Research for stronger health systems during and after crisis

Performance-based financing in fragile and post-conflict states

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Lead: Prof Sophie Witter

Smiling African women in colourful clothes and with babies on their kneessit on a bench outside a consultation room
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:



Publications from this research to date include

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



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