Can paying for results help to achieve the Millennium Development Goals? Overview of the effectiveness of results‐based financing

OBJECTIVE: Results-based financing and pay-for-performance refer to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. Results-based financing is widely advocated for achieving health goals, including the Millennium Development Goals. METHODS: We undertook an overview of systematic reviews of the effectiveness of RBF. We searched the Cochrane Library, EMBASE, and MEDLINE (up to August 2007). We also searched for related articles in PubMed, checked the reference lists of retrieved articles, and contacted key informants. We included reviews with a methods section that addressed the effects of any results-based financing in the health sector targeted at patients, providers, organizations, or governments. We summarized the characteristics and findings of each review using a structured format. RESULTS: We found 12 systematic reviews that met our inclusion criteria. Based on the findings of these reviews, financial incentives targeting recipients of health care and individual healthcare professionals are effective in the short run for simple and distinct, well-defined behavioral goals. There is less evidence that financial incentives can sustain long-term changes. Conditional cash transfers to poor and disadvantaged groups in Latin America are effective at increasing the uptake of some preventive services. There is otherwise very limited evidence of the effects of results-based financing in low- or middle-income countries. Results-based financing can have undesirable effects, including motivating unintended behaviors, distortions (ignoring important tasks that are not rewarded with incentives), gaming (improving or cheating on reporting rather than improving performance), widening the resource gap between rich and poor, and dependency on financial incentives. CONCLUSION: There is limited evidence of the effectiveness of results-based financing and almost no evidence of the cost-effectiveness of results-based financing. Based on the available evidence and likely mechanisms through which financial incentives work, they are more likely to influence discrete individual behaviors in the short run and less likely to create sustained changes.