Rotterdam Global Health Initiative: International Network Meeting

Many low-income countries have chosen to introduce Performance-Based Financing (PBF) schemes that link financial rewards to performance targets. These incentives are supposed to improve quality of care either directly, when it can be incentivised, or indirectly, by increasing providers’ motivation and accountability. Despite the enthusiasm for PBF, the evidence about its impact on provider performance remains mixed. We take advantage of a randomised pilot of P4P in Senegal to test whether PBF improves quality of care. We conducted an audit study in 191 public primary care facilities located in treatment and control areas, where we used unannounced standardised patients to collect objective measures of quality and effectiveness of care. Overall, we found low levels of quality of care. In control facilities, providers completed only 30% of an essential checklist of care, and less than half of patients (42%) were managed according to the recommended guidelines. Furthermore, we found no evidence that the financial incentives provided by the PBF scheme improved any of the measures of quality of care, nor that it increased the likelihood that patients would be managed correctly. The evidence was similar for both rewarded and non-rewarded services. We rule out poor clinical knowledge or lack of understanding of the scheme as potential reasons explaining the lack of effect of PBF. We show suggestive evidence that in this setting where patients have limited information about what constitutes good quality of care, financial incentives are unlikely to improve effort through increased accountability. Moreover, delays in implementation may jeopardise the beneficial effects of incentives on motivation.