Costase Ndayishimiye
Christoph Sowada2
†
Katarzyna Dubas-Jakóbczyk- 1Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Krakow, Poland
- 2Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
Introduction: 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.
Methods: 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.
Results: 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.
Discussion: 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.
Systematic review registration: https://archive.org/details/osf-registrations-vs4fd-v1.
1 Introduction
African leaders have demonstrated a strong commitment to advancing Universal Health Coverage (UHC), as reflected in key policy documents such as the Africa Health Strategy (2007–2015, extended to 2016–2030) and the Addis Ababa Call to Action on UHC in 2019 (1). These documents highlight the continent’s collective efforts to ensure equitable access to quality healthcare services for all citizens. Despite this widespread support, numerous challenges persist in pursuing UHC within resource-limited settings (2).
Strategic purchasing is recognized as a crucial health financing policy approach aimed at optimizing the use of limited resources to progress toward UHC (2, 3). This approach directs funds to priority populations, interventions, and services on the basis of evidence and health needs. Strategic purchasers in healthcare, such as the Ministry of Health, Social Health Insurance Fund, or local authorities, make deliberate decisions on the basis of five key areas: (1) coverage—determining for whom healthcare services should be purchased; (2) benefit package—deciding which services to purchase; (3) contracting—selecting providers; (4) quality—ensuring the quality of services; and (5) provider payment—determining the payment methods and prices for providers (4).
Previous studies have assessed the progress of various aspects of strategic purchasing in some African countries purchasing, including benefit design for improving access to priority services (e.g., high-value services such as reproductive and family planning; maternal, neonatal, and child health services) and stakeholder contracting arrangements (5–8). However, evidence on provider payment reforms in low- and middle-income countries (LMICs)—particularly in sub-Saharan Africa—remains limited, fragmented, and largely descriptive (9). Many existing studies focus on specific schemes such as performance-based financing (PBF), often within individual country contexts (10–13). Systematic analyses that explore broader patterns and influencing factors across LMICs are rare (9, 14).
In contrast, evidence from high-income countries (HICs) shows that reforming healthcare provider payment schemes is a popular policy tool used to improve efficiency, quality, accountability, and overall health system performance (15–19). Payment schemes are designed to influence healthcare providers’ behaviors, thereby playing a crucial role in strategic health purchasing. Common provider payment methods include: fee-for-service (FFS), where providers are paid per individual service delivered; capitation, which pays providers a fixed amount per patient over a set period regardless of service use; and performance-based financing (PBF), which links payments to the achievement of specific quality or service indicators. Each method offers distinct incentives and trade-offs—FFS can encourage an oversupply of care, capitation incentivizes efficiency but risks underprovision, while PBF emphasizes results but may increase administrative complexity (15, 20). Nevertheless, implementing such reforms successfully is challenging and often influenced by a mix of diverse barriers and facilitators (17–19).
This review aimed to identify, map, and systematize recent literature (published within the last decade) on provider payment reform for strategic purchasing and the factors influencing these reforms in 21 African Commonwealth countries (Botswana, Cameroon, Gabon, Gambia, Ghana, Kenya, Eswatini, Lesotho, Malawi, Mauritius, Mozambique, Namibia, Nigeria, Rwanda, Seychelles, Sierra Leone, South Africa, Togo, Uganda, Tanzania, and Zambia). On the basis of general objectives of the scoping method (21), we examined the breadth of existing evidence, identified potential research gaps, and formulated implications for future studies.
2 Methods
The study followed the scoping review methodological guidelines of Peters and colleagues (21, 22), which included five steps: defining review questions, identifying relevant literature, selecting evidence, extracting evidence, and analyzing data. The results were reported via the PRISMA-ScR checklist (23), and the study protocol was registered with the Open Science Framework (24).
2.1 Defining research questions
The specific questions guiding the review were as follows:
1. What type of evidence is available? (study country, publication year, study type, study objective).
2. What type of payment method was analyzed (type of method, type of change)
3. What type of healthcare providers were involved (e.g., primary care vs. hospital)?
4. What factors (obstacles and facilitators) influenced the reform?
2.2 Identifying relevant literature
Three scientific databases—PubMed, Scopus, and Web of Science—were searched for empirical studies. The search strategy was iteratively developed and conducted using multiple synonyms of “healthcare provider” AND “payment” AND “country” in titles and abstracts. Complementary searches included Google and gray literature on relevant organization websites, such as the Strategic Purchasing Africa Resource Centre (SPARC), the WHO via WHO African Region, the World Bank, Responsive and Resilient Health Systems (RESYST), and Health Finance and Governance (HFG) country publications. The reference lists of the included publications were manually searched for additional studies. Details of the search strategy and records for each data source are provided in Supplementary Tables S1–S6. The searches were conducted between June and July 2023.
2.3 Selecting evidence
The publications were selected in two stages: screening abstracts and evaluating full texts on the basis of predefined inclusion and exclusion criteria (Supplementary Table S7). Studies were included if they: (1) focused on provider payments within strategic purchasing; (2) were peer-reviewed empirical studies, policy briefs, theoretical papers, technical reports, books/chapters, or theses; (3) focused on an African Commonwealth country; (4) were published between 2013 and 2023; and (5) were available in English. Studies were excluded if they: (1) did not focus on healthcare provider payment within strategic purchasing (e.g., focused on social insurance schemes, community financing, cost recovery, medication payments, or informal caregiving); (2) were not full-text publications (e.g., conference abstracts); (3) focused on non- African Commonwealth countries; (4) were published before 2013; or (5) were in other languages.
