact The analysis is now complete and a paper has been drafted. 
 
Title Household data on out of pocket payments - Zimbabwe 
Description We have linked two rounds of PICES data, household survey data on health expenditures and income, together with information on whether or not households were exposed to PBF. 
Type Of Material Database/Collection of data 
Year Produced 2020 
Provided To Others? No  
Impact This dataset will be used to analyse the effect of PBF on out of pocket payments and the affordability of health care. 
 
Description Applying the WHO building blocks to study the global health system in an academic paper 
Organisation University of Leeds
Country United Kingdom 
Sector Academic/University 
PI Contribution Jo Borghi bought her health systems expertise and contributed insights to the financing, medical commodities and human resources building blocks.
Collaborator Contribution Garrett Brown is an expert on global health governance and contributing insights into the governance, information systems and service delivery building blocks.
Impact We are working on a paper for a special issue in the journal Disasters. We are also working together organising a webinar on this topic.
Start Year 2020
 
Description Partnership with researchers at the Queen Margaret University 
Organisation Queen Margaret University
Country United Kingdom 
Sector Academic/University 
PI Contribution Sophie Witter was leading a systematic review as we were starting a realist review of P4P. We agreed to liaise with each other regarding which articles were included in the review. Since completing the review Garrett Brown (Leeds), Neha Singh and Jo Borghi have been in discussion with Sophie about one or two joint publications which would reflect on the learning across the reviews and the methodological differences between them.
Collaborator Contribution Garrett Brown initiated and helped sustain the partnership.
Impact Not yet, but we hope to jointly write two academic papers.
Start Year 2018
 
Description Research project partnership 
Organisation National Institute of Health Research
Country Zimbabwe 
Sector Public 
PI Contribution My team have led the development of a theory of change for the project, including the development of a protocol for a realist review, eliciting contributions from all partners. We have guided and supported other partners (Uni of Leeds, Sheffield, TARSC, Manchester) on the development of theories of change for Zimbabwe and Mozambique. We worked with University of Manchester and National Institute of Health Research and Institute of Health on defining quantitative data needs for the project. We have worked with the University of Manchester and Bath on quantitative analyses for the project. We have reviewed and provided input into conference abstracts submitted by the partners relating to the project. We have also reviewed papers drafted by partners.
Collaborator Contribution University of Sheffield/Leeds provided training of staff at TARSC and National Institute of Health on qualitative methods,qualitative interviews and qualitative analysis, developing a guidance document for a policy document review. University of Manchester have mentored staff at National Institute of Health and National Institute of Health Research on quantitative methods. University of Manchester and Bath colleagues have collaborated on a paper and quantitative analyses of DHS data. NIHR and TARSC have worked together on gathering data for the project and organising dissemination activities and workshops.
Impact This collaboration involves political scientists, public health experts, epidemiologists and health economists.
Start Year 2017
 
Description Research project partnership 
Organisation National Institute of Health, Mozambique
Country Mozambique 
Sector Public 
PI Contribution My team have led the development of a theory of change for the project, including the development of a protocol for a realist review, eliciting contributions from all partners. We have guided and supported other partners (Uni of Leeds, Sheffield, TARSC, Manchester) on the development of theories of change for Zimbabwe and Mozambique. We worked with University of Manchester and National Institute of Health Research and Institute of Health on defining quantitative data needs for the project. We have worked with the University of Manchester and Bath on quantitative analyses for the project. We have reviewed and provided input into conference abstracts submitted by the partners relating to the project. We have also reviewed papers drafted by partners.
Collaborator Contribution University of Sheffield/Leeds provided training of staff at TARSC and National Institute of Health on qualitative methods,qualitative interviews and qualitative analysis, developing a guidance document for a policy document review. University of Manchester have mentored staff at National Institute of Health and National Institute of Health Research on quantitative methods. University of Manchester and Bath colleagues have collaborated on a paper and quantitative analyses of DHS data. NIHR and TARSC have worked together on gathering data for the project and organising dissemination activities and workshops.
Impact This collaboration involves political scientists, public health experts, epidemiologists and health economists.
Start Year 2017
 
