Stunted scale-up of a performance-based financing program on HIV and maternal–child health services in Mozambique — a policy analysis

Abstract

Objective: A performance-based financing (PBF) program was implemented for services for HIV, prevention of mother-to-child transmission (PMTCT) and maternal/child health (MCH) in two provinces of Mozambique. This study investigates the determinants of policy scale-up to help accelerate the expansion of PBF in Mozambique and globally from pilot projects to national policies.
Methods: A retrospective policy programme analysis was carried out using in-depth key informant interviews. A total of 24 interviews were conducted with stakeholders from donor agencies, the implementing NGO, district and
provincial health offices, and the Ministry of Health.
Results: Stakeholders reported that the scale-up process of PBF was  influenced by three key determinants: political power, financial sustainability, and available capacity and evidence. In Mozambique, PBF scaled-up provincially but not nationally due to these determinants. The adoption of PBF in Mozambique involved a restricted range of policy actors at the central level and was strongly driven by the donor and a PBF  champion. Provincial scale-up was fostered by political support and increasing capacity over time.
Conclusion: There was a generalised ambivalence and lack of incentive to scale-up PBF from the implementing NGO. Coupled with the lack of  evidence of a positive effect, and of cost-effectiveness in comparison with other models to improve health service delivery and health system  strengthening, it is difficult to argue for the need to scale up the PBF  programme studied. Care needs to be taken to base the adoption of  health policies, including PBF, on a situational analysis and on evidence of intervention effectiveness, cost-benefits and contextual fit.

Keywords: Policy, scalability, implementation research, results-based financing, health financing