Two independent researchers (CN and KDJ) conducted the title and abstract screening phase, achieving an agreement level above 80%. The full-text evaluation was performed by one researcher (CN) and reviewed by KDJ. Mendeley and Rayyan software were used for data management.
2.4 Data extraction
Data extraction tables were created using MS Excel and were tailored to specific research questions. A single researcher (CN) conducted the extraction, which was reviewed by another researcher (KDJ) and further by all coauthors during the draft and final manuscript review stages.
2.5 Data analysis and reporting
The study employed inductive thematic analysis to analyze qualitative data, which was then coded for quantitative summaries and tabulated. The paper types were classified into four categories: empirical studies (original, based on primary data, published in peer-reviewed journals), discussion/policy papers (published in peer-reviewed journals), literature reviews (published in peer-reviewed journals), and technical reports/policy briefs (e.g., policy briefs published by advocacy organizations). For payment methods reforms, the OECD classification (15) was used to code whether the reform modified an existing payment method, introduced an additional method, or replaced it with a new method.
Factors influencing reforms were deductively classified using the health policy framework (25–27), which consists of CONTEXT (systemic factors, e.g., political, economic, and cultural influences), CONTENT (detailed elements of a reform), PROCESS (creation, communication, implementation, and evaluation of the reform), and ACTORS (participants in policymaking: individuals, organizations, groups, and the government).
3 Results
3.1 Search results
The database searches yielded 3,030 records, with 1,603 duplicates. After screening 1,427 titles and abstracts, 65 full texts were reviewed, and 30 met the inclusion criteria. Most studies (n = 19) were excluded because they did not focus on healthcare providers. Four articles from organizations and one from reference lists were included, totaling 35 publications for the final analysis. Figure 1 shows the PRISMA flowchart, and Table 1 lists all included studies by country and relevant details aligned with the study questions.
Figure 1. PRISMA flowchart of the results.
Table 1. Overview of the characteristics of the included studies by country.
3.2 Overview of publications
The 35 studies included (11–13, 28–59) were from eight countries. Of these, 29 were empirical studies, four were technical reports/policy briefs (32, 48, 53, 59), and two were reviews (40, 54). One review was a scoping review mapping progress in strategic health purchasing in Cameroon (54), and the other was a narrative review assessing health purchasing reforms’ effects on equity, access, quality of care, and financial protection in Kenya (40). Empirical studies primarily evaluated specific experiences with payment reforms, notably pay-for-performance [P4P, n = 12/35, also known as results-based financing (RBF) or performance-based financing (PBF)] and capitation (n = 10/35). Studies utilized qualitative (n = 16/35), quantitative (n = 9/35), or mixed methods (n = 4/35) to assess these reforms. Reform assessment often emphasized specific stakeholders’ perspectives, including providers’ experiences, opinions, and preferences (31.42%, n = 11/35). Examples include Ghana’s capitation (30, 31, 56, 57), Kenya’s capitation and fee-for-service (FFS) (37), and PBF in Mozambique (12) and Rwanda (45). Some evaluations took a system perspective (22.85%, n = 8/35), assessing payment methods’ effectiveness in achieving broader healthcare system objectives [for example, the evaluation of PBF strategies to improve maternal health service access and utilization in Cameroon (11)]. In some cases, evaluations aimed to draw lessons from healthcare provider payment reforms for the entire health system. An example is the evaluation of capitation in primary healthcare (PHC) in Ghana, which aimed to inform a nationwide rollout (55). Evaluations could also compare achievements before and after payment reform, as observed in Tanzania’s study on technical efficiency before and after the P4P scheme (47).
3.3 Payment methods reforms
Reforms in many countries frequently centered on adding new payment methods to existing ones (62.85%, n = 22/35), with P4P being the most commonly adopted method to bolster the strategic purchasing of specific curative, preventive, and promotional services (Table 1). Many reforms concentrated particularly on maternal and child health. Primary prevention efforts prioritized vaccinations such as childhood immunizations (e.g., measles) and maternal tetanus vaccinations during prenatal care, as seen in Rwanda (46), Tanzania (13), and Cameroon (11). Prevention measures aimed at controlling infectious diseases such as HIV and tuberculosis were also noted in Mozambique (12), Cameroon (54), and Rwanda (44, 45). In 37.14% (13/35) of the studies, countries added methods with the intention of using mixed methods to pay providers, predominantly combining FFS and capitation. This approach was evident in countries such as Kenya (34, 36–38), Uganda (50), Tanzania (49), and Nigeria (41–43). Other reforms were implemented to completely replace existing payment methods, notably replacing FFS with capitation in PHC, prominently in Ghana (28–32, 55, 56, 58, 59). Ghana introduced capitation in 2012 to contain costs, share financial risk, enhance competition, and improve efficiency and claims processing after previous methods such as FFS and diagnosis-related grouping (G-DRG) were ineffective in addressing these challenges (32, 55, 56).
