ReBUILD & Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom.
Centre of African Studies, University of Edinburgh, Edinburgh, United Kingdom.
PLoS One. 2018 Apr 3;13(4):e0195301. doi: 10.1371/journal.pone.0195301. eCollection 2018.
Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.
在过去十年中，基于绩效的融资（PBF）计划在中低收入国家迅速扩展，得到了多边、双边和全球卫生倡议的大量外部融资。其中许多国家都是脆弱和受冲突影响的国家（FCAS），尽管人们认识到背景对 PBF 的运作很重要，但对于它如何影响 PBF 的采用和实施却很少有研究。本文提出了关于 FCAS 背景如何影响 PBF 的采用、调整、实施和卫生系统效果的初步假设。然后通过对现有灰色文献和已发表文献的综述（共 140 份文件，涵盖 23 个 PBF 计划）来检验这些假设。我们发现，PBF 在 FCAS 环境中更为常见，而且这些环境也更早采用 PBF。在项目文件中，几乎没有解释其采用的理由，特别是与背景特征有关的理由。然而，有一些因素可以解释这一点，包括外部行为者和捐助者的更大作用、对机构改革的更大开放性，以及公共系统内部和政府与捐助者之间的信任度较低，所有这些都有利于更具契约性的方法。这表明，脆弱性的条件并不是在出现之后才出现的，而是有利于 PBF 的迅速出现。我们还记录了 PBF 很少针对人道主义环境进行调整，以及有限的证据表明可能是由背景驱动的卫生系统效果，但这些需要更深入的分析。另一个值得更多研究的领域是 PBF 的政治经济学及其在不同背景下的扩散。
