Performance-based financing in fragile and post-conflict states

Lead: Prof Sophie Witter

Image courtesy of Sophie Witter

Purpose of the research

In the last 15 years, performance-based financing (PBF) has proliferated in low and middle-income settings, particularly in fragile and conflict-affected states (FCAS). There is a small but growing body of evidence of its effectiveness and attempts to understand how it changes and impacts on health systems.

There has been, however, very little attention paid to the impact of the approach in different contexts. This project built on ReBUILD’s earlier work on incentives for health workers in post-conflict settings, and aimed to improve our understanding of PBF programmes in specific FCAS settings. The research focused on how contextual factors influence adoption, adaption, implementation and integration of PBF, and the outputs make recommendations on how to improve PBF programmes and ultimately strengthen health systems in FCAS.

 

Countries and policy context

The work took place in three of the original ReBUILD countries - Uganda, Sierra Leone and Zimbabwe - all of which have PBF health programmes. In each there are major debates around how the programme will evolve, for which the research findings are relevant.

In addition, the research explored three new contexts - northern Nigeria, Central African Republic (CAR) and South Kivu, Democratic Republic of Congo (DRC) - in order to understand how the PBF model has been adapted and implemented in more humanitarian settings, drawing out lessons for governments and donors.

 

Expected areas of influence

The aim of the work was to inform the main players in the field, with the aim of developing more context-specific, embedded and sustainable approaches to PBF:

• National governments in the study contexts and in other FCAS settings, already undertaking or considering the introduction of PBF models.

• Funding agencies including the World Bank, the EU, the Global Fund, and bilaterals such as NORAD and DFID.

• Implementing agencies such as CORDAID or Crown Agents.

• Influential bodies such as the World Health Organisation (WHO) and PBF communities of practice.

 

Outputs:

Publications from this research to date include

• a literature review, ‘Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems’ , which feeds into hypotheses which will be examined in the second stage, and

• a comparative paper, ‘Performance-based financing in three humanitarian settings: principles and pragmatism’ looking at northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo.

• A political economy analysis in Sierra Leone focusing on the dynamics driving the introduction, implementation and discontinuation or institutionalisation of PBF. 'The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process'. (A short video presentation on this paper by Maria Bertone is available to watch here)

• A summary briefing paper, drawing on project outputs up to October 2018: Performance-based financing in fragile and conflict-affected settings - a summary

• A free, open access webinar was held on Wednesday 31st October on Performance-based financing in fragile and conflict-affected settings: from research to practice.

•  A number of videos including:

• Introduction to performance-based financing - Sophie Witter looks at performance-based financing as a way to build strategic purchasing in fragile and conflict-affected states - potentials and pitfalls. 

• • Health financing in fragile and conflict-affected states - insights from preparatory work by Professor Witter and Dr Maria Bertone for a World Health Organization paper.

  • The bumpy trajectory of performance-based financing in Sierra Leone: unpacking the role of external actors - by Maria Bertone.

  • Performance-based financing in fragile and post-conflict states - a summary of ReBUILD's work by Maria Bertone

Remaining components include:

• A political economy analyses in Zimbabwe, focusing on the dynamics driving the introduction, implementation and discontinuation or institutionalisation of PBF.

• Analysis of the creation of a purchasing function linked to PBF, comparing the planned case studies of DRC, Zimbabwe and northern UgandaRemaining componets

 

 

Resource lists

• Resources from ReBUILD's work on health financing in conflict-affected and post-conflict settings (including all the work on performance-based financing)

• Resources on health worker incentives and deployment in post-conflict and post-crisis settings.