A study on the implementation fidelity of the performance-based financing policy in Burkina Faso after 12 months

Examining multiple funding flows to public healthcare providers in low- and middle-income countries - results from case studies in Burkina Faso, Kenya, Morocco, Nigeria, Tunisia and Vietnam

Provider payment methods are traditionally examined by appraising the incentive signals inherent in individual payment mechanisms. However, mixed payment arrangements, which result in multiple funding flows from purchasers to providers, could be better understood by applying a systems approach that assesses the combined effects of multiple payment streams on healthcare providers. Guided by the framework developed by Barasa et al. (2021) (Barasa E, Mathauer I, Kabia E et al. 2021. How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them. Health Policy and Planning  36: 861-8.), this paper synthesizes the findings from six country case studies that examined multiple funding flows and describes the potential effect of multiple payment streams on healthcare provider behaviour in low- and middle-income countries. The qualitative findings from this study reveal the extent of undesirable provider behaviour occurring due to the receipt of multiple funding flows and explain how certain characteristics of funding flows can drive the occurrence of undesirable behaviours. Service and resource shifting occurred in most of the study countries; however, the occurrence of cost shifting was less evident. The perceived adequacy of payment rates was found to be the strongest driver of provider behaviour in the countries examined. The study results indicate that undesirable provider behaviours can have negative impacts on efficiency, equity and quality in healthcare service provision. Further empirical studies are required to add to the evidence on this link. In addition, future research could explore how governance arrangements can be used to coordinate multiple funding flows, mitigate unfavourable consequences and identify issues associated with the implementation of relevant governance measures.

Anthropological overview of kangaroo care in community settings in Madagascar

The management of preterm births remains a major challenge in Madagascar, given the lack of equipped facilities in rural areas, and the absence of precise data concerning the incidence of such births. The World Health Organization (WHO) recommends the kangaroo method (skin-to-skin contact) for the management of preterm infants. In this article, we examine the conditions for success and the obstacles facing kangaroo care in community settings in Madagascar. We performed a qualitative research, collecting data from the districts of Antananarivo and Mahajanga in 2021. In total, 54 semi-structured interviews and two focus group sessions were conducted with the parents of preterm infants and healthcare professionals.The obstacles identified by the research included incomplete and inaccurate knowledge, leading to heterogeneity in the practice of kangaroo care: arbitrary duration, lack of kangaroo care at night, exclusive breastfeeding, and only partially practiced skin-to-skin contact. We found that the conditions for success depended on: (1) the healthcare system, (2) local interpretations of pregnancy, and (3) the structure of the infant's family. Failings of the medical system, cultural habits going against kangaroo care, and "nuclear" and/or "single parent" family structures undermine the application of this practice, jeopardizing upscaling efforts. We hope that the results of this research will guide community strategies for the management of preterm infants and kangaroo care.

Fidelity of kangaroo mother care services in the public health facilities in Bangladesh: a cross-sectional mixed-method study

Background

Kangaroo mother care (KMC) is a proven low-cost intervention to prevent neonatal mortality of pre-term and low birth weight babies and is very relevant to Bangladesh. KMC provides thermal regulation and thus directly avert neonatal mortality. KMC includes early, continuous, and prolonged skin-to-skin contact between an infant and caregiver, exclusive breastfeeding, early discharge from the hospital, and post-discharge follow-up. The purpose of this study was to investigate the fidelity of this intervention’s implementation according to national guidelines across all tiers of government (public) health facilities of Bangladesh.

Methods

We adopted a triangulation mixed-methods approach of both quantitative and qualitative components in this research to support and explain the information obtained from quantitative observation with the help of qualitative interviews on the fidelity of KMC practice. We used an observation checklist to find the fidelity of KMC practice and used semi-structured guidelines to explain and understand the moderators of fidelity through key informant interviews and in-depth interviews. We undertook eight facility visits in four districts, observed twenty-three neonates and their caregivers during KMC practice at those facilities, and conducted twenty-seven key informant interviews with facility managers, health care providers, and five in-depth interviews with caregivers. Extracted information was triangulated and arranged under the themes of the fidelity framework.

Results

Despite being a low-cost intervention, findings exhibit some adherence to the national guideline with several gaps in practice. Leadership played a critical role in ensuring the KMC practice. Specific components of KMC practice, like duration, nutrition maintenance, discharge criteria, and follow-up, were not consistent as recommended. Infrastructure, human resources, developmental partner support, and the demand-side and supply-side responsiveness played a critical role in enacting this human-centric approach’s fidelity. The observed interruption found in the implementation process posed threats to achieve the intended outcome as these caused violations of the basic principles of KMC.

Conclusions

The study findings will help find ways to effectively deliver this intervention so that fidelity of practice is maintained, enhancing KMC services’ quality and advocating towards the successful scale-up of this program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00215-9.

