Table 6 Constructed problem with corresponding ideas and respondents’ quotes

1. Input-based financing systems with passive strategic function causing public service ineffectiveness and inefficiency

Renewed public management structures; strategic purchasing through output-based financing

It is about public financing, it is a matter of giving back power to the state or more capacity to negotiate with the state […] It is about making the public system effective and I have this intimate personal conviction that public systems effectiveness is the best defense of their... sustainability: um, that ineffective public systems will eventually disappear. (I17_TANSCO)

Still, I think [PBF] is a reflection on strategic purchasing issues, and it's still something important, and something positive for us... […] In the mechanism we say uh, here: the health service is supposed uh to provide such service, uh... at such a price, for such volume and uh... and he is paid according to what he actually does and not uh... something more random. (I18_INTORG)

2a. Lack of accountability of public health spending

Output-based aid and better aid-tracking systems

Donors tried several approaches: providing direct funding, relying on input-based financing that is, offering training, training people for... for inputs, uh... without really knowing whether these trainings are used, what is the use of all these books, what is the use of all these documents, et cetera… So we had... we were a little… about to falter, with a funding approach… that did not provide any result. (I34_ACADINST)

2b. Lack of accountability of public health spending

Separation of (purchaser-provider) functions

The implicit recommendation to African countries is that they can proceed towards universal coverage on the basis of the existing model: a national health service characterized by the State fulfilling all the roles: owner, employer, supplier, purchaser, regulator, administrator… A system in which health facilities are public administrations receiving their resources through line item budgets, often even “in kind”. It is precisely this status quo that PBF champions are challenging. (I19)

[NB: This quote is extracted from a blog entry posted by I19 and referred to by the key informant himself during the interview I19a_ACADINST]

3. Unmotivated and underperforming health workers

Setting (financial) incentives for health workers attached to performance indicators, and reinforcing supervision

Of course, PBF brings staff motivation and we also often observe a change of behaviour on the part of the staff, who dev… almost develop a spirit of entrepreneurship; so they try to imagine strategies to receive more patients, and improve the quality of services […]. So there is a certain emulation, bringing in a spirit of entrepreneurship, and leadership, to attract more patients and to improve the quality of services. (I55_NATGOV)

4. Highly centralised countries

Enhancing providers’ autonomy

That’s autonomy for health centers at the primary level, […] instead of sending funding and controlling everything that practitioners can do with this money… even if in the cabinets there are far too many medicines of one kind, while it does not meet the needs. And then it's recognising the... value in the system of health providers, and allowing them to... […] feel valued. (I25_INTORG)

5. Underperforming monitoring systems

Effective health information systems; data for decision making

This is the first time that anybody has an information about… (chuckles) you know… whether it’d be the quality, the quantity, the financing of services… hum… and that is a whole kind of cultural (pause) change where people are actually understanding what’s going on. Hum… and that does contribute to making informed decision-making. Hum… we can track how well certain services are… hum… improving in terms of quantity and quality, where we couldn’t before. (I08_INTORG)