Researching PBF: time to open the black box

2 Jun

In this blog post, Gaute Torsvik (University of Bergen) introduces a forthcoming scientific workshop, which will take place in Norway on June 13 and 14. He argues that researchers studying PBF schemes should go beyond measuring impact only.

Performance-based incentive schemes and reforms are receiving growing attention from governments, aid agencies, donors and researchers. As for Africa alone, 29 countries are today at least piloting a PBF scheme; three of them (Rwanda, Burundi and Sierra Leone) have adopted performance-based financing as a core component of the funding of their whole health system. A major impact evaluation program led by the World Bank assesses the rapid expansion of performance-based financing of health care.

 Why opening the black box is important

Assessments of financial incentives in health care often leave the underlying mechanisms connecting monetary incentives and health outcomes in the dark.  They measure what monetary incentives do to the quantity of health care, few studies ask how and why the change came about.  This is unfortunate since the impact of performance-based financing may depend critically on particular attributes of the design of the incentive scheme, and may also depend on a number of contextual variables.  Furthermore, changing from input to output-based financing of health care will bring about additional organizational changes that may affect health workers incentives to perform in separate ways, making it hard to isolate the effect of monetary incentives.

To be more concrete, suppose performance-based financing provides health facilities with a fixed sum of money for every woman that gives birth at the clinic.  A “what” assessment measures (hopefully by using credible controls) a y % increase in birth attendance in the performance financed facilities.  This is certainly important information, but we should also make an attempt to find out how the increase in attendance came about: Did health workers increase the clinical quality of their work which then attracted more patients to seek assistance at the facility (and if so, did a higher quality maternity care work reduce the quality provided to other patients); did they become more friendly and responsive towards patients; did they reduce informal or formal user fees; did they take active steps to recruit more pregnant women (and how did they do that, by spreading information, by threatening them or by offering incentives?); or did more patients attend because of improved management – more and better drugs, cleaner sites etc.

In addition to addressing how behavior responds to financial incentives, it is important to disclose a second question: why did behavior changed?  At the outset the answer may seem too obvious to be worth reflecting on.  It is not.  Introducing performance-based pay does not only make health worker financially accountable for their performance, performance based financing may also affect the level of supervision and community monitoring of health workers. Enhanced levels of recognition and appraisal of the work that is done may in itself motivate health workers to perform.  Furthermore if incentives are based on team achievements, it has been documented elsewhere that workers tend to make an extra effort to avoid letting the team down. In addition there is now a large literature examining how monetary incentives interact with other extrinsic or intrinsic work motivations.   Together this means that even if we observe that the introduction of performance-based financing makes the health workers more attentive and diligent, it is far from obvious why this is the case.

A scientific workshop gathering researchers and PBF experts

Answering the how and why questions regarding the health workers behavioral response to performance based financing is also a relevant question for PBF experts. More knowledge on this will indeed improve their understanding of the endurance and external validity of the measured impact.  It will also enable them to improve the design of PBF schemes.

It is with this ambitious knowledge program in mind that the Christian Michelsen Institute and the “Incentives for Health Provider Performance Network” will gather an international group of researchers and PBF experts during two days in Bergen, Norway.  We expect very rich discussions between the two groups with the hope that such an innovative dialogue will contribute to better policies.

Stay tuned on this blog in the weeks to come – we will definitely try to share with you the outcomes of our discussion.

2 Responses to “Researching PBF: time to open the black box”


  1. Financement Basé sur la Performance : structurons mieux le débat | Performance Based Financing - 09/06/2013

    […] en soutenant les chercheurs désireux d’étudier le PBF. Nous co-organisons ainsi un atelier scientifique les 13-14 juin à Bergen, en Norvège. Certains des défis relevés par mon collègue Jean-Pierre […]

  2. Proving impact: options in terms of research designs | Performance Based Financing - 03/07/2013

    […] this blog post, Ellen van de Poel (Erasmus University Rotterdam) summarizes discussions held in Bergen  between academics and PBF implementers about the desirability and feasibility of various research […]

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