Financing Health in Africa - Le blog
  • Home
  • Bloggers
  • Collaborative projects
  • Join our COPs
  • Resources
  • About Us
  • Contact Us

Context matters (but how and why?) A review of performance based financing in fragile and conflict-affected health systems

4/26/2018

2 Commentaires

 
Maria Paola Bertone, Sophie Witter, Jean-Benoit Falisse and Giuliano Russo

Last year, Sophie Witter, Maria Bertone, Jean-Benoit Falisse and Giuliano Russo asked the members of CoP PBF via a flash consultation on Collectivity to share documents and reports on PBF in fragile settings to help them carry out a literature review under the ReBUILD project. The objective of the review was to understand the specificity of PBF schemes in fragile and conflict affected states and how the broader context can influence PBF introduction, design and implementation, and mediates PBF’s effects on the health system. In this blog, they share some reflections on their work. You can read the study in full in PLoS One.

Health clinic in Zimbabwe
Health clinic in Zimbabwe. Courtesy of Sophie Witter.

Performance based financing (PBF) has been expanding rapidly across low and middle countries, over the last decade, and in particular in sub-Saharan Africa – and the expansion has not been without debate at both in academic journals and on the ground. So far, the literature has mostly focused on PBF impact evaluation, and still few studies have explored the relationship between context and PBF. However, the importance of the role of the context in influencing the operation of PBF, from its introduction, to the design, implementation and its effects cannot be underestimated, as well explained in a recent blog on Mozambique.

We believe that ‘context’ is a particularly significant element to be considered in particular in fragile and conflict-affected settings. At an intuitive and anecdotal level, researchers and PBF practitioners had often sensed and discussed the potential link between PBF and fragile and conflict-affected settings. Also, a number of the early PBF schemes were implemented in post-conflict settings. Therefore, our objective with this research was to explore the extent to which context (by which we mean the geographic, socio-economic structure, political organisation, and health system organisation, with specific attention to the fault lines inherited from the conflict/crisis period) influenced the design and implementation of PBF schemes in fragile and conflict-affected settings. In the literature, hypotheses about the importance of context spanned between two extremes: some (for example, here and here) had hypothesised that PBF would be unlikely to be effective in environments with, for example, low ability to absorb risk and weak information systems, while others had pointed out that it is of precisely in situations of weak institutions that there may be more potential for PBF to re-align relationships and improve accountability.

We thought that these questions deserved more attention and set out to explore the literature in relation to 53 fragile countries drawn from this list from the World Bank for the years between 2007 and 2017.

CoP PBF as key source for data collection

We reviewed 140 documents, many found in journals, donor or MoHs’ websites and other repositories, but most (42% to be precise) shared by the members of the CoP PBF. Many thanks to each of those who helped us! The experts of the CoP are surely a valuable source of much tacit knowledge and documentation for research and practice alike.

Where and when? Expansion of PBF across fragile settings

We found evidence of PBF schemes in 23 fragile and conflict-affected countries out of the total 53. We also tried to trace, map and analyse the dissemination of PBF via influential agencies, platforms and individuals. Overall, we found that, in the cases considered, advocacy and funding opportunities played a more important role as driving forces than the availability of evidence.

Why? Drivers of PBF adoption in fragile settings

On the reasons why PBF may be adopted in fragile settings, the literature reviewed pointed to some key elements. They include the larger-than-usual place of external actors in most, if not all, of the cases reviewed; the low levels of interpersonal trust and need to strengthen accountability and good governance to which PBF is seen as contributing; the lack of trust between donors and government and fiduciary concerns which PBF is seen to address by setting up an independent cash flow system directly to facilities; the flexibility (or absence) of strong institutions; the fact that interests and power relations are usually less entrenched after prolonged conflict and crisis. More complex is the relation between PBF and decentralization and facility autonomy – although often present in practice because inherited from the conflict period, decentralization and autonomy are rather de facto realities rather than openly acknowledged policies. Overall, we noted that the link between PBF and the experience of conflict and fragility was rarely explicitly made in the documents and, while there is evidence to support the points above, it was often there between the lines.

How? More questions than answers

The evidence is more mixed regarding factors supporting (or not) PBF implementation. We thought there may be more adaptation of PBF designs in fragile settings, but in fact many schemes appeared to be a copy-and-paste from the first Rwandan project. However, we found interesting cases where PBF was adapted to face the challenges of acute, humanitarian crisis, which we are analysing further (stay tuned!). In terms of PBF sustainability, which we defined at its most basic level by checking whether PBF continued over time, there are examples of start-stop(-start again?) approaches such as in Sierra Leone and Chad, but also of more sustainable schemes (Rwanda, Burundi) where PBF was linked to broader health financing/system reforms. Even less evidence is available on how the effects of PBF on the health system are mediated by features of fragility.

In conclusion

The study points to some evidence confirming that certain conditions of fragility may favour the rapid emergence of PBF -- however, many patterns we found are not unique to fragile settings and are found in other settings as well, and (importantly) fragile countries are often very different one from another. Also, the documents available on these issues are still few, and we will need primary data collection to make sense of this complexity. For now, many questions remain open. For example, does PBF rebuild accountability and trust where they are most lacking, or simply circumvent the problem? How it is affected by pre-existing levels of facility autonomy? Can PBF in fragile settings be seen as the continuation of the practice of topping-up salary, by humanitarian organisations? Is PBF better adapted to specific types of fragile settings, e.g. humanitarian/early recovery settings (and if so, how)?

