{"id":39290,"date":"2018-01-17T11:15:30","date_gmt":"2018-01-17T11:15:30","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjgh\/?p=39290"},"modified":"2018-01-17T11:26:14","modified_gmt":"2018-01-17T11:26:14","slug":"the-baby-and-the-bathwater-can-we-have-a-more-constructive-debate-on-performance-based-financing","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjgh\/2018\/01\/17\/the-baby-and-the-bathwater-can-we-have-a-more-constructive-debate-on-performance-based-financing\/","title":{"rendered":"The baby and the bathwater: can we have a more constructive debate on performance-based financing?"},"content":{"rendered":"

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By\u00a0Godelieve van Heteren<\/em><\/p>\n

Paul et al\u2019s critique<\/strong><\/p>\n

In a recent paper<\/a> in BMJ Global Health<\/em>, 24 authors (Paul et al) \u2013 the majority of whom are French-speaking academics and consultants from northern countries \u2013 declared that performance-based financing (PBF) in low- and middle-income country (LMIC) health systems needs an urgent rethink. They claim it is a donor fad. They argue that PBF is gaining too much traction, too much money is being spent (and wasted) and the gaps between promise and practice of PBF often go unchallenged.<\/p>\n

They state that PBF\u2019s dissemination is indiscriminate, with too much simplistic copy\u2013pasting of a \u2018PBF model\u2019 (which the authors do not further explicate); that the current communities of PBF practitioners and practice thinkers are complicit in it all and not \u2018independent\u2019 enough to carry out the proper research that would set things straight.<\/p>\n

What is required, the authors contend, is a group of \u2018independent\u2019 researchers to keep a finger on the pulse of implementation and to recommend better strategies to countries, donors and others, so that country stakeholders would no longer blindly follow World Bank models but work instead on matters that are more sustainable and country specific.<\/p>\n

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Declaring my bias<\/strong><\/p>\n

Let me come clear right away. I am fully biased. I\u2019m a 59-year old white, middle-class woman from one of the richer countries in Europe. And I am a PBF person. I am too old to believe in being \u2018independent\u2019 or 100% objective. We are all driven by subjective feelings, however much our work requires us to be objective.<\/p>\n

I believe in building things together; and I have, with thousands of friends, colleagues, and constructive adversaries, been involved \u2013 as an academic, iNGO director, parliamentarian, lecturer, trainer, and evaluator \u2013 in struggles for forms of health (systems) strengthening that boost quality and equity and use public funds efficiently. I have seen fashions come and go in global health. I have seen gains but also the wastages that occur in health systems. I learnt in the school of life that things work best when defined, carried out and managed by the people most concerned. I have worked with idealists and ideologues, passionados and power freaks, opportunist-hoppers and people who with amazing commitment stay with their promises and beliefs through thick and thin.<\/p>\n

I have experienced on my own continent and elsewhere various incarnations of insurance systems, national health systems, input-based models, output schemes, pilots, projects, and large-scale programmmes. I have weighed the pros and cons of input systems versus output systems, vertical thinking versus attempts to horizontalise. And I have had the pleasure to deal with the lobby and advocacy groups for all these approaches.<\/p>\n

But in the end, I prefer PBF to any other health systems approach. Not because it is perfect, but because in principle and in its make-up, it is an open and dynamic approach. It is based on a sense of human nature and potential, an awareness of tough social processes and a commitment to good governance, which resounds with my own life\u2019s experience.<\/p>\n

\u00a0<\/strong><\/p>\n

Where I agree with Paul et al <\/strong><\/p>\n

Paul et al built strawmen instead of bridges, with the risk of throwing the baby of PBF (i.e. years of critical practical development) away with the academic bathwater. But there are many points on which PBF practitioners like myself could agree with them, including that:<\/p>\n