An Exploration of the Unintended Consequences of Performance-Based Financing in 6 Primary Healthcare Facilities in Burkina Faso

Document Type : Original Article


1 École de santé publique de l’Université de Montréal, Montreal, QC, Canada

2 Association Action Gouvernance Intégration Renforcement (AGIR), Ouagadougou, Burkina Faso

3 IRD (French Institute for Research on Sustainable Development), CEPED, Université de Paris, Paris, France


Performance-based financing (PBF) is promoted to improve the quality and quantity of healthcare services in low-income countries. Despite the complexity of the intervention, little attention has been given to studying its unintended consequences. Our objective is to increase evidence on the unintended consequences of PBF in Burkina Faso.
Using the diffusion of innovations theory, we conducted a multiple case study. The cases were 6 healthcare facilities in two districts. Between April 2015 and 2016, we collected data through 101 semi-structured interviews, discussions, observations, and documents. We conducted thematic analysis using a hybrid deductive-inductive approach. Secondary data was used to illustrate the evolution of reported services. We conducted a cross-case synthesis to identify the results arising independently from more than 1 case.

A desirable unintended consequence of PBF was that 3 facilities limited the sale of non-prescribed medication to encourage patients to consult. Undesirable unintended consequences were found in the majority of facilities including fixation on measures rather than on underlying objectives, the pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices. Providers in all facilities deliberately manipulated medical registers and documents, such that the reported quantity and quality of care differed from what was actually delivered. While most participants indicated that PBF was more advantageous than previous practices, the long payment delays were a source of dissatisfaction and demotivation across all facilities. Dissatisfaction also emerged in relation to the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered “unqualified” in guidelines. Results in many facilities revealed suboptimal planning, a perception of the intervention as “budgetivorous,” as well as tensions related to the principle of managerial autonomy.

PBF led to numerous unintended consequences that could undermine the intervention’s effectiveness. The findings contribute to a more comprehensive picture of the consequences of implementing PBF. Policy-makers can use the results of this study to devise effective strategies before, during and after the implementation of the intervention to minimize undesirable unintended consequences and promote desirable ones.



Supplementary File 1 (Download)

Supplementary File 2 (Download)

Supplementary File 3 (Download)

Supplementary File 4 (Download)

Supplementary File 5 (Download)



