Project Information

Objective: The Health System Performance project seeks to increase the coverage of quality maternal, neonatal and child health (MNCH) services, particularly targeting poor and vulnerable populations.
Status: Active
Date Effective: 09/30/2011 to 06/30/2017
Financing: HRITF $11 million and IDA $32.8 million
Other Financial Contributions: N/A

Photo Credit: World Bank/ Stephan Gladieu


The Health System Performance project was designed to address supply-side and demand-side barriers. On the supply-side, the lack of human resources for health and their unequal geographic distribution coupled with inadequate incentives and staff demotivation negatively impact the quality of care. In turn, this poor quality of care correlates directly with high maternal mortality rates (Saizonou, 2006).  On the demand-side, the cost of care, including the cost of medical drugs, is a major impediment to service utilization: among children under-five who had fever, 51 percent in the wealthier quintile took malaria drugs the day when the fever occurred (or the day after), compared to 31 percent in the poorest quintile (DHS, 2006).


RBF Payments

The Health System Performance project uses Results-Based Financing (RBF) to concurrently improve the quality of care and boost MNCH service utilization. On the supply-side, the Ministry of Health contracts and incentivizes health facilities and community health workers to deliver a package of quality MCNH services, including free malaria care.  Disbursed quarterly upon the achievement and the verification of results, up to 50 percent of these performance-based financing (PBF) payments can be used to incentivize personnel. On the demand side, PBF facilities subcontract and incentivize community relays – composed of community members – to provide health promotion and referral services at community level. These PBF facilities directly pay community relays based on the quantity and accuracy of referrals.


On the supply-side, the verification function is overseen by an international non-governmental organization. This independent entity assesses the quantity of services provided on a quarterly basis by comparing data contained in health facility registries with data generated by exit surveys. It also implements with district health teams quarterly verifications of the quality of services delivered at health facility level, and supports peer reviews of the quality of care at hospital level.  The quality of care is measured at all levels through the administration of a quality check list. Conversely, community-based organizations carry out quarterly household surveys to ascertain that services were delivered as reported and biannual surveys to measure community satisfaction.


Status and Achievements

The supply-side PBF scheme has been a flexible and versatile in Benin.  Government ownership and strong collaboration among development partners have not only facilitated rolling out RBF nationwide (since July 2015), but also enabled indicators to be purchased by several donors, including the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The RBF program is now managed through a virtual multi- donor basket fund.

A survey conducted in early 2015 and focusing on the performance of Human Resources for Health (HRH) indicated that the supply-side PBF scheme influenced some aspects of the quality of care – for example, it underlined improvements in providers’ responsiveness to patients.

Lessons Learned

The supply-side PBF mechanism has proven to be flexible and versatile, fostering a strong collaboration between the government and development partners and ensuring the relevance of PBF within the national health system and laying the foundations for sustainability.   

The flexibility of the scheme has been instrumental in further improving and expanding the approach: it facilitated the use of PBF to contribute to Malaria Free Health Care and the introduction of community RBF, as well as PBF with private for profit health facilities and free health care for the poorest.


The impact evaluation seeks to measure the impact of RBF on health outcomes, particularly endeavoring to uncover factors driving results. It also focuses on effects of RBF on equity in maternal and child health, as well as on health worker performance. The impact evaluation is an experimental design, using mixed methods. The end line survey is planned for late 2016.