LEARNING LESSONS ON IMPLEMENTING PERFORMANCE BASED FINANCING, FROM A MULTI-COUNTRY EVALUATION KIT (ROYAL TROPICAL INSTITUTE) In collaboration with Cordaid and WHO

Drawing lessons from country study reports Cordaid/ HealthNet TPO experiences in PBF pilot projects in: Democratic Republic of Congo Tanzania Zambia Burundi Rwanda National PBF (retrospective study) Acknowledgements The Royal Tropical Institute of the Netherlands (KIT) would like to express sincere appreciation to all the people who contributed to this report and to all of the participants who were actively engaged in the preceding series of country evaluation studies of Performance Based Financing (PBF)-on which this report is based. A special word of acknowledgement for Frank van de Looij who actively participated in the organization of the multi-country process and peer review of the synthesis report on behalf of Cordaid. To all those who participated at country level in Burundi, Democratic Republic of the Congo (DRC), Tanzania, Zambia and Rwanda we appreciated your invaluable contributions and reflective approach. We wish to acknowledge the diligent efforts of the team leaders and national consultants and to the field and head office staff in Cordaid, HealthNet TPO and HDP Rwanda who proactively engaged in supporting the logistics and coordination of the field work. To WHO Geneva health systems experts who participated at all stages from the methodology design to the dissemination. To those who commented on this synthesis report, to the staff in KIT who have supported the editorial work and to DGIS who co-financed this report. vii Executive Summary In recent years the 'Performance Based Financing' (PBF) approach has received increasing attention. Evidence to date has largely demonstrated that the actual 'modality input planning' does not incite health providers to perform better, because money flows are not linked to results. The professionals and constituencies that are in favour of PBF support the hypothesis that enhanced productivity and quality of care are contingent on linking outputs to financial incentives. However, benefits of performance based financing are still inconclusive with suggestions that it is not sustainable, it will not have a pro-poor effect, or it may create perverse incentives. The evidence up to now cannot fully substantiate either debate sufficiently in the absence of more extensive operational research and formative evaluations. This synthesis report thereby explores the lessons learned on design, implementation and effects of financial incentives in the form of performance based financing in the health sector, as supported in Sub–Saharan Africa by the two Dutch NGO's Cordaid and HealthNet TPO. Towards this aim a multi-country study was undertaken led by the Royal …