Building a forward-looking research agenda

The example in box 8.1 shows how processes can be supported through various technological innovations that together facilitate a more efficient, transparent, and accountable way to engage through means that were previously unimaginable. An important first step in this process is a feasibility assessment that explores the cost and realism of such an approach and identifies any potential downside risks. This assessment must also consider the policy environment, local capacity, political economy, and how such an approach would build on existing infrastructure.

While technological advances are rapid and hold promise, these should be explored with caution. An enabling policy environment is necessary for making such investments effective, and this is not always a given. Political economy and change management considerations are necessary as such investments can be disruptive and challenge power relationships. Further, there are potential downside risks, such as the use of personal identity data for the wrong purposes, that need to be fully understood and mitigated.

Many PBF initiatives have meticulously documented their performance, and thanks to rigorous impact evaluations, it can be seen where the approach has worked. However, the PBF initiatives studied in these impact evaluations are a set of interventions that include aspects like autonomy, community engagement, decentralization, and enhanced supervision—not just the purchasing mechanism. These studies have revealed the effects of the set of interventions vis-à-vis the status quo or against another counterfactual package of interventions, such as DFF. However, a health system or PFM practitioner might be most interested in the marginal effect of any one of the above-mentioned changes. For example, what is the effect of allowing greater facility autonomy, and what might it take to get there? Can facilities be introduced one by one into the government’s chart of accounts? Sending funds to providers might require training them in accounting and reporting. Is this realistic, and how would it affect accountability and service delivery?

It may be most useful for practitioners to understand these individual effects and view PBF as a point on a continuum of DFF. When viewed as a continuum and broken down into its component parts, each aspect can be addressed and studied individually to pursue meaningful reforms in the PFM space. These may mimic specific PBF processes and would affect