Performance-based financing in fragile and post-conflict states
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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 is, however, very little attention paid to the impact of the approach in different contexts. This project builds on ReBUILD’s earlier work on incentives for health workers in post-conflict settings, and aims to improve our understanding of PBF programmes in specific FCAS settings. It focuses on how contextual factors influence adoption, adaption, implementation and integration of PBF, and makes recommendations on how to improve PBF programmes and ultimately strengthen health systems in FCAS.
Countries and policy context
The work is taking place in three of the original ReBUILD countries, all of which have PBF health programmes: Uganda, Sierra Leone and Zimbabwe. In each there are major debates around how the programme will evolve, which our research can influence.
In addition, we are examining 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, and to draw out early lessons for governments and donors.
Expected areas of influence
Our aim is to influence 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.
Influential bodies such as WHO and PBF communities of practice.
So far we have published:
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
we are about to publish 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.
That second stage has three components.
A review of the adaptation of PBF to humanitarian crisis and post-conflict recovery, focused on the planned case studies of CAR, Nigeria, and DRC. This has been completed and submitted for publication
Two political economy analyses in Sierra Leone and 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 Uganda.