Ssengooba Freddie, McPake Barbara, Palmer Natasha
Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Uganda.
Soc Sci Med. 2012 Jul;75(2):377-83. doi: 10.1016/j.socscimed.2012.02.050. Epub 2012 Apr 20.
Performance-based contracting (PBC) is a tool that links rewards to attainment of measurable performance targets. Significant problems remain in the methods used to evaluate this tool. The primary focus of evaluations on the effects of PBC (black-box) and less attention to how these effects arise (open-box) generates suboptimal policy learning. A black-box impact evaluation of PBC pilot by the Development Research Group of the World Bank (DRG) and the Ministry of Health (MOH) concluded that PBC was ineffective. This paper reports a theory-based case study intended to clarify how and why PBC failed to achieve its objectives. To explain the observed PBC implementation and responses of participants, this case study employed two related theories i.e. complex adaptive system and expectancy theory respectively. A prospective study trailed the implementation of PBC (2003-2006) while collecting experiences of participants at district and hospital levels. Significant problems were encountered in the implementation of PBC that reflected its inadequate design. As problems were encountered, hasty adaptations resulted in a de facto intervention distinct from the one implied at the design stage. For example, inadequate time was allowed for the selection of service targets by the health centres yet they got 'locked-in' to these poor choices. The learning curve and workload among performance auditors weakened the validity of audit results. Above all, financial shortfalls led to delays, short-cuts and uncertainty about the size and payment of bonuses. The lesson for those intending to implement similar interventions is that PBC should not be attempted 'on the cheap'. It requires a plan to boost local institutional and technical capacities of implementers. It also requires careful consideration of the responses of multiple actors - both insiders and outsiders to the intended change process. Given the costs and complexity of PBC implementation, strengthening conventional approaches that are better attuned to low income contexts (financing resource inputs and systems management) remains a viable policy option towards improving health service delivery.
基于绩效的合同（PBC）是一种将奖励与可衡量的绩效目标达成情况挂钩的工具。用于评估该工具的方法仍存在重大问题。评估主要关注PBC的效果（黑箱），而较少关注这些效果是如何产生的（白箱），这导致政策学习效果欠佳。世界银行发展研究小组（DRG）和卫生部（MOH）对PBC试点进行的黑箱影响评估得出结论，PBC无效。本文报告了一项基于理论的案例研究，旨在阐明PBC未能实现其目标的方式和原因。为了解释观察到的PBC实施情况及参与者的反应，该案例研究分别采用了两个相关理论，即复杂适应系统理论和期望理论。一项前瞻性研究跟踪了PBC的实施过程（2003 - 2006年），同时收集了地区和医院层面参与者的经验。PBC实施过程中遇到了重大问题，反映出其设计存在缺陷。随着问题的出现，仓促的调整导致了一种事实上与设计阶段所暗示的干预不同的干预方式。例如，卫生中心在选择服务目标时时间不足，但却“锁定”了这些不佳的选择。绩效审计人员的学习曲线和工作量削弱了审计结果的有效性。最重要的是，资金短缺导致了延迟、走捷径以及奖金规模和支付的不确定性。对于那些打算实施类似干预措施的人来说，教训是PBC不应“偷工减料”地尝试。它需要一个提升实施者当地机构和技术能力的计划。它还需要仔细考虑多个行为者（包括预期变革过程的内部人员和外部人员）的反应。鉴于PBC实施的成本和复杂性，加强更适合低收入环境的传统方法（资助资源投入和系统管理）仍然是改善卫生服务提供的可行政策选择。
