Performance-based financing for improving HIV/AIDS service delivery: A systematic review

Amitabh B. Suthar, Jason M. Nagata, Sabin Nsanzimana, Till Bärnighausen, Eyerusalem K. Negussie, Meg C. Doherty

Research output: Contribution to journalArticlepeer-review


Background: Although domestic HIV/AIDS financing is increasing, international HIV/AIDS financing has plateaued. Providing incentives for the health system (i.e. performance-based financing [PBF]) may help countries achieve more with available resources. We systematically reviewed effects of PBF on HIV/AIDS service delivery to inform WHO guidelines. Methods: PubMed, WHO Index Medicus, conference databases, and clinical trial registries were searched in April 2015 for randomised trials, comparative contemporaneous studies, or time-series studies. Studies evaluating PBF in people with HIV were included when they reported service quality, access, or cost. Meta-analyses were not possible due to limited data. This study is registered with PROSPERO, number CRD42015023207. Results: Four studies, published from 2009 to 2015 and including 173,262 people, met the eligibility criteria. All studies were from Sub-Saharan Africa. PBF did not improve individual testing coverage (relative risk [RR], 1.00, 95% confidence interval [CI] 0.89 to 1.13), improved couples testing coverage (RR 1.11, 95% CI 1.02 to 1.20), and improved pregnant women testing coverage (RR 1.29, 95% CI 1.28-1.30). PBF improved coverage of antiretrovirals in pregnant women (RR 1.55, 95% CI 1.50 to 1.59), infants (RR 1.92, 95% CI 1.84 to 2.01), and adults (RR 1.74, 1.64 to 1.85). PBF reduced attrition (RR 0.84, 95% CI 0.74 to 0.96) and treatment failure (odds ratio 0.55, 95% CI 0.32 to 0.97). Potential harms were not reported. Conclusions: Although the limited data suggests PBF positively affected HIV service access and quality, critical health system and governance knowledge gaps remain. More research is needed to inform national policymaking.

Original languageEnglish (US)
Article number6
JournalBMC health services research
Issue number1
StatePublished - Jan 4 2017


  • AIDS
  • Access
  • Antiretroviral therapy
  • Efficiency
  • HIV
  • HIV testing
  • HIV treatment
  • Health financing
  • Quality
  • Service
  • Universal health coverage

ASJC Scopus subject areas

  • Health Policy


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