Factors inhibiting and enabling performance-based financing in health care delivery across low and middle-income countries: a scoping review

Background: Emerging financing strategies in the health sector have been developed to improve the impact of investments and enhance healthcare outcomes. One promising approach is Results-based Financing, which establishes a connection between financial incentives and pre-established performance targets. This innovative approach holds the potential to strengthenhealthcare delivery and strengthen overall healthcare systems.Aim:The scoping review endeavored to systematically delineate the body of evidence pertaining tofacilitators and barriers to the implementation of performance-based financing within the realm of healthcare provision in low-and middle-income nations.Methods:The review used Preferred Reporting Items for Systematic Reviews and a Meta-Analysis extension for Scoping Reviews checklist to select, appraise, and report the findings. We searched PubMed, Web of Science, and Google Scholar databases and grey literature published between January 2000 and March 2022. We conducted the abstract screening with two independent reviewers. We also performed full-article screening. We used the six methodological frameworks proposed by Arksey and O'Malley. The results were thematically analyzed.Results:Of the 1071 searched studies, 34 met the eligibility criteria. 41% of the studies were descriptive, 26% cross-sectional, 18% trial, and 15% cohort studies. The enabling and inhibiting factors of performance-based financing in healthcaredelivery have been identified. Moreover, the review revealed that performance-based financing's influence on service delivery is context-specific.Conclusion:The facilitators and impediments to the effectiveness of performance-based financing in enhancing service delivery are contingent upon a holistic comprehension of the contextual factors, meticulous design, and efficient execution. Factors such as the level of care facilities, presence of community-based initiatives, stakeholder involvement, and participatory design emerge as key facilitators. Conversely, barriers such as communication obstacles, inadequacies in the PBF models, and deficiencies in the healthcare workforce are recognized as inhibitors. By harnessing the insights derived from a multitude of evidence incorporated in this scrutiny, stakeholders can deftly navigate the intricacies of performance-based financing, while also considering the prospective areas for further exploration and research

Nigeria in the COVID era: Health system strengthening for national security and prosperity

The coronavirus disease­19 pandemic has spread to all parts of the world. As of 20 May 2022, over 500 million confirmed cases have occurred with over 6 million deaths. In Nigeria, over 255,000 cases have occurred with more than 3000 deaths. The pandemic has adversely affected virtually all aspects of human endeavour, with a severe impact on the health system. The Nigerian health system was ill prepared for the pandemic, and this further weakened it. The impacts of the pandemic on the health system include disruption of health services, low motivation of the health workforce, unresponsive leadership and poor funding. The national response, though initially weak, was ramped up to expand capacity building, testing, public enlightenment, creation of isolation and treatment centres and research. The funding for the national response was from the government, private sector and multilateral donors. Nigeria must comprehensively strengthen its health system through motivating and building the capacity of its human resources for health, improved service delivery and provision of adequate funding, to be better prepared against future pandemics.

Strengthening the oral health system in Nigeria: A health systems building block approach

Aim: The present study aimed to describe the building blocks of the oral health system, including the role that the community plays in strengthening the oral health system in Nigeria. Methodology: This research was a scoping review of the existing literature retrieved from search engines and databases. Thus, we utilised grey literature, peer-reviewed literature, policy documents and websites. The oral health system was analysed using the World Health Organisation's Health systems framework, and we adapted this framework by introducing a seventh block, community participation. We also inserted the links between the oral health service delivery and oral health workforce blocks of the framework to improve the oral health outcomes. Results: More dental clinics are required to improve the availability and accessibility of oral health services. Dental workforce expansion is imperative. This can be approached by training of junior cadre dental professionals and incorporating community health practitioners to deliver basic oral care. There is an unregulated access to medication to treat dental conditions; hence, oral disease treatments need to be included in the country's treatment guidelines to improve standard of care. The government needs to improve on overall health spending and invariably increase oral health care allocation urgently. Furthermore, the country's stewardship of oral health care is hinged on well disseminated and implemented national policies on oral health. The oral health system can achieve its overall goals with community participation, engagement and ownership. Conclusion: Strengthening the oral health system in Nigeria requires urgent attention on each building block and cross-cutting interventions across the system's building blocks. The role of the community will need to be recognised because it is vital in sustaining any organisational change.