It would be interesting to hear more from the CoP experts on these questions, and on your experience of designing and implementing PBF in fragile settings. In your views, how does context affect design and implementation? What do you do, or have you have done, to adapt your PBF model to the specific context?


Do not hesitate to share your thoughts in the comments section.

2 Commentaires
Sharon Wayne
11/7/2020 09:20:35 pm

I want to thank Dr Emu a very powerful spell caster who help me to bring my husband back to me, few month ago i have a serious problem with my husband, to the extend that he left the house, and he started dating another woman and he stayed with the woman, i tried all i can to bring him back, but all my effort was useless until the day my friend came to my house and i told her every thing that had happened between me and my husband, then she told me of a powerful spell caster who help her when she was in the same problem I then contact Dr Emu and told him every thing and he told me not to worry my self again that my husband will come back to me after he has cast a spell on him, i thought it was a joke, after he had finish casting the spell, he told me that he had just finish casting the spell, to my greatest surprise within 48 hours, my husband really came back begging me to forgive him, if you need his help you can contact him with via email: Emutemple@gmail.com or add him up on his whatsapp +2347012841542 is willing to help any body that need his help. 

Répondre
Laura Hobson
12/28/2022 11:56:28 am

I was really stressed by Acid reflux issues with my newborn and had consulted Chief Dr Lucky. He gave us a thorough consultation and the medicines were equally effective. In a couple of weeks there was big improvement in my son and we are very pleased with the progress. We cannot thank Chief Dr Lucky enough. Highly recommended.

Email chiefdrlucky@gmail.com

WhatsApp +2348132777335

Répondre



Laisser un réponse.


    Our websites

    Photo
    Photo
    Photo

    We like them...

    SINA-Health
    International Health Policies
    CGD

    Archives

    Septembre 2019
    Juin 2019
    Avril 2019
    Mars 2019
    Mai 2018
    Avril 2018
    Mars 2018
    Février 2018
    Janvier 2018
    Décembre 2017
    Octobre 2017
    Septembre 2017
    Août 2017
    Juillet 2017
    Juin 2017
    Mai 2017
    Avril 2017
    Mars 2017
    Février 2017
    Janvier 2017
    Décembre 2016
    Novembre 2016
    Octobre 2016
    Septembre 2016
    Août 2016
    Juillet 2016
    Avril 2016
    Mars 2016
    Février 2016
    Janvier 2016
    Décembre 2015
    Novembre 2015
    Octobre 2015
    Septembre 2015
    Août 2015
    Juillet 2015
    Juin 2015
    Mai 2015
    Avril 2015
    Mars 2015
    Février 2015
    Janvier 2015
    Décembre 2014
    Octobre 2014
    Septembre 2014
    Juillet 2014
    Juin 2014
    Mai 2014
    Avril 2014
    Mars 2014
    Février 2014
    Janvier 2014
    Décembre 2013
    Novembre 2013
    Octobre 2013
    Septembre 2013
    Août 2013
    Juillet 2013
    Juin 2013
    Mai 2013
    Avril 2013
    Mars 2013
    Février 2013
    Janvier 2013
    Décembre 2012
    Novembre 2012
    Octobre 2012
    Septembre 2012
    Août 2012
    Juillet 2012
    Juin 2012
    Mai 2012
    Avril 2012
    Mars 2012
    Février 2012
    Janvier 2012
    Décembre 2011
    Novembre 2011
    Octobre 2011

    Tags

    Tout
    2012
    Accountability
    Aid
    Alex Ergo
    Assurance Maladie
    Bad
    Bamako Initiative
    Bénin
    Bruno Meessen
    Burkina Faso
    Burundi
    Civil Society
    Communauteacute-de-pratique
    Communauté De Pratique
    Community Of Practice
    Community Participation
    Conference
    Cop
    Course
    Couverture Universelle
    CSU
    Déclaration De Harare
    Divine Ikenwilo
    Dr Congo
    économie Politique
    élections
    équité
    Equity
    Fbp
    Financement Basé Sur Les Résultats
    Financement Public
    Fragilité
    Fragility
    Free Health Care
    Global Fund
    Global Health Governance
    Gratuité
    Gratuité
    Health Equity Fund
    Health Insurance
    ICT
    Identification Des Pauvres
    Isidore Sieleunou
    Jb Falisse
    Jurrien Toonen
    Kenya
    Knowledge-management
    Kouamé
    Leadership
    Mali
    Management
    Maroc
    Maternal And Child Health
    Médicaments
    Mise En Oeuvre
    Mutuelle
    National Health Accounts
    Ngo
    Niger
    Omd
    OMS
    Parlement
    Participation Communautaire
    Pba
    Pbf
    Plaidoyer
    Policy Process
    Politique
    Politique De Gratuité
    Politique De Gratuité
    Post Conflit
    Post-conflit
    Private Sector
    Processus Politique
    Qualité Des Soins
    Qualité Des Soins
    Quality Of Care
    Recherche
    Redevabilité
    Reform
    Réforme
    Research
    Results Based Financing
    Rwanda
    Santé Maternelle
    Secteur Privé
    Sénégal
    Société Civile
    Uganda
    Universal Health Coverage
    User Fee Removal
    Voeux 2012
    Voucher
    WHO

Powered by Create your own unique website with customizable templates.