Conclusions

intervention in both countries included the removal of user fees, but this displaced a greater source of revenue in Nigeria. To some extent, health workers may have compensated by cutting back on some dimensions of the quality of care, including tests for which they may have received additional payments from the patients, as the health workers’ income was less dependent on these payments.

This chapter considered the evidence available from impact evaluations of PBF pilots, as well as from the academic literature, to shed light on several questions about the use of PBF to improve effective coverage. It began with a stylized theoretical discussion of the various channels through which PBF interacts with the health system to possibly produce changes in population health. The channels discussed are consistent with an early hypothesis that PBF would improve health worker effort and thus the quality of care provided in primary health care settings (Fritsche, Soeters, and Meessen 2014). At the same time, these PBF programs have come under criticism on several counts, in particular their complexity of design and implementation, donor-driven backing, and potential to degrade health systems by crowding out intrinsic health worker motivation (Shroff, Bigdeli, and Meessen 2017; Ireland, Paul, and Dujardin 2011; Meessen, Soucat, and Sekabaraga 2011; Paul et al. 2018; Paul, Brown, and Ridde 2020). The chapter thus considered impacts on service utilization and quality of care as well as health worker motivation and satisfaction.

A review of the evidence and results from the primary analysis showed that PBF improves at least some measures of structural capacity, highlighting the need for continued investments in facility infrastructure. Then, the chapter delved further into the evidence on PBF schemes and their impacts on effective coverage. It found that in most contexts, PBF leads to some improvements in terms of coverage. However, the chapter found limited and mixed evidence that PBF has a significant impact on effective coverage or quality of care, although it did not find that PBF negatively impacts health worker motivation. Perhaps the most salient takeaway from this analysis is that heterogeneity in impact highlights the complexity of implementation. Chapter 6 further investigates the impact of PBF and compares it with policy alternatives such as demand-side incentives and direct facility financing.