Coping with the supply-side effects of free maternal healthcare policies in seven sub-saharan african countries: a systematic review

Free maternal healthcare policies (FMHP) result in enormous supply-side effects on care delivery in sub-Saharan Africa (SSA). This review synthesises the mechanisms adopted by supply-side actors to cope with the effects of FMHP and the results of coping mechanisms on policy objectives in seven SSA countries. We searched bibliographic databases for articles published in English for research that reported supply-side effects of FMHP, coping mechanisms, and effects of various coping mechanisms on attainment of reform objectives. Out of 215 studies identified, nine qualified for inclusion. Selected studies were exploratory in design and based on either mixed or qualitative methods. While local health system authorities and health facilities coping mechanisms that were intended to enhance implementation, facility managers and staff engaged in self-interest adaptation decisions and behaviours. Lack of explicit policy commitment to enhancing organisational and managerial capacity of local health authorities contribute to sustaining negative supply-side effects and adverse coping mechanisms. Without due consideration to governance and health system strengthening, FMHP are prone to perverse outcomes that undermine intended benefits. Context-specific empirical studies are needed to further conceptualise the supply-side effect ­ coping mechanism ­ consequential effect nexus of the policy

Community based health insurance as a viable option for health financing: An assessment of household willingness to pay in Lagos, Nigeria

The high cost and effect of out of pocket payments for health care on households in developing countries have led to the use of community-based health insurance (CBHI) as a viable alternative for health care funding. The overall objective of the study was to assess the perception and determinants of willingness-to-pay (WTP) for a proposed community based health insurance scheme in urban and rural households in Lagos State. The multi-stage sampling technique was used with 960 household heads enrolled in the study. A pre-tested, semi-structured, interviewer administered questionnaire was used to collect data from the respondents. The contingent valuation method was used to elicit household willingness to enrol and pay for a proposed community based health insurance scheme. Data was analysed using Statistical Package for Social Sciences software (SPSS) version 17. This study revealed that 86.3% of the households in the rural LGA and 78.6% of the households in the urban LGA were willing to pay for the proposed community based health insurance scheme (p=<0.001). The households were willing to pay a mean amount of ₦957.56 and ₦754.83/ household/ month in the urban and rural area respectively (p<0.001). The paper concludes by emphasizing the high willingness among households to participate in the proposed hypothetical CHBI scheme. This highlights its prospects of increasing access to quality health care in Lagos especially amongst vulnerable low-income households

A situational analysis of eye care services in Swaziland

Compared to other African countries, Swaziland performs the worst in terms of providing eye health care services. A priority goal of the World Health Organization (WHO) is to alleviate childhood blindness, particularly in low-income countries such as Swaziland, where many people live in poverty, which is a contributor to poor health outcomes. A mixed method approach that entailed a document review, key informant interviews and clinical facility assessment questionnaires was used. Hospitals and mission clinics offering ophthalmic services were identified through the website of the Ministry of Health and verified during key informant interviews. A saturated sampling procedure was applied due to the few facilities that offer eye care services. Six framework components from the WHO for analysing health systems were utilised in an eye health care service context: leadership and governance, eye health services, eye health workforce, eye health financing systems, eye health medical supplies and technologies, and eye health information systems. Poor management, lack of accountability, poor monitoring and evaluation mechanisms, weak coordination and ineffective private-public sector regulations were identified as factors that lead to poor eye care in the country. The optometrists indicated that refractive services are the most rendered ophthalmic services. The exodus of healthcare practitioners has contributed to the downfall of the public health sector in the country. Five government eye care facilities, 3 government hospitals, 1 non-governmental organization (NGO) and a church mission clinic were included in this analysis. The eye services distribution favors the more affluent areas, particularly the more urban Hhohho Region, which is also where most of the eye health professionals are located. No campaigns have been conducted to prevent childhood blinding diseases or create awareness about getting children's eyes tested for refractive correction. The burden of eye diseases among children in Swaziland remains unknown. More eye health care personnel and equipped facilities are needed throughout the country, and the eye health care program needs to be adopted

Impact of performance-based financing on health-care quality and utilization in urban areas of Cameroon

This article looks at a pilot project designed to estimate the impact of performance-based financing (PBF) on the quality and utilization of health care in a predominantly urban setting - the Littoral region of Cameroon. It uses three quasi-experimental impact evaluation methods involving matching and difference-in-difference. Results show that the PBF pilot had a positive and significant impact on most essential aspects of quality of care. Meanwhile; there was no impact on any of the indicators of health service utilization with the exception (limited) of modern contraceptive methods. These findings suggest that the setting and indicators chosen are important in achieving maximum impact. However; it should also be noted that improvements in utilization might be limited as a result of high baseline figures. Finally; the findings show that the quality of care seems to be the most promising aspect in terms of improvements related to PBF in urban settings

Cout direct de la prise en charge du traumatisme cranio-encepahlique au CHR de Segou au Mali : quel financement pour la PEC au Mali ?

