Can payment by results ensure equitable access to contraceptive services? a qualitative case study

Background: The Leave No One Behind (LNOB) agenda compels sexual and reproductive health and rights (SRHR) implementers to focus on the multiple and intersecting forms of discrimination and inequalities. One strategy to address these is Payment by Results (PbR). Using the Women’s Integrated Sexual Health (WISH) programme as a case study, this paper examines if and how PbR can ensure equitable reach and impact. Methods: Given the complexity of PbR mechanisms, a theory-based approach was used in the design and analysis of this evaluation, drawing on four case studies. These were conducted by reviewing global and national programme data and by interviewing 50 WISH partner staff at national level and WISH programme staff at global and regional levels. Results: The case studies found that inclusion of equity-based indicators in the PbR mechanism had demonstrable effects on people’s incentives, on how systems work, and on modes of working. The WISH programme was successful in achieving its desired programme indicators. The use of Key Performance Indicators (KPIs) clearly incentivised several strategies for service providers to innovate and reach adolescents and people living in poverty. However, there were trade-offs between performance indicators that increased coverage and others that increased equitable access, as well as several systemic challenges that limited the possible incentive effects. Conclusions: The use of PbR KPIs incentivised several strategies to reach adolescents and people living in poverty. However, the use of global indicators was too simplistic, resulting in several methodological issues.