| Issue/Objective |
Background: Sub-Saharan African (SSA) countries are actively reforming how they pay primary health care providers - through performance-based/results-based financing (PBF/RBF), capitation, user-fee removal, and hybrid purchasing arrangements - to advance universal health coverage (UHC). Evidence on how these reforms affect health-system performance remains geographically dispersed and unevenly reported across outcome domains.
Objective: To map the scope, design, and reported health-system outcomes of provider payment reforms in SSA, and to identify evidence gaps relevant to UHC.
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| Methodology/Approach |
Methods: We conducted a scoping review following the Arksey and O'Malley framework with Levac et al. and JBI enhancements, reported using PRISMA-ScR. MEDLINE, Embase, Scopus, Web of Science, and EBSCO were searched (2015 - 2026), supplemented by Google Scholar and citation tracking. Eligible studies examined a provider payment reform implemented at scale in any SSA country and reported at least one health-system outcome. Two reviewers independently screened records in Covidence and extracted data using a piloted form. Findings were synthesized narratively using the Walt and Gilson Policy Analysis Triangle (context, content, process, actors) and the health system outcomes were reported using the WHO Health System Performance Assessment domains (quality of care, efficiency, equity, financial protection). |
| Results |
Results: From 1,815 records identified, 1,432 were screened after de-duplication, 193 underwent full-text review, and 41 studies from 19 SSA countries were included. PBF/RBF variants dominated (n = 28), followed by capitation (n = 6), user-fee removal or exemption (n = 6), and one cash-transfer/hybrid mechanism. Most reforms were government-led or government - donor mixed and targeted primary health care. Reported effects were predominantly mixed rather than uniformly positive. Quality of care was the best-covered domain (30 studies; 12 positive, 17 mixed, 1 negative), with gains most consistent in structural and process indicators. Efficiency (24 studies; 12 positive, 9 mixed, 3 negative) appeared mainly as higher service productivity, offset in some settings by verification and administrative costs. Equity effects (23 studies) were strongly design-sensitive: pro-poor gains occurred chiefly where reforms embedded ultra-poor targeting or demand-side subsidies. Financial protection was the least measured domain, with out-of-pocket expenditure assessed in 7 studies and catastrophic health expenditure in fewer than 4. Payment delays, verification burden, donor dependence, and weak complementary infrastructure were recurrent implementation bottlenecks. |
| Discussion/Conclusion |
Conclusions: Provider payment reforms in SSA can plausibly contribute to UHC, but impact is conditional on context, design, implementation fidelity, and donor - government alignment. Future reforms and research should engineer equity into reform design, routinely measure financial protection, and evaluate hybrid purchasing arrangements to sustain progress toward UHC. |
| Presenters and Affiliations |
Fitsum Woldeyohannes York University |
