Local Stakeholders’ Perceptions about the Introduction of Performance-Based Financing in Benin: A Case Study in Two Health Districts

Document Type : Original Article

Authors

1 Universite de Liègeand Research Group on the Implementation of the Agenda for Aid Effectiveness in the Health Sector (GRAP-PA Sante), Liège, Belgium

2 Universite d’Abomey-Calavi, LADYD, Cotonou, Benin

Abstract

Background
Performance-Based Financing (PBF) has been advanced as a solution to contribute to improving the performance of health systems in developing countries. This is the case in Benin. This study aims to analyse how two PBF approaches, piloted in Benin, behave during implementation and what effects they produce, through investigating how local stakeholders perceive the introduction of PBF, how they adapt the different approaches during implementation, and the behavioural interactions induced by PBF.
 
Methods
The research rests on a socio-anthropological approach and qualitative methods. The design is a case study in two health districts selected on purpose. The selection of health facilities was also done on purpose, until we reached saturation of information. Information was collected through observation and semi-directive interviews supported by an interview guide. Data was analysed through contents and discourse analysis.
 
Results
The Ministry of Health (MoH) strongly supports PBF, but it is not well integrated with other ongoing reforms and processes. Field actors welcome PBF but still do not have a sense of ownership about it. The two PBF approaches differ notably as for the organs in charge of verification. Performance premiums are granted according to a limited number of quantitative indicators plus an extensive qualitative checklist. PBF matrices and verification missions come in addition to routine monitoring. Local stakeholders accommodate theoretical approaches. Globally, staff is satisfied with PBF and welcomes additional supervision and training. Health providers reckon that PBF forces them to depart from routine, to be more professional and to respect national norms. A major issue is the perceived unfairness in premium distribution. Even if health staff often refer to financial premiums, actually the latter are probably too weak—and ‘blurred’—to have a lasting inciting effect. It rather seems that PBF motivates health workers through other elements of its ‘package’, especially formative supervisions.
 
Conclusion
If the global picture is quite positive, several issues could jeopardise the success of PBF. It appears crucial to reduce the perceived unfairness in the system, notably through enhancing all facilities’ capacities to ensure they are in line with national norms, as well as to ensure financial and institutional sustainability of the system.

