Results-Based Financing (RBF) approaches have grown in number, geographical coverage and type over the past 15 years in low and middle income countries (LMICs). They remain however largely dependent on external support, financial and technical, and to a large extent operating as parallel programmes. The aim of this paper was to draw on experiences from possibly more developed RBF schemes in middle and high income countries (HICs) in order to provide guidance for the future in LMIC settings. RBF in this paper focussed on supply-side approaches, so excluding strategies such as conditional cash transfers. Sustainability was defined in relation to four main domains: de facto, financial, institutional and social/political/technical.
The paper was based on a literature review conducted over June-August 2015. Search terms included: 1) high or middle income countries AND 2) results based financing/performance based financing/pay for performance/performance based incentives AND 3) sustainability/mainstreaming. A variety of case studies were then chosen. All middle-income country case studies found were included. The other high-income countries were chosen to represent a mix globally. 41 experts were also contacted for their insights and further materials, given that written sources did not cover the questions of interest in depth. The main limitation was the non-comprehensive nature of the search, which also focussed in the first instance on English language texts.
For each chosen scheme information was extracted on the following: purpose, how long the scheme has been implemented, how they were funded, funding trajectory and scale of the programme, results of evaluations, information on political economy, whether the scheme was incorporated into mainstream systems or run as a stand-alone programme, and any lessons on why the scheme was sustained or not. Information on institutional arrangements was also extracted under five headings: 1) How have purchasing arrangements evolved? 2) How have funds been pooled or not to pay for the RBF scheme? 3) How have provider payments been adapted? 4) How were IT systems used, adapted, added to? What is the role of the Health Management Information Systems? 5) Who provided verification and other functions (including supervision)?
Seven HIC schemes were analysed (from Australia, France, the UK, South Korea, the US, Estonia and Germany) alongside five middle income country experiences (from Brazil, Turkey, the Philippines, Nicaragua and China). Some countries operate several types of RBF programmes.
The review highlights the diversity of rationales, contexts and approaches to RBF in high and middle income countries, which means we have to be cautious about drawing lessons for low income countries which are currently developing their own pilots and national schemes. Nevertheless, some observations can be drawn out which may be useful in considering the way forward and providing some tentative lessons in LMICs.