Photo: Ingrid Sjursen

Ottar Mæstad

Research Professor / Special Adviser, Director Development Learning Lab


Post from International Helath Policies

The PBF workshop in Bergen: Impressions and observations from a junior researcher

By Keovathanak Khim, PhD candidate at the University of Melbourne

Two trends were apparent in Bergen.

The first one was related to the need to better understand how different elements of PBF interact with and improve staff performance and health system functions and vice versa. For example, to what extent and in what context do financial incentives improve staff motivation or undermine intrinsic motivation; when and in what context do other mechanisms, e.g. encouragement and supervision, impact staff performance; when and how does empowerment of staff and managers impact interactions and communication within a system, and improve results? Participants agreed that qualitative approaches can address some of the current evidence gaps in PBF by explaining processes of PBF and the impact of the approach.

Second, many participants also emphasized the  need for impact evaluation designs which are both methodologically robust and feasible in the field. Impact measures should be related to higher order- outcomes, such as changes in equity and efficiency in a health system, morbidity and mortality in a population, and issues such as catastrophic health care expenditure.

Global health problems tend to be complex and context-specific; they thus need an approach that is versatile and adaptable, such as PBF. PBF approaches promise to tackle and overcome health system constraints. These promises can be met with adequate research and documentation. This workshop represented another step forward in this direction by engaging researchers and practitioners in an open and fruitful dialogue and fostering a better understanding of PBF approaches. One can only hope that this workshop will be followed by other workshops of a similar nature. It is fair to say that workshops like this one are increasingly becoming the hallmark of the PBF community.

Read the complete blog post

Blog posts before the work shop:

Performance based financing: Let’s try to have a more constructive conversation

In this blog post on the blog International Health Policies, Bruno Meessen , one of the key speakers in the work shop, reflects on the criticism he has heard on PBF over the past years. He identifies seven main causes of disagreement and offers each time ways to improve the debate and have a more fruitful discussion.


In almost 15 years of commitment to a cause which is now known as PBF, I’ve heard plenty of different criticisms on PBF. Let’s say I’ve had my share. These criticisms are sometimes cautiously formulated or formulated as questions or hypotheses, but you often sense that the real dispute goes much deeper. Also, unfortunately, critics often mix different types of arguments. If such a strategy can be effective as a rhetorical strategy for a specific audience, it doesn’t necessarily help the debate, I believe.

To enable a more constructive discussion, it’s important to clarify the nature of criticisms by trying to identify the underlying causes of disagreement. In this blog post, I  distinguish seven main elements of criticism. For each, we can also identify a possible solution.

1st pattern: A different informational basis

2nd pattern: Different analytical frameworks

3rd pattern: Different normative choices

4th source of disagreement: Speculation on different trajectories

5th source of disagreement: A conflict of interests

6th source of disagreement: The sociology of the field of international health

7th source of disagreement: Our “all too human” flaws


The PBF debate is crucial for the future of health systems in Africa in particular. We have crossed the Rubicon: the strategy is now present in almost all African countries. We thus encourage all PBF stakeholders and actors to focus on constructive contributions in order to ensure that these reforms are well done, and/or quickly  amended if necessary.

The strategy can be improved and will continue to evolve: a health system should be seen in a dynamic way, and institutional arrangements which structure health systems should be revised when disadvantages outweigh benefits.


So we urge both critics and supporters of PBF to engage in a constructive discussion. This will ultimately benefit the population we have in mind.

Read the complete blog post.


Gaute Torsvik (University of Bergen) introduces the workshop in a blog on performancebased financing. Researchers studying PBF schemes should go beyond measuring impact only and explore how behavior responds to financial incentives: Why does behavior change? 

