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 (PBF) 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.

There’s more on ReBUILD’s PBF work here.

Key messages

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.

Key messages for donors include:

  • Processes for introduction of PBF in FCAS settings need to be especially sensitive and iterative, to allow local leadership to develop and continue.
  • There is no one model for PBF – given the range of challenges, institutional arrangements and political economy configurations, PBF must be locally adapted and flexibly implemented.
  • PBF can be one mechanism for providing more flexible resources (with accountability) to frontline providers; however, it has to emerge from local situation analysis and be situated within the health system as a whole. It should not be a stand-alone measure.

You can download the brief here.

Further information

We welcome comments on this and other aspects of ReBUILD’s work. For further information or to make any comments on the brief please contact Sophie Witter.