Africa's progress towards the health related Millennium Development Goals remains limited. This can be partly explained by inadequate performance of health care providers. It is therefore critical to incentivize this performance. Payment methods that reward performance related to quantity and quality, called performance based financing (PBF), have recently been introduced in over 30 African countries. While PBF meets considerable enthusiasm from governments and donors, the evidence on its effects is still limited.

Paying health facilities incentives based on their performance is one form of results-based financing (RBF). Verification of the performance of the providers is a vital part of RBF program implementation. Burundi was one of the first African countries to introduce performance-based financing (PBF). The PBF scheme is implemented in the whole country and is led by the Ministry of Health (MoH). It pays incentives based on quantity of services provided as well as a quality of care component.

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Performance-based financing (PBF) has attracted considerable interest from governments and aid agencies in low-income countries as a means to increase productivity and quality of health-care providers. In Africa alone, more than 35 countries are in the process of introducing payment methods that reward performance. The Burundi Government has gradually rolled out PBF across all provinces between 2006 and 2010. Our aim was to evaluate whether this has led to changes in the quantity and quality of health-care services provided.

Institutional arrangements of health systems and the incentives they set are increasingly recognized as critical to promote or hinder performance in the health sector. Looking at complex health system interventions from an institutional perspective may contribute to better understanding what are the paths and processes that lead to the results of such interventions. In this article, we propose an analytical framework drawing from new institutional economics.

Until recently, women in Burundi's Batwa community didn't give birth in health facilities, but at home, where they died of complications too often. But women like Denise Ntakirutimana now benefit from a program that pays health facilities for delivery of quality maternal and child health services.

Article: Jane Zhang, Photo: Peter Von Elling

This feature article examines the challenges of PBF in Burundi and the ambitious government effort to scale it up across the country, in concert with a major reform - free healthcare for pregnant women and children under five. The pilots were mostly successful and have led to a PBF scheme that also works to ensure equity among vastly unequal provinces and health facilities. The national program is off to a promising start.   

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