Description Research project partnership 
Organisation Training and Research Support Centre
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution My team have led the development of a theory of change for the project, including the development of a protocol for a realist review, eliciting contributions from all partners. We have guided and supported other partners (Uni of Leeds, Sheffield, TARSC, Manchester) on the development of theories of change for Zimbabwe and Mozambique. We worked with University of Manchester and National Institute of Health Research and Institute of Health on defining quantitative data needs for the project. We have worked with the University of Manchester and Bath on quantitative analyses for the project. We have reviewed and provided input into conference abstracts submitted by the partners relating to the project. We have also reviewed papers drafted by partners.
Collaborator Contribution University of Sheffield/Leeds provided training of staff at TARSC and National Institute of Health on qualitative methods,qualitative interviews and qualitative analysis, developing a guidance document for a policy document review. University of Manchester have mentored staff at National Institute of Health and National Institute of Health Research on quantitative methods. University of Manchester and Bath colleagues have collaborated on a paper and quantitative analyses of DHS data. NIHR and TARSC have worked together on gathering data for the project and organising dissemination activities and workshops.
Impact This collaboration involves political scientists, public health experts, epidemiologists and health economists.
Start Year 2017
 
Description Research project partnership 
Organisation University of Bath
Department Department of Economics
Country United Kingdom 
Sector Academic/University 
PI Contribution My team have led the development of a theory of change for the project, including the development of a protocol for a realist review, eliciting contributions from all partners. We have guided and supported other partners (Uni of Leeds, Sheffield, TARSC, Manchester) on the development of theories of change for Zimbabwe and Mozambique. We worked with University of Manchester and National Institute of Health Research and Institute of Health on defining quantitative data needs for the project. We have worked with the University of Manchester and Bath on quantitative analyses for the project. We have reviewed and provided input into conference abstracts submitted by the partners relating to the project. We have also reviewed papers drafted by partners.
Collaborator Contribution University of Sheffield/Leeds provided training of staff at TARSC and National Institute of Health on qualitative methods,qualitative interviews and qualitative analysis, developing a guidance document for a policy document review. University of Manchester have mentored staff at National Institute of Health and National Institute of Health Research on quantitative methods. University of Manchester and Bath colleagues have collaborated on a paper and quantitative analyses of DHS data. NIHR and TARSC have worked together on gathering data for the project and organising dissemination activities and workshops.
Impact This collaboration involves political scientists, public health experts, epidemiologists and health economists.
Start Year 2017
 
Description Research project partnership 
Organisation University of Leeds
Department School of Politics and International Studies
Country United Kingdom 
Sector Academic/University 
PI Contribution My team have led the development of a theory of change for the project, including the development of a protocol for a realist review, eliciting contributions from all partners. We have guided and supported other partners (Uni of Leeds, Sheffield, TARSC, Manchester) on the development of theories of change for Zimbabwe and Mozambique. We worked with University of Manchester and National Institute of Health Research and Institute of Health on defining quantitative data needs for the project. We have worked with the University of Manchester and Bath on quantitative analyses for the project. We have reviewed and provided input into conference abstracts submitted by the partners relating to the project. We have also reviewed papers drafted by partners.
Collaborator Contribution University of Sheffield/Leeds provided training of staff at TARSC and National Institute of Health on qualitative methods,qualitative interviews and qualitative analysis, developing a guidance document for a policy document review. University of Manchester have mentored staff at National Institute of Health and National Institute of Health Research on quantitative methods. University of Manchester and Bath colleagues have collaborated on a paper and quantitative analyses of DHS data. NIHR and TARSC have worked together on gathering data for the project and organising dissemination activities and workshops.
Impact This collaboration involves political scientists, public health experts, epidemiologists and health economists.
Start Year 2017
 
