Back to History

Fields Changed


Field Before After
Trial Status on_going completed
Trial End Date March 30, 2020 June 30, 2023
Last Published April 14, 2018 05:26 PM February 23, 2024 01:13 PM
Study Withdrawn No
Intervention Completion Date May 15, 2022
Data Collection Complete Yes
Final Sample Size: Number of Clusters (Unit of Randomization) 58 health zones in 6 provinces
Was attrition correlated with treatment status? No
Is there a restricted access data set available on request? Yes
Restricted Data Contact ;
Program Files No
Data Collection Completion Date May 15, 2022
Is data available for public use? No
Intervention End Date January 01, 2020 May 15, 2022
Keyword(s) Health Health
Building on Existing Work No
Back to top


Field Before After
Paper 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 programs 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 at 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 the 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.
Paper Citation Shapira, G., Clarke-Deelder, E., Booto, B.M. et al. Impacts of performance-based financing on health system performance: evidence from the Democratic Republic of Congo. BMC Med 21, 381 (2023).
Paper URL
Back to top