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Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink?
  1. Elisabeth Paul1,2,
  2. Lucien Albert3,
  3. Badibanga N’Sambuka Bisala4,
  4. Oriane Bodson2,
  5. Emmanuel Bonnet5,
  6. Paul Bossyns6,
  7. Sandro Colombo7,
  8. Vincent De Brouwere8,
  9. Alexandre Dumont9,
  10. Dieudonné Sèdjro Eclou10,
  11. Karel Gyselinck6,
  12. Fatoumata Hane11,
  13. Bruno Marchal8,
  14. Remo Meloni12,
  15. Mathieu Noirhomme13,
  16. Jean-Pierre Noterman14,
  17. Gorik Ooms15,
  18. Oumar Mallé Samb16,
  19. Freddie Ssengooba17,
  20. Laurence Touré18,
  21. Anne-Marie Turcotte-Tremblay19,
  22. Sara Van Belle8,
  23. Philippe Vinard20,
  24. Valéry Ridde9
  1. 1 Tax Institute, Université de Liège, Liège, Belgium
  2. 2 Faculty of Social Sciences, Université de Liège, Liège, Belgium
  3. 3 International Health Unit, University of Montreal, Montreal, Quebec, Canada
  4. 4 Expert in district health systems based on primary healthcare, Groupe d’Appui à la Recherche et Enseignement en Santé Publique, Mbuji-Mayi, Democratic Republic of the Congo
  5. 5 Résiliences, Research Institute for Development (IRD), Bondy, France
  6. 6 Health Sector Thematic Unit, Belgian Development Agency (ENABEL), Brussels, Belgium
  7. 7 Independent Consultant, Madrid, Spain
  8. 8 Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
  9. 9 CEPED, Research Institute for Development (IRD), Paris Descartes University, INSERM, Paris, France
  10. 10 LADYD, Université d’Abomey-Calavi, Abomey-Calavi, Benin
  11. 11 Department of Sociology, Université Assane Seck, Ziguinchor, Senegal
  12. 12 Independent Consultant, Kigali, Rwanda
  13. 13 Independent Consultant, Brussels, Belgium
  14. 14 Independent Consultant, Bunia, Democratic Republic of the Congo
  15. 15 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
  16. 16 Global Health, Department of Health Sciences, Université du Québec en Abitibi-Témiscamingue, Quebec City, Quebec, Canada
  17. 17 Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
  18. 18 Anthropologist, Research Association Miseli, Bamako, Mali
  19. 19 University of Montreal Public Health Research Institute, Montreal, Quebec, Canada
  20. 20 Alter Santé Internationale, Montpellier, France
  1. Correspondence to Dr Elisabeth Paul; E.Paul{at}


This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

  • health policy
  • health systems

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Handling editor Seye Abimbola

  • Contributors EP and VR had the initial idea for this paper. They wrote the first draft and all authors contributed to the development of ideas, writing the manuscript, commenting on drafts and approved the final version.

  • Funding EP and OB are funded in part by the ARC grant for Concerted Research Actions, financed by the French Community of Belgium (Wallonia-Brussels Federation).

  • Disclaimer The views expressed are those of the authors, and not necessarily those of their respective institutions.

  • Competing interests Some authors have been involved in PBF programmes as a researcher and/or consultant and/or staff of a donor agency.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Correction notice Since original publication of this article a French translated version has been made available and can be viewed in the online supplementary material.

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