Health care provider payment reforms in African states of the Commonwealth—a scoping review

TL;DR

This study reviews healthcare payment reforms in African Commonwealth countries, highlighting limited evidence and key factors influencing these reforms.

Contribution

The paper provides a comprehensive scoping review of provider payment reforms in 21 African Commonwealth countries, identifying gaps and influencing factors.

Findings

Reforms often added new payment methods to existing ones or replaced fee-for-service with capitation.

Political inattention and weak policy frameworks hindered reform contexts.

Limited stakeholder capacity and lack of holistic approaches impacted reform success.

Abstract

Healthcare provider payment reform is a key element of strategic purchasing to improve health system efficiency, equity, and quality. Although such reforms are well documented in high-income countries, evidence in low- and middle-income countries—particularly in sub-Saharan Africa—remains limited and fragmented. This scoping review aimed to identify, map, and systematize recent literature on provider payment reform for strategic purchasing and the factors influencing these reforms in 21 African Commonwealth countries.

The review followed the scoping review methodological guidelines of Peters et al. and was reported using the PRISMA-ScR checklist. Studies were retrieved from scientific databases and supplemented with gray literature. Factors influencing the reforms were analysed using a health policy framework covering context, content, process, and actors.

Thirty-five full-text publications were included (29 empirical studies, four technical reports/policy briefs, and two reviews). The evidence spans eight countries, with six focusing on performance-based financing (PBF). Reforms often added new payment methods to existing ones (62.85%, n = 22/35), replaced existing methods (typically fee-for-service (FFS) with capitation in primary care (28.57%, n = 10/35)), or adopted mixed methods (37.14%, n = 13/35), with blending FFS and capitation being the most common. Multiple factors influenced different reform dimensions. Political inattention and inadequate policy, legal, and regulatory frameworks hindered the reform context. Reform content depended on clear core elements such as performance indicators, guidelines, tariffs, financial rewards, and provider autonomy. Factors such as a lack of reform piloting, chronic underfunding, fragmented funding flows, and inadequate monitoring and evaluation mechanisms hindered the reform process. The actor dimension was impacted by a lack of a holistic approach to stakeholders and limited stakeholder capacity to implement reforms.

Current evidence for implementing provider payment reforms remains limited—concentrated in a few countries and often focused on specific reform types or evaluations from a single perspective. Future studies could focus on more comprehensive reform evaluations, incorporating multistakeholder perspectives and links with other elements of strategic purchasing.

https://archive.org/details/osf-registrations-vs4fd-v1.

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