Research for stronger health systems during and after crisis

New paper on performance-based financing

Wednesday, 04 Apr 2018


Context matters (but how and why?)

A new paper has been published this week by the ReBUILD Consortium which looks at the issue health system financing. Context matters (but how and why?) A hypothesis-led literature review of performance-based financing in fragile and conflict-affected health systems’ considers performance-based financing (PBF) and examines how context affects its adoption and implementation.

The team, led by Professor Sophie Witter of the Institute for Global Health and Development at Queen Margaret University, Edinburgh, interrogated available grey and published literature (140 documents in total, covering 23 PBF schemes), analysing how context may influence the adoption, adaption, implementation and health system effects of PBF.

 They found that PBF has been more common in fragile and conflict-affected settings (FCAS), which were also more commonly early adopters. However, the literature gave very little explanation of the rationale for its adoption, especially in relation to contextual features. In their paper, the team suggests several factors which could explain this uptake, all of which favour more contractual approaches and indicate that conditions of fragility may favour the rapid emergence of PBF.

Prof Witter said:

“PBF is an important potential tool for health care financing but the match to contextual needs and conditions is critical. There is recognition of this in the existing literature but little focused study of how and why different contexts influence the uptake and implementation of PBF. We contribute here to better understanding of how fragility and conflict-affectedness have influenced the adoption, adaption and implementation of PBF, analysing 23 PBF schemes across three continents.  The aim is to support more nuanced policy-making and research in this area”.


About performance-based financing

PBF schemes typically aim to improve health services by providing bonuses to service providers (usually facilities, but often with a portion paid to individual staff) based on the verified quantity of outputs produced. They have been expanding rapidly across low and middle-income countries in the past decade, particularly focused on maternal and child health services, with considerable external financing from multilateral, bilateral and global health initiatives. Many of the countries adopting PBF have been FCAS.

There’s more on the ReBUILD Consortium’s work into PBFs and other aspects of health financing in our resources section.

Access the paper

Bertone MP1, Falisse J-B2, Russo G3, Witter S1 (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.

1 ReBUILD & Institute for Global Health and Development, Queen Margaret University, Edinburgh (UK)
2 Centre of African Studies, University of Edinburgh, Edinburgh (UK)
3 Centre for Primary Care and Public Health, Queen Mary University, London (UK)