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Why performance-based contracting failed in Uganda--an "open-box" evaluation of a complex health system intervention
Freddie Ssengooba1, Barbara McPake, Natasha Palmer
1Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Uganda. Sengooba@musph.ac.ug
Social Science & Medicine (1982)
|May 8, 2012
Summary
Performance-based contracting (PBC) failed due to inadequate design, poor implementation, and financial shortfalls. Improving health services requires strengthening conventional approaches rather than costly PBC interventions.
Area of Science:
- Health policy and systems research
- Public health management
- Contracting in healthcare
Background:
- Performance-based contracting (PBC) links rewards to performance targets but faces evaluation challenges.
- Black-box evaluations focus on PBC effects, neglecting the mechanisms of change, hindering policy learning.
- Previous evaluations of a PBC pilot by the World Bank and Ministry of Health deemed it ineffective.
Purpose of the Study:
- To conduct a theory-based case study clarifying why a PBC intervention failed.
- To analyze the implementation process and participant responses using complex adaptive systems and expectancy theories.
- To provide lessons for future performance-based interventions in healthcare.
Main Methods:
- A prospective case study design, tracking PBC implementation from 2003-2006.
- Qualitative data collection through participant experiences at district and hospital levels.
- Application of complex adaptive systems and expectancy theories to analyze implementation dynamics.
Main Results:
- Inadequate PBC design led to significant implementation problems and hasty adaptations.
- Health centers faced 'lock-in' due to insufficient time for target selection.
- Weaknesses in performance auditing and financial shortfalls undermined the intervention's validity and effectiveness.
Conclusions:
- PBC implementation is complex and costly, requiring substantial investment in local capacity.
- Careful consideration of actor responses and context is crucial for successful PBC.
- Strengthening conventional health system financing and management may be more viable in low-income settings.
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