OBJECTIVE: Results-based financing and pay-for-performance refer to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. Results-based financing is widely advocated for achieving health goals, including the Millennium Development Goals.
METHODS: We undertook an overview of systematic reviews of the effectiveness of RBF. We searched the Cochrane Library, EMBASE, and MEDLINE (up to August 2007). We also searched for related articles in PubMed, checked the reference lists of retrieved articles, and contacted key informants. We included reviews with a methods section that addressed the effects of any results-based financing in the health sector targeted at patients, providers, organizations, or governments. We summarized the characteristics and findings of each review using a structured format.
RESULTS: We found 12 systematic reviews that met our inclusion criteria. Based on the findings of these reviews, financial incentives targeting recipients of health care and individual healthcare professionals are effective in the short run for simple and distinct, well-defined behavioral goals. There is less evidence that financial incentives can sustain long-term changes. Conditional cash transfers to poor and disadvantaged groups in Latin America are effective at increasing the uptake of some preventive services. There is otherwise very limited evidence of the effects of results-based financing in low- or middle-income countries. Results-based financing can have undesirable effects, including motivating unintended behaviors, distortions (ignoring important tasks that are not rewarded with incentives), gaming (improving or cheating on reporting rather than improving performance), widening the resource gap between rich and poor, and dependency on financial incentives.
CONCLUSION: There is limited evidence of the effectiveness of results-based financing and almost no evidence of the cost-effectiveness of results-based financing. Based on the available evidence and likely mechanisms through which financial incentives work, they are more likely to influence discrete individual behaviors in the short run and less likely to create sustained changes.
BACKGROUND: Norway is the lead promoter of results-based financing (RBF) as one of fi ve actions being taken as part of the Global Campaign for the Health Millennium Development Goals and plans to support the use of RBF through the World Bank and in bilateral agreements with selected countries focusing on achieving the Millennium Development Goals (MDGs) of reducing child and maternal mortality (MDG 4 and 5). RBF-schemes can be targeted at different levels: recipients of healthcare, individual providers of healthcare, healthcare facilities, private sector organisations, public sector organisations, sub-national governments, and national governments. METHOD: This report consists of an overview of systematic reviews and a critical appraisal of four evaluations of RBF schemes in the health sector in low and middle-income countries (LMIC). RESULTS: Ten systematic reviews that met the inclusion criteria for this report were summarised. In addition, four evaluations of RBF schemes in LMIC were critically appraised, including financial incentives targeted at patients, individual providers, organisations, and governments. There are few rigorous studies of RBF and overall the evidence of its effects is weak.
• Financial incentives targeting recipients of healthcare and individual healthcare professionals appear to be effective in the short run for simple and distinct, well-defined behavioural goals. There is less evidence that financial incentives can sustain long-term changes.
• The use of RBF in LMIC has commonly been as part of a package that may include increased funding, technical support, training, changes in management, and new information systems. It is not possible to disentangle the effects of RBF and there is very limited quantitative evidence of RBF per se having an effect, other than in the context of conditional cash transfers to poor and disadvantaged groups in Latin America to motivate preventive care.
Results-based financing and pay-for-performance refer to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. Results-based financing is widely advocated for achieving health goals, including the Millennium Development Goals.
METHODS:
We undertook an overview of systematic reviews of the effectiveness of RBF. We searched the Cochrane Library, EMBASE, and MEDLINE (up to August 2007). We also searched for related articles in PubMed, checked the reference lists of retrieved articles, and contacted key informants. We included reviews with a methods section that addressed the effects of any results-based financing in the health sector targeted at patients, providers, organizations, or governments. We summarized the characteristics and findings of each review using a structured format.
RESULTS:
We found 12 systematic reviews that met our inclusion criteria. Based on the findings of these reviews, financial incentives targeting recipients of health care and individual healthcare professionals are effective in the short run for simple and distinct, well-defined behavioral goals. There is less evidence that financial incentives can sustain long-term changes. Conditional cash transfers to poor and disadvantaged groups in Latin America are effective at increasing the uptake of some preventive services. There is otherwise very limited evidence of the effects of results-based financing in low- or middle-income countries. Results-based financing can have undesirable effects, including motivating unintended behaviors, distortions (ignoring important tasks that are not rewarded with incentives), gaming (improving or cheating on reporting rather than improving performance), widening the resource gap between rich and poor, and dependency on financial incentives.
CONCLUSION:
There is limited evidence of the effectiveness of results-based financing and almost no evidence of the cost-effectiveness of results-based financing. Based on the available evidence and likely mechanisms through which financial incentives work, they are more likely to influence discrete individual behaviors in the short run and less likely to create sustained changes.
