The DRC context

Although the DRC has been post-conflict since 2003, its health system remains weak; hospitals and clinics lack personnel and equipment, and often run out of critical medicine and supplies. Few public sector health workers receive any government payments; this is due to the payroll being out of date and plagued by ‘ghost workers’, which are people listed on the payroll to receive a salary but who do not currently practice in health facilities.5 Therefore, in an effort to maintain health service delivery, donors have been implementing PBF schemes across the country for several years. Many of these have been delivered as stand-alone PBF programmes; for example, a previous health programme called Access to Healthcare (ATH) funded by the Department for International Development (DFID) between 2008 and 2013 channelled payments to workers outside of the national system. By 2015, a quarter of all health zones were receiving PBF support from various different donors.6 Its roll-out has been endorsed by the Ministry of Health, but there is no national PBF scheme for the country as yet.

However, in the DRC, the evidence suggests that health workers do not value PBF payments as much as they do fixed salaries.7 8 Effects of PBF on performance have also been mixed in this context. In one study, PBF led to efficiency gains and improvements in service quality9; another study demonstrated that PBF did elicit an increase in efforts to target service provision, but did not stimulate demand for services, and even resulted in a reduction of intrinsic motivation of workers.10

An alternative to PBF

In 2013, a new health systems strengthening programme funded by DFID called Accès Aux Soins de Santé Primaire (Access to Primary Healthcare/ASSP) commenced. In contrast to other donor programmes that were continuing with PBF or introducing follow-on PBF schemes, ASSP started to phase PBF out from its predecessor programme ATH. It was hypothesised that the presence of PBF—among other reasons including a low national budget for health, poor governance and security issues—had reduced incentives for the government to salary its health workers, thus potentially undermining system-wide reform in the sector. Instead, the ASSP programme worked 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.5

In practice, the phasing out of PBF proved difficult: it was perceived to have caused an exodus of workers from facilities as well as to have negatively affected their motivation and relationships with the local community.11 Part of the reason was that the change was poorly communicated, and performance payments were much higher than other sources of revenue received by workers including salaries, and so their removal constituted a significant economic shock to workers.8 11 Nonetheless, those workers who remained in facilities post-withdrawal of PBF indicated they would prefer to receive a fixed salary payment from the government compared with a performance payment from donors, as they saw the former as a more sustainable source of income.8

ASSP eventually succeeded in updating the health worker payroll for the provinces of Kasai and Kasai Central, as described by Likofata et al.5 Ghost worker payments were redistributed to thousands of previously undercompensated or uncompensated health workers in the civil service. However, the solution was not solely technical. The payment of health workers was outside the control of the Ministry of health, and under the purview of the Ministries of Finance, Budget and Public Sector Reform. Development partners involved in implementing ASSP therefore had to build relationships and work across these different Ministries, in order to secure government ownership and influence change. This was particularly crucial as there would have been vested interests within Ministries to maintain the status quo as salaries tend to be intricately tied to patronage and issues of political expediency.12 The DRC’s Health Development Plan 2016–2020 also now acknowledges there is a continued need to strengthen information systems on human resources for health and improve on the number of salaried workers.13

Lessons learnt

Several key lessons were learnt from this experience. First, PBF can serve as a distraction from the pursuit of more challenging interventions that are needed to address the underlying constraints of health systems. In the DRC, the financial compensation received by workers under donor-funded PBF schemes was effectively serving as a partial substitute for salaries, as only a minority of workers were being paid by the government; a similar analogy would be that of applying a plaster to an infected wound, rather than treating the underlying infection. The attraction of PBF for donors is understandable as it allows them to measure and demonstrate to their own governments and tax payers the results and value for money of their investments. On the other hand, interventions that require donors normally focused on health to work across several Ministries may seem less appealing.

Yet, a failure to address the problems at root can lead to a perpetuation of weak government leadership and accountability.14 In fragile and conflict-affected states such as the DRC, despite close coordination with government, PBF schemes are often still too complex for states to manage within their existing systems, and so involve the introduction of parallel systems to channel funding to providers and verify performance. Due to poor governance and accountability in the DRC, partners do not provide budget support; instead, PBF funds go directly into the accounts of health facilities. This results in PBF undermining rather than reinforcing state capacity.15 Furthermore, given that donor funding for performance-based incentives will in all likelihood eventually be withdrawn, there is the risk of creating a dependency on an income source that is not sustainable over the long term, with all the negative consequences that can entail.

Another lesson learnt was the need to understand the financial environment within which health workers operate when considering PBF initiatives.16 It has been acknowledged that PBF initiatives are often implemented as stand-alone projects without due consideration being given to the overall health system environment and their integration therein.17 Although the PBF model employed by the ATH programme did show evidence of improvements in performance over the short term,10 it could not have been sustainably financed in the absence of external aid. Soucat et al have highlighted the importance of understanding how PBF could be blended with the existing base payment mechanism to effectively align provider incentives with health policy objectives.17 This is key to ensuring that the system is structurally and financially sustainable; rather than adding extra income through a parallel system, existing income payments may be adjusted to make a proportion of it performance based. More recent innovations, like the Global Financing Facility which has started in the DRC, may also provide a good mechanism to support government efforts to enhance domestic resource mobilisation.18 The authors would argue, however, that the payment of salaries to workers should first be ensured before introducing more complex remuneration structures.