The Haut-Katanga pilot program and impact evaluation described in this paper is intended to provide rigorous evidence, using a randomized intervention design, of the effects of a Performance-Based Financing (PBF) strategy in the difficult conditions of rural DRC. The pilot seeks to contribute to the national dialogue on PBF by analyzing the effects of the strategy on
(i) production of health services (quantity and quality),
(ii) management of the facility and behavior of health staff, and
(iii) behavior of households.
It will also shed light on a number of issues relevant to broader health sector reform, including questions related to user fees and other revenues from patients, management of personnel, levels of managerial autonomy, and decentralization. As implementation of the pilot is currently ongoing and results have not yet been measured, this paper is limited to a description of the strategy and the design of the program and impact evaluation.
International financing of health services represents over half of total public financing and is mostly channeled through disease-specific programs as well as more comprehensive support to primary health care through contracted non-governmental organizations (NGOs). These public-private partnerships build on a long tradition of cooperation between the government administration and church-based health providers as well as the significant recent humanitarian programs implemented by NGOs. Some NGO contracts have a performance-based financing (PBF) element, with third-party monitoring of indicators tied to financial incentives.
More significant has been the experience with PBF mechanisms to incentivize health workers, including PBF mechanisms implemented by NGOs in the east of the country as well as strategies put in place by contracted NGOs under a World Bank emergency project starting in 2002. Various sorts of PBF mechanisms to remunerate health workers are currently being implemented in approximately 20% of health zones, often funded through multilateral and bilateral donor support. Moreover, PBF has had increasing in prominence in the national health policy dialogue, particularly in the context of planned decentralization whereby the provinces would become responsible for government health worker salaries.