Le traumatisme cranien encephalique (TCE) est la deuxieme cause d'admission aux urgences de l'hopital Nianankoro Fomba de Segou. Il touche l'adulte jeune avec un faible pouvoir d'achat. L'objectif de ce travail etait d'evaluer le cout direct de la prise en charge (PEC) du TCE en reanimation et de proposer les modalites de financement pour sa PEC au Mali. Il s'agissait d'une etude prospective de Septembre 2009 a Decembre 2010 au centre hospitalier Nianankoro Fomba de Segou. Tous les patients admis pour TCE en reanimation pour plus de 24 heures etaient inclus. La tranche d'age 2140 etait predominante. Toutes les couches socioprofessionnelles etaient exposees. Le cout moyen des ordonnances etait de 55.392 CFA. L'evacuation sanitaire etait effectuee dans 15 cas pour un frais de 60.700 francs. Pour manque de moyens; 75% des patients decedes n'etaient pas evacues en 3eme reference. Le cout moyen de la PEC etait de 99.385 Francs (39.115-282.944). Le cout total des prestations s'elevait a 7.269.320 francs CFA. Le cout de la PEC des TCE est eleve et constitue un determinant majeur de la morbimortalite liee a ce fleau

Sources of Health Care Financing among Patients at the Ahmadu Bello University Teaching Hospital; Zaria; Nigeria

Introduction: Health care financing is the mobilization of funds for health care services. This study determined the various sources of health care financing among the patients on admission at the Ahmadu Bello University Teaching Hospital (ABUTH); Shika-Zaria in 2011 and the effects of the medical bills on the patients and their family members. Methodology: A multi-staged sampling technique was used to select 100 clients for the study. The clients were stratified into the four major wards of the ABUTH; the medical; surgical; obstetrical and gynecological and the pediatric wards. A total of 25 clients were equally allocated to each ward and these were then selected by balloting. Information was sought on their socio-demographic characteristics; sources of the health care financing and the adverse effects of the medical bills on the patients and their family members. Results: Majority of the clients were married; Hausa Muslim housewives who earned N5;000/month (less 1 $/day). Most were aged between 20 and 29 (34) with a mean age of 36.7 years. Patients' relatives paid for the medical bill in most of the cases (48); 37 paid through out of pocket; while 11 used the National Health Insurance Scheme (NHIS) respectively. The medical expenses affected family feeding (29.3); while 16 of the patients could not get full medical services due to lack of funds; 8.8 could not pay school fees of their children and 12.2 were indebted. There were no significant association between the age; sex; marital status; monthly income; occupational status and the clients' sources of health care financing. Majority of the clients (65) were not aware of the NHIS. Most (80) of the patients would want to use the health insurance scheme (NHIS) if they have access to the opportunity. Conclusions: The main source of health care financing in this tertiary center was through out of pocket expenditure by patients and their relatives. Recommendation: There is a need for the urgent implementation of the community health insurance scheme in Nigeria for the benefit of the less privileged

Constraints; Challenges and Prospects of Public-Private Partnership in Health-Care Delivery in a Developing Economy

Background: In Nigeria; concerns on the quality and financing of health-care delivery especially in the public sector have initiated reforms including support for public-private partnerships (PPP) at the Federal Ministry of Health. Likewise; Enugu State has developed a draft policy on PPP since 2005. However; non-validation and non-implementation of this policy might have led to loss of interest in the partnership. Aim: The aim of this study was to provide evidence for planning the implementation of PPP in Enugu State health system via a multi-sectoral identification of challenges; constraints and prospects. Subjects and Methods: Pre-tested questionnaires were administered to 466 respondents (251 health workers and 215 community members); selected by multi-stage sampling method from nine Local Government Areas of Enugu State; Nigeria; over a study period of April 2011 to September 2011. Data from the questionnaires were collated manually and quantitative data analyzed using SPSS version 15 (Chicago; IL; USA). Results: Only 159 (34.1; 159/466) of all respondents actually understood the meaning of PPP though 251 (53.9) of them had claimed knowledge of the concept. This actual understanding was higher among health workers (57.8; 145/251) when compared with the community members (6.5; 14/215) (P 0.001). Post-PPP enlightenment reviews showed a more desire for PPP implementation among private health-care workers (89.4; 101/113) and community leaders/members (55.4; 119/215). Conclusion: PPP in health-care delivery in Enugu State is feasible with massive awareness; elaborate stakeholder's engagements and well-structured policy before implementation. A critical challenge will be to convince the public sector workers who are the anticipated partners to accept and support private sector participation

The Double-Edged Sword: Financial Source of Household Healthcare Expenditure in Ghana

In many regions; some of the most formidable enemies of health are joining forces with the allies of poverty to impose a double burden of disease; disability and premature death. This paper looks at the main financial sources households use to finance healthcare in Ghana. It examines the spatial and socio-economic dynamics and the challenges these pose to health and development. Analysis of the 2003 Ghana World Health Survey data indicates that approximately 41of households depend on more than one financial source with 88 depending on household income to finance healthcare expenditure. The high dependency on household income will erode gains in the economic and health sector in the midst of the recent global economic recession. Comprehensive national health insurance programs that cover emerging disease conditions will mitigate the double burden of disease on households in emerging economies

Innovative Financing for Health: What are the Options for South Africa?

