Unravelling performance-based financing effects beyond impact evaluation: results from a qualitative study in Cameroon
About the poster
This poster is based on this published paper by Manuela De Allegri, Maria Paola Bertone, Shannon McMahon, Idrissou Mounpe Chare and Paul Jacob Robyn.
Performance-based financing (PBF) has acquired increased prominence as a means of reforming health system purchasing structures in low- and middle-income countries. A number of impact evaluations have noted that PBF often produces mixed and heterogeneous effects. However, most evaluations heavily rely on quantitative methods which are not sufficient to explain the mechanisms through which PBF produces changes, and so far little systematic effort has been channeled towards understanding what causes heterogeneity, including looking more closely at implementation processes.
This qualitative study aimed to close this gap in knowledge by attempting to unpack the mixed and heterogeneous effects detected by an existing quantitative impact evaluation in Cameroon to inform further implementation as the country scales up the PBF approach. Data was collected at all levels of the health system (national, district and facility) and at the community level, using a mixture of in-depth interviews and focus group discussions. Deductive and inductive analytical techniques were combined and analyst triangulation applied.
The study found that changes in health service delivery were bolstered by the increased availability of resources and by the setting of clear, attainable targets for health workers and managers. The heterogeneity could be explained not only by pre-existing health system factors (eg rigid policies and protocols, reliance on user charges, and shortcomings in infrastructure and personnel), but also by challenges related to the implementation of the PBF program itself (eg limited financial literacy, lack of explicit pro-poor targeting strategy etc.). Health workers reported greater capacity to produce services that could be delivered at the community level (eg vaccination) compared to those requiring clients to come to the facility (eg delivery), suggesting that geographical and financial barriers represent an important obstacle even in the context of PBF programs.
PBF’s ability to generate change appears to be closely linked to the program’s ability to adjust implementation plans to existing health systems and to execute the program in a more fluid manner. In light of Cameroon’s commitment to scaling up PBF, it follows that substantial efforts should be made to overcome these organisational, infrastructural and demand-side barriers and to smooth implementation processes, thus enabling healthcare providers to use PBF resources and management models to a fuller potential.