Performance-based Financing in Africa: Time to Test Measures for Equity

Abstract

Over the past 15 years, hundreds of millions of dollars have been invested in reforms founded on performance-based financing (PBF) in low- and middle-income countries. While evidence on its effectiveness and efficiency is still controversial, there appears to be an emerging consensus that equity has not been adequately considered. In this article, we show how PBF-type interventions in Africa have not sufficiently taken into account equity of access to care for the worst-off and their financial protection. In reviewing the history of health reforms in Africa, we show that this omission is nothing new. We suggest that strategic purchasing and PBF-type actions would benefit from being implemented in ways that promote equity and the financial protection of populations in Africa. Without such a reorientation of reforms, it will be impossible to achieve universal health coverage by 2030.

Keywords

equity Africa performance-based financing health reforms strategic purchasing universal health coverage

A new journal, Health Systems & Reform, has published a special issue on a strategy that has recently spread in Africa: performance-based financing (PBF). In health care, results-based financing (RBF) is defined as “an instrument that links financing to predetermined results, with payment made only upon verification that the agreed-upon results have actually been delivered.”¹ RBF may produce changes on the supply side (i.e., provision of health care services) or the demand side of health care delivery. PBF is a form of RBF that mainly addresses the supply side: for a selection of services, if health care providers perform well, they receive output-based payments at the individual and collective level on top of all or some of their regular input-based salaries and budgets.² PBF promoters argue that it is not just a provider payment mechanism – as opposed to input-based financing (budget), fee-for-service, or case-based payments for instance – but that it can catalyze comprehensive reforms and help address structural problems of public health services.¹ PBF is even intended as a reform attempt at the global scale, driven largely by funding agencies.^3,49 In this article, we do not question the choice of PBF as a financing mechanism, as an alternative to other financing methods, or as a catalyst for reforms, nor do we question the ideology beyond its introduction – see a recent paper 3 and some responses among others^4,5 for an idea of the debates over the question in low- and middle-income countries (LMICs) – but we take it for granted and focus on equity considerations in PBF programs.

Indeed, in the recent Health Systems & Reform special issue, several experts from the World Health Organization (WHO) explain that PBF has been in place for more than 15 years in LMICs.⁴ Importantly, they entrench PBF in the discourse of “strategic purchasing.” On the website of WHO, strategic purchasing is defined as follows: “active, evidence-based engagement in defining the service-mix and volume, and selecting the provider-mix in order to maximize societal objectives.”⁵ Building from this, the authors remind us that this reform centered on service provision and provider remuneration mechanisms must not disregard the importance of reinforcing health systems as a whole. However, this article does not mention of health equity. Yet, according to WHO’s 2010 World Health Report, equity (both vertical and horizontal) is a core principle of health systems and their performance.⁶ As such, health system strengthening⁷ and debates on how to achieve universal health coverage (UHC) cannot afford to ignore this issue of equity. Although the WHO 2012 action plan on health systems financing to promote UHC did discuss the issue of equity at length,⁸ there appears to be a certain path dependency of the neglect of equity in health system reforms over the past 30 years, especially in Africa.^8,9 The absence of explicit consideration for equity in that paper is an indication of the logical continuation of the history of reforms that have been largely proposed and funded by global health actors from the North and, often, accepted by authorities in the South.

A Long History of Disregard for Equity in Reforms

Our objective here is to underscore that history appears to repeat itself. Equity issues (like those related to health system strengthening) are relegated to the background, while global health actors focus on attempts to demonstrate effectiveness of interventions. Many readers will recall that, when the WHO and UNICEF persuaded countries to implement user fees widely with the Bamako Initiative in the late 1980s, the worst-off were forgotten in practice, even though measures had been planned for them.¹⁰ In Burkina Faso, for example, both the implementers and decision makers clearly admitted that they had shelved the issue of access for the worst-off, claiming the matter was too complex.^11,12 It took more than 15 years and 25 years for UNICEF and World Bank officials, respectively, to acknowledge they had neglected the equity issue.^13–15 Similar failures in addressing equity were later observed with mutual health insurance programs in the 1990s¹⁶ and sometimes, although not always,^11,17 with public user-fees exemption policies in the 2000s. Those exemption policies were seen as an opportunity to strengthen health systems,¹⁸ which is precisely what some people believe PBF should offer today.¹⁹

