Mapping and analysis of health financing in South Kivu province (DRC) / Cartographie et analyse du financement de la santé dans la province du Sud-Kivu (RDC)

Introduction: In South-Kivu, the health system is underfunded due to numerous constraints. Several initiatives have been tested but are insufficient for increasing and sustaining health financing. Purpose of research: Analyze the health financing system in South-Kivu, through a mapping as well as quantitative and qualitative analysis of health financing mechanisms. Results: The provincial health financing system is fragmented, with poorly coordinated mechanisms and interventions, leading to duplication of health system strengthening activities in addition to the absence of a mechanism for pooling external funding flows. Costs recovery (i.e. user fees) and external supports are the most widely used schemes while the government hardly contributes to the financing of the provincial health system. Mutual health insurance is supposed to improve access to health care, but its coverage is still extremely low. Results-Based Financing and free health care programs, fully financed by external donors, are irregular and insufficiently sustainable. Conclusions: It would be critical to implement a strategic purchasing model that is anchored in local institutions, owned by all stakeholders, and integrating all existing financing mechanisms, which could be supported by a common fund supporting the provincial health system. The "Single Contract" initiative developed to harmonize, pool, and sustain external programs, could be a good basis in this respect. This would involve strengthening policy dialogue, developing an investment case to support resource mobilization and implementing a joint monitoring and evaluation platform for disbursements led by the provincial health authorities.

Introduction: Au Sud-Kivu, en République démocratique du Congo, le système de santé est sous-financé dû à de nombreuses contraintes. Plusieurs initiatives ont été testées mais restent insuffisantes pour augmenter et pérenniser le financement de la santé. But de l'étude: Analyser le système de financement de la santé au Sud-Kivu, par une cartographie et une analyse quantitative et qualitative des mécanismes de financement. Résultats: Le système de financement de la santé de la province est fragmenté, avec des mécanismes et interventions peu coordonnés, suscitant des duplications d'activités d'appui au système de santé, en plus de la quasi-absence de mécanisme de mise en commun des appuis extérieurs. Le recouvrement des coûts et les financements extérieurs sont les mécanismes les plus utilisés alors que l'État contribue très faiblement au financement du système provincial de santé. Les mutuelles de santé sont censées améliorer l'accès aux soins, mais leur taux de couverture reste extrêmement faible. Le financement basé sur les résultats et la gratuité des soins, intégralement compensés par les donateurs extérieurs, sont irréguliers et insuffisamment pérennes. Conclusions: Il serait essentiel d'adopter au Sud-Kivu un modèle d'achat stratégique, ancré dans les institutions locales, approprié par l'ensemble des parties prenantes, qui intègre l'ensemble des mécanismes de financement existants et qui soit appuyé par un fonds commun d'appui au système provincial de santé. L'initiative du Contrat unique développée pour harmoniser, mettre en commun et pérenniser les programmes extérieurs peut servir de base pour élaborer un tel modèle. Ceci impliquerait de renforcer le dialogue politique, d'élaborer un dossier d'investissement pour soutenir la mobilisation des ressources et de créer une plateforme conjointe de suivi et d'évaluation des décaissements, pilotée par les autorités provinciales de santé.

COVAX - Time to reconsider the strategy and its target.

COVAX, the international initiative supporting COVID-19 vaccination campaigns globally, is budgeted to be the costliest public health initiative in low- and middle-income countries, with over 16 billion US dollars already committed. While some claim that the target of vaccinating 70% of people worldwide is justified on equity grounds, we argue that this rationale is wrong for two reasons. First, mass COVID-19 vaccination campaigns do not meet standard public health requirements for clear expected benefit, based on costs, disease burden and intervention effectiveness. Second, it constitutes a diversion of resources from more cost-effective and impactful public health programmes, thus reducing health equity. We conclude that the COVAX initiative warrants urgent review.

What theories underpin performance-based financing? A scoping review.

PURPOSE: The study aims to explore the theoretical bases justifying the use of performance-based financing (PBF) in the health sector in low- and middle-income countries (LMICs). DESIGN/METHODOLOGY/APPROACH: The authors conducted a scoping review of the literature on PBF so as to identify the theories utilized to underpin it and analyzed its theoretical justifications. FINDINGS: Sixty-four studies met the inclusion criteria. Economic theories were predominant, with the principal-agent theory being the most commonly-used theory, explicitly referred to by two-thirds of included studies. Psychological theories were also common, with a wide array of motivation theories. Other disciplines in the form of management or organizational science, political and social science and systems approaches also contributed. However, some of the theories referred to contradicted each other. Many of the studies included only casually alluded to one or more theories, and very few used these theories to justify or support PBF. No theory emerged as a dominant, consistent and credible justification of PBF, perhaps except for the principal-agent theory, which was often inappropriately applied in the included studies, and when it included additional assumptions reflecting the contexts of the health sector in LMICs, might actually warn against adopting PBF. PRACTICAL IMPLICATIONS: Overall, this review has not been able to identify a comprehensive, credible, consistent, theoretical justification for using PBF rather than alternative approaches to health system reforms and healthcare providers' motivation in LMICs. ORIGINALITY/VALUE: The theoretical justifications of PBF in the health sector in LMICs are under-documented. This review is the first of this kind and should encourage further debate and theoretical exploration of the justifications of PBF.

An assessment of the core capacities of the Senegalese health system to deliver Universal Health Coverage.

Senegal is firmly committed to the objective of universal health coverage (UHC). Various initiatives have been launched over the past decade to protect the Senegalese population against health hazards, but these initiatives are so far fragmented. UHC cannot be achieved without health system strengthening (HSS). Here we assess the core capacities of the Senegalese health systems to deliver UHC, and identify requirements for HSS in order to implement and facilitate progress towards UHC. Based on a critical review of existing data and documents, complemented by the authors' experience in supporting UHC policy making and implementation, we evaluate the main foundational and institutional bottlenecks relative to the six health system building blocks, together with an analysis of the demand-side of the health system, which facilitate or hamper progress towards UHC. Despite the fact that many institutions are now in place to deliver UHC, important weaknesses limit progress along the two dimensions of UHC. Substantial disparities characterise resource allocation in the health sector, and health risk protection schemes are highly fragmented. This spreads down to the rest of the health system including service delivery and consequently, impacts on health outcomes. These constraints are acknowledged by the authorities, solutions have been proposed, but these necessitate strong political will. Moreover, progress towards UHC is constrained by the difficulty to act on social determinants of health and a lack of fiscal space.

Budgeting challenges on the path towards universal health coverage: the case of Benin.

BACKGROUND: In its pursuance of universal health coverage (UHC), the government of Benin is piloting a project of mandatory social insurance for health entitled "ARCH". METHODS: We analysed budget data and ARCH documents, and conducted four observation missions in Benin between March 2018 and January 2020. Results are presented in terms of the three classical objectives of public expenditure management. RESULTS: The government of Benin faces important budgeting challenges when it comes to implementing the ARCH social insurance project: (i) the fiscal space is quite limited, there is a limited potential for new taxes and these may not benefit the ARCH funding, hence the need to prioritise fiscal resources without jeopardising other areas; (ii) the purchasing of health services should be more strategic so as to increase allocative efficiency and equity; (iii) the efficiency of the expenditure process needs to be improved, and more autonomy needs to be devoted to the operational level, so as to ensure that health facilities are reimbursed in a timely fashion in order to meet insured people's health costs, in such a way as to avoid jeopardizing the financial equilibrium of these facilities. CONCLUSION: The important budgeting challenges faced by Benin when it comes to implementing its UHC policy are also faced by many other African countries. It is important to avoid a situation in which the resources dedicated by the government to the social health insurance system are at the expense of a reduction in the financing of preventive and promotional primary healthcare services.

Assessment of Anhedonia in Adults With and Without Mental Illness: A Systematic Review and Meta-analysis.

Importance: Anhedonia, a reduced capacity for pleasure, is described for many psychiatric and neurologic conditions. However, a decade after the Research Domain Criteria launch, whether anhedonia severity differs between diagnoses is still unclear. Reference values for hedonic capacity in healthy humans are also needed. Objective: To generate and compare reference values for anhedonia levels in adults with and without mental illness. Data Sources: Web of Science, Scopus, PubMed, and Google Scholar were used to list all articles from January 1, 1995 to July 2, 2019, citing the scale development report of a widely used anhedonia questionnaire, the Snaith-Hamilton Pleasure Scale (SHAPS). Searches were conducted from April 5 to 11, 2018, and on July 2, 2019. Study Selection: Studies including healthy patients and those with a verified diagnosis, assessed at baseline or in a no-treatment condition with the complete 14-item SHAPS, were included in this preregistered meta-analysis. Data Extraction and Synthesis: Random-effects models were used to calculate mean SHAPS scores and 95% CIs separately for healthy participants and patients with current major depressive disorder (MDD), past/remitted MDD, bipolar disorder, schizophrenia, substance use disorders, Parkinson disease, and chronic pain. SHAPS scores were compared between groups using meta-regression, and traditional effect size meta-analyses were conducted to estimate differences in SHAPS scores between healthy and patient samples. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Main Outcomes and Measures: Self-reported anhedonia as measured by 2 different formats of the SHAPS (possible ranges, 0-14 and 14-56 points), with higher values on both scales indicating greater anhedonia symptoms. Results: In the available literature (168 articles; 16 494 participants; 8058 [49%] female participants; aged 13-72 years), patients with current MDD, schizophrenia, substance use disorder, Parkinson disease, and chronic pain scored higher on the SHAPS than healthy participants. Within the patient groups, those with current MDD scored considerably higher than all other groups. Patients with remitted MDD scored within the healthy range (g = 0.1). This pattern replicated across SHAPS scoring methods and was consistent across point estimate and effect size analyses. Conclusions and Relevance: The findings of this meta-analysis indicate that the severity of anhedonia may differ across disorders associated with anhedonia. Whereas anhedonia in MDD affects multiple pleasure domains, patients with other conditions may experience decreased enjoyment of only a minority of life's many rewards. These findings have implications for psychiatric taxonomy development, where dimensional approaches are gaining attention. Moreover, the SHAPS reference values presented herein may be useful for researchers and clinicians assessing the efficacy of anhedonia treatments.

Misunderstandings and ambiguities in strategic purchasing in low- and middle-income countries.

Strategic purchasing is branded as an approach that is necessary for progress towards universal health coverage. While we agree that publicly purchased health services should respond to society's needs and patient expectations, and thus generally endorse strategic purchasing, here we would like to explore two emerging concerns within current discussions in low- and middle-income countries. First, there exists a great deal of misunderstanding and conceptual unclarity, within practitioner groups, around the concept of strategic purchasing and what instruments it incorporates. Second, there is a growing trend to regularly fuse strategic purchasing into a performance-based financing (PBF) discourse in ways that increasingly blur their distinctive properties and policy orientations, while perhaps too easily obfuscating potential tensions. We believe the discourse on strategic purchasing would benefit from better conceptual clarity by dissociating and prioritising its two objectives, namely: priority should be given to needs-based allocation of resources, while rewarding performance is a subsequent concern. We argue there is a need for a more thoroughgoing conceptual and empirical re-examination of strategic purchasing's priorities, its link with PBF, as well as for a wider evidence-base on what strategic purchasing tools exist and which are most appropriate for diverse contexts.

Falling Through the Cracks: The Need to Include Acute Pancreatitis in Risk Assessment Models for Acute Deep Venous Thrombosis.

Acute pancreatitis is an inflammatory condition caused by an insult to the pancreas. Pancreatitis is associated with local and systemic complications such as splenic vein thrombosis and systemic inflammatory response syndromes (SIRS), respectively. Pancreatitis increases the risk of deep vein thrombosis (DVT) through a combination of increased production of pro-inflammatory cytokines and systemic vascular injury. However, DVT and pulmonary embolism remain under-recognized and underappreciated complications of acute pancreatitis as they fall through the cracks in the commonly used venous thromboembolism (VTE) risk assessment model. We therefore propose that VTE prophylaxis needs to be considered by all clinicians when admitting and evaluating patients with acute pancreatitis and that acute pancreatitis needs to be included on the various VTE risk assessment calculators as it is a significant risk factor for the development of VTE.

How is equity approached in universal health coverage? An analysis of global and country policy documents in Benin and Senegal.

BACKGROUND: Equity seems inherent to the pursuance of universal health coverage (UHC), but it is not a natural consequence of it. We explore how the multidimensional concept of equity has been approached in key global UHC policy documents, as well as in country-level UHC policies. METHODS: We analysed a purposeful sample of UHC reports and policy documents both at global level and in two Western African countries (Benin and Senegal). We manually searched each document for its use and discussion of equity and related terms. The content was summarised and thematically analysed, in order to comprehend how these concepts were understood in the documents. We distinguished between the level at which inequity takes place and the origin or types of inequities. RESULTS: Most of the documents analysed do not define equity in the first place, and speak about "health inequities" in the broad sense, without mentioning the dimension or type of inequity considered. Some dimensions of equity are ambiguous - especially coverage and financing. Many documents assimilate equity to an overall objective or guiding principle closely associated to UHC. The concept of equity is also often linked to other concepts and values (social justice, inclusion, solidarity, human rights - but also to efficiency and sustainability). Regarding the levels of equity most often considered, access (availability, coverage, provision) is the most often quoted dimension, followed by financial protection. Regarding the types of equity considered, those most referred to are socio-economic, geographic, and gender-based disparities. In Benin and Senegal, geographic inequities are mostly pinpointed by UHC policy documents, but concrete interventions mostly target the poor. Overall, the UHC policy of both countries are quite similar in terms of their approach to equity. CONCLUSIONS: While equity is widely referred to in global and country-specific UHC policy documents, its multiple dimensions results in a rather rhetorical utilisation of the concept. Whereas equity covers various levels and types, many global UHC documents fail to define it properly and to comprehend the breadth of the concept. Consequently, perhaps, country-specific policy documents also use equity as a rhetoric principle, without sufficient consideration for concrete ways for implementation.

Performance-based Financing in Africa: Time to Test Measures for Equity.

Over the past 15 years, hundreds of millions of dollars have been invested in reforms founded on performance-based financing (PBF) in low- and middle-income countries. While evidence on its effectiveness and efficiency is still controversial, there appears to be an emerging consensus that equity has not been adequately considered. In this article, we show how PBF-type interventions in Africa have not sufficiently taken into account equity of access to care for the worst-off and their financial protection. In reviewing the history of health reforms in Africa, we show that this omission is nothing new. We suggest that strategic purchasing and PBF-type actions would benefit from being implemented in ways that promote equity and the financial protection of populations in Africa. Without such a reorientation of reforms, it will be impossible to achieve universal health coverage by 2030.

Universal Health Coverage in Francophone Sub-Saharan Africa: Assessment of Global Health Experts' Confidence in Policy Options.

Many countries rely on standard recipes for accelerating progress toward universal health coverage (UHC). With limited generalizable empirical evidence, expert confidence and consensus plays a major role in shaping country policy choices. This article presents an exploratory attempt conducted between April and September 2016 to measure confidence and consensus among a panel of global health experts in terms of the effectiveness and feasibility of a number of policy options commonly proposed for achieving UHC in low- and middle-income countries, such as fee exemptions for certain groups of people, ring-fenced domestic health budgets, and public-private partnerships. To ensure a relative homogeneity of contexts, we focused on French-speaking sub-Saharan Africa. We initially used the Delphi method to arrive at expert consensus, but since no consensus emerged after 2 rounds, we adjusted our approach to a statistical analysis of the results from our questionnaire by measuring the degree of consensus on each policy option through 100 (signifying total consensus) minus the size of the interquartile range of the individual scores. Seventeen global health experts from various backgrounds, but with at least 20 years' experience in the broad region, participated in the 2 rounds of the study. The results provide an initial "mapping" of the opinions of a group of experts and suggest interesting lessons. For the 18 policy options proposed, consensus emerged only on strengthening the supply of quality primary health care services (judged as being effective with a confidence score of 79 and consensus score of 90), and on fee exemptions for the poorest (judged as being fairly easy to implement with a confidence score of 66 and consensus score of 85). For none of the 18 common policy options was there consensus on both potential effectiveness and feasibility, with very diverging opinions concerning 5 policy options. The lack of confidence and consensus within the panel seems to reflect the lack of consistent evidence on the proposed policy options. This suggests that experts' opinions should be framed within strengthened inclusive and "evidence-informed deliberative processes" where the trade-offs along the 3 dimensions of UHC-extending the population covered against health hazards, expanding the range of services and benefits covered, and reducing out-of-pocket expenditures-can be discussed in a transparent and contextualized setting.

Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach.

BACKGROUND: Performance-based financing (PBF) is often proposed as a way to improve health system performance. In Benin, PBF was launched in 2012 through a World Bank-supported project. The Belgian Development Agency (BTC) followed suit through a health system strengthening (HSS) project. This paper analyses and draws lessons from the experience of BTC-supported PBF alternative approach - especially with regards to institutional aspects, the role of demand-side actors, ownership, and cost-effectiveness - and explores the mechanisms at stake so as to better understand how the "PBF package" functions and produces effects. METHODS: An exploratory, theory-driven evaluation approach was adopted. Causal mechanisms through which PBF is hypothesised to impact on results were singled out and explored. This paper stems from the co-authors' capitalisation of experiences; mixed methods were used to collect, triangulate and analyse information. Results are structured along Witter et al framework. RESULTS: Influence of context is strong over PBF in Benin; the policy is donor-driven. BTC did not adopt the World Bank's mainstream PBF model, but developed an alternative approach in line with its HSS support programme, which is grounded on existing domestic institutions. The main features of this approach are described (decentralised governance, peer review verification, counter-verification entrusted to health service users' platforms), as well as its adaptive process. PBF has contributed to strengthen various aspects of the health system and led to modest progress in utilisation of health services, but noticeable improvements in healthcare quality. Three mechanisms explaining observed outcomes within the context are described: comprehensive HSS at district level; acting on health workers' motivation through a complex package of incentives; and increased accountability by reinforcing dialogue with demand-side actors. Cost-effectiveness and sustainability issues are also discussed. CONCLUSION: BTC's alternative PBF approach is both promising in terms of effects, ownership and sustainability, and less resource consuming. This experience testifies that PBF is not a uniform or rigid model, and opens the policy ground for recipient governments to put their own emphasis and priorities and design ad hoc models adapted to their context specificities. However, integrating PBF within the normal functioning of local health systems, in line with other reforms, is a big challenge.

Performance-based financing in the heath sector in low- and middle-income countries: Is there anything whereof it may be said, see, this is new?

Whereas performance-based financing (PBF) is now developing fast in the health sector in low- and middle-income countries and is presented an innovative approach-concomitantly, subject to a separate research stream-it shares many features of the "managing for results" (MfR) and performance-based budgeting (PBB) currents that have existed for decades. In this paper, we first argue that PBF as currently developed in the health sector in low- and middle-income countries shares many features and thus can be viewed as an avatar of MfR and more precisely PBB. Secondly, we draw lessons from the literature on MfR and PBB so as to (1) better apprehend PBF conceptually and (2) avoid pitfalls and better design PBF schemes in practice. We argue that the lessons from the theoretical and empirical literature on MfR and PBB offer interesting insights to feed into a "theory of change" of PBF, enabling to analyse critical aspects and better design PBF schemes. Moreover, it is hoped that just like MfR processes have been demonstrated as having the potential to boost individual performance not only through links with financial incentives but also through acting on other sources of motivation, one can demonstrate more accurately by which mechanisms the various elements of the PBF package can help improve health sector results.

Local stakeholders' perceptions about the introduction of performance-based financing in Benin: a case study in two health districts.

BACKGROUND: Performance-Based Financing (PBF) has been advanced as a solution to contribute to improving the performance of health systems in developing countries. This is the case in Benin. This study aims to analyse how two PBF approaches, piloted in Benin, behave during implementation and what effects they produce, through investigating how local stakeholders perceive the introduction of PBF, how they adapt the different approaches during implementation, and the behavioural interactions induced by PBF. METHODS: The research rests on a socio-anthropological approach and qualitative methods. The design is a case study in two health districts selected on purpose. The selection of health facilities was also done on purpose, until we reached saturation of information. Information was collected through observation and semi-directive interviews supported by an interview guide. Data was analysed through contents and discourse analysis. RESULTS: The Ministry of Health (MoH) strongly supports PBF, but it is not well integrated with other ongoing reforms and processes. Field actors welcome PBF but still do not have a sense of ownership about it. The two PBF approaches differ notably as for the organs in charge of verification. Performance premiums are granted according to a limited number of quantitative indicators plus an extensive qualitative checklist. PBF matrices and verification missions come in addition to routine monitoring. Local stakeholders accommodate theoretical approaches. Globally, staff is satisfied with PBF and welcomes additional supervision and training. Health providers reckon that PBF forces them to depart from routine, to be more professional and to respect national norms. A major issue is the perceived unfairness in premium distribution. Even if health staff often refer to financial premiums, actually the latter are probably too weak-and 'blurred'-to have a lasting inciting effect. It rather seems that PBF motivates health workers through other elements of its 'package', especially formative supervisions. CONCLUSION: If the global picture is quite positive, several issues could jeopardise the success of PBF. It appears crucial to reduce the perceived unfairness in the system, notably through enhancing all facilities' capacities to ensure they are in line with national norms, as well as to ensure financial and institutional sustainability of the system.

Aid for health in times of political unrest in Mali: does donors' way of intervening allow protecting people's health?

Mali has long been a leader in francophone Africa in developing systems aimed at improving aid effectiveness, especially in the health sector. But following the invasion of the Northern regions of the country by terrorist groups and a coup in March 2012, donors suspended official development assistance, except for support to NGOs and humanitarian assistance. They resumed aid after transfer of power to a civil government, but this was not done in a harmonized framework. This article describes and analyses how donors in the health sector reacted to the political unrest in Mali. It shows that despite its long sector-wide approach experience and international agreements to respect aid effectiveness principles, donors have not been able to intervene in view of safeguarding the investments of co-operation in the past decade, and of protecting the health system's functioning. They reacted to the political unrest on a bilateral basis, stopped working with their ministerial partners, interrupted support to the health system which was still expected to serve populations' needs and took months before organizing alternative and only partial solutions to resume aid to the health sector. The Malian example leads to a worrying conclusion: while protecting the health system's achievements and functioning for the population should be a priority, and while harmonizing donors' interventions seems the most appropriate way for that purpose, donors' management practices do not allow for reacting adequately in times of unrest. The article concludes by a number of recommendations.

Results from implementation of aid effectiveness principles in the health sector in Mali.

The international community holds high expectations for aid producing demonstrable results in the health sector, at the global and developing country levels. Yet, measuring the effectiveness of aid presents methodological challenges. Existing evaluation frameworks are not sufficiently geared toward learning whether and how practices have changed. We present a framework for measuring the results of implementing aid effectiveness principles at three levels: implementation process, health system strengthening, and outcomes/impact. We developed this framework in the context of monitoring results on the effectiveness of the aid agenda in the health sector in Mali. Despite some changes in behavior that resulted in increased aid effectiveness and improved results at system and outcome levels, overall, the aid effectiveness principles have not been fully implemented. Thus expectations in terms of health outcomes should be realistic.

Can performance-based financing be used to reform health systems in developing countries?

Over the past 15 years, performance-based financing has been implemented in an increasing number of developing countries, particularly in Africa, as a means of improving health worker performance. Scaling up to national implementation in Burundi and Rwanda has encouraged proponents of performance-based financing to view it as more than a financing mechanism, but increasingly as a strategic tool to reform the health sector. We resist such a notion on the grounds that results-based and economically driven interventions do not, on their own, adequately respond to patient and community needs, upon which health system reform should be based. We also think the debate surrounding performance-based financing is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the performance-based financing package.