Keywords

Main Subjects

References

  1. Meessen B, Soucat A, Sekabaraga C. Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform? Bull World Health Organ 2011; 89:153-6. doi: 10.2471/BLT.10.077339
  2. Eichler R, Levine R. Performance Incentives for Global Health: Potential and Pitfalls. Washington: Center for Global Development, Performance-Based Incentives Working Group; 2009.
  3. Witter S, Toonen J, Meessen B, Kagubare J, Fritsche G, Vaughan K. Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation. BMC Health Serv Res 2013; 13: 367. doi: 10.1186/1472-6963-13-367
  4. Catholic Organisation for Relief and Development Aid (Cordaid). PBF in Action: Theories and Instruments, PBF Course Guide (fifth edition). The Hague: Cordaid; 2014.
  5. Fritsche GB, Soeters R, Meessen B. Performance-based financing toolkit. Washington, DC: The World Bank; 2014.
  6. Paul E, Eclou D, Sossouhounto N. Perspectives de recherche sur les perceptions des acteurs vis-à-vis de l’introduction du financementbasésur les résultats (FBR) dans le secteur de la santé au Bénin [Research perspectives on stakeholders’ perceptions about results-based financing (RBF) in the health sector in Benin]. Report of the 5th GRAP-PA Santé mission in Benin, 8-15 November. Université de Liège; 2013.
  7. Soeters R, Vroeg P. Why there is so much enthusiasm for performance-based financing, particularly in developing countries. Bull World Health Organ 2011; 89: 699-700.
  8. The World Bank. Performance-Based Financing Toolkit [internet]. Available from: http://web.worldbank.org/WBSITE/EXTERNAL/ TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/ EXTPmenuP:9409463~pagePK:64168427~piPK:64168435~theSitePK:9409457,00.html
  9. PBF Community of Practice (CoP) website. Available from: http://performancebasedfinancing.org/
  10. Oxman AD, Fretheim A. Can paying for results help to achieve the Millennium Development Goals? A critical review of selected evaluations of results-based financing. J Evid Based Med 2009; 2: 70-83. doi: 10.1111/j.1756-5391.2009.01020.x
  11. Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev 2012; 2. doi: 10.1002/14651858.CD007899.pub2
  12. Brown GW, Barnes A, Harman S, Gruia M, Papamichail A. Annotated literature review: African actors, global health governance and performance-based funding. Discussion Paper 98. Harare: EQUINET; 2013.
  13. Paul E, Robinson M. Performance Budgeting, Motivation and Incentive. In: Robinson M, editor. Performance Budgeting: Linking Funding and Results. Washington and New York: International Monetary Fund & Palgrave/McMillan; 2007: 330-75.
  14. Ireland M, Paul E, Dujardin B. Can performance-based financing be used to reform health systems in developing countries? Bull World Health Organ 2011; 89: 695-8. doi: 10.2471/BLT.11.087379
  15. Ssengooba F, McPake B, Palmer N. Why performance-based contracting failed in Uganda – An ‘open-box’ evaluation of a complex health system intervention. Soc Sci Med 2012; 75: 377-83. doi: 10.1016/j.socscimed.2012.02.050
  16. Fox S, Witter S, Wylde E, Mafuta E, Lievens T. Paying health workers for performance in a fragmented, fragile state: reflections from Katanga Province, Democratic Republic of Congo. Health Policy Plan 2014; 29: 96-105. doi: 10.1093/heapol/czs138
  17. Mayaka Manitu S, Muvudi Lushimba M, Bertone MP, de Borman N. Le financement basé sur la performance en République Démocratique du Congo: comparaison de deux experiences pilotes [Performance-based financing in DRC: a comparison of two pilot experiences]. PBF Community of Practice Working Paper Series WP6; 2011.
  18. Rusa L, Ngirabega J, Janssen W, Van Bastelaere S, Porignon D, Vandenbulcke W. Performance-based financing for better quality of services in Rwandan health centres: 3-year experience. Trop Med Int Health 2009; 14: 830-7. doi: 10.1111/j.1365-3156.2009.02292.x
  19. Basinga P, Gertler PJ, Binagwaho A, Soucat AL, Sturdy J, Vermeersch CM. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet 2011; 377: 1421-8. doi: 10.1016/S0140-6736(11)60177-3
  20. Renmans D, Paul E, Dujardin B. Analysing Performance-Based Financing under the lenses of the Principal-Agent theory. Brussels: Université Libre de Bruxelles; 2014.
  21. Miller G, Singer Babiarz K. Pay-for-Performance Incentives in Low- and Middle-Income Country Health Programs. Working Paper No. 18932. Cambridge: National Bureau of Economic Research; 2013.
  22. Olivier de Sardan JP. La rigueur du qualitatif  [Rigour in qualitative research]. Louvain-la-Neuve: Academia Bruylant; 2008. p. 105-24.
  23. Olivier de Sardan JP. Anthropology for Development: Understanding Contemporary Social Change. London: Zed Books Ltd; 2005.
  24. Jaffré Y, Olivier de Sardan JP, editors. Une médecine inhospitalière: les difficiles relations entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest [Inhospitable medical practice: difficult relationships between healthcare providers and patients in five Western African capital cities]. Paris: Karthala; 2003.
  25. Ridde V. Per diems undermine health interventions, systems and research in Africa: burying our heads in the sand. Trop Med Int Health 2010. doi: 10.1111/j.1365-3156.2010.02607.x
  26. Priedeman Skiles M, Curtis SL, Basinga P, Angeles G. An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Health Policy Plan 2013; 28: 825-37. doi: 10.1093/heapol/czs122
  27. Jansen C, Lodi E, Lodenstein E, Toonen J, editors. Vers une couverture maladie universelle au Bénin [Towards universal health coverage in Benin]. Amsterdam: KIT Publishers; 2013.

 

 

Files

History

  • Receive Date: 27 May 2014
  • Revise Date: 24 September 2014
  • Accept Date: 25 September 2014
  • First Publish Date: 25 September 2014

Share

How to cite

Statistics