After a few decades of practical experience, we can safely say that Performance-Based Financing (PBF) can be a powerful approach, but only if we keep agile on updating it. Call it bananas, I don’t care…but in moving PBF/RBF let’s be clear and constantly critical about the basics, brace ourselves for the serious battles, be honest about money and power, and act collectively…
Ten years of PBF CoP is a great occasion to take stock of achievements and challenges in the wondrous world of performance-based rhetoric and practice. Over the last decade, the spotlight has been on a range of ‘results’- and ‘performance’-based strategies (RBF/PBF), in the health arena and beyond, proposed in different parts of the world to end the suffering, corruption and inefficiencies that derive from input-based policies and dysfunctional social systems.
Many of us, working in the global health domain have tried to examine how such strategies could be advanced, carefully, to the benefit of ever larger numbers of people. Through considerable trial and error and explicit learning, RBF/PBF has grown from predominantly supply-oriented, financial strategies to start, to full-fledged health systems approaches today. In these contexts, science, notably operational research, matters a lot.
In the process, PBF/RBF reflections were enriched by other health systems perspectives. Insights from the domains of governance, political economy, public finance management, demand-side health interventions, citizens’ and community engagement were often embraced. And all this resulted in deeper conversations, sharper thinking, and interesting spaces of practical convergence. In this respect, the PBF/RBF journey has been open, energizing and productive. It has even led a growing number of people to consider that PBF/RBF could be beneficial as one of the motors of Universal Health Coverage (UHC).
Over this last decades RBF/PBF programs in countries have grown, from local pilots to nation-wide endeavors. And with that expansion, the harsh realities of power politics often kicked in. If we are honest, we are only just now arriving at the real battlegrounds of PBF/RBF health systems change, and there, nobody is innocent. Let’s explore this current state of affairs a bit, to see what needs to be done.
PBF in the era of accelerating UHC
At the last United Nations General Assembly (UNGA) in September 2019, the global health community gathered in New York in a special UHC Forum and presented an overview of the progress made in offering more equitable, good quality health and health care to the world’s populations.
Despite advances in UHC, the overall diagnoses were dire: As many as 5 billion people would be left without full access to healthcare in 2030 at the present rate of progress according to Universal Health Coverage Global Monitoring Report 2019. Progress had been made in lower income countries, mainly through interventions for infectious diseases and reproductive, maternal, new-born and child health services. But the poorest and conflict-ridden countries lag far behind, with progress on UHC slowed down since 2010. Based on current trends, by 2030 only 39%- 63% of the global population would be covered for essential health services. In addition, levels of catastrophic health expenditures which represent out-of-pocket spending in proportion to household income, rose continuously from 2000 to 2015. Nearly a billion people spent more than 10% of household income on health in 2015, and over 200 million spent more than 25%, according to the report. Global inequities are still staggering. And issues which on paper seem very solvable in practice remain unresolved.
A range of commentaries followed suit: It’s the economy, stupid; it’s global politics, stupid; it’s neocolonialism, stupid. Often commentators deem ‘somebody else’ responsible for the disappointing state of affairs. However, self-serving finger pointing does not help to confront what is really going on. Reality forces us to acknowledge we are all in the same boat, together. Today, pervasive systems of global power, economic exploitation or outright extraction have fundamental impacts on the lives of people. Many humans feel powerless in the face of it all. But what is worse, rather than facing the real power struggles head-on, we often get sidetracked in oceans of petty conflicts, silly haggling and foolish grandstanding, distracting us from the tougher tasks at hand.
With the emergence of new generations of global citizens, the major economic and ecological crises are once again spilling over into the streets. In 2020, we will have to move to the next stage, face the big stuff collectively, or become redundant.
Five constructive confrontations
Health people often find themselves at the intersection of various vital policy arenas. This privileged position can and should be used for constructive collective confrontation of the major global concerns. In health systems performance, five points of contention and such confrontation are particularly urgent:
1. We have to start confronting our collective political economy, no one excepted. We need to stop fooling around and become ruthlessly open and transparent about the political economy, including the money flows in the 7.5 trillion $ global health industry. Follow the money and face the systemic wastage! Everybody who has worked longer than a week in fields like domestic health financing, public finance management or global development partner coordination – anywhere in the world - can tell you stories, ranging from massive wastage, corruption and embezzlement to smaller scale survival tactics (as in the case of health workers who do not earn enough to feed their children). To allow this wastage to continue is no longer acceptable: This money could potentially cover a large part of the real health financing needs. A systemic PBF approach can further contribute to boost governance, by driving funds more directly to the frontline of service delivery and introduce proper verification mechanisms at all levels of the system.
2. We need to confront what it takes to put primary care and public health quality center-stage. We need to be uncompromisingly logical and create top-notch primary health care and public health, before engaging in tertiary fancy-fair projects. As the 2019 UNGA UHC report mentioned: “Investing an additional US$ 200 billion a year on scaling up primary health care across low and middle-income countries would potentially save 60 million lives, increase average life expectancy by 3.7 years by 2030, and contribute significantly to socio-economic development.” A PBF systems approach starts from the basic levels of the health system: communities and primary health care, and in principle puts 70% of the available funds at the basis. This move to the frontline is now internationally called for. To face the vested interests in illogical health systems will not be easy, but it is urgent.
3. We need to address the crisis in human capacity as highest priority. We need to invest massively in people, especially the young; not in terms of the individualist panic-y ‘degree collection’ which we now see many young people pushed into in so many parts of the world, but as part of calm, continuous, collective learning, with a very clear vision of health as public good. To start a new collective human resources agenda will require carving out solid time for a new debate on ‘collective interest’ and ‘collective action’ which has become difficult in our hasty world of individualized pressures. Here, the increased operational autonomy at each level of the system, which is one of the best practices in PBF, has already been seen to boost the pleasure and self-confidence of health workers. Combined with the principle of independency to recruit staff where needed introduces elements into the system, which have been proven attractive to health staff and may contribute to moving people towards the healthcare arena.
4. We need to confront ‘equity and access’, but not until after quality has been assured. This is a particularly important area of convergence. PBF in many places has already drawn on general modernized equity mechanisms which governments try to implement to serve their populations. PBF subsidies follow mechanisms of geographical, regional, indigents equity and help to refine these.
5. We need to confront the emergency of factoring in planet and climate in all work. We need to align our health efforts from the start with efforts which are currently emerging around the globe to benefit people and planet. As PBF community, it would be interesting in this context to explore introducing climate friendly measures in PBF quality service delivery, and to explore digital possibilities (exchanges, education, conferencing) further.
The PBF/RBF health systems approach is anchored in a set of principles and best-fit practices. As suggested above, it could very constructively assist the above fundamental struggles. PBF/RBF encompasses key governance notions such as separation of power, autonomy of operation and ownership. Quality should come first, in order to give people access to good quality services, and not to death-traps. PBF rests on sound economic and public health tenets. So instead of getting lost in side-stories, let’s face the core battles of health systems reform head-on, not as missionaries or gurus, but – starting locally - with an open and self-critical eye to learn constantly from practical challenges along the road.
We are equipped to help accelerate UHC, and Health4All. In real life, in real engagement. After decades of practical learning, now is the time for RBF/PBF thinkers and doers to step up to that challenge. Now is the time!
Would love to hear from other bloggers, how this engagement can be advanced in PBF practice.