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Performance-based financing versus improving salary payments to workers: insights from the Democratic Republic of Congo
  1. Rishma Maini,
  2. Sandra Mounier-Jack,
  3. Josephine Borghi
  1. Global Health Department, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Rishma Maini; mainirishma{at}

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  • Performance-based financing (PBF) has been extensively employed by donors in low-income and middle-income countries as a strategy to improve health service delivery.

  • In the Democratic Republic of Congo, PBF is being implemented by donors and is endorsed by the Ministry of Health in a context where only a minority of health workers receive a government salary.

  • A donor-funded health systems strengthening programme, which did not employ PBF, has recently succeeded in facilitating the payment of health workers by government.

  • The programme achieved this by working closely with the government to conduct a census of health workers in order to update the payroll, which would in turn increase the number of salaried health workers.

  • Key lessons learnt from this experience included the importance of understanding the existing financial architecture of health workers and its underlying constraints, and focusing on sustainable, national solutions rather than stand-alone donor-driven quick fix solutions, which may be more challenging to maintain over the longer term.


Performance-based financing (PBF) is a type of provider payment mechanism where a financial incentive is given to healthcare workers that is linked to performance.1 Also known as pay-for-performance (P4P), its use in low-income and middle-income countries has grown since 2005 when Rwanda adopted it as national policy.1 Well-designed PBF schemes can be accompanied by broader reforms, which aim to clarify roles and responsibilities, strengthen accountability and address certain structural problems facing health systems.1 However, a recent paper by Paul et al has raised concerns over the potential system-wide and long-term effects of PBF, which may be damaging to health services in low-income and middle-income countries.2 This has led to a public debate on the evidence both for and against PBF in different settings,3 4 and the authors would like to contribute to this by sharing an …

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