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. 2020 Dec;18(6):801-810.
doi: 10.1007/s40258-020-00567-8.

Performance-Based Financing, Basic Packages of Health Services and User-Fee Exemption Mechanisms: An Analysis of Health-Financing Policy Integration in Three Fragile and Conflict-Affected Settings

Eelco Jacobs  1 , Maria Paola Bertone  2 , Jurrien Toonen  3 , Ngozi Akwataghibe  3 , Sophie Witter  2
Affiliations

Performance-Based Financing, Basic Packages of Health Services and User-Fee Exemption Mechanisms: An Analysis of Health-Financing Policy Integration in Three Fragile and Conflict-Affected Settings

Eelco Jacobs et al. Appl Health Econ Health Policy. 2020 Dec.

Erratum in

Abstract

Background: As performance-based financing (PBF) is increasingly implemented across sub-Saharan Africa, some authors have suggested that it could be a 'stepping stone' for health-system strengthening and broad health-financing reforms. However, so far, few studies have looked at whether and how PBF is aligned to and integrated with national health-financing strategies, particularly in fragile and conflict-affected settings.

Objective: This study attempts to address the existing research gap by exploring the role of PBF with reference to: (1) user fees/exemption policies and (2) basic packages of health services and benefit packages in the Central African Republic, Democratic Republic of Congo and Nigeria.

Methods: The comparative case study is based on document review, key informant interviews and focus-group discussions with stakeholders at national and subnational levels.

Results: The findings highlight different experiences in terms of PBF's integration. Although (formal or informal) fee exemption or reduction practices exist in all settings, their implementation is not uniform and they are often introduced by external programmes, including PBF, in an uncoordinated and vertical fashion. Additionally, the degree to which PBF indicators lists are aligned to the national basic packages of health services varies across cases, and is influenced by factors such as funders' priorities and budgetary concerns.

Conclusions: Overall, we find that where national leadership is stronger, PBF is better integrated and more in line with the health-financing regulations and, during phases of acute crisis, can provide structure and organisation to the system. Where governmental stewardship is weaker, PBF may result in another parallel programme, potentially increasing fragmentation in health financing and inequalities between areas supported by different donors.

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Conflict of interest statement

Ethics approval for this study was obtained from the Research Ethics Panel of Queen Margaret University (Edinburgh). Informed consent was obtained from every interviewee and FGD participant, after they had been informed of the study objectives and been offered the possibility to refrain from answering or withdraw from the interview/discussion at any point without further consequences. The authors declare that they have no competing interests. We acknowledge the financial support of The UK Department for International Development (DFID) through the ReBUILD grant, as well as the support of the African Economic Research Council. The views expressed do not necessarily reflect official policies of the UK government or of our funders.

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