P erformance - B ased F inancing I mproves C overage
care that are in part financial—directly addressing these barriers may improve coverage; (2) inadequate supply-side financing that affects the availability of staff and other key inputs to the production of effective coverage; (3) ineffective health system management practices, which can be improved through goal setting, supportive feedback, and so forth, which in turn can better martial existing resources to produce effective coverage; and (4), related to (3), strategies to motivate health workers independent of financial incentives. An effective PBF program would thus provide incentives at the margins that a health worker can control, and these programs can have a broader place under health financing. However, other constraints to improving effective coverage might be better addressed under alternative financing mechanisms or other approaches to health system reform. The conceptual framework provided here identifies several dimensions along which it may be expected that financial incentives would affect the coverage of services, quality of care, and perhaps even health equity. The next section turns to recent evidence on the impact of PBF on these dimensions in the contexts of primary health service delivery in LMICs.
Evidence of the impact of PBF on the quality and quantity of health service delivery in LMICs An early PBF pilot that was implemented in Rwanda showed that the use of performance pay for strategic purchasing successfully increased institutional delivery rates (Basinga et al. 2011). Considering this evidence and the persistent conundrum of health system financing in LMICs, several donors and lending agencies encouraged governments in LMICs to adopt PBF approaches. The argument made in favor of these interventions was that PBF improves both the efficiency and the quality of care (Shroff, Bigdeli, and Meessen 2017; Ireland, Paul, and Dujardin 2011). The World Bank’s Health Results Innovation Trust Fund (HRITF) supports and evaluates LMIC governments in paying providers based on their results in the provision of maternal, newborn, and child health care (see box 1.1, in chapter 1). Of the completed impact evaluations in the HRITF portfolio, most of them present at least some evidence of impacts on service utilization and many on quality of care (Kandpal 2016). Most frequently, the impacts on quality are observed on structural quality, with all the studies in question reporting improvements in the availability of basic delivery and antenatal 107
