Performance-based financing in fragile and conflict-affected settings - a summary
Witter, S. & Bertone M. (2018)
This brief presents a summary of ReBUILD’s research into performance-based financing in fragile and conflict-affected settings, with a particular focus on studies conducted in Sierra Leone, Democratic Republic of Congo, northern Nigeria, Uganda, Central African Republic and Zimbabwe. It presents a background to the work, methodology, summary and key findings.
You can download the brief here.
Performance-based financing (PBF) is particularly common in fragile and conflict-affected settings (FCAS), and some features of these settings may favour the emergence of PBF, for example:
the greater role of external actors and donor
a greater openness to institutional reform
lower levels of trust within the public system and between government and donors.
However, findings are mixed regarding PBF implementation and effectiveness in FCAS settings. Despite the ‘PBF principles’ codified over time (such as strict separation of functions and comprehensive verification systems), adaptation to context, flexibility in implementation and pragmatism (rather than copy-and-paste approaches) appear to be key elements to ensure the survival - and perhaps success - of PBF, especially in humanitarian settings.
When PBF is analysed as a health financing/system reform, evidence is mixed and expectations should be realistic. For example, in relation to strategic purchasing, PBF remained one purchasing mechanism amongst many, with traction mostly on the services covered in its package and limited wider transformative effects.
Political economy analyses highlight the drivers of PBF across settings:
In Sierra Leone, external actors, internal divisions and the resource/capacity-strapped environment led to lack of ownership and appropriation at national level and may explain the start-stop-start story of PBF.
In Zimbabwe, despite initial resistance, ownership later developed, with substantive changes introduced by the Ministry of Health and Child Care (MoHCC). But challenges and tensions remain - for example, in terms of longer-term funding and institutionalisation.