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.
Resource allocation and health financing
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
KEMRI-Wellcome Trust has conducted research to understand how county hospitals in Coastal Kenya set priorities and allocate resources between services. Data was collected in 2012 and 2013. This brief presents the key findings from the research, showing how hospital managers set priorities and the reasons behind their decisions. Even though the study was conducted pre-devolution, findings remain relevant post-devolution, especially in counties where hospitals still enjoy financial autonomy and as they plan ways to structure hospital financing and priority setting. The brief provides recommendations for county departments of health to improve hospital financing and budgeting, and for hospital managers to improve priority setting and ensure a fair allocation of resources between services. Key messages from the report included that hospitals lack explicit processes for setting healthcare priorities; this provides room for the use of inappropriate priority setting criteria such as lobbying and favouritism. Evidence is not used in decision- making. Hospitals are severely under-resourced and depend on user fee revenues. This has turned hospitals into revenue-maximisers whereby managers prioritise services that generate revenue through user-fees and overlook services with limited moneymaking potential, including those for young children and disabled people. Many key stakeholders including middle level managers, clinicians and community members, are not included in priority setting processes. It is important for hospital managers to institute clearly defined procedures and ensure that priority setting is inclusive. Hospital managers are often clinicians with limited training and skills in management and leadership. Many did not choose to become leaders. Educational institutions and county departments of health both have a role to play in strengthening management and leadership capacity, as well as incentivising hospital managers.
This paper describes and evaluates the budgeting and planning processes in public hospitals in Kenya. The authors used a qualitative case study approach to examine these processes in two hospitals in Kenya and collected data by in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), by a review of documents, and non-participant observations within the hospitals over a 7 month period. The budgeting and planning process in the case study hospitals was characterized by lack of alignment, inadequate role clarity and the use of informal priority-setting criteria. The hospitals incorporated economic criteria by considering the affordability of alternatives, but rarely considered the equity of allocative decisions. In the first hospital, stakeholders were aware of - and somewhat satisfied with - the budgeting and planning process, while in the second hospital they were not. Decision making in both hospitals did not result in reallocation of resources. With regard to procedures, the budgeting and planning process in the first hospital was more inclusive and transparent, with the stakeholders more empowered compared to the second hospital. In both hospitals, decisions were not based on evidence, implementation of decisions was poor and the community was not included. There were no mechanisms for appeals or to ensure that the procedures were met in both hospitals. Public hospitals in Kenya could improve their budgeting and planning processes by harmonising these processes, improving role clarity, using explicit priority-setting criteria, and by incorporating both consequences (efficiency, equity, stakeholder satisfaction and understanding, shifted priorities, implementation of decisions), and procedures (stakeholder engagement and empowerment, transparency, use of evidence, revisions, enforcement, and incorporating community values).
Inequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services. A mixed methods approach was used in Rungwe district where maternal and child health insurance cards had been implemented. To assess equity, three categories of beneficiaries’ education levels were used and were compared to that of women of reproductive age in the region from previous surveys. To explore factors influencing women’s decisions on delivery site and use of the maternal and child health insurance card and attitudes towards the birth experience itself, a qualitative assessment was conducted at representative facilities at the district, ward, facility, and community level. A total of 31 in-depth interviews were conducted on women who delivered during the previous year and other key informants. Women with low educational attainment were under-represented amongst those who reported having received the maternal and child health insurance card and used it for facility delivery. Qualitative findings revealed that problems during the current pregnancy served as both a motivator and a barrier for choosing a facility-based delivery. Decision about delivery site was also influenced by having experienced or witnessed problems during previous birth delivery and by other individual, financial, and health system factors, including fines levied on women who delivered at home. To improve equity in access to facility-based delivery care using strategies such as maternal and child health insurance cards it is necessary to ensure beneficiaries and other stakeholders are well informed of the programme, as only giving women insurance cards does not guarantee their access to facility-based delivery.
Oxfam have announced that it is now possible to count the cost of paying for healthcare for households around the world. A group of experts tasked with developing the indicator framework to measure progress towards the Sustainable Development Goals (SDGs), have agreed to measure financial risk protection of universal health coverage by ‘’proportion of the population with large household expenditures on health as a share of total household expenditure or income”. This signals a great shift in from the previous dangerous indicator that would just measure population with access to health insurance or a public health system. The previous indicator was flawed because it did not measure whether or not people were actually financially protected against potentially catastrophic costs for health care. It would have also failed to measure progress across different income groups or by gender. It was also dangerous as it sent a signal to governments around the world that health insurance was the route to achieving Universal Health Coverage despite robust and scientific evidence that many voluntary health insurance schemes have exacerbated inequality. The change to the new indicator that ‘measures what matters’ was advocated for civil society organisations, academics, development agencies and statistical authorities expressed their deep concerns through letters, lobbying and public statements.