Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK; Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, Germany.
Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, Germany.
Soc Sci Med. 2022 Jul;305:115065. doi: 10.1016/j.socscimed.2022.115065. Epub 2022 May 25.
In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health.
近年来，绩效激励型融资（PBF）作为一种改革中低收入国家医疗服务提供者付费机制的手段受到关注。尤其是在与需求侧干预措施相结合的情况下，PBF 被认为还将使最弱势群体受益。然而，影响评估往往发现并非如此。在布基纳法索，PBF 与具体的公平措施相结合，以提高极端贫困人口的医疗利用率，但未能产生预期效果。我们的研究使用过程追踪方法学来揭示公平措施缺乏影响力的原因。我们依靠已发表的证据、二次数据分析和定性研究的结果来支持或否定假设的因果机制，即公平措施的重构变革理论。我们的研究结果表明，各种背景、设计和实施方面的挑战是如何阻碍因果机制按计划展开的。这些挑战包括需求方极端贫困人口的识别和豁免问题，以及供应方的财务问题和考虑因素。从更广泛的角度来看，我们的研究结果强调了在最脆弱人群面临的复杂障碍的情况下，改善极端贫困人口获得医疗服务的困难。从方法论的角度来看，我们的研究证明了过程追踪在补充全球卫生领域复杂干预措施的其他评估形式方面的价值和适用性。
