Performance-based financing (PBF) in low- and middle-income countries: What is the theory of change, actually?

Performance-based financing (PBF) is expanding in low- and middle-income countries (LMICs) despite mixed results; indeed, it has been criticised for potential perverse effects and unintended effects are demonstrated. Attributing results to PBF as such is extremely difficult because (i) health systems inherently comprise “structural” incentives and are subject to various reforms beyond PBF; and (ii) there are misunderstandings and controversies about the mere definition and the theory behind PBF. Moreover, PBF schemes encompass different components (e.g. financial premiums conditioned on reaching pre-agreed results, focus and feedback on key performance indicators, coaching, additional resources at facility level, …) and their designs may infinitely vary. Yet, we still did not have a clear and consistent explanation of why and how PBF is supposed to produce results. We explore (i) the theoretical justification of PBF and (ii) the theory of change (ToC) of PBF in the health sector in LMICs. The literature on PBF-related approaches is fragmented across disciplines. -The most commonly used theory to justify PBF is the principal-agent theory. Theory-based evaluation has progressively imposed itself as more appropriate approach to study complex issues. There are few theory-based evaluations and partial attempts to “open the black box” of PBF and identify its ToC / programme theory / causal pathways / mechanisms / transmission of effects. PBF has to a large extent been justified theoretically on the grounds of economic currents – even if the economic rationale is limited by the validity of its (sometimes very) limitative assumptions. For instance, the principal-agent theory does not hold in complex systems such as health. As a conclusion: - The theories used to justify PBF to date are few and insufficiently credible - Studies aimed at uncovering the ToC of PBF are recent and unfinished - Most existing PBF ToCs are not theory-based - Actors need to make the theories underlying their interventions more explicit, disentangling the PBF package - Performance premiums conditioned on reaching a number of predetermined performance criteria may not be justified - If PBF is justified neither by strong theoretical arguments, nor by generalizable evidence, it is definitely marked by a neoliberal ideology, and the promotion of lack of trust and competition over cooperation between actors in the health system - Taboo: Is the debate over PBF definition a way to conceal the debate over PBF ideology