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Bull World Health Organ. 2011 Sep 1;89(9):695-8. doi: 10.2471/BLT.11.087379.

Can performance-based financing be used to reform health systems in developing countries?

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School of Public Health, Université Libre de Bruxelles, Brussels, Belgium.


Over the past 15 years, performance-based financing has been implemented in an increasing number of developing countries, particularly in Africa, as a means of improving health worker performance. Scaling up to national implementation in Burundi and Rwanda has encouraged proponents of performance-based financing to view it as more than a financing mechanism, but increasingly as a strategic tool to reform the health sector. We resist such a notion on the grounds that results-based and economically driven interventions do not, on their own, adequately respond to patient and community needs, upon which health system reform should be based. We also think the debate surrounding performance-based financing is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the performance-based financing package.

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