Performance-based financing: the need for more research

While several developing countries have been implementing PBF as a strategy to finance health services, a polarized debate between the “proponents” and “opponents” of this approach is gaining prominence.^1–4 Ireland et al.⁵ provide a critical view on the paper by Meessen et al.,⁶ mainly opposing the argument that PBF, on its own, can be considered as a strategy to reform health systems in developing countries. One of their main criticisms is the lack of evidence. Evidence, of course, should ideally be central to any health sector reform but applying this rule rigorously can lead to inertia. Looking back on the history of public health, we note that many important health reforms implemented in Africa – such as selective primary care for child survival or the health district strategy – were not developed based on recommendations from rigorous experimental studies.⁷ Health reformers should carefully consider different opportunities based on their potential to maximize the delivery and uptake of proven maternal and child health interventions.⁸

As African public health experts, we believe that PBF is interesting due to its potential. Having said this, we agree that implementing health reforms based on evidence is crucial. For example, some components of selective primary health care, such as growth monitoring, were implemented even though little was known about their cost-effectiveness.⁷ However, a recent evaluation of the primary-care approach has shown interesting results⁹ and the global public health community has since gained important knowledge on successful interventions in primary health care.

We think that Ireland et al. minimize the growing body of evidence on PBF implementation produced in recent years. Many studies have been published providing details on how to implement PBF and one experimental study has been published on the impact of the approach.¹⁰ Clearly, rigorous research is still needed, especially more theoretical and qualitative studies that address the “how and why” and test hypotheses of potential adverse effects of PBF. Continuous checking and integration of the PBF approach is needed during implementation and this should be informed by operational research aimed at aligning PBF with the existing health system.

The World Bank, through a grant from the Government of Norway, has launched several PBF initiatives in developing countries, systematically accompanied with an impact evaluation strategy using different innovative research designs.¹¹ These initiatives should include formative research to address the rapidly changing social and political context that may influence policy implementation.¹²

The debate around PBF should be evidence-based with critical appraisal. Both proponents and opponents should avoid taking a dogmatic position. Both parties have agreed that PBF is not a panacea. The provision of input items and other key interventions, such as provider training, supervision and health-system strengthening, should continue with the aim of producing results. A research agenda and an effective community of practice embracing all views on PBF is critical to understanding more about its potential for helping developing countries to reach some of the United Nations Millennium Development Goals.