What happens when performance-based financing meets free healthcare? Evidence from an interrupted time-series analysis

In spite of the wide attention performance-based financing (PBF) has received over the past decade, no evidence is available on its impacts on quantity and mix of service provision nor on its interaction with parallel health financing interventions. Our study aimed to examine the PBF impact on quantity and mix of service provision in Burkina Faso, while accounting for the parallel introduction of a free healthcare policy. We used Health Management Information System data from 838 primary-level health facilities across 24 districts and relied on an interrupted time-series analysis with independent controls. We placed two interruptions, one to account for PBF and one to account for the free healthcare policy. In the period before the free healthcare policy, PBF produced significant but modest increases across a wide range of maternal and child services, but a significant decrease in child immunization coverage. In the period after the introduction of the free healthcare policy, PBF did not affect service provision in intervention compared with control facilities, possibly indicating a saturation effect. Our findings indicate that PBF can produce modest increases in service provision, without altering the overall service mix. Our findings, however, also indicate that the introduction of other health financing reforms can quickly crowd out the effects produced by PBF. Further qualitative research is required to understand what factors allow healthcare providers to increase the provision of some, but not all services and how they react to the joint implementation of PBF and free health care.

What theories underpin performance-based financing? A scoping review

PURPOSE

The study aims to explore the theoretical bases justifying the use of performance-based financing (PBF) in the health sector in low- and middle-income countries (LMICs).

DESIGN/METHODOLOGY/APPROACH

The authors conducted a scoping review of the literature on PBF so as to identify the theories utilized to underpin it and analyzed its theoretical justifications.

FINDINGS

Sixty-four studies met the inclusion criteria. Economic theories were predominant, with the principal-agent theory being the most commonly-used theory, explicitly referred to by two-thirds of included studies. Psychological theories were also common, with a wide array of motivation theories. Other disciplines in the form of management or organizational science, political and social science and systems approaches also contributed. However, some of the theories referred to contradicted each other. Many of the studies included only casually alluded to one or more theories, and very few used these theories to justify or support PBF. No theory emerged as a dominant, consistent and credible justification of PBF, perhaps except for the principal-agent theory, which was often inappropriately applied in the included studies, and when it included additional assumptions reflecting the contexts of the health sector in LMICs, might actually warn against adopting PBF.

PRACTICAL IMPLICATIONS

Overall, this review has not been able to identify a comprehensive, credible, consistent, theoretical justification for using PBF rather than alternative approaches to health system reforms and healthcare providers' motivation in LMICs.

ORIGINALITY/VALUE

The theoretical justifications of PBF in the health sector in LMICs are under-documented. This review is the first of this kind and should encourage further debate and theoretical exploration of the justifications of PBF.

A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries

Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve health outcomes in low-and middle-income countries (LMICs). This realist review aims to understand how, why and under what circumstance P4P works in LMICs.We systematically searched peer-reviewed and grey literature databases, and examined the mechanisms underpinning P4P effects on: utilisation of services, patient satisfaction, provider productivity and broader health system, and contextual factors moderating these. This evidence was then used to construct a causal loop diagram.We included 112 records (19 grey literature; 93 peer-reviewed articles) assessing P4P schemes in 36 countries. Although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.

Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research

Pay-for-performance (P4P) is the provision of financial incentives to healthcare providers based on pre-specified performance targets. P4P has been used as a policy tool to improve healthcare provision globally. However, researchers tend to cluster into those working on high or low- and middle-income countries (LMICs), with still limited knowledge exchange, potentially constraining opportunities for learning from across income settings. We reflect here on some commonalities and differences in the design of P4P schemes, research questions, methods and data across income settings. We highlight how a global perspective on knowledge synthesis could lead to innovations and further knowledge advancement.

Does performance-based financing curb stock-outs of essential medicines? Results from a randomised controlled trial in Cameroon

OBJECTIVE

In 2011, the government of Cameroon launched its performance-based financing (PBF) scheme. Our study examined the effects of the PBF intervention on the availability of essential medicines (EM).

METHODS

Randomised control trial whereby PBF and three distinct comparison groups were randomised in a total of 205 health facilities across three regions. Baseline data were collected between March and May 2012 and endline data 36 months later. We defined availability of multiple EM groups by assessing stock-outs for at least one day over the 30 days prior to the survey date and estimated changes attributable to PBF using a series of difference-in-difference regression models, adjusted for relevant facility-level covariates. Data were analysed stratified by region and area to assess effect heterogeneity.

RESULTS

Our estimates suggest that PBF intervention had no effect on the stock-outs of antenatal care drugs (P = 0.160), vaccines (P = 0.396), integrated management of childhood illness drugs (P = 0.681) and labour and delivery drugs (P = 0.589). However, the intervention was associated with a significant reduction of 34% in stock-outs of family planning medicines (P = 0.028). We observed effect heterogeneity across regions and areas, with significant decreases in stock-outs of family planning products in North-West region (P = 0.065) and in rural areas (P = 0.043).

CONCLUSIONS

The PBF intervention in Cameroon had limited effects on the reduction of EMs stock-outs. These poor results were likely the consequence of partial implementation failure, ranging from disruption and discontinuation of services to limited facility autonomy in managing decision-making and considerable delay in performance payment.

