This study describe how quality of care is incorporated into performance-based financing (PBF) programmes, what quality indicators are being used, and how these indicators are measured and verified. An exploratory scoping methodology was used to characterise the full range of quality components in 32 PBF programmes, initiated between 2008 and 2015 in 28 low- and middle-income countries, totalling 68 quality tools and 8,490 quality indicators. The programmes were identified through a review of the peer-reviewed and grey literature as well as through expert consultation with key funder representatives. Most of the PBF programmes were implemented in sub-Saharan Africa and most were funded primarily by the World Bank. On average, PBF quality tools contained 125 indicators predominately assessing maternal, newborn, and child health and facility management and infrastructure. Indicators were primarily measured via checklists which largely (over 90%) measured structural aspects of quality, such as equipment, beds, and infrastructure. Of the most common indicators across checklists, 74% measured structural aspects and 24% measured processes of clinical care. The quality portion of the payment formulas were in the form of bonuses (59%), penalties (27%), or both (hybrid) (14%). The median percentage (of a performance payment) allocated to health facilities was 60%, ranging from 10% to 100%, while the median percentage allocated to health care providers was 55%, ranging from 20% to 80%. Nearly all of the programmes included in the analysis (91%) verified quality scores quarterly (every 3 months), typically by regional government teams. PBF is argued by the authors to be a potentially appealing instrument to link verified performance measurement with strategic incentives and could ultimately help meet policy priorities. They also raise substantial variation and complexity in how PBF programmes incorporate quality of care considerations suggesting a need to further examine whether differences in design are associated with differential programme impacts.
Resource allocation and health financing
In many developing countries where the majority of the population works in the informal sector, there are critical debates over the best financing mechanisms to progress towards UHC. In Kenya, government health policy has prioritized a contributory financing strategy (social health insurance) as the main financing mechanism for UHC. However, there are currently no studies that have assessed the cost of either social health insurance (SHI) as the contributory approach or an alternative financing mechanism involving non-contributory (general tax funding) approaches to UHC in Kenya. This study critically assessed the financial requirements of both contributory and non-contributory mechanisms to financing UHC in Kenya in the context of large informal sector populations, to provide estimates of financial resource needs for UHC over a 17-year period (2013-2030). The 17-year period was necessary because the Government of Kenya aims to achieve UHC by 2030. The results show that SHI is financially sustainable (that is expenditure does not outstrip revenue) within the first five years of implementation, but it becomes less sustainable with time. Modelling for a non-contributory scenario, on the other hand, showed greater sustainability both in the short- and long-term. The financial resource requirements for universal access to health care through general government revenue are compared with a contributory health insurance scheme approach. Although both funding options would require considerable government subsidies, given the magnitude of the informal sector in Kenya and their limited financial capacity, a tax-funded system would be less costly and more sustainable in the long-term than an insurance scheme approach. However, more innovative financing for health care as well as giving the health sector higher priority in government expenditure will be required to make the non-contributory financing mechanism more sustainable.
Health systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. Expansion of health insurance is being promoted in the quest for sustainable healthcare financing for many of the health systems in the region. However, the broader policy implications of expanding health insurance coverage have not been fully investigated and contextualised to many African health systems. The authors interviewed 37 key informants drawn from public, private and civil society organisations involved in health service delivery in Botswana. They aimed to determine the potential health system impacts that would result from expanding the health insurance scheme covering public sector employees. Study participants were selected through purposeful sampling, stakeholder mapping, and snowballing. The authors thematically synthesised their views, focusing on the key health system areas of access to medicines, efficiency and cost-effectiveness, as intermediate milestones towards universal health coverage. Participants suggested that expansion of health insurance would be characterised by increased financial resources for health and catalyse an upsurge in utilisation of health services particularly among those with health insurance cover. As a result, the health system, particularly within the private sector, would be expected to see higher demand for medicines and other health technologies. However, majority of the respondents cautioned that, realising the full benefits of improved population health, equitable distribution and financial risk protection, would be wholly dependent on having sound policies, regulations and functional accountability systems in place. It was recommended that, health system stewards should embrace efficient and cost-effective delivery, in order to make progress towards universal health coverage. Despite the prospects of increasing financial resources available for health service delivery, expansion of health insurance is reported to come with many challenges. They argue that decision-makers keen to achieve universal health coverage, must view health financing reform through the holistic lens of the health system and its interactions with the population, in order to anticipate its potential benefits and risks. Failure to embrace this comprehensive approach, would potentially lead to counterproductive results.