3.4 Types of providers involved
Certain payment reforms targeted specific providers, such as replacing FFS with capitation in PHC. However, most reforms, such as PBF, were broadly applied across various provider categories, including PHCs, hospitals, and/or specialty care (11, 46, 48, 51, 54). Both public and nonpublic sectors were sometimes included, as seen in Kenya (37) and Tanzania (49), where capitation and FFS were applied to public, private, and charity providers, and in Cameroon (11, 48), for PBF.
3.5 Factors influencing payment reforms
In the surveyed countries, various interconnected factors impacted different reform dimensions (Table 1). The reform context was frequently shaped by political will, policies, legal frameworks, and governance structures for strategic purchasing practices. Political neglect often led to superficial endorsement of reforms without sustained commitment, resulting in inconsistent implementation (32, 42, 58). Inadequacies in legal and regulatory frameworks hindered the effective operationalization of reforms, resulting in implementation inefficiencies and gaps (13, 34–36, 39, 50, 51, 54).
Reform content factors stemmed from essential elements such as guidelines, performance indicators, tariffs, financial incentives, and providers’ autonomy over finances. These were important to ensure clarity, consistency, and alignment with reform objectives. Guidelines guided reform implementors (32, 41, 43, 46, 49–51). Unclear indicators hindered many reforms, but good examples were observed in countries like Rwanda (46), Cameroon (54), Ghana (32), Nigeria (41, 43), and Uganda (50, 51). Transparent tariffs provided fair incentives (33, 43, 48, 49), whereas financial autonomy allowed providers to use resources flexibly, responsively, and responsibly [e.g., PBF programs in Camerron (48, 54), Mozambique (12), and Tanzania (13)].
Several factors impacted the reform process dimension, with top barriers stemming from the absence of reform piloting, chronic underfunding, fragmented funding flows, and inadequate monitoring and evaluation mechanisms. Piloting reform helped identify implementation challenges and informed its redesign before a nationwide rollout [e.g., capitation in Ghana (55) and PBF programs in Rwanda (44–46) and Tanzania (13, 47)]. Piloting proved essential for detecting and addressing potential issues early. Chronic underfunding crippled the ability to sustain long-term reform initiatives. Payment reform in various countries suffered heavy dependency on donor funds (13, 31, 32, 41, 43, 47–52, 54, 56, 57, 59). Fragmented funding flows with often multiple payment systems further exacerbated these issues by creating inefficiencies and misallocations of resources (11, 36, 39, 40, 42, 43, 47–49, 51, 54, 57). Inadequate monitoring and evaluation mechanisms led to a lack of accountability and transparency, impeding the ability to measure progress and make necessary adjustments (11, 34, 35, 39–42, 48, 51, 54).
Finally, the reform actor dimension was frequently impacted by barriers associated with a lack of a holistic approach to stakeholders and inadequate stakeholder capacity to perform reform tasks. Reforms and involved stakeholders varied within and between countries. Frequent actors can generally be grouped into government, purchasers, healthcare providers (including provider groups), and the general public. Notably, in most reforms, the general public, such as citizens or patients and their associations, was commonly overlooked (12, 29, 34–36, 41, 51, 53, 55).
4 Discussion
Evidence suggests that since 2013, only eight of the 21 African Commonwealth countries have implemented healthcare provider payment reforms. This underscores a scarcity consistent with previous findings in low-income economy countries (19). Countries typically add new payment methods to existing ones (usually P4P for different providers), replace FFS with capitation in PHC, or mix these two methods. This shift from FFS to capitation aims to contain costs, as FFS can lead to cost increases and service oversupply, jeopardizing the financial stability of purchasers (16). Capitation has been identified as a preferred approach for PHC financing in LMICs due to its potential to align incentives with population health goals (60). For instance, Thailand’s capitation-based system has helped expand comprehensive PHC coverage at the district level (60, 61). Capitation is known to promote efficiency (62), reduce costs (63, 64), generate attractive provider revenue (65), promote compliance with guidelines and policies (66), and improve provider performance and patient education (67). However, it can also affect care quality and quantity (65), may discourage providers from serving high-risk patients (68), and affect patient-provider relationships (68). Many countries have adopted mixed payment systems that combine FFS and capitation (34, 36–43, 49, 50), a strategy supported by high-income country literature in PHC (16). Mixed payment models can offset the disadvantages of pure payment methods and make them attractive options for policymakers (16, 69–73).
The factors influencing payment reforms in the surveyed countries are broadly consistent with those in the international literature (18, 19). Contextual factors such as political will and regulatory frameworks play crucial roles in most reforms, particularly when they coincide with other health policies and political priorities (19). We found that the success of a reform largely depended on its clarity and transparency in content elements such as performance indicators, payment rates and quality criteria as well as its potential to generate positive perceptions and interests among key stakeholders, particularly providers. Consistent with previous studies, deficiencies in these elements can lead to several problems, such as tensions between providers and reformers, which can stagnate reform efforts (19, 74). The reform process is often hindered by chronic underfunding, largely driven by donor influence in low-resource settings and further exacerbated by high fragmentation in financing and health service delivery systems, as consistently observed by previous researchers (19, 74). Conversely, piloting reforms is often considered a key process facilitator, helping countries identify implementation challenges and inform redesign before nationwide rollout. However, the selection of pilot sites must also consider political and contextual factors. In Ghana, for example, choosing a region associated with opposition political interests led to suspicion and resistance, illustrating how local dynamics can undermine the credibility of reform piloting (32, 58). Finally, we emphasize the importance of stakeholder engagement for successful reform implementation, but ensuring that stakeholders have sufficient capacity to carry out the assigned tasks is crucial. Many payment reforms were hindered by the lack of sufficient capacity of stakeholders (e.g., financial capacity, human resources, technical skills, and tools such as IT). An interesting approach is the technique observed in Ghana (32) of mapping the capacities of stakeholders and forming groups for those who are unable to implement reforms independently. Further research is needed to evaluate this practice and shed light on potential challenges and strengths or feasibility in other, particularly resource-limited, countries.
