Fox Sarah, Witter Sophie, Wylde Emily, Mafuta Eric, Lievens Tomas
ReBUILD Programme, Queen Margaret University, Edinburgh, UK. E-mail:
Health Policy Plan. 2014 Jan;29(1):96-105. doi: 10.1093/heapol/czs138. Epub 2013 Jan 15.
The health financing system in the Democratic Republic of Congo (DRC) presents an extreme example of low government investment, high dependency on user fees and poor harmonization across donors. Within this context, performance-based financing mechanisms are being implemented by various donors in the expectation that they will improve health worker motivation and service delivery performance. Drawing on qualitative and quantitative data at different levels of the health system, this study focuses on one such programme in Katanga Province, which combines paying for performance (P4P) with a reduction in fees to users. Despite adding considerably to facility resources (providing the majority of the resources in the case study facilities), there was no evidence of benefits in terms of any of the service inputs, processes or outputs measured. The findings suggest that the positive effects on health worker motivation cannot be taken as a given, particularly, when staff are often expected to increase their workload to achieve the performance objectives and when another source of income, the income from user fees, may be reduced due to a fall in the prices of services. Moreover, in a context where health workers were already almost entirely dependent on users for their remuneration before the donor programme was introduced, the incentive effects of a performance contract may be muted. In addition, other income sources have particular value for staff, it seems-even though salaries and government allowances were low, and frequently delayed, health workers were highly dissatisfied at not receiving them. Salaries were seen as a more assured and long-term source of funding and an important recognition of their role as agents of the state. The authors conclude that while there may be a role for P4P in fragile contexts such as the DRC, to be effective it needs to be rooted in wider financing and human resource policy reforms.
刚果民主共和国的卫生筹资系统是政府投资低、对使用者付费高度依赖且捐助方之间协调不佳的极端例子。在此背景下，各种捐助方正在实施基于绩效的筹资机制，期望借此提高卫生工作者的积极性和服务提供绩效。本研究利用卫生系统不同层面的定性和定量数据，聚焦于加丹加省的一个此类项目，该项目将按绩效付费（P4P）与降低使用者费用相结合。尽管该项目大幅增加了机构资源（在案例研究机构中提供了大部分资源），但在所衡量的任何服务投入、过程或产出方面，均未发现有受益的证据。研究结果表明，对卫生工作者积极性的积极影响不能被视为理所当然，特别是当工作人员常常被期望增加工作量以实现绩效目标，以及当另一个收入来源——使用者费用收入——可能因服务价格下降而减少时。此外，在引入捐助方项目之前，卫生工作者的薪酬几乎完全依赖使用者的情况下，绩效合同的激励效果可能会减弱。另外，其他收入来源对工作人员似乎具有特殊价值——尽管工资和政府津贴很低且经常延迟发放，但卫生工作者对未收到这些收入极为不满。工资被视为更可靠和长期的资金来源，以及对他们作为国家工作人员角色的重要认可。作者得出结论，虽然在刚果民主共和国这样的脆弱环境中，按绩效付费可能会发挥作用，但要想有效，它需要扎根于更广泛的筹资和人力资源政策改革之中。