“Introducing performance-based pay does not only make health worker financially accountable for their performance, performance based financing may also affect the level of supervision and community monitoring of health workers. Enhanced levels of recognition and appraisal of the work that is done may in itself motivate health workers to perform.  Furthermore if incentives are based on team achievements, it has been documented elsewhere that workers tend to make an extra effort to avoid letting the team down. In addition there is now a large literature examining how monetary incentives interact with other extrinsic or intrinsic work motivations.   Together this means that even if we observe that the introduction of performance-based financing makes the health workers more attentive and diligent, it is far from obvious why this is the case.

A scientific workshop gathering researchers and PBF experts
Answering the how and why questions regarding the health workers behavioral response to performance based financing is also a relevant question for PBF experts. More knowledge on this will indeed improve their understanding of the endurance and external validity of the measured impact.  It will also enable them to improve the design of PBF schemes.

It is with this ambitious knowledge program in mind that the Chr. Michelsen Institute and the “Incentives for Health Provider Performance Network” will gather an international group of researchers and PBF experts during two days in Bergen, Norway.  We expect very rich discussions between the two groups with the hope that such an innovative dialogue will contribute to better policies."

Read the complete blogpost


Performance-based incentive   schemes and reforms are receiving growing attention from governments, aid agencies, donors and researchers. As for Africa alone, 29 countries are today at least piloting a PBF scheme; three of them (Rwanda, Burundi and Sierra Leone) have adopted performance-based financing as a core component of the funding of their whole health system. 

While operational knowledge has accumulated very rapidly, many questions remain from a more scientific perspective. Over the last years, the research program has mainly been steered towards demonstrating the impact of PBF strategies. This orientation, partly determined by the way many PBF pilot schemes are funded (a Trust Fund operated by the World Bank and funded by Norway and UK), leaves other questions in the dark.

PBF has been a source of debate for several years and it will probably remain so for some more years. In the follow-up of a recent debate triggered by a Cochrane Review, a call for innovative dialogue was issued.  

Chr. Michelsen Institute in Bergen, Norway and the “Incentives for Health Provider Performance Network” are happy to invite international researchers and PBF experts to a scientific workshop on “Performance-based financing of health care provision in low-income countries: Going beyond impact evaluation”. 

See detailed programmeProgramme


Thursday 13 June

08.30-09.00         Coffee and registration

09.00-09.30         Welcome

09.30-11.00         Session I:  Perspectives and Mechanisms

11.00-11.15         Coffee and fruit

11.15-12.30         Session II: Evaluating Impact: Findings from Cambodia                                                                        

12.30-13.30         Lunch

13.30-14.45         Session III: Studies in Tanzania 

14.45-15.15         Coffee and fruit

15.15-17.00         Session IV: PBF studies in the African Great lakes

19.30                   Dinner at Zupperia. All invited.


Friday   14 June   

09.00-10.30         Session V: Research protocols

10.30-10.45         Coffee and fruit

10.45-13.00         Session VI: Moving the PBF research program forward 

11.15-13.00         Group Work

13.00-14.00         Lunch

14.00-15.30         Session VII: Discussion of group work

Please note: Participation by invitation only.



Journal Article | 2011

Informal payments and the quality of health care: Mechanisms revealed by Tanzanian health workers

Informal payments for health services are common in many transitional and developing countries. The aim of this paper is to investigate the nature of informal payments in the health sector...
Ottar Mæstad and Aziza Mwisongo (2011)
in Health Policy vol. 99 no.2 pp. 107-115
Journal Article | 2010

Overworked? On the relationship between workload and health worker performance

The shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there...
Ottar Mæstad, Gaute Torsvik and Arild Aakvik (2010)
in Journal of Health Economics vol.29 no.5 pp.686-698
Journal Article | 2010

Teaching business in Tanzania: Evaluating participation and performance

There is increased awareness that success among small-scale entrepreneurs in developing countries requires more than microfinance, and that an important limiting factor for business growth is the level of human...
Kjetil Bjorvatn and Bertil Tungodden (2010)
in Journal of the European Economic Association vol. 8 no. 2-3 pp. 561-570