This study highlights important research gaps. In African Commonwealth countries, current evidence on provider payment reforms for strategic health purchasing is limited—not only because such reforms have been implemented in relatively few countries, but also because, where they do exist, the available evidence often focuses on specific types of reforms and/or presents evaluations from a single perspective. Our results help define indications for future studies. First, PBF is the most commonly implemented reform (studies were identified in six of the eight countries for which evidence was found). Previous studies have also shown that such outcome-based payment models have gained traction, but their scope is narrow and they focus on specific diseases or conditions (18, 75, 76). In particular, studies have reported mixed results concerning the long-term viability of P4P in similar settings (77, 78), and a review of PBF in LMICs concluded that no definitive conclusions could be drawn regarding the likely impact of PBF (79). Therefore, the effectiveness of these methods in the studied settings remains to be investigated. Second, it is worth noting that the majority of studies examining the impacts of capitation reforms focus on experiences in Ghana. While these insights are undoubtedly valuable, they may not provide a comprehensive understanding of how such payment reforms play out in other countries on the continent. Third, many of the reforms included are broad and target multiple providers at the same time. This approach often lacks the nuance needed to determine which methods are most effective for certain types of providers. Although some countries combine methods that can sometimes mitigate the unintended consequences of individual payment methods, previous research has suggested that certain methods may be more suitable for particular types of providers while proving ineffective for others (80). Examples include capitation for PHC plus FFS for priority interventions, FFS with P4P for episodic care, and DRGs with global budget (70). This practice of which methods should be blended for specific types of providers particularly needs to be investigated in the studied countries. Additionally, it is crucial to acknowledge the absence of experiences regarding other value-based payment methods, such as bundled payment methods, within the study settings. Bundled payments are crucial for effective care continuity, especially for chronic conditions (70). Future research should examine the potential of such payment initiatives in African settings and assess their feasibility. Additionally, the provider payment method defines the mechanism used to transfer funds from purchasers to providers (20) and is just one of five interrelated elements of the strategic purchasing framework (4, 5). Future studies could be aimed at a more comprehensive reform evaluation, e.g., from a multistakeholder perspective and/or in interconnection/relation with other elements of strategic purchasing. Finally, the issue of factors influencing payment reform success can be investigated via targeted original research, with a focus on developing policy recommendations for best practices to overcome specific barriers.
This review has several strengths. It is the first study to systematically synthesize provider payment reforms in African Commonwealth countries using a structured health policy framework. The search strategy included both peer-reviewed and gray literature. However, certain limitations should be noted. The review included only English-language literature. Although this is justified given that English is the common official language in Commonwealth countries, relevant local-language sources may have been excluded. Additionally, the study relied on publicly available published evidence, which may omit unpublished reform documentation or evaluations. Finally, in line with the scoping review methodology (22), we did not assess the quality of the included studies.
5 Conclusion
This study highlights a major research gap in healthcare provider payment reforms in African Commonwealth countries. The evidence shows a trend toward supplementing traditional methods with new ones, such as P4P, replacing FFS with capitation, or mixed models. Unlike high-income countries, which prioritize bundled payments for chronic diseases, African countries’ reforms often focus on specific diseases such as HIV or maternal health. Success factors in Africa are similar to those in high-income countries, but unique challenges include fragmented funding and heavy reliance on donors.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
CN: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing. CS: Formal analysis, Writing – review & editing, Visualization. KD-J: Conceptualization, Formal analysis, Methodology, Writing – review & editing, Visualization.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2025.1446497/full#supplementary-material
References
1. Barasa, E, Hakiba, S, Fenny, AP, Omaswa, F, Moosa, S, Bendhaou, K, et al. The state of universal health coverage in Africa: report of the Africa Health Agenda International Conference Commission. Nairobi: Amref Health Africa (2021). Available at: https://repository.amref.ac.ke/handle/123456789/211
2. Gatome-Munyua, A, and Cashin, C. Introduction to the special issue on making progress on strategic health purchasing in Africa. Heal Syst Reform. (2022) 8:2129026. doi: 10.1080/23288604.2022.2129026
3. Gatome-Munyua, A, Sieleunou, I, Sory, O, and Cashin, C. Why is strategic purchasing critical for universal health coverage in sub-Saharan Africa? Health Syst Reform. (2022) 8:e2051795. doi: 10.1080/23288604.2022.2051795
4. World Health Organization . Regional Office for South-East Asia, 2017. Strategic Purchasing and Provider Payment Methods for Universal Health Coverage, World Health Organization. Regional Office for South-East Asia. Switzerland. Available at: https://coilink.org/20.500.12592/rnbkz8 (Accessed June 06, 2025).