Performance-based Financing’s Neglect of Equity

As World Bank experts have pointed out, “another concern about P4P [pay for performance] schemes is equity [. . .] One of the concerns about paying for performance is that it could [. . .] increase inequities in the health system.”²⁰ In 2014, the World Bank published a guide to support countries in applying PBF.²¹ While this guide includes a chapter on equity, it nevertheless provides little evidence to support the effectiveness of the recommended actions to foster access to care by the worst-off. However, like the 2012 WHO action plan on health systems financing to promote UHC, the World Bank guide highlights the importance of evaluating and monitoring equity issues when implementing PBF, which in practice proves difficult to implement and has not sufficiently been done. An analysis of several PBF implementation manuals suggests PBF is not well-adapted to prevent health inequities.²² Yet, as of 2017, SINA Health’s PBF manual does mention 6 core equity instruments, targeting either health facilities, health staff, or poor populations:

“subsidize positive externalities and public goods” (i.e., compensations for providing health care services with positive externalities because they address public health issues, such as tuberculosis and immunization)

incentivizing suppliers to modulate the price of curative tariffs for the population

“implement geographic equity bonus” (i.e., in order to motivate health professionals to work in rural and remote regions)

“apply the provider equity bonus” (i.e., for health centers located in isolated areas)

“exempt a proportion of vulnerable people up to 5% to 20% of all fee-paying patients”

“target 50% or 100% of a population for exemption in case of natural or humanitarian emergencies”¹⁸

There is a need for further research on the use of these instruments in PBF programs: their implementation and effectiveness has not sufficiently been investigated.

Indeed, until recently, only equity bonuses (instruments #3 and #4), i.e., purchasing services at different prices depending on the isolation of health centers or regions, were taken into account by PBF projects.²³ A 2017 review examines whether 32 PBF programs in 28 LMICs included equity bonuses within their PBF quality evaluation. Based on the documents included in this review, its authors conclude that only 5 countries (i.e., Benin, Burkina Faso, Cameroon, Lesotho, and Mozambique) out of 23 incorporated equity bonuses.²⁴ On the contrary, equity of access for the poorest patients – those for whom we are all engaged if we are concerned about the issue of the right to health and universal care^25,26 – has been neglected in many places where PBF was tested. The hundreds of millions of dollars invested over the past 15 years in PBF pilot schemes in LMICs²⁷ could have been used to help strengthen equity in a more systematic fashion.

The most emblematic case of lack of consideration for equity is certainly Rwanda. In the early days of PBF expansion across Africa, Rwanda was considered exemplary, but today, the most recent data on population use of health services suggest it is neither very effective for children²⁸ nor equitable.^29,30 One solution that has been advanced to improve equity in health services use – by reaching out to people who never or very rarely use health services despite having serious needs – is to reinforce community health activities,³¹ which could include implementing PBF for community health workers. Studies are under way to determine whether community results-based financing (or “cRBF”), which includes PBF for community health workers, has helped to improve equity, but one study conducted in several countries has concluded that, currently, “little rigourous evidence of the effects of cRBF exists.”³² Another study reached the same conclusion regarding the absence of equity in mutual health insurance programs in Rwanda.³³ Other authors concluded that, in Rwanda, “PBF is not inherently pro-poor.”²⁹ This implicitly calls for specific actions in this area to advance toward UHC,²⁶ which do not appear to have been undertaken in most countries.

To our knowledge, on the African continent, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, the Republic of Congo, and Senegal have engaged in PBF-type reforms with specific measures targeting the worst-off.³⁴ In the Republic of the Congo, a recent evaluation of the pilot project funded by the World Bank shows that the curative consultations for the poor were purchased for US$1, as opposed to US$0.40 for the non-poor. However, the research does not give any indication of the effects of this purchase at different prices for the poor, and as for the other indicators, impacts are presented as a whole without consideration for equity.³⁵ In Benin, PBF was introduced in 2012 under 2 models supported by different programs, but specific measures aimed at improving equity took more time to be implemented (geographic equity bonuses in 2014; large-scale active targeting process of the poorest in 2017). Due notably to insufficient effects of PBF on the use of health services,³⁶ most donor funding ended in 2017, with no domestic plan to continue financing PBF. In Burkina Faso, at least 100 000 people have received a user-fees exemption card through a PBF program financed by the World Bank (with about 7 times larger bonuses paid for their consultations). The population welcomed the initiative, as did health workers, although some of the latter are worried about the quality and delays of implementation and delayed reimbursements.^37,38,50 The impact evaluation of this promising approach is not yet available. In Burundi, PBF was added on to the user-fees exemption policy. While the process looks promising,39 results regarding equity are not yet available. The payment of larger bonuses for indigents, as planned in one of the 2 programs, was stymied by major implementation problems. In Central African Republic, a 2014 report by Cordaid has shown how, as per equity instrument #6 (see above), increasing subsidies in health centers enabled providers to offer free health care to selected populations (the most vulnerable, pregnant women, and children under 5 years old) affected by a severe political crisis.⁴⁰ However, the results of this intervention are presented in a descriptive manner, and a more rigorous evaluation is needed. In Cameroon, the trial of one PBF model implemented in 6 Catholic health centers in the far north of the country was a failure, and “poor and vulnerable people were missed.”⁴¹ Recently, the World Bank’s impact evaluation of PBF implementation in 26 districts has not addressed the distribution of benefits from an equity perspective, and access to health care for the poorest is not addressed.⁴² A recent qualitative research on this PBF intervention show that "offering higher reimbursements for the care of the very poor does not seem to be enough to effectively reach disadvantaged populations and increase care among the very poor...⁴³ Lastly, in Senegal, the PBF program was supplemented by a pilot project of conditional cash transfers for the worst-off in several districts, but the results are not yet known, and project implementation has been slowed down by a number of constraints.