  1. World Health Organization. Health Financing for Universal Coverage. Moving from Passive to Strategic Purchasing. 2019;  Accessed December 6, 2019.
  2. Kutzin J, Witter S, Jowett M, Bayarsaikhan D. Developing a National Health Financing Strategy: A Reference Guide. Geneva: World Health Organization; 2017.
  3. Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. JAMA. 2007;14(4):415-423. doi:10.1197/jamia.M2373
  4. Eijkenaar F, Emmert M, Scheppach M, Schöffski O. Effects of pay for performance in health care: a systematic review of systematic reviews. Health Policy. 2013;110:115-130. doi:10.1016/j.healthpol.2013.01.008
  5. Cashin C, Chi Y-L, Smith P, Borowitz M, Thomson S. Paying for Performance in Health Care. Implications for Health System Performance and Accountability. Berkshire: Open University Press; 2014.
  6. Gorter AC, Ir P, Meessen B. Evidence Review. Results-Based Financing of Maternal and Newborn Health Care in Low- and Lower-Middle-Income Countries. German Federal Ministry for Economic Cooperation & Development; 2013.
  7. 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(CD007899). doi:10.1002/14651858.CD007899.pub2
  8. Basinga P, Gertler PJ, Binagwaho A, Soucat ALB, Sturdy J, Vermeersch CMJ. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet. 2011;377(9775):1421-1428.
  9. Chimhutu V, Lindkvist I, Lange S. When incentives work too well: locally implemented pay for performance (P4P) and adverse sanctions towards home birth in Tanzania - a qualitative study. BMC Health Serv Res. 2014;14:23. doi:10.1186/1472-6963-14-23
  10. Kalk A, Paul FA, Grabosch E. Paying for performance in Rwanda: does it pay off? Trop Med Int Health. 2010;15(2):182-190. doi:10.1111/j.1365-3156.2009.02430.x
  11. Sieleunou I, Turcotte-Tremblay A-M, De Allegri M, et al. How does performance-based financing affect the availability of essential medicines in Cameroon? A qualitative study. Health Policy Plan. 2019;34(Supple 3):iii4-iii19. doi:10.1093/heapol/czz084
  12. Antony M, Bertone MP, Barthes O. Exploring implementation practices in results-based financing: the case of the verification in Benin. BMC Health Serv Res. 2017;17(204). doi:10.1186/s12913-017-2148-9
  13. 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(2):377-383. doi:10.1016/j.socscimed.2012.02.050
  14. Turcotte-Tremblay A-M, Gali Gali IA, De Allegri M, Ridde V. The unintended consequences of community verifications for performance-based financing in Burkina Faso. Soc Sci Med. 2017;191:226-236. doi:10.1016/j.socscimed
  15. Lohmann J, Muula AS, Houlfort N, De Allegri M. How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi. Soc Sci Med. 2018;208:1-8. doi:10.1016/j.socscimed.2018.04.053
  16. Aninanya GA, Howard N, Williams JE, et al. Can performance-based incentives improve motivation of nurses and midwives in primary facilities in northern Ghana? A quasi-experimental study. Global Health Action. 2016;9:32404. doi:10.3402/gha.v9.32404
  17. Macarayan EK, Ratcliffe HL, Otupiri E, et al. Facility management associated with improved primary health care outcomes in Ghana. PloS One. 2019;14(7):e0218662. doi:10.1371/journal.pone.0218662
  18. Maini R, Lohmann J, Hotchkiss DR, Mounier-Jack S, Borghi J. What happens when donors pull out? Examining differences in motivation between health workers who recently had performance-based financing (PBF) withdrawn with workers who never received PBF in the Democratic Republic of Congo. Int J Health Policy Manag. 2019;8(11):646-661. doi:10.15171/ijhpm.2019.55
  19. Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.
  20. Bloomrosen M, Starren J, Lorenzi NM, Ash JS, Patel VL, Shortliffe EH. Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting. J Am Med Inform Assoc. 2011;18(1):82-90. doi:10.1136/jamia.2010.007567
  21. Béland D, Ridde V. Ideas and policy implementation: understanding the resistance against free health care in Africa. Glob Health Gov. 2016;X(3):9-23.
  22. Jabeen S. Unintended outcomes evaluation approach: A plausible way to evaluate unintended outcomes of social development programmes. Eval Program Plann. 2018;68:262-274. doi:10.1016/j.evalprogplan.2017.09.005
  23. Koch D-J, Schulpen L. Introduction to the special issue ‘unintended effects of international cooperation.’ Eval Program Plann. 2018;68:202-209. doi:10.1016/j.evalprogplan.2017.10.006
  24. de Zwart F. Unintended but not unanticipated consequences. Theory Soc. 2015;44(3):283-297. doi:10.1007/s11186-015-9247-6
  25. Burlyuk O, Noutcheva G. Unintended Consequences of EU External Action. Int Spect (Rome).2019;54(1):1-15. doi:10.1080/03932729.2019.1558522
  26. Turcotte-Tremblay A-M, De Allegri M, Gali Gali IA, Ridde V. The unintended consequences of combining equity measures with performance-based financing in Burkina Faso. Int J Equity Health. 2018;17(1):109. doi:10.1186/s12939-018-0780-6
  27. Société d'études et de recherche en santé publique. Rapport d'étape de progrès de la mise en oeuvre et du suivi du processus communautaire de sélection des indigents au Burkina Faso. Ouagadougou: SERSAP; 2014.
