Background:
Performance-Based Financing (PBF) has been advanced as a solution to contribute to improving
the performance of health systems in developing countries. This is the case in Benin. This study aims to analyse
how two PBF approaches, piloted in Benin, behave during implementation and what effects they produce, through
investigating how local stakeholders perceive the introduction of PBF, how they adapt the different approaches
during implementation, and the behavioural interactions induced by PBF.
Methods:
The research rests on a socio-anthropological approach and qualitative methods. The design is a case
study in two health districts selected on purpose. The selection of health facilities was also done on purpose, until
we reached saturation of information. Information was collected through observation and semi-directive interviews
supported by an interview guide. Data was analysed through contents and discourse analysis.
Results:
The Ministry of Health (MoH) strongly supports PBF, but it is not well integrated with other ongoing
reforms and processes. Field actors welcome PBF but still do not have a sense of ownership about it. The two PBF
approaches differ notably as for the organs in charge of verification. Performance premiums are granted according
to a limited number of quantitative indicators plus an extensive qualitative checklist. PBF matrices and verification
missions come in addition to routine monitoring. Local stakeholders accommodate theoretical approaches. Globally,
staff is satisfied with PBF and welcomes additional supervision and training. Health providers reckon that PBF
forces them to depart from routine, to be more professional and to respect national norms. A major issue is the
perceived unfairness in premium distribution. Even if health staff often refer to financial premiums, actually the
latter are probably too weak—and ‘blurred’—to have a lasting inciting effect. It rather seems that PBF motivates
health workers through other elements of its ‘package’, especially formative supervisions.
Conclusion:
If the global picture is quite positive, several issues could jeopardise the success of PBF. It appears
crucial to reduce the perceived unfairness in the system, notably through enhancing all facilities’ capacities to ensure
they are in line with national norms, as well as to ensure financial and institutional sustainability of the syste