Impacts of performance-based financing on health system performance: evidence from the Democratic Republic of Congo

BMC Medicine

Research Article

Dominique Baabo¹  Didier Ramanana¹  Delphin Antwisi¹  Baudouin Makuma Booto¹  Günther Fink²  Emma Clarke-Deelder²  Michel Muvudi³  Gil Shapira³  Saloua Benami³  Hadia Samaha³  György Bèla Fritsche³ 

[1] Ministry of Public Health, Kinshasa, Democratic Republic of Congo;The Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland;The World Bank, Washington, D.C., USA;

关键词: Performance-based financing;    Health systems;    Quality of care;    Maternal and child health;   

DOI  :  10.1186/s12916-023-03062-8

 received in 2023-04-24, accepted in 2023-09-04,  发布年份 2023

来源: Springer

【 摘 要 】

BackgroundHealth systems’ weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such programs introduced in LMICs to date.MethodsWe used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021–2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers’ satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain.ResultsThe PBF program improved the structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01–0.08), technical process quality by 5 ppts (0.03–0.07), and non-technical process by 2 ppts (0–0.04). PBF also increased coverage of priority health services by 3 ppts (0.02–0.04). Improvements were also observed for facility management (9 ppts, 0.04–0.15), service fee policies, and users’ satisfaction with service affordability (14 ppts, 0.07–0.20). Service fees and health workers’ satisfaction were not affected by the program.ConclusionsThe results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals.Trial registrationAmerican Economics Association Trial registry AEARCTR-0002880.

【 授权许可】

CC BY   
© BioMed Central Ltd., part of Springer Nature 2023

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