Despite these notable progresses toward considering equity in PBF, it remains unclear to what extent these equity instruments have yielded positive effects in terms of access to health care services for the most vulnerable and reduction of health inequities.

Suggestions for Better Consideration of Equity

Recently, the WHO reasserted that, in aiming to achieve equity in the context of UHC, it would be unacceptable to extend coverage to those who are well-off before ensuring at least essential coverage for the worst-off. It is therefore crucial that global health actors – all of us – keep in mind the history of our omissions and mobilize to ensure the worst-off also benefit from any reform. It is becoming urgent that the principle of proportionate universalism,^44,45 which calls for the intensity of actions to be proportionate to the needs of different populations, be made a conditionality of any project, policy, or reform aimed at progressing toward UHC. Students, experts, researchers, decision makers, and other actors also need to receive training on this concept and its application, and they need to be organized to implement it, which is not easy but essential. Thus, over the next 15 years, we will need to ensure that health systems strengthening in LMICs involves deploying strategies for everyone but not to the detriment or neglect of the worst-off.⁴⁴ Specific measures must be implemented to ensure the needs of the worst-off and those along the entire social gradient are taken into account to achieve a health system (and a society) that is not only more effective but also fairer. PBF, like all other strategies aimed at reforming and reinforcing health systems, must also pay attention to equity. It is never too late – and the experience of Burkina Faso shows it is both possible and socially accepted, although implementation challenges remain. As some senior staff at the WHO are now asserting, perhaps a little hastily given the lack of evidence regarding LMICs (see e.g., Paul et al.³), “the question is not whether to introduce a reform with the label P4P [pay for performance] but rather how to introduce, extend, and institutionalize mechanisms for strategic purchasing of health services.”¹⁹ It will be crucial that these reforms do not, once again, ignore equity. The Innov8 approach being promoted by the WHO could be useful to ensure that these efforts “leave no one behind.”⁴⁵ Based on our experience, we offer below some suggestions to consider in PBF and strategic purchasing for equity in Africa (Box 1). However, a systematic review on this subject is urgently needed.

• Systematize larger bonuses for rural and disadvantaged regions.

• Purchase services for the worst-off at a higher rate than for others, with a unit fee that is sufficient to cover the actual cost of the service needed.

• Exempt all patients, or at least indigents, from user fees in primary care.

• Ensure timely reimbursement of the cost of the medication for the worst off.

• Link an (active) community-based indigent selection process with a (passive) selection by health professionals in health centers.

• Organize platforms for supply–demand dialogue to better understand the worst-off’s expectations and adapt health services.

• Include community management representatives in the distribution of PBF bonuses.

• Consider testing an incentive policy aimed at encouraging community health workers to support the worst-off in accessing health care.

• Guarantee a method of distribution of bonuses in health centers that is transparent and equitable and that will correct existing imbalances between health care workers.

• Monitor, evaluate, and regularly share the results of strategic purchasing-type reforms as they relate to equity.

We believe that these suggestions will be easier to implement in countries where there is a strong political will to reduce health inequities. Donors may want to test these policy ideas, but to ensure financial and institutional sustainability – which cannot be secured without government ownership – they should work hand-in-hand with local policymakers⁴⁶ and street-level workers.⁴⁷ All along pilot scheme implementation, donors should primarily equip governments to find sustainable financial solutions so as to achieve improved health equity.