  28. Ministère de la Santé. Evaluation finale de la phase-test du financement basé sur les résultats dans les districts sanitaires de Boulsa, Léo et Titao. Ouagadougou: Ministère de la Santé; 2013.
  29. Steenland M, Robyn PJ, Compaore P, et al. Performance-based financing to increase utilization of maternal health services: Evidence from Burkina Faso. SSM - Population Health. 2017;3:179-184. doi:10.1016/j.ssmph.2017.01.001
  30. Ministère de la Santé. Guide de mise en oeuvre du financement basé sur les résultats dans le secteur de la santé. Ouagadougou: Ministère de la Santé; 2013.
  31. Yin RK. Case Study Research: Design and Methods. 4th ed. Thousand Oaks, CA: SAGE Publications; 2009.
  32. Turcotte-Tremblay AM. The Unintended Consequences of a Complex Intervention Combining Performance-Based Financing with Health Equity Measures in Burkina Faso [Thesis]. Montreal: Department of social and preventive medicine, Université de Montréal; 2020.
  33. Zombré D, Turcotte-Tremblay A-M, Sangaré A, et al. Méthode mixte et participative de sélection d’études de cas multiples pour l’évaluation d’intervention de santé au Burkina Faso et au Mali: de l’éthique à l’émique [Poster]. Published 2016.
  34. Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. Thousand Oaks, CA: SAGE Publications; 2015.
  35. Willis JW. Foundations of Qualitative Research. Interpretive and Critical Approaches. SAGES Publications ed. Thousand Oaks, California: SAGE Publications; 2007.
  36. Spicer E. Human Problems in Technological Change. A Casebook. New York: Russell Sage Foundation; 1952.
  37. Warford MK. Testing a diffusion of innovations in education model (DIEM). Innov J. 2005;10(3):1-41.
  38. Guba EG. Criteria for assessing the trustworthiness of naturalistic inquiries. ECTJ. 1981;29(2):75. doi:10.1007/BF02766777
  39. Pluye P, Hong QN. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu Rev Public Health. 2014;35:29-45. doi:10.1146/annurev-publhealth-032013-182440
  40. Olivier de Sardan J-P, Tidjani Alou A. Epistemology, Fieldwork, and Anthropology. New York: Palgrave Macmillan; 2015.
  41. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5(1):80-92.
  42. Ministère de la Santé. Stratégie nationale de mise en œuvre du financement basé sur les résultats. Burkina Faso; 2010.
  43. ST-FBR. Résultats Quantitatifs. Ouagadougou: St-FBR; 2016.
  44. Cataldo F, Kielmann K. Qualitative Research to Enhance the Evaluation of Results-Based Financing Programmes: the Promise and the Reality. Washington, DC: World Bank Group;2016.
  45. Lipsky M. Street-Level Bureaucracy: Dilemmas of the Individual in Public Service. New York: Russell Sage Foundation; 1980.
  46. Melberg A, Diallo AH, Storeng KT, Tylleskär T, Moland KM. Policy, paperwork and ‘postographs’: global indicators and maternity care documentation in rural Burkina Faso. Soc Sci Med. 2018;215:28-35. doi:10.1016/j.socscimed.2018.09.001
  47. Maxwell JA. Using qualitative methods for causal explanation. Field Methods. 2004;16(3):243-264. doi:10.1177/1525822X04266831
  48. Maxwell JA. The importance of qualitative research for causal explanation in education. Qual Inq. 2012;18(8):655-661. doi:10.1177/1077800412452856
  49. Olivier de Sardan J-P, Bako MTA, Harouna A. Les normes pratiques en vigueur dans les secteurs de l’éducation et la santé au Niger Une base pour des réformes ancrées dans les réalités? Lasdel; 2018.
  50. Kuunibe N, Lohmann J, Schleicher M, et al. Factors associated with misreporting in performance-based financing in Burkina Faso: implications for risk-based verification. Int J Health Plann Manage. 2019;34(4):1217-1237. doi:10.1002/hpm.2786
  51. Deci EL, Ryan RM. Intrinsic Motivation and Self-determination in Human Behavior. New York: Plenum Press; 1985.
  52. Kok MC, Dieleman M, Taegtmeyer M, et al. Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plan. 2014;30(9):1207-1227. doi:10.1093/heapol/czu126
  53. Bodson O. Analyse pré évaluative de la fidélité de l’implantation de la politique de financement basé sur les résultats au Burkina Faso. Liège: Université de Liège; 2014.
  54. Paul E, Sossouhounto N, Eclou DS. Local stakeholders’ perceptions about the introduction of performance-based financing in Benin: a case study in two health districts. Int J Health Policy Manag. 2014;3(4):207-214. doi:10.15171/ijhpm.2014.93
  55. World Bank. International Development Association Project Appraisal Document on a Proposed Grant in the Amount of SDR 55.7 Million (US$80 Million Equivalent) to the Republic of Burkina Faso for a Health Services Reinforcement Project. Washington, DC: World Bank; 2018.
  56. Government of Sierra Leone. Education Sector Plan 2018-2020. Sierra Leone; December 17, 2019.
Volume 11, Issue 2
February 2022
Pages 145-159
  • Receive Date: 02 September 2019
  • Revise Date: 29 April 2020
  • Accept Date: 27 May 2020
  • First Publish Date: 01 February 2022