De Allegri Manuela, Bertone Maria Paola, McMahon Shannon, Mounpe Chare Idrissou, Robyn Paul Jacob
Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany.
Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.
BMJ Glob Health. 2018 Mar 25;3(2):e000693. doi: 10.1136/bmjgh-2017-000693. eCollection 2018.
Performance-based financing (PBF) has acquired increased prominence as a means of reforming health system purchasing structures in low-income and middle-income countries. A number of impact evaluations have noted that PBF often produces mixed and heterogeneous effects. Still, little systematic effort has been channelled towards understanding what causes such heterogeneity, including looking more closely at implementation processes.
Our qualitative study aimed at closing this gap in knowledge by attempting to unpack the mixed and heterogeneous effects detected by the PBF impact evaluation in Cameroon to inform further implementation as the country scales up the PBF approach. We collected data at all levels of the health system (national, district, facility) and at the community level, using a mixture of in-depth interviews and focus group discussions. We combined deductive and inductive analytical techniques and applied analyst triangulation.
Our findings indicate that heterogeneity in effects across facilities could be explained by pre-existing infrastructural weaknesses coupled with rigid administrative processes and implementation challenges, while heterogeneity across indicators could be explained by providers' practices, privileging services where demand-side barriers were less substantive.
In light of the country's commitment to scaling up PBF, it follows that substantial efforts (particularly entrusting facilities with more financial autonomy) should be made to overcome infrastructural and demand-side barriers and to smooth implementation processes, thus, enabling healthcare providers to use PBF resources and management models to a fuller potential.
基于绩效的融资（PBF）作为改革低收入和中等收入国家卫生系统采购结构的一种手段，已日益受到关注。一些影响评估指出，PBF往往会产生复杂且各异的效果。然而，在理解造成这种异质性的原因方面，系统性的努力仍很少，包括更深入地审视实施过程。
我们的定性研究旨在填补这一知识空白，试图剖析喀麦隆PBF影响评估中发现的复杂且各异的效果，以便在该国扩大PBF方法时为进一步实施提供参考。我们通过深入访谈和焦点小组讨论相结合的方式，在卫生系统的各个层面（国家、地区、机构）以及社区层面收集数据。我们结合了演绎和归纳分析技术，并应用了分析三角互证法。
我们的研究结果表明，各机构间效果的异质性可归因于先前存在的基础设施薄弱，以及僵化的行政流程和实施挑战，而各指标间的异质性可归因于提供者的做法，即在需求方障碍较小的服务上给予优先考虑。
鉴于该国致力于扩大PBF，因此应做出大量努力（特别是赋予机构更多财务自主权）来克服基础设施和需求方障碍，并理顺实施流程，从而使医疗服务提供者能够更充分地利用PBF资源和管理模式。
