title: Does performance-based financing increase value for money in low- and middle- income countries? A systematic review.
abstract: Governments of low- and middle-income countries (LMICs) are widely implementing performance-based financing (PBF) to improve healthcare services. However, it is unclear whether PBF provides good value for money compared to status quo or other interventions aimed at strengthening the healthcare system in LMICs. The objective of this systematic review is to identify and synthesize the existing literature that examines whether PBF represents an efficient manner of investing resources. We considered PBF to be efficient when improved care quality or quantity was achieved with equal or lower costs, or alternatively, when the same quality of care was achieved using less financial resources. A manual search of the reference lists of two recent systematic reviews on economic evaluations of PBF was conducted to identify articles that met our inclusion and exclusion criteria. Subsequently, a search strategy was developed with the help of a librarian. The following databases and search engines were used: PubMed, EconLit, Google Scholar and Google. Experts on economic evaluations were consulted for validation of the selected studies. A total of seven articles from five LMICs were selected for this review. We found the overall strength of the evidence to be weak. None of the articles were full economic evaluations; they did not make clear connections between the costs and effects of PBF. Only one study reported using a randomized controlled trial, but issues with the randomization procedure were reported. Important alternative interventions to strengthen the capacities of the healthcare system have not been considered. Few studies examined the costs and consequences of PBF in the long term. Important costs and consequences were omitted from the evaluations. Few LMICs are represented in the literature, despite wide implementation. Lastly, most articles had at least one author employed by an organization involved in the implementation of PBF, thereby resulting in potential conflicts of interest. Stronger empirical evidence on whether PBF represents good value for money in LMICs is needed.
authors.affiliation: University of Montreal Public Health Research Institute, 7101 Avenue du Parc, office 3060, Montreal, QC, Canada, H3N 1X9. anne-marie.turcotte-tremblay@umontreal.ca.|School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC, Canada, H3N 1X9. anne-marie.turcotte-tremblay@umontreal.ca.
authors.forename: Anne-Marie
authors.initials: AM
authors.lastname: Turcotte-Tremblay
authors.affiliation: School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC, Canada, H3N 1X9.|Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, Canada, H4H 1R3.
authors.forename: Jessica
authors.initials: J
authors.lastname: Spagnolo
authors.affiliation: Institute of Public Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.
authors.forename: Manuela
authors.initials: M
authors.lastname: De Allegri
authors.affiliation: University of Montreal Public Health Research Institute, 7101 Avenue du Parc, office 3060, Montreal, QC, Canada, H3N 1X9.|School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC, Canada, H3N 1X9.
authors.forename: Valéry
authors.initials: V
authors.lastname: Ridde
keywords: Economic evaluation; Efficiency; Low- and middle- income countries (LMICs); Performance-based financing (PBF); Review