Impacts of Performance-Based Financing on Health System Performance - Evidence from the Democratic Republic of Congo

Jul 19, 2026

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Health systems’ weakness remains a major barrier to achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) is increasingly used in low- and middle-income countries, yet findings on its effects are fragmented. This study analyzes health system impacts of a large PBF program in the Democratic Republic of the Congo, comparing outcomes against unconditional transfers. Results show improvements across multiple quality and coverage domains, with persistent gaps suggesting further health-system investments and human-resources reforms are needed.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages49

Reading Time2 h 3 min

Abstract

Background

Methods

Results

Conclusions

Trial registration

Background and study rationale

Challenges in access and quality

Pay-for-performance approach

Study design and setting

Public Disclosure Authorized Public Disclosure Authorized Impacts of performance-based financing on health system performance: evidence from the Democratic Republic of Congo Gil Shapira 1, Emma Clarke-Deelder3, Baudouin Makuma Booto2, Hadia Samaha 1, György Bèla Fritsche1, Michel Muvudi 1, Dominique Baabo2, Delphin Antwisi2, Didier Ramanana2, Saloua Benami 1, and Günther Fink3 Affiliations: 1 The World Bank, Washington, United States 2 Ministry of Public Health, Kinshasa, the Democratic Republic of Congo 3 The Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland Corresponding author: Gil Shapira, [gshapira@worldbank.org](gshapira@worldbank.org) Abstract Background: Health systems’ weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such program introduced in LMICs to date. Methods: We used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started in the end of 2016. Follow-up data collection took place in 2021-2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers’ satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain. Results: The PBF program improved structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01-0.08), technical process quality by 5 ppts (0.03-0.07), and non-technical process by 2 ppts (0-0.04) . PBF also increased coverage of priority health services by 3 ppts (0.02-0.04) . Improvements were also observed for facility management (9 ppts, 0.04- 0.15), service fee policies and users’ satisfaction with service affordability (14 ppts, 0.07-0.20) . Service fees and health workers’ satisfaction were not affected by the program. Conclusions: The results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals. Trial registration: American Economics Association Trial registry AEARCTR-0002880 Key Words: performance-based financing; health systems; quality of care; maternal and child health Background Although coverage of essential health services has increased in recent decades in low-and middle-income countries, the burden of preventable mortality remains high and appears to be driven largely by lack of access to quality care.(1) In many health facilities, major quality gaps have been observed even for basic services such as routine pediatric and antenatal care.(2) (3) At the same time, the share of the population incurring financial hardship associated with use of health services has increased and inequities with respect to service access and health outcomes persist.(4) Facing these challe

FAQs

What problem does the study address regarding health systems in low-income settings?

The study addresses persistent weaknesses in health systems that hinder universal access to quality care, including quality gaps and ongoing financial hardship linked to accessing services.

How was the PBF program evaluated in the Democratic Republic of the Congo?

Fifty-eight health zones across six provinces were randomly assigned to a control group receiving unconditional transfers or to a PBF program that began in late 2016. Follow-up data collection was conducted in 2021–2022 using multiple facility, provider, patient, and household measures.

What were the main findings on the impact of PBF on health system performance?

The PBF program improved structural quality, technical process quality, non-technical process quality, facility management, and coverage of priority services, and increased service-fee policy improvements and satisfaction related to affordability. Service fees and provider satisfaction were reported as not affected in some assessed aspects.

Jul 19, 2026

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