Antony Matthieu, Bertone Maria Paola, Barthes Olivier
AEDES Consulting, Rue Joseph II 34, Brussels, 1000, Belgium.
BMC Health Serv Res. 2017 Mar 14;17(1):204. doi: 10.1186/s12913-017-2148-9.
Results-based financing (RBF) has been introduced in many countries across Africa and a growing literature is building around the assessment of their impact. These studies are usually quantitative and often silent on the paths and processes through which results are achieved and on the wider health system effects of RBF. To address this gap, our study aims at exploring the implementation of an RBF pilot in Benin, focusing on the verification of results.
The study is based on action research carried out by authors involved in the pilot as part of the agency supporting the RBF implementation in Benin. While our participant observation and operational collaboration with project's stakeholders informed the study, the analysis is mostly based on quantitative and qualitative secondary data, collected throughout the project's implementation and documentation processes. Data include project documents, reports and budgets, RBF data on service outputs and on the outcome of the verification, daily activity timesheets of the technical assistants in the districts, as well as focus groups with Community-based Organizations and informal interviews with technical assistants and district medical officers.
Our analysis focuses on the actual practices of quantitative, qualitative and community verification. Results show that the verification processes are complex, costly and time-consuming, and in practice they end up differing from what designed originally. We explore the consequences of this on the operation of the scheme, on its potential to generate the envisaged change. We find, for example, that the time taken up by verification procedures limits the time available for data analysis and feedback to facility staff, thus limiting the potential to improve service delivery. Verification challenges also result in delays in bonus payment, which delink effort and reward. Additionally, the limited integration of the verification activities of district teams with their routine tasks causes a further verticalization of the health system.
Our results highlight the potential disconnect between the theory of change behind RBF and the actual scheme's implementation. The implications are relevant at methodological level, stressing the importance of analyzing implementation processes to fully understand results, as well as at operational level, pointing to the need to carefully adapt the design of RBF schemes (including verification and other key functions) to the context and to allow room to iteratively modify it during implementation. They also question whether the rationale for thorough and costly verification is justified, or rather adaptations are possible.
基于结果的融资（RBF）已在非洲许多国家推行，围绕其影响评估的文献日益增多。这些研究通常是定量研究，对于成果实现的途径和过程以及RBF对更广泛卫生系统的影响往往语焉不详。为填补这一空白，我们的研究旨在探索在贝宁实施的一项RBF试点项目，重点关注结果核实情况。
本研究基于参与试点的作者开展的行动研究，这些作者是支持贝宁RBF实施的机构的一部分。虽然我们与项目利益相关者的参与观察和业务合作为本研究提供了信息，但分析主要基于在项目实施和记录过程中收集的定量和定性二手数据。数据包括项目文件、报告和预算、关于服务产出及核实结果的RBF数据、各地区技术助理的每日活动时间表，以及与社区组织的焦点小组讨论和对技术助理及地区医务人员的非正式访谈。
我们的分析聚焦于定量、定性和社区核实的实际做法。结果表明，核实过程复杂、成本高且耗时，实际上最终与最初设计的情况有所不同。我们探讨了这对该计划运作的影响，以及其产生预期变革的潜力。例如，我们发现核实程序占用的时间限制了用于数据分析和向机构工作人员反馈的时间，从而限制了改善服务提供的潜力。核实方面的挑战还导致奖金支付延迟，使努力与奖励脱节。此外，地区团队的核实活动与日常任务整合有限，导致卫生系统进一步垂直化。
我们的结果凸显了RBF背后的变革理论与实际计划实施之间可能存在的脱节。这在方法层面具有重要意义，强调分析实施过程对于全面理解结果的重要性；在操作层面也有意义，表明需要根据实际情况仔细调整RBF计划的设计（包括核实及其他关键功能），并在实施过程中留出迭代修改的空间。这些结果还引发了对于进行全面且成本高昂的核实的合理性的质疑，或者说是否有可能进行调整。
