Exploratory study estimating the impact of performance-based financing (PBF) on quality of care and on the contextual factors mediating the effectiveness of PBF in improving quality of care in Zimbabwe

Background: Ensuring value for health sector spending is a universal concern for policy makers in low-and middle-income countries (LMICs), where health care demands are rising and health sector financing is limited. Performance-based financing (PBF) is more frequently being implemented in LMICs to improve quality of care and ultimately health system outcomes. Through PBF, LMICs can potentially reduce variation in clinical practice, because PBF provider incentives are directly linked to achievement of predefined quality of care standards and adherence to quality protocols. Zimbabwe implemented PBF in 16 districts as a health system reform to improve the quality and coverage of health services from 2011. This paper first estimates the impact of PBF on quality of care, and then explores contextual factors mediating the effectiveness of PBF in improving quality of care LMICs were at various stages of piloting and scaling up performance-based incentive schemes (4). The underlying rationale is that performance-based financing (PBF) can extrinsically motivate health providers through incentives. By financially rewarding improvements in quality of health care, health providers will make greater efforts to achieve better results (3). As such, PBF is a core component of strategic purchasing of health services in a growing number of LMICs. Strategic purchasing helps link resources for health to the effective delivery of quality services (6). can or and that determine made to care by 27.7% (P<0.0001). Conclusions: Evaluations of complex health system reform interventions such as PBF need to go beyond exploring effects on priority health outcomes. As a strategic purchasing tool, PBF design should be informed by a country’s contextual factors. At the same time, evidence on contextual factors outside the control of policy makers and the health system—such as mean population wealth—must be better understood and documented.