Julia Lohmann | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 21, 2015

Background: Performance-based financing (PBF) has received considerable attention from low and middle income country governments and development partners in recent years. PBF schemes attempt to compensate for the lack of incentives for high performance inherent in traditional input-based health financing systems by linking health care provider reimbursements to measurable performance indicators, adopting long-established private sector practices of tying parts of the salary to work performance. While there is an increasing body of evidence on the impact of PBF on health service coverage and quality, little is known about the ‘PBF black box’–the mechanisms and processes through which PBF schemes exert (or not) their impact on health system performance. Such research is urgently needed to understand mixed impact evaluation results, and to improve on PBF intervention design.

Methodology: We addressed this gap in knowledge by exploring health workers’ perceptions of and reactions to the performance-based incentives in the context of an impact evaluation of the Malawian Results-Based Financing for Maternal and Neonatal Health Initiative. Specifically, we conducted in-depth interviews and a structured survey with health workers in the 17 intervention health facilities one and two years after the introduction of the intervention.

Results: We present the results of our research, discussing key themes related to incentive amounts, distribution, and use, such as expectations, fairness, transparency, and autonomy. We pay particular attention to the difference between individual and collective incentives, as well as to changes in perceptions and reactions over time.

Conclusions: Our findings give insight into factors associated with success or failure of PBF schemes, and provide guidance for future PBF design. Understanding the effects of PBF programs on providers will be critical to understand theory of change, and reasons for PBF success and failure in achieving objectives.