Are pilot programmes able to give rise to sustainable health system effects? The case of performance-based financing in Benin

Background: Sustainability, understood as “the continuation of benefits from a development intervention after major development assistance has been completed”, is a major performance criterion of development programmes. Performance-based financing (PBF) was implemented in Benin between 2012 and 2017, with support from four donors and along two models. However, insufficient demonstrated results and lack of national ownership led to the termination of PBF programmes in most districts in 2017. The termination of PBF in Benin represents a unique opportunity to analyse the ability of PBF to generate sustainable effects. This study aims to appraise the sustainability of PBF programmes through assessing the effects that were maintained after 9 months of termination.
Methods: Sustainability was examined from the perspective of health practitioners, using a qualitative approach. Semi-structured interviews were led with healthcare providers and managers (N=59) in two health districts during PBF implementation in 2017, and thematically analysed. This enabled to identify perceptions regarding PBF’s effect over providers’ competences and behaviour in their day-to-day work. These results were confronted with those from another round of semi-structured interviews led with some of the stakeholders already interviewed (N=38) and conducted 9 months after the programme stopped.
Results: Our results proved helpful to understand the dynamics of the transition period following PBF termination, the strategies implemented at the local level to guarantee sustainability of effects, and the effect of programme termination on healthcare providers’ performance and motivation. The PBF programmes aimed to motivate individuals in delivering health services. When implemented, they produced some positive effects on interpersonal communication and supervision, but also caused demotivation due to irregularity, low level and perceived unfair distribution of financial incentives. Our study shows that hardly no resource was dedicated to an exit strategy, so as to ensure continuing effects of PBF. Therefore, PBF termination was a major source of demotivation for healthcare practitioners, mainly attributable to the cessation of financial premiums that were already taken for granted, as well as to worsening in working conditions due to the withdrawals of PBF funding used for the recruitment of additional staff and the purchase of equipment for health facilities.
Discussion / Conclusion: This study enabled to shed light on the poor preparation and understand the dynamics of the transition period following PBF termination, and to appraise effects on health practitioners’ motivation. It shows that PBF effects were not sustained. Greater attention should be paid to sustainability issues in future PBF programmes.