Performance-based Financing and Strengthening Health Governance in the Fragile State of the Democratic Republic of Congo

Abstract

This article explores the outcomes of performance-based financing for strengthening the health system in the context of state-building in the Democratic Republic of Congo. It focuses specifically on health system governance, which plays a pivotal role in the process of building the health system. Based on long-term qualitative field research, it examines the effectiveness of PBF in three areas of health system governance: structural governance from a capacity-building perspective, health service-provision management and demand-side empowerment for effective accountability. In general, the study found that PBF has positively impacted the process of health system-building in these three areas. Although much is still lacking, health governance and the provision of services improved, while patient-centered care and social accountability strengthened the provider–patient relationship. However, donors, state officials and other stakeholders doubted their sustainability. In addition to structural threats related to state fragility and uncertain sustainability, transforming transactional motivation into transformational change is a challenge. Ultimately, PBF supports state-building in the health sector, but it cannot repair a collapsed state.