The paper assesses the options for additional innovative financing that could be considered in South Africa; covering both raising new funds and linking funds to results. New funds could come from: i) the private sector; including the mining and mobile phone industry; ii) from voluntary sources; through charities and foundations; iii) and through further expanding health (sin) levies on products such as tobacco; alcohol and unhealthy food and drinks. As in other countries; South Africa could earmark some of these additional sources for investment in interventions and research to reduce unhealthy behaviors and influence the determinants of health. South Africa could also expand innovative linking of funds to improve overall performance of the health sector; including mitigating the risks for non-state investment and exploring different forms of financial incentives for providers and patients. All such innovations would require rigorous monitoring and evaluation to assess whether intended benefits are achieved and to look for unintended consequences

Accessing community health services: challenges faced by poor people with disabilities in a rural community in South Africa

Poor people with disabilities who live in poor rural societies experience unique problems in accessing health services. Their situation is influenced by multiple factors which unfold and interplay throughout the person's life course. The difficulties do not only affect the person with a disability and his or her family, but also impact on the relevant care unit. The barriers are rooted in a life in poverty, upheld and maintained by poverty-reinforcing social forces of the past and the present, and reinforced by the lack of the person's perspective of the health services. This article explores how difficulties may interact and influence access to and utilisation of health services, and how this may render health services out of reach even when they are available. The study reveals that non-compliance is not necessarily about neglect but could as well be a matter of lived poverty. The study was based on in-depth interviews with people with disabilities and family members, and semi-structured interviews with health personnel. The data analysis is contextual and interpretive. When offering health services to people with disabilities living in resource-poor settings, services should take into consideration the person's history, the needs, and the resources and abilities of the family group. Rethinking access to health services should transcend a narrow medical institutionalisation of health professional's training, and include a patient's perspective and a social vision in understanding and practice. Such rethinking requires health service models that integrate the skills of health professionals with the skills of disabled people and their family members. Such skills lie dormant at community level, and need to be recognised and utilised

An Overview of Health Financing Patterns and the Way Forward in the WHO African Region

The way a health system is financed affects the performance of its other functions of stewardship; input (or resource) creation and services provision; and ultimately; the achievement of health system goals of health improvement (or maintenance); responsiveness to people's non-medical expectations and fair financial contributions. To analyse the changes between 1998 and 2002;in health financing from various sources; and to propose ways of improving the performance of health financing function in the WHO African Region. A retrospective analysis of data obtained from the World Health Report; 2005. The analysis reported in this paper is based on the National Health Accounts (NHA) data for the 46 WHO Member States in the African Region. The data were obtained from the World Health Report 2005. It consisted of information on: levels of per capita expenditure on health; total expenditure on health as a percentage of gross domestic product (GDP); general government expenditure on health as a percentage of total expenditure on health; private expenditure on health as a percentage of total expenditure on health; general government expenditure on health as a percentage of total government expenditure; external expenditure as a percentage of total expenditure on health; social security expenditure on health as a percentage of general government expenditure on health; out-of-pocket expenditure as a percentage of private expenditure on health; and private prepaid plans as a percentage of private expenditure on health. The analysis was done using Lotus SmartSuite software. Results: The analysis revealed that: fifteen countries spent less than 4.5of their GDP on health; forty four countries spent less than 15 of their national annual budget on health; sixty three percent of the governments in the Region spent less than US$10 per person per year; fifty per cent of the total expenditure on health in 24 countries came from government sources; prepaid health financing mechanisms cover only a small proportion of populations in the Region; private spending constituted over 40 of the total expenditure on health in 31; direct out-of-pocket expenditures constituted over 50of the private health expenditure in 38 countries. Every country needs to develop clear pro-poor health financing policy and a comprehensive health financing strategic plan with a clear roadmap of how it plans to transit from the current health financing state dominated by inequitable; catastrophic and impoverishing direct out-of-pocket payments to a visionary scenario of universal coverage. The strategic plan should strengthening of health sector advocacy and health financing capacities; health economics evidence generation and utilisation in decision-making; making better use of available and expected resources; monitoring of equity in financing; strengthening of the exemption mechanisms; managed removal of direct out-of-pocket payments (for countries that choose to); and improving country-led sectoral coordination mechanisms (e.g. Sector Wide Approaches)