Strengthening health systems to improve utilization, quality and efficiency of service delivery is a challenge that continues to stump smart people working in public health and development. A promising and increasingly prominent solution is paying health workers, health facilities and households to behave in ways that generate better health results. A few months ago, Ruth Levine reported on an upcoming workshop that would convene teams of African implementers and researchers to develop performance-based incentive schemes within their own health systems. Below, Rena Eichler reports back on her experiences from that workshop.

Frustration about poor health results and interest in the potential of "paying for performance" motivated participants from 10 African countries (DRC, Ghana, Kenya, Nigeria, Liberia, Malawi, Tanzania, Uganda, Zanzibar and Zambia) to attend the first ever regional workshop on Performance-Based Incentives in Health in early May in Kigali, Rwanda. Evidence suggests that linking payment to health outputs, such as number of children immunized or number of women delivering babies safely, can generate the hoped-for results that other approaches have not delivered (this evidence will soon be documented in a forthcoming book on performance-based incentives. Each country team developed a detailed road map to design and implement performance based incentives to address the priority health problems in their countries. Interestingly, virtually all teams included a strong focus on child and maternal health.

Participants learned about performance based incentive initiatives from countries as diverse as Afghanistan, Haiti, Nicaragua, Uganda, and Rwanda. A field trip to observe health facilities and talk with Rwandan health workers operating under payment for performance was the icing on the cake that convinced the few skeptics that remained. One participant commented that health workers can fake information but they can't fake enthusiasm. Another participant remarked, after learning about strategies a health facility had introduced to pay traditional birth attendants to refer pregnant women for prenatal care and deliveries as well as other community outreach strategies, that they did not know of any other approach that had generated as many innovative "bottom up" solutions to assuring access to essential services.

In addition to the workshop topic being new, the process to choose participants was also innovative. Rather than the usual way workshop participants are identified - through existing donor networks or asking governments to choose - an international call for country teams to submit expressions of interest was launched. Teams of 3 stakeholders, representing the payer or policy maker, service providers, and another stakeholder group were required to apply jointly. Applications asked for brief statements to assess understanding of health sector performance problems and ability to champion a process of change. This competitive process attracted highly motivated and qualified teams and was much of the reason for workshop's success.

Financed by USAID, the workshop was convened by Tanzania based ECSA, with technical input from the Health Systems 20/20 Project, IDRC, the Center for Global Development, Africa Health 2010 Project, the Rwanda Performance Based Financing Project, and the Rwandan Ministry of Health. The conceptual framework and some cases drew from the Center for Global Development Working Group on Performance-Based Incentives. We look forward to learning the details of what countries implement and the health impact that results.

At the end of this month, there will be an opportunity to learn more about performance-based incentives in practice through a panel at the Global Health Council Conference on Wednesday, May 30, 2:30-4:30 pm.