5. Gatome-Munyua, A, Sieleunou, I, Barasa, E, Ssengooba, F, Issa, K, Musange, S, et al. Applying the strategic health purchasing progress tracking framework: lessons from nine African countries. Health Syst Reform. (2022) 8:e2051796. doi: 10.1080/23288604.2022.2051796
6. Yameogo, P, Uwaliraye, P, and Hitimana, R. Strategic health purchasing: Policymakers’ perspectives. Nairobi (Kenya): Strategic Purchasing Africa Resource Center (SPARC). (2022). Available at: https://sparc.africa/resources/strategic-health-purchasing-policymakers-perspectives/
7. Gatome-Munyua, A, Tapsoba, C, and Cashin, C. Collaborative learning to advance knowledge and implementation of strategic health purchasing in sub-Saharan Africa. Health Syst Reform. (2022) 8:e2051793. doi: 10.1080/23288604.2022.2051793
8. Honda, A . What is strategic purchasing for health? London: RESYST, London School of Hygiene and Tropical Medicine (2014).
9. Ghazaryan, E, Delarmente, BA, Garber, K, Gross, M, Sriudomporn, S, and Rao, KD. Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review. Health Policy Plan. (2021) 36:1344–56. doi: 10.1093/heapol/czab050
10. Ndayishimiye, C, Nduwayezu, R, Sowada, C, and Dubas-Jakóbczyk, K. Performance-based financing in Rwanda: a qualitative analysis of healthcare provider perspectives. BMC Health Serv Res. (2025) 25:418. doi: 10.1186/s12913-025-12605-z
11. Nkangu, M, Little, J, Asahngwa, C, Deonandan, R, Pongou, R, Adams, O, et al. Examining the Implementation of the Performance-Based Financing Equity Strategy in Improving Access and Utilization of Maternal Health Services in Cameroon: A Qualitative Study. Int J Environ Res Public Health. (2022) 19:14132. doi: 10.3390/ijerph192114132
12. Schuster, RC, de Sousa, O, Reme, AK, Vopelak, C, Pelletier, DL, Johnson, LM, et al. Performance-based financing empowers health workers delivering prevention of vertical transmission of HIV services and decreases desire to leave in Mozambique. Int J Health Policy Manag. (2018) 7:630–44. doi: 10.15171/ijhpm.2017.137
13. Manongi, R, Mushi, D, Kessy, J, Salome, S, and Njau, B. Does training on performance based financing make a difference in performance and quality of health care delivery? Health care provider’s perspective in Rungwe Tanzania. BMC Health Serv Res. (2014) 14:154. doi: 10.1186/1472-6963-14-154
14. Waithaka, D, Cashin, C, and Barasa, E. Is performance-based financing a pathway to strategic purchasing in sub-Saharan Africa? A synthesis of the evidence. Heal Syst Reform. (2022) 8:e2068231. doi: 10.1080/23288604.2022.2068231
15. OECD ed. Better Ways to Pay for Health Care. OECD. Paris: OECD Health Policy Studies (2016). 168 p.
16. Ndayishimiye, C, Tambor, M, Behmane, D, Dimova, A, Dūdele, A, Džakula, A, et al. Health care provider payment schemes and their changes since 2010 across nine Central and Eastern European countries – a comparative analysis. Health Policy (New York). (2025) 153:105261. doi: 10.1016/j.healthpol.2025.105261
17. Ndayishimiye, C, Tambor, M, Behmane, D, Dimova, A, Dūdele, A, Džakula, A, et al. Factors influencing health care providers payment reforms in central and Eastern European countries. Inq J Health Care Organ Provision Financ. (2024) 61:00469580241287626. doi: 10.1177/00469580241287626
18. Leao, DLL, Cremers, H-P, van Veghel, D, Pavlova, M, Hafkamp, FJ, and Groot, WNJ. Facilitating and inhibiting factors in the design, implementation, and applicability of value-based payment models: a systematic literature review. Med Care Res Rev. (2023) 80:467–83. doi: 10.1177/10775587231160920
19. Ndayishimiye, C, Tambor, M, and Dubas-Jakóbczyk, K. Barriers and facilitators to health-care provider payment reform – a scoping literature review. Risk Manag Healthc Policy. (2023) 16:1755–79. doi: 10.2147/RMHP.S420529
20. Langenbrunner, JC, Cashin, C, and O’Dougherty, S. (eds.). Designing and implementing health care provider payment systems: how-to manuals. Washington, DC: The World Bank (2009). 321 p.
21. Peters, MDJ, Marnie, C, Tricco, AC, Pollock, D, Munn, Z, Alexander, L, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. (2020) 18:2119–26. doi: 10.11124/JBIES-20-00167
22. Peters, MDJ, Godfrey, CM, Khalil, H, McInerney, P, Parker, D, and Soares, CB. Guidance for conducting systematic scoping reviews. JBI Evid Implement. (2015) 13:141–6. doi: 10.1097/XEB.0000000000000050
23. Tricco, AC, Lillie, E, Zarin, W, O’Brien, KK, Colquhoun, H, Levac, D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. (2018) 169:467–73. doi: 10.7326/M18-0850
24. Ndayishimiye, C, Tambor, M, and Dubas-Jakóbczyk, K. Health care providers payment reforms in African states of the Commonwealth of Nations [Internet]. OSF; (2023). Available from: https://archive.org/details/osf-registrations-vs4fd-v1 (Accessed Mar 16, 2024)
26. Walt, G, and Gilson, L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. (1994) 9:353–70. doi: 10.1093/heapol/9.4.353
27. Stockdale, R, and Standing, C. An interpretive approach to evaluating information systems: a content, context, process framework. Eur J Oper Res. (2006) 173:1090–102. doi: 10.1016/j.ejor.2005.07.006
28. Andoh-Adjei, FX, Boudewijns, B, Nsiah-Boateng, E, Asante, FA, van der Velden, K, and Spaan, E. Effects of capitation payment on utilization and claims expenditure under national health insurance scheme: A cross-sectional study of three regions in Ghana. Health Econ Rev. (2018) 8:1–10. doi: 10.1186/s13561-018-0203-9
29. Abduali, IA, Adams, A-M, and Abdulai, M-E. Seeking healthcare under the National Health Insurance Scheme’s capitation payment method in Wa Municipality, Ghana: subscribers’ perspectives. Afr J Sci Technol Innov Dev. (2019) 11:45–54. doi: 10.1080/20421338.2018.1547511
30. Andoh-Adjei, F-X, Nsiah-Boateng, E, Asante, FA, van der Velden, K, and Spaan, E. Provider preference for payment method under a national health insurance scheme: a survey of health insurance-credentialed health care providers in Ghana. PLoS One. (2019) 14:e0221195. doi: 10.1371/journal.pone.0221195
31. Aikins, M, Tabong, PT-N, Salari, P, Tediosi, F, Asenso-Boadi, FM, and Akweongo, P. Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: a qualitative study among key stakeholders. PLoS One. (2021) 16:e0253109. doi: 10.1371/journal.pone.0253109
32. Amporfu, E, and Arthur, E Ghana’s experience with changing provider payment to capitation in primary health care. Lancet Global Health Commission on Financing Primary Health Care. Working Paper No. 5. London: London School of Hygiene & Tropical Medicine (2022). Available at: https://www.lshtm.ac.uk/media/59821
33. Amporfu, E, Agyei-Baffour, P, Edusei, A, Novignon, J, and Arthur, E. Strategic health purchasing progress mapping: a spotlight on Ghana’s National Health Insurance Scheme. Health Syst Reform. (2022) 8:e2058337. doi: 10.1080/23288604.2022.2058337
34. Munge, K, Mulupi, S, Barasa, EW, and Chuma, J. A critical analysis of purchasing arrangements in Kenya: the case of the National Hospital Insurance Fund. Int J Health Policy Manag. (2018) 7:244–54. doi: 10.15171/ijhpm.2017.81
35. Mbau, R, Barasa, E, Munge, K, Mulupi, S, Nguhiu, PK, and Chuma, J. A critical analysis of health care purchasing arrangements in Kenya: a case study of the county departments of health. Int J Health Plann Manag. (2018) 33:1159–77. doi: 10.1002/hpm.2604
36. Munge, K, Mulupi, S, Barasa, E, and Chuma, J. A critical analysis of purchasing arrangements in Kenya: the case of micro health insurance. BMC Health Serv Res. (2019) 19:45. doi: 10.1186/s12913-018-3863-6
37. Obadha, M, Chuma, J, Kazungu, J, and Barasa, E. Health care purchasing in Kenya: Experiences of health care providers with capitation and fee-for-service provider payment mechanisms. Int J Health Plann Manag. (2019) 34:e917–33. doi: 10.1002/hpm.2707
38. Obadha, M, Chuma, J, Kazungu, J, Abiiro, GA, Beck, MJ, and Barasa, E. Preferences of healthcare providers for capitation payment in Kenya: A discrete choice experiment. Health Policy Plan. (2020) 35:842–54. doi: 10.1093/heapol/czaa016
39. Kazungu, J, Kabia, E, Munge, K, and Barasa, E. Assessing the progress and gaps in strategic health purchasing in Kenya. Wellcome Open Res. (2021) 6:81. doi: 10.12688/wellcomeopenres.16606.1
40. Kabia, E, Kazungu, J, and Barasa, E. The effects of health purchasing reforms on equity, access, quality of care, and financial protection in Kenya: a narrative review. Health Syst Reform. (2022) 8:2114173. doi: 10.1080/23288604.2022.2114173
41. Ezenduka, C, Obikeze, E, Uzochukwu, B, and Onwujekwe, O. Examining healthcare purchasing arrangements for strategic purchasing in Nigeria: a case study of the Imo state healthcare system. Health Res Policy Syst. (2022) 20:41. doi: 10.1186/s12961-022-00844-z
42. Ezenwaka, U, Gatome-Munyua, A, Nwankwor, C, Olalere, N, Orji, N, Ewelike, U, et al. Strategic health purchasing in Nigeria: investigating governance and institutional capacities within federal tax-funded health schemes and the formal sector social health insurance programme. Health Syst Reform. (2022) 8:e2074630. doi: 10.1080/23288604.2022.2074630
43. Onwujekwe, O, Mbachu, CO, Okeke, C, Ezenwaka, U, Ogbuabor, D, and Ezenduka, C. Strategic health purchasing in Nigeria: exploring the evidence on health system and service delivery improvements. Health Syst Reform. (2022) 8:2111785. doi: 10.1080/23288604.2022.2111785
44. Binagwaho, A, Condo, J, Wagner, C, Ngabo, F, Karema, C, Kanters, S, et al. Impact of implementing performance-based financing on childhood malnutrition in Rwanda. BMC Public Health. (2014) 14:1–8. doi: 10.1186/1471-2458-14-1132
45. Ngo, DKL, Sherry, TB, and Bauhoff, S. Health system changes under pay-for-performance: the effects of Rwanda’s national programme on facility inputs. Health Policy Plan. (2017) 32:11–20. doi: 10.1093/heapol/czw091
46. Umuhoza, SM, Musange, SF, Nyandwi, A, Gatome-Munyua, A, Mumararungu, A, Hitimana, R, et al. Strengths and weaknesses of strategic health purchasing for universal health coverage in Rwanda. Heal Syst Reform. (2022) 8:e2061891. doi: 10.1080/23288604.2022.2061891
47. Binyaruka, P, and Anselmi, L. Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania. BMJ Glob Health. (2020) 5:e002326. doi: 10.1136/bmjgh-2020-002326
