The debate concerning performance-based financing in Africa South of the Sahara: analysis of the nature

Performance-based financing (PBF) is a strategy designed to link thefunding of health services to predetermined results. Payment by an independent strategic purchaser is subject to verification of effective achievement of health outcomes in terms ofquantity and quality. This article investigates the complex tensions observed in relation to performance based financing (PBF) and identifies some reasons for disagreement on this approach. This study was essentially qualitative. Interviews were conducted with a panel of experts on PBF mobilizing their ability to reflect on the various arguments and positions concerning this financing mechanism. To enhance our analyses, we proposed a framework based on the main reasonsfor scientific or political controversies and factors involved in their emergence. Analysis of the information collected therefore consisted of combining experts verbatim reports with corresponding factors of controversies of our framework. Graphic representations of the differences were also established. Tensions concerning PBF are based on facts (experts' interpretation ofPBF), principles and values (around each expert's conceptual framework), balances of power between experts but also inappropriate behavior in the discussion process. Viewpoints remain isolated, each individual experience and an overview are lacking, which can interfere with decision-making and maintain the Health system reform crisis. Potential solutions to reduce these tensions are proposed. Our study shows that experts have difficulties agreeing on a theoretical priority approach to PBE. A good understanding of the nature of the tensions and an improvement in the quality of dialogue will promote a real dynamic of change and the proposal of an agenda of PBF actions.