By Keovathanak Khim, 2010 Emerging Voice and PhD candidate at the University of Melbourne, Australia
Communication and exchange of ideas that work are as important as applying these ideas in the field to address today’s increasingly complex and diverse health problems. The Performance-based financing (PBF) community embraces this philosophy, so it recently organized another two-day workshop, “Performance-based financing of health care provision in low-income countries: Going beyond impact evaluation” (June 13-14), in Bergen, Norway. The workshop was supported by the Christian Michelsen Institute, with participation of approximately 35 researchers from academia, PBF experts, practitioners, and policy makers from government and aid agencies. The aim of the workshop was to present research delving into the question “what exactly happens to health care services when PBF is introduced” and contribute to the clarification of the overall research programme on PBF. In this piece I will share my impressions of the workshop and give a number of observations pertaining to PBF.
The workshop was a combination of presentations, questions and answers, open plenary and small group discussions. The first day started with presentations of theoretical explanations and experimental research related to providers’ behavior under different regimes of incentives, and research on PBF schemes in Cambodia, Tanzania and Burundi. The second day focused on research designs, feasibility of different designs, efficiency of a PBF scheme relative to alternative schemes and transaction cost issues. Further in-depth discussions took place in small groups which explored professionalism boosting programmes, key dimensions of the PBF “black box”, the interaction between PBF and health system functions and different designs of impact evaluation. Many of the topics were related to previous publications and ongoing debates about PBF. Discussions were well moderated allowing a variety of voices and insights from the field and government officials to be heard. Consequently, sessions were well attended and discussions were lively and engaging. They reflected a sincere interest to share, learn and foster a better understanding.
As expected, PBF definitions differed widely, influenced as they were by different experiences, settings and understandings. Everybody however seemed to agree on the basics of Performance-Based Financing: PBF is a form of supply-side interventions based on a contractual arrangement that creates an enabling environment for staff and facilities to improve their performance. PBF is a sub-set of Results-Based Financing (RBF), which was recently mentioned by Jim Kim as a key mechanism for the World Bank’s global health activities. Whereas all PBF schemes employ some form of payment to incentivize facilities (which may then decide themselves to reward their staff for the extra effort), not all schemes that use financial incentives can be labeled as PBF schemes. PBF contains several other elements which, for instance, clearly delineate the mission of each health system component, improve the efficacy of monitoring and verification of results, or promote community participation. These elements are flexible and can be adapted for use in different contexts, and add to the strengths of PBF.
Two trends were apparent in Bergen.
The first one was related to the need to better understand how different elements of PBF interact with and improve staff performance and health system functions and vice versa. For example, to what extent and in what context do financial incentives improve staff motivation or undermine intrinsic motivation; when and in what context do other mechanisms, e.g. encouragement and supervision, impact staff performance; when and how does empowerment of staff and managers impact interactions and communication within a system, and improve results? Participants agreed that qualitative approaches can address some of the current evidence gaps in PBF by explaining processes of PBF and the impact of the approach.
Second, many participants also emphasized the need for impact evaluation designs which are both methodologically robust and feasible in the field. Impact measures should be related to higher order- outcomes, such as changes in equity and efficiency in a health system, morbidity and mortality in a population, and issues such as catastrophic health care expenditure.
Global health problems tend to be complex and context-specific; they thus need an approach that is versatile and adaptable, such as PBF. PBF approaches promise to tackle and overcome health system constraints. These promises can be met with adequate research and documentation. This workshop represented another step forward in this direction by engaging researchers and practitioners in an open and fruitful dialogue and fostering a better understanding of PBF approaches. One can only hope that this workshop will be followed by other workshops of a similar nature. It is fair to say that workshops like this one are increasingly becoming the hallmark of the PBF community.