Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches

Analyse de la mortalité bovine en France de 2003 à 2009

La mortalité bovine est un problème important, tant au plan économique que du point de vue du bien-être animal. Nous avons analysé les données enregistrées dans la base de données nationale d'identification de 2003 à 2009, décrivant la carrière d'environ 75 millions de bovins, afin de fournir des statistiques fiables de la mortalité bovine en France. Les résultats de cette étude constituent un référentiel pouvant être utilisé pour évaluer des situations observées en élevage. En moyenne sur cette période, le risque de mortalité périnatale des mâles et des femelles atteignait respectivement 7,9% et 6,0% dans le cheptel laitier, et 4,7% et 3,2% dans le cheptel allaitant. Le risque de mortalité annuel moyen des animaux de plus de deux ans était de 3,5% chez les laitiers et de 2,0% chez les allaitants. La mortalité des bovins laitiers était significativement plus élevée que celle des allaitants pour les dix classes d'âge étudiées, sauf celle de un à deux ans. La modélisation des données hebdomadaires a permis de décrire la saisonnalité des taux de mortalité, qui était différente selon le sous-groupe populationnel considéré. Les taux de mortalité des veaux de moins de sept jours présentaient notamment deux pics d'ampleur équivalente (en décembre et juillet), tandis que les autres classes d'âge présentaient un pic principal en hiver, visiblement associé chez les adultes au pic de vêlage. Les résultats de cette modélisation ont par ailleurs révélé une augmentation significative des taux de mortalité de 2003 à 2009, probablement en partie due à l'épizootie de fièvre catarrhale ovine qui s'est propagée en France en 2007-2008. L'augmentation des taux de mortalité bovine a déjà été constatée dans de nombreux pays, suggérant la nécessité de mettre en place des mesures correctrices.Cattle mortality represents both an economical and an animal welfare issue. We analyzed the data recorded in the National Cattle Register from 2003 to 2009, gathering data about 75 million cattle, to provide reliable statistics of cattle mortality in France. On average over this period, the perinatal mortality risk in males and females reached respectively 7.9% and 6.0% in dairy cattle, and 4.7% and 3.2% in beef cattle. The average annual mortality risk of animals over two years was 3.5% for dairy and 2.0% for beef cattle. Mortality of dairy cattle was significantly higher than that of beef cattle for the ten age groups studied, except for those of one to two years. Weekly data were modeled to describe the seasonality of mortality, which was different among the different sub-population groups. The mortality rate of calves less than seven days old showed two peaks of equal magnitude (in December and July), while other age groups showed a major peak in the winter, apparently associated in adults to the peak of calving. The modeling results of the model also revealed a significant increase in death rates from 2003 to 2009, probably partly due to the blue tongue epizootic that spread in France from 2007 to 2008. Rising rates of cattle mortality have already been observed in many countries, suggesting the need to implement corrective measures

Longitudinal evaluation of three azithromycin distribution strategies for treatment of trachoma in a sub-Saharan African country, Mali

Objectives: Trachoma, caused by repeated ocular infections with Chlamydia trachomatis is an important cause of blindness. Mass azithromycin distribution is part of current recommended strategies for controlling trachoma. In order to ascertain an efficient strategy model at an acceptable cost, an intervention study was conducted in Mali between May 2000 and February 2002. Methods: Three azithromycin administration strategies were evaluated: mass community-based treatment of all residents (strategy 1), treatment of all children under 11 years of age and of women between 15 and 50 (strategy II), and treatment targeted to inhabitants of households where at least one child had clinically active trachoma diagnosed (strategy 111). In a particular Malian area in which trachoma was known to be mesoendemic, three villages were selected for each of the three strategies. According to the strategy allocation, adults were eventually given a single dose of I g azithromycin, and children a unique dose of 20 mg/kg. Moreover, cleanliness and washing of children's faces were assessed, and additional questions were addressed about education, environmental and socio-economic conditions for each household at baseline. Ophthalmic examination was performed at baseline and 1, 6 and 12 months after inclusion. The outcome variable was clinically active trachoma frequency 12 months after intervention among children under I I years of age. A descriptive analysis was performed, and then logistic regression models were built to test the efficiency of the three strategies. Results: Among children under 11 years of age, the active trachoma prevalence fell dramatically in each strategy, from 23.7% to 6.4% in strategy 1, from 20.8% to 6.8% in strategy 11, and from 20.2% to 8.5% in strategy III. After adjustment on age (adjusted odds ratio [AOR] = 0.81; 95% confidence interval [95% Cl]: 0.75-0.87) and on active trachoma occurrence at baseline (AOR = 3.81; [95% Cl]: 2.70-5.39), the multiple logistic regression model showed that both strategies I and II gave similar results, while strategy III appeared significantly less effective (AOR = 1.56; [95% CI]: 1.00-2.43). Conclusion: In mesoendemic trachoma areas, targeted treatment to all children under I I years of age and women between 15 and 50 (strategy 11) was as effective as indiscriminate mass distribution (strategy 1) and more effective than treatment targeted to inhabitants of households where at least one child had active trachoma diagnosed (strategy 111). Strategy 11 could therefore reduce the prevalence and intensity of trachoma infection at a lower cost than mass community-based treatment of all residents (strategy 1)

Performance-based financing in low-income and middle-income countries : isn&8217;t it time for a rethink ?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches