Background: Performance-based financing (PBF) is a healthcare reform that is widely adopted in low- and middle-income countries (LMICs). PBF is an intervention designed to strengthen healthcare systems in LMICs. It represents a fundamental shift towards improving healthcare amongst the most vulnerable, with a focus on maternal and child health services. Broadly, there are gaps regarding PBF’s effect on healthcare systems and various aspect of healthcare, including efforts to implement universal healthcare coverage. PBF introduced an innovative component—the PBF equity instrument—geared towards achieving universal health coverage. The effect of this equity instrument has not been studied. There is significant gap regarding how it is defined and implemented in various context. Cameroon has one of the highest maternal mortality rates in sub–Saharan Africa and with high out-of-pocket expenses that impede access to maternal health services. PBF was introduced in Cameroon in 2012 with a focus on maternal health services and was adopted in 2017 as a national strategy towards achieving universal coverage, however, the definition and implementation of the PBF equity elements remain a gap in Cameroon and sub-Saharan Africa. This dissertation is focused on studying the PBF equity elements in Cameroon in order to get a broader perspective on the effect of the PBF equity elements as a policy tool in improving the lives of the most vulnerable population to ensure no one is left behind in the efforts towards achieving universal health coverage.
Objectives: This dissertation aimed (1) to investigate and characterize the effect of the PBF equity elements in improving equity in access to selected maternal services (2) to understand how the equity elements is defined and implemented in Cameroon; and (3) to generate a framework that will facilitate the identification of gaps and challenges, in turn informing policy development that is relevant to PBF equity elements in Cameroon and PBF research on equity in other countries; and (4) to explore health providers experiences before and after the introduction of PBF in Cameroon.
Methods: This dissertation employed a mixed methods approach to address the above objectives, involving the use of multiple frameworks and triangulation across and within objectives. First, to investigate the effect of PBF on equity in improving access to maternal services, I designed a systematic review with a focus on one of the equity elements—subsidizing user fees to reduce out-of-pocket expenses to improve access to maternal health services. The aim was to get a broader overview of the PBF equity element and to understand the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services in sub–Saharan Africa. Second, I narrowed the assessment to a specific context-Cameroon. Given the heterogenous nature of care delivery in Cameroon, I investigated the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services across healthcare sectors using a before-and-after study design. The rationale was to address the limitations of an earlier PBF impact evaluation in Cameroon, in particular, potential heterogeneity across settings and sectors which had not been considered. Third, to describe and define the implementation of the PBF equity elements in Cameroon, I conducted a grounded theory study -given that it is a new policy that has not been well studied -to understand the social processes and actions from health facilities, health providers, PBF managers and the community, and generated a theoretical framework to inform the challenges and gaps in the implementation process. Finally, as a newly adopted health reform, I conducted an in-depth qualitative study to understand the experiences of health care provides before -and-after the implementation of PBF and its equity elements and the potential for sustainability of the policy especially the equity strategies in Cameroon.
Findings: The findings provide an overarching understanding on the effect of one of the PBF equity elements in improving access to maternal health services in sub–Saharan Africa, and in particular, an understanding of the effect of the PBF equity elements in improving access and utilization of selected maternal services in Cameroon. At the health system level, the findings provide an understanding of the focus of the equity elements within the context of Cameroon and further insight on the gaps and limitations in the implementation of the PBF equity elements and the potential challenges in sustainability towards achieving universal health coverage. At the health facility level, it provides an understanding on how the PBF equity elements is understood, defined, and implemented and provides directions on the challenges to inform policy and to guide research. At the individual level, it provides an overview of the expectations of health care providers from a supply side perspective and the potential effect it has on demand creation from women and households in improving access to maternal health services. Overall, the findings provide insight on how the equity elements are defined and implemented but also provides opportunity and areas of improvement and detailed how PBF equity elements can be further assessed and how delays in payment of PBF incentives can potentially affect the realization of the equity elements in improving access and utilization of maternal health services amongst the poor and vulnerable.
Conclusion: Equity is central and essential to the delivery of services to achieve universal health coverage. The adoption of PBF in Cameroon is a step toward achieving universal health coverage with the recognition that universal health coverage cannot be effectively implemented in an institution without good governance. The PBF initiative is viewed as an entry point for universal health coverage, in order to evaluate the level of preparedness of health facilities to embrace universal health coverage in terms of quality of health care, production, good managerial skills, and financial management. However, due to administrative bottlenecks, the government has yet to accept some of the established principles of PBF—this in turn causes delays in payment and this hampers the effective implementation of some of the PBF equity strategies. Therefore, though PBF is a national policy, the actors at the central level, i.e., the Ministry of Public Health, are not playing their role effectively in enabling full implementation of PBF best practices and theories.
| Identifer | oai:union.ndltd.org:uottawa.ca/oai:ruor.uottawa.ca:10393/44522 |
| Date | 17 January 2023 |
| Creators | Nguilefem, Miriam Nkangu |
| Contributors | Yaya, Sanni, Little, Julian |
| Publisher | Université d'Ottawa / University of Ottawa |
| Source Sets | Université d’Ottawa |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
| Rights | Attribution-NonCommercial 4.0 International, http://creativecommons.org/licenses/by-nc/4.0/ |
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