Lannes, Laurence
(2015)
An analysis of health service delivery performance in Rwanda.
PhD thesis, London School of Economics and Political Science.
Abstract
Health systems worldwide fail to produce optimal health outcomes, and successive reforms have sought to make them more efficient, more equitable and more responsive. The overarching objective of this thesis is to explore how to motivate healthcare providers in improving performance in service delivery in low income
countries. The thesis explores whether financial incentives for healthcare providers raise productivity and how they may affect equity in utilization of healthcare services and responsiveness to patients’ needs. The thesis argues that, as performance-based financing (PBF) focuses on supply side barriers, it may lead to
efficiency gains rather than equity improvements. It uses data from a randomized controlled impact evaluation in Rwanda to generate robust evidence on performance-based financing and address a gap in the knowledge on its unintended consequences. Statistical methods are used to analyze four aspects: the impact on health workforce productivity; the impact on health workforce responsiveness; the impact on equity in utilization of basic health services; and, the impact on spatial disparities in the utilization of health services. Findings indicate that performancebased financing has a positive impact on efficiency: it raises health workforce productivity through higher workload and lower absenteeism; and, it encourages healthcare providers to be more responsive which positively impacts the quality of care perceived by patients. Findings also indicate that the impact on equity is uncertain as PBF can deter equity in access for the poorest in the absence of a
compensating mechanism; however, PBF is a powerful reform catalyzer and can reduce inequalities between regions and households when combined with appropriate reforms that control for its potential perverse effects. This thesis advocates that strategies aiming to raise healthcare providers’ motivation should be used to raise performance in service delivery in low-income countries with particular attention to their effect on end users.
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