Participatory action research (PAR) seeks to understand and improve the world by changing it, where those affected collectively validate experience and analysis, act and learn from action to produce new knowledge. While transformative, it is often local in nature. With African health systems influenced by global policies and funds, EQUINET sought to use the internet to implement PAR in multiple countries in east and southern Africa (ESA), as PARonline. Performance based financing (PBF) is one such global process. It is the transfer of money or material goods conditional upon taking a measurable action or achieving a predetermined performance target. There has been little systematic evaluation of the system-wide effects of PBF, nor of its impacts on comprehensive primary health care (PHC). Given the longstanding policy commitment to PHC in the region, this PARonline research thus asked: How is the use of health targets in PBF affecting health workers professional roles, work and interaction with communities and their ability to deliver comprehensive PHC? The research involved 21 online participants from seven sites in five ESA countries, including health workers from primary health centres, community members in health centre committees and country site facilitators from national health civil society. It also included offline local discussions with an average of 19 community members and 15 health workers per site. This report presents the experience and views of these primary care health workers, community members and local organisations on the implementation of PBF and its effects on PHC and the proposals for how to respond to both the positive and negative features found. There were positive features, such as in the increased funding and income for primary care services and health workers, and the investment in training and in strengthened service monitoring. There was some variation across countries that provide useful ideas for exchange, such as on the funding of community workers or flexibility for local use of funds. In general, however, the current application of PBF was found to fall short on delivering features of comprehensive PHC. While aiming to strengthen bottom-up accountability in services, neither health workers nor community members felt empowered by PBF, feeling their views and evidence to be disregarded and seeing themselves as implementers of targets defined at higher levels. We observed real trade-offs between PBF and the way comprehensive PHC is funded and delivered. Being selective can be efficient, but can also leave gaps in the system. The online participants viewed that unless the wider collective inputs for facilities and promotion and prevention in the community are funded, population health will not improve. This is noted to call for improved domestic funding to meet gaps in PHC. It also implies that PBF, as a significant funding stream, integrate resources and measures for these system inputs and for more holistic health services.
PAR work, Values, policies and rights, Equitable health services, Resource allocation and health financing, Governance and participation in health
Title of publication How does target-driven funding affect comprehensive primary health care in east and southern Africa?
Date of publication
Loewenson R et al., How does target-driven funding affect comprehensive primary health care in east and southern Africa? EQUINET, Harare
performance based financing; health financing; primary health care; participatory action research; east and southern Africa
East and southern Africa region
Equinet Publication Type
Discussion paper, Reports