WHO estimates an additional 250 000 mortalities between 2030 and 2050 will be attributable to climate-associated increases in malnutrition, malaria, diarrhoea, respiratory disease, water inaccessibility, and heat stress. Spillover effects on state and regional security are argued to be inevitable. The World Economic Forum has identified climate change as the single greatest threat to global stability because of its considerable consequences on the health and stability of developing nations. The complex interaction between climate change, health system burdens, and poor health outcomes, and their subsequent impact on politics, security, and society can be captured within the concept of a so-called climate-health-security nexus. Many of the world's poorest and most politically fragile nations lie at the centre of this nexus. Within this nexus, poverty, state fragility, poor pre-existing health outcomes, and high susceptibility to climate change converge to amplify the effects of future famines, droughts, and neglected tropical diseases. This amplification subsequently leads to worsened economies, social instability, and reliance on external support. The nations most at risk for climate-triggered health crises are primarily scattered throughout sub-Saharan Africa and south Asia and are already afflicted by the highest rates of disease burden globally (table, appendix). Notably, most of these countries are low-income nations without the resources to adequately contend with climate-related challenges.
Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers’ job satisfaction, motivation, and attrition in Zambia. It uses a randomised intervention/control design to evaluate before–after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. Mixed methods were employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion sought to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centres were staffed with qualified personnel and the personnel had role clarity. In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.
In 2013, Zimbabwe’s voluntary medical male circumcision (VMMC) program adopted performance-based financing (PBF) to speed progress towards ambitious VMMC targets. The PBF intended to encourage low-paid healthcare workers to remain in the public sector and to strengthen the public healthcare system. The majority of the incentive supports healthcare workers who perform VMMC alongside other routine services; a small portion supports province, district, and facility levels. This qualitative study assessed the effect of the PBF on healthcare worker motivation, satisfaction, and professional relationships. The study objectives were to: 1) Gain understanding of the advantages and disadvantages of PBF at the healthcare worker level; 2) Gain understanding of the advantages and disadvantages of PBF at the site level; and 3) Inform scale up, modification, or discontinuation of PBF for the national VMMC program. Sixteen focus groups were conducted: eight with healthcare workers who received PBF for VMMC and eight with healthcare workers in the same clinics who did not work in VMMC and, therefore, did not receive PBF. Fourteen key informant interviews ascertained administrator opinion. Findings suggest that PBF appreciably increased motivation among VMMC teams and helped improve facilities where VMMC services are provided. However, PBF appears to contribute to antagonism at the workplace, creating divisiveness that may reach beyond VMMC. PBF may also cause distortion in the healthcare system: Healthcare workers prioritised incentivised VMMC services over other routine duties. To reduce workplace tension and improve the VMMC program, participants suggested increasing healthcare worker training in VMMC to expand PBF beneficiaries and strengthening integration of VMMC services into routine care. In the low-resource, short-staffed context of Zimbabwe, PBF enabled rapid VMMC scale up and achievement of ambitious targets; however, side effects make PBF less advantageous and sustainable than envisioned. Careful consideration is warranted in choosing whether, and how, to implement PBF to prioritise a public health program.
Despite the proliferation of the term ‘fiscal space for health’ in recent years, there has been no comprehensive review of how the concept can be applied to assess and support the expansion of resources for the health sector. There is also a certain amount of confusion regarding the conceptual underpinnings and application of fiscal space for health analysis, notably regarding the way in which such analysis can help countries realise potential fiscal space for health expansion. In this paper, a qualitative review of 35 studies was undertaken in four stages to identify all fiscal space for health studies and to systematically assess their findings and methods. These four stages involved a literature search, crowd-sourcing techniques, data extraction, and comprehensive qualitative analysis. The study shows that economic growth, budget re-prioritisation and efficiency improving measures are the main drivers of fiscal space for health expansion. There is scarce evidence regarding the prospective role of earmarked funds, and development assistance for health in expanding fiscal space for the sector. The lack of standardised methods and metrics to systematically assess fiscal space for health results in variations in the analytical approaches used, and limits study relevance and applicability for policy reform. The paper concludes that a more contextualised approach to fiscal space analysis is required, which focuses on key sources of fiscal space for health expansion and includes efficiency enhancements. Fiscal space analysis should be systematically embedded in domestic budgeting processes and explicitly consider both technical and political feasibility of assessed options. Adopting this approach could offer considerable potential for optimising government budget and expenditure decisions and more effectively support progress toward UHC.
