Does dosage matter? Effects of Results-based Financing layered on top of less comprehensive direct facility financing in Tanzania

Loha, E., Somville, V., Borghi, J. ORCID: https://orcid.org/0000-0002-0482-5451, Binyaruka, P., & Mæstad, O. (2026). Does dosage matter? Effects of Results-based Financing layered on top of less comprehensive direct facility financing in Tanzania. Health Policy and Planning 10.1093/heapol/czag058. (In Press)

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Abstract

Performance-based financing at health facility level has improved service delivery in many low- and middle-income countries. However, the high costs of implementing such schemes have prompted interest in less complex forms of direct health facility financing.

This paper measures the effects of layering a full-blown performance-based financing scheme (Results-based Financing, RBF) on top of a less comprehensive direct financing scheme in Tanzania. This enables us to assess whether implementing a less comprehensive scheme exhausted the potential for financing reforms to improve service delivery, or whether there are significant gains from adding more resources and incentives to the scheme.

We estimated the effects of RBF using a difference-in-differences approach. Over four years, we tracked 150 health facilities and more than 3,000 households, equally divided between eight districts that implemented both schemes and six districts that implemented only the less comprehensive scheme.

Strong positive trends were observed for most outcomes in both groups of districts. At the same time, RBF had positive and statistically significant effects on 14 of 24 directly incentivized outcomes and on 22 of 47 other outcomes, including on service coverage (e.g., prenatal and vaccination services), service quality (e.g., content of care for antenatal and delivery services, drug availability, communication and responsiveness) and patient satisfaction. A negative effect was estimated for one outcome only (use of family planning method). Statistically significant effects of RBF ranged from -4.3 to 16.2 percentage points (average: 8.7 pp.). Analysis of intermediary outcomes revealed that RBF had a positive effect on health worker job satisfaction.

We conclude that dosage matters: Comprehensive direct financing schemes – with more resources and incentives – can significantly improve service delivery beyond what is achieved by less comprehensive ones.

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