48. SPARC (2021). Strategic health purchasing in Cameroon: a summary of progress, challenges, and opportunities.
49. Kuwawenaruwa, A, Makawia, S, Binyaruka, P, and Manzi, F. Assessment of strategic healthcare purchasing arrangements and functions towards universal coverage in Tanzania. Int J Health Policy Manag. (2022) 11:3079–89. doi: 10.34172/ijhpm.2022.6234
50. Ekirapa-Kiracho, E, Mayora, C, Ssennyonjo, A, Baine, SO, and Ssengooba, F. Purchasing health care services for universal health coverage: policy and programme implications for Uganda In: Universal health coverage in Uganda: looking back and forward to speed up the progress. Kampala (Uganda): Makerere University (2017). 205–25.
51. Ekirapa-Kiracho, E, Ssennyonjo, A, Cashin, C, Gatome-Munyua, A, Olalere, N, Ssempala, R, et al. Strategic Purchasing Arrangements in Uganda and Their Implications for Universal Health Coverage. Heal Syst Reform. (2022) 8:2084215. doi: 10.1080/23288604.2022.2084215
52. Yé, M, Aninanya, GA, Sié, A, Kakoko, DCV, Chatio, S, Kagoné, M, et al. Establishing sustainable performance-based incentive schemes: views of rural health workers from qualitative research in three sub-Saharan African countries. Rural Remote Health. (2014) 14:2681. doi: 10.22605/RRH2681
53. Cashin, C, Eichler, R, and Hartel, L. Unleashing the potential of strategic purchasing: HFG Series: Advances in Health Finance and Governance. Nairobi (Kenya): Strategic Purchasing Africa Resource Centre (SPARC) (2018).
54. Sieleunou, I, Tamga, DDM, Maabo Tankwa, J, Aseh Munteh, P, and Longang Tchatchouang, EV. Strategic health purchasing progress mapping in Cameroon: a scoping review. Health Syst Reform. (2021) 7:e1909311. doi: 10.1080/23288604.2021.1909311
55. Aboagye, AQQ . Capitation in healthcare financing in Ghana. East Afr Med J. (2013) 90:156–63. doi: 10.5539/gjhs.v5n5p67
56. Agyei-Baffour, P, Oppong, R, and Boateng, D. Knowledge, perceptions and expectations of capitation payment system in a health insurance setting: a repeated survey of clients and health providers in Kumasi, Ghana. BMC Public Health. (2013) 13:1–9. doi: 10.1186/1471-2458-13-1220
57. Agyepong, IA, Aryeetey, GC, Nonvignon, J, Asenso-Boadi, F, Dzikunu, H, Antwi, E, et al. Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme--a systems approach. Health Res Policy Syst. (2014) 12:35. doi: 10.1186/1478-4505-12-35
58. Atuoye, KN, Vercillo, S, Antabe, R, Galaa, SZ, and Luginaah, I. Financial sustainability versus access and quality in a challenged health system: an examination of the capitation policy debate in Ghana. Health Policy Plan. (2016) 31:1240–9. doi: 10.1093/heapol/czw058