Description Research project partnership 
Organisation University of Manchester
Country United Kingdom 
Sector Academic/University 
PI Contribution My team have led the development of a theory of change for the project, including the development of a protocol for a realist review, eliciting contributions from all partners. We have guided and supported other partners (Uni of Leeds, Sheffield, TARSC, Manchester) on the development of theories of change for Zimbabwe and Mozambique. We worked with University of Manchester and National Institute of Health Research and Institute of Health on defining quantitative data needs for the project. We have worked with the University of Manchester and Bath on quantitative analyses for the project. We have reviewed and provided input into conference abstracts submitted by the partners relating to the project. We have also reviewed papers drafted by partners.
Collaborator Contribution University of Sheffield/Leeds provided training of staff at TARSC and National Institute of Health on qualitative methods,qualitative interviews and qualitative analysis, developing a guidance document for a policy document review. University of Manchester have mentored staff at National Institute of Health and National Institute of Health Research on quantitative methods. University of Manchester and Bath colleagues have collaborated on a paper and quantitative analyses of DHS data. NIHR and TARSC have worked together on gathering data for the project and organising dissemination activities and workshops.
Impact This collaboration involves political scientists, public health experts, epidemiologists and health economists.
Start Year 2017
 
Description Research project partnership 
Organisation University of Sheffield
Country United Kingdom 
Sector Academic/University 
PI Contribution My team have led the development of a theory of change for the project, including the development of a protocol for a realist review, eliciting contributions from all partners. We have guided and supported other partners (Uni of Leeds, Sheffield, TARSC, Manchester) on the development of theories of change for Zimbabwe and Mozambique. We worked with University of Manchester and National Institute of Health Research and Institute of Health on defining quantitative data needs for the project. We have worked with the University of Manchester and Bath on quantitative analyses for the project. We have reviewed and provided input into conference abstracts submitted by the partners relating to the project. We have also reviewed papers drafted by partners.
Collaborator Contribution University of Sheffield/Leeds provided training of staff at TARSC and National Institute of Health on qualitative methods,qualitative interviews and qualitative analysis, developing a guidance document for a policy document review. University of Manchester have mentored staff at National Institute of Health and National Institute of Health Research on quantitative methods. University of Manchester and Bath colleagues have collaborated on a paper and quantitative analyses of DHS data. NIHR and TARSC have worked together on gathering data for the project and organising dissemination activities and workshops.
Impact This collaboration involves political scientists, public health experts, epidemiologists and health economists.
Start Year 2017
 
Description Meeting with Crown Agents representative from Zimbabwe to discuss study findings 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Supporters
Results and Impact We were approached by Andrew Keith from Crown Agents regarding the publication by Fichera et al. 2021 based on the PEMBA work in Zimbabwe. We held an online meeting to discuss the findings in detail and their policy implications for Crown Agents and Zimbabwe. We shared further information via email and as a direct result of this engagement, developed a proposal for further dissemination and engagement work in Zimbabwe under the Medical Research Foundation Changing Policy and Practice grant.
Year(s) Of Engagement Activity 2021
 
Description PEMBA RBF DISSEMINATION AND VALIDATION ZOOM MEETING 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The meeting aimed to share the research findings with policy, academic and implementers to:
i. hear and discuss the quantitative findings from the study
ii. hear and discuss the findings from the updated policy review and Theory of Change based
findings.
iii. discuss the perceived critical drivers of positive and negative outcomes and make
conclusions and recommendations in relation to areas for further improvement.
Year(s) Of Engagement Activity 2020
 
Description PEMBA RBF DISSEMINATION AND VALIDATION ZOOM MEETING 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact This was a second dissemination event targeting those who could not attend the first event. The aims were the same.
Year(s) Of Engagement Activity 2020
 
Description PEMBA Theory of change workshop in Mozambique 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact This was a theory of change workshop designed to develop a theory of change for performance based financing in Mozambique.
Year(s) Of Engagement Activity 2019
 
Description Theory of change workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact This workshop was planned to disseminate findings from our policy review related to performance based financing (PBF) in Zimbabwe, and to introduce the research team to Zimbabwe policy makers and other stakeholders including donors and health care managers. The workshop then involved a series of small group discussed designed to refine and finalise a theory of change for the PBF programme in Zimbabwe, and agree on priority indicators and data sources for use in our analysis of quantitative data. The meeting was opened by the Permanent Secretary of the Ministry of Health. The workshop raised issues relevant to the past and proposed future format of the PBF in Zimbabwe and assisted to validate policy and practice findings from the desk review and interviews.
Year(s) Of Engagement Activity 2018