Using implementation science theories and frameworks in global health

In global health, researchers and decision makers, many of whom have medical, epidemiology or biostatistics background, are increasingly interested in evaluating the implementation of health interventions. Implementation science, particularly for the study of public policies, has existed since at least the 1930s. This science makes compelling use of explicit theories and analytic frameworks that ensure research quality and rigour. Our objective is to inform researchers and decision makers who are not familiar with this research branch about these theories and analytic frameworks. We define four models of causation used in implementation science: intervention theory, frameworks, middle-range theory and grand theory. We then explain how scientists apply these models for three main implementation studies: fidelity assessment, process evaluation and complex evaluation. For each study, we provide concrete examples from research in Cuba and Africa to better understand the implementation of health interventions in global health context. Global health researchers and decision makers with a quantitative background will not become implementation scientists after reading this article. However, we believe they will be more aware of the need for rigorous implementation evaluations of global health interventions, alongside impact evaluations, and in collaboration with social scientists.

At what cost is performance-based financing implemented? Novel evidence from Malawi

Our study estimated the full economic cost of implementing performance-based financing [PBF, the Support for Service Delivery Integration Performance-Based Incentives (SSDI-PBI) programme], as a means of first introducing strategic purchasing in a low-income setting, Malawi. Our analysis distinguished design from implementation costs and traces costs across personnel and non-personnel cost categories over the 2012-15 period. The full cost of the SSDI-PBI programme amounted to USD 3 402 187, equivalent to USD 6.46 per targeted beneficiary. The design phase accounted for about one-third (USD 1 161 332) of the total costs, while the incentives (USD 1 140 436) represented about one-third of the total cost of the intervention and about half the cost of the implementation phase. With a cost of USD 1 605 178, personnel costs represented the dominant cost category. Our study indicated that the introduction of PBF entailed consumption of a substantial amount of resources, hence representing an important opportunity cost for the health system.

Stakeholder Perceptions and Context of the Implementation of Performance-Based Financing in District Hospitals in Mali

BACKGROUND

To improve the performance of the healthcare system, Mali's government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa.

METHODS

This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle's members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership.

CONCLUSION

The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention.

To the bone: Comment on "I wanted a skeleton … they brought a prince": A qualitative investigation of factors mediating the implementation of a Performance Based Incentive program in Malawi

Recently, McMahon and colleagues set out to build on a widely-used fidelity framework, assessing the role of moderating factors during the implementation of performance-based financing programs in Malawi. Their attempt draws again the attention to the importance of approaching real word implementation issues from a theoretical perspective. It also highlights the importance of fidelity assessment within process evaluation of health programs. In this comment we argue that theoretical developments in the field of implementation science in global health would benefit from an accurate understanding of existing conceptual frameworks as well as from taking into account all contemporary contributions.

"I wanted a skeleton … they brought a prince": A qualitative investigation of factors mediating the implementation of a Performance Based Incentive program in Malawi

While several evaluations have examined the extent to which performance based financing (PBF) programs induce changes in the quantity and quality of health services provided, less is known about the process of implementing PBF. We conducted a process evaluation of a PBF intervention in Malawi that focused on understanding moderators of program implementation. Informed by a seminal theory of implementation, we first created a timeline and taxonomy of key events in the program lifeline and then undertook 25 in-depth interviews with stakeholders including implementers, central-level ministry officials and district-level health staff. While seven "moderator categories" emerged in this study, two categories (program complexity and quality of delivery) proved especially crucial in terms of moderating implementation and sparking adaptations. Complexity refers primarily to the manner in which PBF requires that those implementing the program have business acumen and forecasting skills, which are often beyond the purview of a clinician's training and thus proved challenging. Regarding quality of delivery, the program struggled to issue rewards in a timely and adequate manner, which proved highly problematic as it undermined a bedrock feature of PBF. Adaptations and adaptability refers here to a program's ability to make changes; the program proved rigid in several respects although nimble in terms of adjusting the verification process (upon noticing revengeful behaviors in peer verification). This PBF program is unique in several respects and findings cannot be generalized to all PBF programs. Nevertheless, process evaluations that draw from or expand upon existing implementation theories can allow researchers to better disentangle complex programming. We hope that more process evaluations, which track both core elements and necessary adaptations of PBF implementation, can further advance understandings of why PBF implementation functions or fails within a given setting, thereby enhancing implementers' abilities to replicate facilitators and bypass barriers.

Performance-based Financing in Africa: Time to Test Measures for Equity

Over the past 15 years, hundreds of millions of dollars have been invested in reforms founded on performance-based financing (PBF) in low- and middle-income countries. While evidence on its effectiveness and efficiency is still controversial, there appears to be an emerging consensus that equity has not been adequately considered. In this article, we show how PBF-type interventions in Africa have not sufficiently taken into account equity of access to care for the worst-off and their financial protection. In reviewing the history of health reforms in Africa, we show that this omission is nothing new. We suggest that strategic purchasing and PBF-type actions would benefit from being implemented in ways that promote equity and the financial protection of populations in Africa. Without such a reorientation of reforms, it will be impossible to achieve universal health coverage by 2030.