South Africa could prevent almost half-a-million deaths over 40 years by introducing its proposed tax on sugary drinks, according to the World Health Organisation (WHO). “No country in the world has hit obesity with a 20% tax, so South Africa could be a world leader and reduce childhood obesity,” said the WHO’s Dr Temo Waqanivalu. He was speaking at the recent public hearing on the proposed tax on sugary drinks, convened by parliament’s committees of finance and health. “A child eating burger and chips, washed down with sugary drink and followed by crisps and chocolate bar, would have to run a half-marathon to get rid of the effects. You cannot out-exercise a bad diet,” said Waqanivalu. The report says at the packed meeting, all parties agreed that South Africa had a significant problem with obesity but while academics praised the tax, industry players pleaded for other measures. Treasury has proposed a tax of 2.29c per gram of sugar on soft drinks, which would work out to be about a 20% tax on a Coca Cola.
Priority setting and resource allocation in healthcare organisations often involves the balancing of competing interests and values in the context of hierarchical and politically complex settings with multiple interacting actor relationships. Despite this, few studies have examined the influence of actor and power dynamics on priority setting practices in healthcare organisations. This paper examines the influence of power relations among different actors on the implementation of priority setting and resource allocation processes in public hospitals in Kenya. The authors used a qualitative case study approach to examine priority setting and resource allocation practices in two public hospitals in coastal Kenya. They collected data by a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations in case study hospitals over a period of 7 months. The authors applied a combination of two frameworks, Norman Long’s actor interface analysis and VeneKlasen and Miller’s expressions of power framework to examine and interpret findings. The interactions of actors in the case study hospitals resulted in socially constructed interfaces between: 1) senior managers and middle level managers 2) non-clinical managers and clinicians, and 3) hospital managers and the community. Power imbalances resulted in the exclusion of middle level managers (in one of the hospitals) and clinicians and the community (in both hospitals) from decision making processes. This resulted in, amongst others, perceptions of unfairness, and reduced motivation in hospital staff. It also puts to question the legitimacy of priority setting processes in these hospitals. The authors suggest that designing hospital decision making structures to strengthen participation and inclusion of relevant stakeholders could improve priority setting practices. This should however, be accompanied by measures to empower stakeholders to contribute to decision making. They also suggest that strengthening soft leadership skills of hospital managers could also contribute to managing the power dynamics among actors in hospital priority setting processes.
This paper examines the potential to expand public HIV financing, and the extent to which governments have been utilising these options. First, with data from the 14 most HIV-affected countries in sub-Saharan Africa, the authors estimate the potential increase in public HIV financing from economic growth, increased general revenue generation, greater health and HIV prioritisation, as well as from more unconventional and innovative sources, including borrowing, health-earmarked resources, efficiency gains, and complementary non-HIV investments. The authors then adopt a novel empirical approach to explore which options are most likely to translate into tangible public financing, based on cross-sectional econometric analyses of 92 low and middle-income country governments' most recent HIV expenditure between 2008 and 2012. If all fiscal sources were simultaneously leveraged in the next five years, public HIV spending in these 14 countries could, it is estimated, increase from US$3.04 to US$10.84 billion per year. This could cover resource requirements in South Africa, Botswana, Namibia, Kenya, Nigeria, Ethiopia, and Swaziland, but not even half the requirements in the remaining countries. The empirical results suggest that, in reality, even less fiscal space could be created (a reduction by over half) and only from more conventional sources. International financing may also crowd in public financing. The authors observe that most HIV-affected lower-income countries in sub-Saharan Africa will not be able to generate sufficient public resources for HIV in the medium-term, even if they take very bold measures. Considerable international financing will be required for years to come. HIV funders will need to engage with broader health and development financing to improve government revenue-raising and efficiencies