six countries

However, most Health Results Innovation Trust Fund pilots typically intervened in the primary health setting. Here, evidence of health impacts is more limited. In the initial Rwanda pilot, there was evidence of a 69 percent reduction in wasting among children younger than age three, and in Zimbabwe, a 36 percent reduction in severe stunting.

Apart from these instances, in primary health care, evidence linking PBF to improved health outcomes is rare. For instance, Gage and Bauhoff (2020) assess the impact of PBF programs on neonatal health outcomes in Africa. They pool Demographic and Health Surveys and Multiple Indicator Cluster Surveys in Burundi, Lesotho, Senegal, Zambia, and Zimbabwe to estimate the effect of World Bank-supported PBF projects on early neonatal mortality and low birthweight. They do not find a statistically significant impact of PBF on neonatal mortality. In contrast, Kaila and Kandpal (2021) use nationally representative household surveys and administrative data from Nigeria and find that the PBF intervention reduced neonatal mortality relative to business-asusual, although not to the policy counterfactual of direct facility financing (discussed in chapter 6).

Impact of PBF on health worker motivation and satisfaction in six countries

There have been long-standing concerns that PBF schemes can lead to reductions in health worker motivation (Paul et al. 2018). Scholars have argued, as discussed in further detail in box 5.2, that while PBF may improve extrinsic motivation driven by financial rewards, there can be an equal or more powerful crowding-out of intrinsic motivation, resulting in an ambiguous effect on overall health worker motivation. Intrinsic motivation, driven by factors such as autonomy, altruism, and purpose, is likely to be strong among health providers who perform cognitively complex tasks in suboptimal settings (Lohmann, Houlfort, and De Allegri 2016; Himmelstein, Ariely, and Woolhandler 2014). Given this, the idea of “intrinsic motivation crowding-out” is important in the context of LMIC health systems.

Although health worker motivation is recognized to be a key element in bringing about changes in health worker performance, the exact motivation mechanisms through which PBF affects health worker performance are poorly understood in the context of LMIC health systems