Performance-based financing in low income and middle-income countries: isn’t it time for a rethink?
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Date
2018
Journal Title
Journal ISSN
Volume Title
Publisher
BMJ global health
Abstract
This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient
and equitable approach to improving the performance of health systems in low-income and middle-income
countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the
potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what
was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many
contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been
raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and
perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second,
there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the
lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself
as a comprehensive approach that makes it possible to address all aspects of the health system in any context,
PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting
attention and resources from broader processes of change and necessary reforms. Too little care is given to systemwide
and long-term effects, so that PBF can actually damage health services and systems. This paper ends by
proposing entry points for alternative approaches.
Description
Keywords
middle-income countries, health sector
Citation
Paul, E., Albert, L., Bisala, B. N. S., Bodson, O., Bonnet, E., Bossyns, P., ... & Ridde, V. (2018). Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink?. BMJ global health, 3(1), e000664.10.1136/ bmjgh-2017-000664