International Journal of Health Policy and Management

International Journal of Health Policy and Management

Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach

Document Type : Original Article

Authors
Elisabeth Paul 1
Mohamed Lamine Dramé 2
Jean-Pierre Kashala 2
Armand Ekambi Ndema 2
Marcel Kounnou 3
Julien Codjovi Aïssan 4
Karel Gyselinck 5
1 Economie politique et économie de la santé, Faculté des Sciences sociales, Université de Liège, Liège, Belgium
2 PASS-Sourou Programme, Belgian Development Agency, Benin
3 Comé District, Ministry of Health, Comé, Benin
4 Atacora-Donga Departmental Health Team, Ministry of Health, Natitingou, Benin
5 Belgian Development Agency, Brussels, Belgium
10.15171/ijhpm.2017.42
Abstract
Background
Performance-based financing (PBF) is often proposed as a way to improve health system performance. In Benin, PBF was launched in 2012 through a World Bank-supported project. The Belgian Development Agency (BTC) followed suit through a health system strengthening (HSS) project. This paper analyses and draws lessons from the experience of BTC-supported PBF alternative approach – especially with regards to institutional aspects, the role of demand-side actors, ownership, and cost-effectiveness – and explores the mechanisms at stake so as to better understand how the “PBF package” functions and produces effects.
 
Methods
An exploratory, theory-driven evaluation approach was adopted. Causal mechanisms through which PBF is hypothesised to impact on results were singled out and explored. This paper stems from the co-authors’ capitalisation of experiences; mixed methods were used to collect, triangulate and analyse information. Results are structured along Witter et al framework.
 
Results
Influence of context is strong over PBF in Benin; the policy is donor-driven. BTC did not adopt the World Bank’s mainstream PBF model, but developed an alternative approach in line with its HSS support programme, which is grounded on existing domestic institutions. The main features of this approach are described (decentralised governance, peer review verification, counter-verification entrusted to health service users’ platforms), as well as its adaptive process. PBF has contributed to strengthen various aspects of the health system and led to modest progress in utilisation of health services, but noticeable improvements in healthcare quality. Three mechanisms explaining observed outcomes within the context are described: comprehensive HSS at district level; acting on health workers’ motivation through a complex package of incentives; and increased accountability by reinforcing dialogue with demand-side actors. Cost-effectiveness and sustainability issues are also discussed.
 
Conclusion
BTC’s alternative PBF approach is both promising in terms of effects, ownership and sustainability, and less resource consuming. This experience testifies that PBF is not a uniform or rigid model, and opens the policy ground for recipient governments to put their own emphasis and priorities and design ad hoc models adapted to their context specificities. However, integrating PBF within the normal functioning of local health systems, in line with other reforms, is a big challenge.
Keywords
Performance-Based Financing (PBF)
Health System Strengthening (HSS)
Local Health System
Benin
Low-
and Middle-Income Countries (LMICs)
Demand-Side Actors
Subjects

"Watch the Video Summary"

