Article Text

Download PDFPDF

Unraveling PBF effects beyond impact evaluation: results from a qualitative study in Cameroon
  1. Manuela De Allegri1,
  2. Maria Paola Bertone2,
  3. Shannon McMahon1,
  4. Idrissou Mounpe Chare3,
  5. Paul Jacob Robyn4
  1. 1 Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
  2. 2 Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
  3. 3 Department of Sociology, University of Yaoundé I, Yaoundé, Cameroon
  4. 4 Health, Nutrition, and Population Unit, The World Bank, Washington, District of Columbia, USA
  1. Correspondence to Dr Manuela De Allegri, Institute of Public Health;{at}


Introduction 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.

Methods 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.

Results 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.

Conclusion 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.

  • health policy
  • health systems
  • health systems evaluation
  • qualitative study

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:

View Full Text

Statistics from


  • MDA and MPB contributed equally.

  • Handling editor Seye Abimbola

  • Contributors MDA and PJR initiated the study and identified the broad research design and methodology. MDA, PJR, SMM and IM were responsible for discussions with the IE and the local teams and for making all specific study design and methodology choices. SMM, MDA and IMC drafted the interview guides. IMC was in charge of training research assistance and coordinating data collection. MPB was in charge of analysis, supported by MDA for purpose of triangulation. MPB and MDA drafted the final manuscript, with contributions from all authors.

  • Funding This study was financed by the World Bank Health Results Innovation Trust Fund.

  • Competing interests This study was financed by the Health Results Innovation Trust Fund, managed by the World Bank. The authors report having received personal fees from the World Bank during the conduct of the study, but not for re-elaborating findings for the manuscript and writing it. While the last author is staff at the World Bank, all other authors are independent academic researchers and for this study, they were engaged as consultants by the World Bank for various periods of time. The authors were granted full autonomy in making scientific decisions and re-elaborated findings from the study for this publication beyond the framework of their consultancy contract with the World Bank. The World Bank did not interfere with the decision to write this manuscript, its content or the decision to submit it for publication. Hence, the views presented represent those of the authors and can by no means be considered representative of the World Bank and its Directors.

  • Patient consent Obtained.

  • Ethics approval The study obtained ethical clearance from the National Ethical Committee for Research for Human Health of the Ministry of Public Health in Cameroon.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Given the sensitive nature of qualitative research and the possibility to identify single respondents (even once names are removed), we are not in the position to make the full transcripts of the interviews available on a public depository. However, we are willing to make data available upon reasonable request. Interested persons should contact the corresponding author.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.