Conclusion

When we ask ourselves whether we have collectively advanced toward the objective of achieving UHC in 2030, the issue of equity – and particularly access to care for the worst-off through strategic purchasing – should be taken into account not just in the discourse but through concrete actions. In effect, “UHC is more than an aspirational goal: It embodies widely shared health policy objectives on which all countries seek to make progress – equity in service use.”⁴⁸ We need to keep working on a much larger scale to organize strategic purchasing and actions that support equity and the financial protection of populations.

Footnotes

Acknowledgments

The authors thank Donna Riley who translated and edited the first version of this article.

Author's Note

Elisabeth Paul is now affiliated to Université libre de Bruxelles, School of Public Health, Brussels, Belgium.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: VR was a coresearcher on the baseline survey for the impact evaluation of PBF in Burkina Faso but has not received a salary from the funder (the World Bank). IS, VR, and EP have been involved as consultants in supporting PBF implementation in Cameroon and Benin. The other authors have no conflicts of interest regarding the publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: AMTT and IS received a training bursary from the Canadian Institutes of Health Research (CIHR) and LG from the Fonds de Recherche du Québec–Société et Culture (FRQSC). EP is funded by the “Effi-Santé” research project funded at the University of Liège, Belgium, through the ARC grant for Concerted Research Actions, financed by the French Community of Belgium (Wallonia-Brussels Federation).

Author Biographies

Valéry Ridde, PhD, is a research director at IRD (French Institute for Research on Sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, and a researcher with the University of Montreal’s public health research institute (IRSPUM). He is striving to overcome the significant knowledge deficit in implementation science and equity of health interventions in global health.

Lara Gautier is a PhD candidate in joint international supervision at the University of Montreal’s School of Public Health (ESPUM) and Paris Diderot University’s Centre d’Etudes en Sciences Sociales sur les Mondes Africains, Américains et Asiatiques (CESSMA). Her thesis focuses on the political economy of global health financing reforms in sub-Saharan Africa. She is a member of the Research Chair REALISME in global health intervention research. She coordinates the REALISME Research Papers. She occasionally teaches at Heildelberg University’s Institute of Public Health and trains Mali-based researchers on the use of qualitative research softwares. Prior to joining academia, Gautier worked in various international organizations and NGOs in the fields of global health and social policy in low- and middle-income countries for 5 years. Currently, she also volunteers at Médecins du Monde France and at Centre social d’aide aux immigrants in Montreal, Canada.

Anne-Marie Turcotte-Tremblay is a PhD candidate in public health at the University of Montreal. Her doctoral research aims to document the unintended consequences of a complex intervention that combines performance-based financing with health equity measures in Burkina Faso. She also collaborates with research teams studying performance-based financing in Mali and Cameroon. For her master’s degree in community health, she studied the implementation of mutual health organizations in Benin. She also worked as a research and program coordinator in global health and health promotion for over 10 years. Her research interests are related to health equity, health financing, and implementation science.

Isidore Sieleunou is a medical doctor and currently a PhD candidate in public health at the School of Public Health, University of Montreal. He has more than 15 years of experience in global health. His experience and expertise cover the full spectrum of levels (management at peripheral level, policy at national level, and scientific evidence and global advocacy at international level). His expertise is health care financing and health systems reform in low-income countries, mainly focusing on sub-Saharan Africa. He is a cofounder of Research for Development International (), an organization dedicated to global health research, policy formulation, and implementation of evidence-based and innovative health interventions in developing countries.

Elisabeth Paul earned a PhD in management science in 2006 with the thesis “Improving Public Outcomes in Developing Countries. Application of Incentive Theory to Aid and Public Resource Management” (University of Liège, magna cum laude). She combines an academic career and field experience in the spheres of development aid and global health. She was a technical assistant at the Ministry of Health (planning department) in Mali from 2007 to 2009 and has been a freelance consultant since then. Her fields of specialization are aid effectiveness (SWAp, budget support), support to health systems strengthening, performance-based financing, and public finance management in Francophone Africa. She has led numerous missions (evaluations, technical support, project formulation) in a dozen low- and middle-income countries, especially in Western Africa. She also teaches a number of courses (public finance management, health economics, evaluation of health programs, health policies, health planning). She is now the scientific coordinator of a research project on universal health coverage in Benin and Senegal, based at the University of Liège, and part-time lecturer at the Université libre de Bruxelles.

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