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 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.

  • 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 WHO and PBF communities of practice.



So far we have published:


Resource lists