Paying health workers for performance in a fragmented, fragile state: reflections from Katanga Province, Democratic Republic of Congo

Sarah Fox, Sophie Witter, Emily Wylde, Eric Matufa, Tomas Lievens

Research output: Contribution to journalArticlepeer-review

45 Citations (Scopus)
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The health financing system in the Democratic Republic of Congo (DRC)
presents an extreme example of low government investment, high dependency
on user fees and poor harmonization across donors. Within this context,
performance-based financing mechanisms are being implemented by various
donors in the expectation that they will improve health worker motivation and
service delivery performance. Drawing on qualitative and quantitative data at
different levels of the health system, this study focuses on one such programme
in Katanga Province, which combines paying for performance (P4P) with a
reduction in fees to users. Despite adding considerably to facility resources
(providing the majority of the resources in the case study facilities), there was
no evidence of benefits in terms of any of the service inputs, processes or
outputs measured. The findings suggest that the positive effects on health
worker motivation cannot be taken as a given, particularly, when staff are often
expected to increase their workload to achieve the performance objectives and
when another source of income, the income from user fees, may be reduced due
to a fall in the prices of services. Moreover, in a context where health workers
were already almost entirely dependent on users for their remuneration before
the donor programme was introduced, the incentive effects of a performance
contract may be muted. In addition, other income sources have particular value
for staff, it seems—even though salaries and government allowances were low,
and frequently delayed, health workers were highly dissatisfied at not receiving
them. Salaries were seen as a more assured and long-term source of funding and
an important recognition of their role as agents of the state. The authors
conclude that while there may be a role for P4P in fragile contexts such as the
DRC, to be effective it needs to be rooted in wider financing and human
resource policy reforms.
Original languageEnglish
Pages (from-to)96-105
Number of pages10
JournalHealth Policy and Planning
Issue number1
Early online date15 Jan 2013
Publication statusPublished - Jan 2014


  • results-based financing
  • tracking health financing flows
  • health worker pay and motivation
  • fragile states


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