  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(2):153-156. doi:10.2471/BLT.10.077339
  2. 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
  3. Basinga P, Gertler PJ, Binagwaho A, et al. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet. 2011;377(9775:421-1428. doi:10.1016/S0140-6736(11)60177-3
  4. 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(7):830-837. doi:10.1111/j.1365-3156.2009.02292.x
  5. Renmans D, Holvoet N, Garimoi Orach C, Criel B. Opening the ‘black box’ of performance-based financing in low- and lower middle-income countries: a review of the literature. Health Policy Plan. 2016;31(9):1297-1309. doi:10.1093/heapol/czw045
  6. 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
  7. Van Belle S, Marchal B, Dubourg D, Kegels G. How to develop a theory-driven evaluation design? Lessons learned from an adolescent sexual and reproductive health programme in West Africa. BMC Public Health. 2010;10(1):741. doi:10.1186/1471-2458-10-741
  8. Belgian Development Agency. Dossier technique et financier – Programme d’appui au secteur de la sante “PASS-Sourou”, Bénin. 2014. Code DGD: NN 3014055. Code navision: BEN 13 025 11.
  9. De Zutter P. Des histoires, des savoirs, des hommes. l’expérience est un capital. Série Dossiers pour un débat n°35. Paris: Eds. Charles-Léopold Meyer; 1994.
  10. 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 2014;3(4):207-214. doi:10.15171/ijhpm.2014.93
  11. Etats généraux de la santé au Bénin. Rapport général, Cotonou, November 21-24, 2007.
  12. République du Bénin, Ministère de la Santé. Plan national de développement sanitaire 2009-2018.
  13. World Bank. ‘Project Appraisal Document on a Proposed IDA Grant in the Amount of SDR 14.9 million (US$22.8 million equivalent) of which SDR 5.1 million originates from pilot CRW resources (US$7.8 million equivalent) to the Republic of Benin for a Health System Performance Project’, Report No: 53930-BJ; April 9, 2010.
  14. Fritsche GB, Soeters R, Meessen B. Performance-Based Financing Toolkit. Washington, DC: The World Bank; 2014.
  15. République du Bénin, Ministère de la Santé. La pérennisation du financement basé sur les résultats (FBR) dans le secteur de la santé au Bénin. Aide-mémoire de la mission conjointe du 12 au 16 octobre 2015.
  16. République du Bénin, Ministère de la Santé. La pérennisation du financement basé sur les résultats (FBR) dans le secteur de la santé au Bénin. Aide-mémoire de la mission conjointe du 5 au 8 juillet 2016.
  17. Jansen C, Lodi E, Lodenstein E, Toonen J, eds. Vers une couverture maladie universelle au Bénin (Towards universal health coverage in Benin). Amsterdam: KIT Publishers; 2013.
  18. AEDES/Scen-Afrik. PRPSS. Analyse du coût de la vérification et de l’AT dans le cadre du FBR au Bénin; Power Point Presentation, July 2016.
  19. Johnson P, Bello K, Meessen B, Korachais C. Effets des expériences du financement basé sur les résultats (FBR) dans le secteur de la santé au Bénin. Une analyse à partir des données de routine collectées de 2010 à 2015. Institute of Tropical Medicine, Antwerp, and CERRHUD for Gavi and the Global Fund; July 2016.
  20. Sambiéni NE (Dir.). Les mécanismes à l’œuvre dans la production d’effets différenciés du financement basé sur les résultats (FBR) dans le secteur de la santé au Bénin, rapport général (financement: Fonds mondial). Université de Parakou, FLASH; 2016.
  21. Paul E, Renmans D. Performance-based financing in the heath sector in low- and middle-income countries: Is there anything whereof it may be said, see, this is new? Int J Health Plann Manage. 2017. doi:10.1002/hpm.2409
  22. Bertone MP, M Lagarde, S Witter. Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone. BMC Health Serv Res. 2016;16:286. doi:10.1186/s12913-016-1546-8
  23. Lemière C, De Walque D, Ayivi-Guedehoussou N, Juquois M. Evaluation d’Impact du Financement Basé sur les Résultats, Rapport d’analyse de l’enquête de base; 2012.
  24. Ghesquière G, Hounouvi AT, Dramé ML, Gyselinck K, Paul E. Les opportunités du financement basé sur les résultats comme plateforme d’interactions entre l’offre et la demande pour le renforcement du système local de santé au Bénin. Belgian Development Agency (BTC); November 2015.
  25. Community of Practice Health Service Delivery. Renewing health districts for advancing universal health coverage in Africa. Report of the regional conference “Health districts in Africa: progress and perspectives 25 years after the Harare Declaration”; October 21-23, 2013; Dakar, Senegal.
  26. Peerenboom PB, Basenya O, Bossuyt M et al. La bonne gouvernance dans la réforme du financement du système de santé au Burundi. Santé Publique 2014;2(26):229-240.
  27. Nahimana E, McBain R, Manzi A, et al. Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda. Glob Health Action. 2016;28;9:32943. Doi:10.3402/gha.v9.32943
  28. Bhatnagar A, George AS. Motivating Health Workers Up to a Limit: Partial Effects of Performance-Based Financing on Working Environments in Nigeria. Health Policy Plan. 2016;31(7):868-877. doi:10.1093/heapol/czw002
  29. Lohmann J, Houlfort N, De Allegri M. Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing. Soc Sci  Med. 2016;169:1-8. doi:10.1016/j.socscimed.2016.09.006
  30. Aninanya GA, Howard N, William JE, et al. Can performance-based incentives improve motivation of nurses and midwives in primary facilities in northern Ghana? A quasi-experimental study. Glob Health Action 2016;9:32404. doi:10.3402/gha.v9.32404
  31. Khim K. Are health workers motivated by income? Job motivation of Cambodian primary health workers implementing performance-based financing. Glob Health Action. 2016;9:31068. doi:10.3402/gha.v9.31068
  32. Shen GC, Nguyen HTH, Das A, Sachingongu N, Chansa C, Qamruddin J, Friedman J. Incentives to change: effects of performance-based financing on health workers in Zambia. Hum Resour Health. 2017;15(1):20. doi:10.1186/s12960-017-0179-2
  33. 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
  34. 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(9):695-698. doi:10.2471/BLT.11.087379
  35. Borghi J, Little R, Binyaruka P, Patouillard E, & Kuwawenaruwa A. In Tanzania, the many costs of pay-for-performance leave open to debate whether the strategy is cost-effective. Health Affairs. 2015;34(3):406-414. doi:10.1377/hlthaff.2014.0608
  36. Paul E. Marché de services relatif à réalisation d’une étude sur la viabilité et la pérennisation de l’approche du Financement Basé sur les Résultats (FBR) au Bénin – Rapport final, CSC BTC/CTB BEN 405. Published July 18, 2016.
International Journal of Health Policy and Management
Volume 7, Issue 1
2018
Pages 35-47

  • Received Date 04 January 2017
  • Revised Date 21 March 2017
  • Accepted Date 25 March 2017
  • First Published Date 01 January 2018
  • Published Date 01 January 2018