Mapping the extent to which performance-based financing (PBF) programs reflect quality, informed choice, and voluntarism and implications for family planning services: A review of PBF operational manuals

RBF programs have the potential to ensure that clients' needs for quality services are met through the use of strategic incentives in healthcare provision and promoting more client-centered healthcare systems. Performance-based financing (PBF) programs are a specific subset of RBF initiatives, distinguished by a focus on monetary incentives to healthcare providers for achieving agreed performance measures under certain conditions. PBF programs use financial disbursements to incentivize health service delivery and quality, and rights-based programming has informed efforts to strengthen and scale family planning (FP) services. However, there has been little done to understand the linkages between PBF and a rights-based approach (RBA) to FP services. To address this gap, a review of PBF operational manuals was undertaken together with an analysis of PBF indicators relevant to FP services. The review identified 23 PBF operational documents and assessed the sensitivity of FP services in those PBF programs to eight rights principles recognized by the World Health Organization. The review found that rights were not uniformly represented across the 23 PBF programs. The most commonly identified rights principles - accountability and quality - are features of most FP services in the 23 PBF programs identified in this review. Less commonly represented rights included accessibility, acceptability, and informed choice. None of the 23 programs spoke to agency/voluntarism in their FP services. The review demonstrates that current PBF programs are not designed with a rights-based approach, and PBF guidelines could better reflect the importance of patient-centered, rights-based programming. Given the mixed evidence for PBF benefits, concerns about poor country ownership of PBF programs, and a risk of perverse incentives in early versions of PBF programs that did not take a systematic alignment with rights-based approaches, greater attention to the rights principles of acceptability, accessibility, availability, and quality; accountability; agency and empowerment; equity and non-discrimination; informed choice and decision-making; participation; and privacy and confidentiality would improve health service delivery and health system performance for all stakeholders with consumers at the center. The review highlights the need for PBF programs to be designed with a rights-based approach, incorporating principles such as informed choice, acceptability, and accessibility. This would ensure that PBF programs prioritize the needs and preferences of clients, particularly vulnerable populations, and promote more equitable and effective healthcare systems. By aligning PBF programs with a rights-based approach, policymakers and program implementers can improve health outcomes, increase access to quality services, and promote more client-centered healthcare systems.