C onclusion and O perational I mplications
efficiency and access to quality services. Finally, rigorous third-party verification of results is another introduction by PBF that is necessitated by its direct relationship to the subsequent budget and the risks of gaming associated with the use of self-reported administrative data for making payments. Linking payments to verified outputs can be costly, but it has been particularly popular among donors who appreciate the direct relationship between payment, results, and accountability. Because of the popularity of the PBF mechanisms among donors, the overall investment in health in LMICs is likely to have increased. This chapter builds on past experience to provide a forward-looking perspective. The following four messages emerge: (1) sustainability of interventions, particularly those geared at revamping the financing of entire health systems, is critical and about more than just money; (2) the four facility tenets—provider autonomy, financial management capacity, unified payment systems, and output orientation—should be systematically supported to build health systems; (3) PBF incentives should be understood in the broader health financing context; and (4) the potential of technological advances to facilitate provider payment reform should be better examined and exploited. These key messages call for the development of a new research agenda that is more focused on the design and implementation of PBF reforms and their role in health systems strengthening.
Message 1: Recognize that sustainability is about more than just money Fiscal space for health is always constrained, but this is particularly the case as countries are struggling with the economic consequences of COVID-19 and increased expenditure pressures across all sectors. Domestic contributions to PBF engagements may therefore become more difficult to mobilize, although they may provide essential contributions to basic primary care services, and many of these reforms are recognized as quintessential for health system reform by academics and practitioners alike (Barroy et al. 2019). As long as the PBF engagement is conducted in parallel to regular PFM processes, such financial contributions may be at risk. As governments can no longer afford to finance both the regular budget and offbudget schemes, the off-budget schemes are likely to be cut. If PBF reforms were financed through off-budget schemes, this risks the sustainability of the reforms. If all the aforementioned changes (provider autonomy, 225
