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

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.

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.

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.