59. Anyona, RM . (2018). Strategic purchasing through prioritisation of primary healthcare in Ghana. p. 1–12.
60. Hanson, K, Brikci, N, Erlangga, D, Alebachew, A, De Allegri, M, Balabanova, D, et al. The Lancet Global Health Commission on financing primary health care: putting people at the centre. Lancet Glob Heal. (2022) 10:e715–72. doi: 10.1016/S2214-109X(22)00005-5
61. Sundararaman, T . Health care financing in Thailand: learnings in the theory and practice of universal health coverage. New Delhi: Resource Centre for Health Systems (2024). Available at: https://rthresources.in/wp-content/uploads/2024/09/Tables_2_to_6_Thailand_UHC_financin%20.pdf
62. Andoh-Adjei, F-X, Spaan, E, Asante, FA, Mensah, SA, and Van Der Velden, K. A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries. Ghana Med J. (2016) 50:207–19. doi: 10.4314/gmj.v50i4.3
63. Yip, W, and Eggleston, K. Addressing government and market failures with payment incentives: hospital reimbursement reform in Hainan, China. Soc Sci Med. (2004) 58:267–77. doi: 10.1016/s0277-9536(03)00010-8
64. Ponce, P, Marcelli, D, Guerreiro, A, Grassmann, A, Gonçalves, C, Scatizzi, L, et al. Converting to a capitation system for dialysis payment–the Portuguese experience. Blood Purif. (2013) 34:313–24. doi: 10.1159/000343128
65. Mills, A, Bennett, S, Siriwanarangsun, P, and Tangcharoensathien, V. The response of providers to capitation payment: a case-study from Thailand. Health Policy. (2000) 51:163–80. doi: 10.1016/s0168-8510(00)00059-2
66. van Dijk, CE, Verheij, RA, Spreeuwenberg, P, van den Berg, MJ, Groenewegen, PP, Braspenning, J, et al. Impact of remuneration on guideline adherence: empirical evidence in general practice. Scand J Prim Health Care. (2013) 31:56–63. doi: 10.3109/02813432.2012.757078
67. Pearson, WS, King, DE, and Richards, C. Capitated payments to primary care providers and the delivery of patient education. J Am Board Fam Med. (2013) 26:350–5. doi: 10.3122/jabfm.2013.04.120301
68. Hennig-Schmidt, H, Selten, R, and Wiesen, D. How payment systems affect physicians’ provision behaviour—an experimental investigation. J Health Econ. (2011) 30:637–46. doi: 10.1016/j.jhealeco.2011.05.001
69. Kutzin, J . A descriptive framework for country-level analysis of health care financing arrangements. Health Policy. (2001) 56:171–204. doi: 10.1016/s0168-8510(00)00149-4
70. Mathauer, I . Mixed provider payment systems: What are the issues? Geneva: World Health Organization (2017). Available at: https://www.who.int/docs/default-source/health-financing/strategic-purchasing/d1-s2-mathauer-who.pdf
71. Feldhaus, I, and Mathauer, I. Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature. BMC Health Serv Res. (2018) 18:1–14. doi: 10.1186/s12913-018-3779-1
72. Quentin, W, Stephani, V, Berenson, RA, Bilde, L, Grasic, K, Sikkut, R, et al. How Denmark, England, Estonia, France, Germany, and the USA pay for variable, specialized and low volume care: a cross-country comparison of in-patient payment systems. Int J Health Policy Manag. (2022) 11:2940–50. doi: 10.34172/ijhpm.2022.6536
73. Brosig-Koch, J, Hennig-Schmidt, H, Kairies-Schwarz, N, and Wiesen, D. The Effects of Introducing Mixed Payment Systems for Physicians: Experimental Evidence. Health Econ. (2017) 26:243–62. doi: 10.1002/hec.3292
74. Nagy, B, and Brandtmüller, Á. Implementing risk adjusted capitation payments with health care reforms in Hungary. Competitio. (2008) 7:147–60. doi: 10.21845/comp/2008/2/8
75. Vlaanderen, FP, Tanke, MA, Bloem, BR, Faber, MJ, Eijkenaar, F, Schut, FT, et al. Design and effects of outcome-based payment models in healthcare: a systematic review. Eur J Health Econ. (2019) 20:217–32. doi: 10.1007/s10198-018-0989-8
76. National Audit Office . Outcome-based payments schemes: government’s use of payment by results. London: National Audit Office (2015). Available at: https://www.nao.org.uk/insights/outcome-based-payment-schemes-governments-use-of-payment-by-results/
77. Lemière, C, Torsvik, G, Mæstad, O, Herbst, CH, and Leonard, KL. Evaluating the impact of results-based financing on health worker performance. Washington, DC: World Bank (2013).
78. Magrath, P, and Nichter, M. Paying for performance and the social relations of health care provision: an anthropological perspective. Soc Sci Med. (2012) 75:1778–85. doi: 10.1016/j.socscimed.2012.07.025
79. Witter, S, Fretheim, A, Kessy, FL, and Lindahl, AK. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev. (2012) 2:CD007899. doi: 10.1002/14651858.CD007899.pub2
Keywords: healthcare provider, strategic purchasing, payment reform, commonwealth, Africa
Citation: Ndayishimiye C, Sowada C and Dubas-Jakóbczyk K (2025) Health care provider payment reforms in African states of the Commonwealth—a scoping review. Front. Public Health. 13:1446497. doi: 10.3389/fpubh.2025.1446497
Edited by:
Jing Yuan, Fudan University, ChinaReviewed by:
Ayan Jha, The Palladium Group, United StatesEugenia Amporfu, Kwame Nkrumah University of Science and Technology, Ghana
Monica Jain, International Initiative for Impact Evaluation, India
Copyright © 2025 Ndayishimiye, Sowada and Dubas-Jakóbczyk. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Costase Ndayishimiye, Y29zdGFzZS5uZGF5aXNoaW1peWVAZG9jdG9yYWwudWouZWR1LnBs
†ORCID: Costase Ndayishimiye, orcid.org/0000-0003-1829-0037
Christoph Sowada, orcid.org/0000-0002-8900-1119
Katarzyna Dubas-Jakóbczyk, orcid.org/0000-0002-6368-2868