Effect of results-based financing on facility-based maternal mortality at birth: an interrupted time-series analysis with independent controls in Malawi

Balancing the scales? Evaluating the impact of results-based financing on maternal health outcomes and related inequality of opportunity in Zimbabwe

This study evaluates the impact of results-based financing (RBF) on maternal health outcomes and the inequality of opportunity (IOP) in these outcomes in Zimbabwe. We employ a difference-in-differences approach that leverages the staggered implementation of the programme across 60 districts, exploiting temporal variation in the introduction of RBF and individual-level variation in birth timing. Our analysis uses nationally representative, pooled cross-sectional data from the 2005/2006, 2010/2011, and 2015 Zimbabwe demographic and health surveys. Employing the extended two-way fixed effects (ETWFE) estimator to address biases associated with staggered rollouts, we find significant positive effects of RBF on maternal health outcomes. The programme is associated with an increase in the number of prenatal care visits by 0.185 units (p < 0.01), first-trimester care by 7.7 percentage points (pp) (p < 0.01), facility births by 8.6 pp (p < 0.01), and professional delivery assistance by 3.4 pp (p < 0.01), while reducing C-section rates by 1.3 pp (p < 0.01). Additionally, RBF is associated with reductions in IOP in prenatal care visits, early prenatal care, facility births, and professional delivery assistance by 3.8, 1.3, 8.4, and 4.9 pp (p < 0.01), respectively. These findings underscore the potential of RBF to enhance maternal health outcomes and promote health equity. Integrating equity considerations into health system strengthening initiatives is essential. Policymakers should ensure that health interventions improve access and balance opportunities across various socio-economic and demographic groups. This evidence suggests that RBF schemes can improve access to and equity in healthcare services, particularly in low-income settings such as Zimbabwe.

Good while it lasted? Estimating the long-term and withdrawal effects of results-based financing in Malawi on maternal care utilisation using routine data

OBJECTIVES

This study aimed to evaluate the effect of introduction and subsequent withdrawal of the Results-based Financing for Maternal and Newborn Health Initiative (RBF4MNH) in Malawi on utilisation of facility-based childbirths, antenatal care (ANC) and postnatal care (PNC).

DESIGN

A controlled interrupted time series design was used with secondary data from the Malawian Health Management Information System.

SETTING

Healthcare facilities at all levels identified as providing maternity services in four intervention districts and 20 non-intervention districts in Malawi.

PARTICIPANTS

Routinely collected, secondary data of total monthly service utilisation of facility-based childbirths, ANC and PNC services.

INTERVENTIONS

The intervention is the RBF4MNH initiative, introduced by the Malawian government in 2013 to improve maternal and infant health outcomes and withdrawn in 2018 after ceasing of donor funding.

OUTCOME MEASURES

Differences in total volume and trends of utilisation of facility-based childbirths, ANC and PNC services, compared between intervention versus non-intervention districts, for the study period of 90 consecutive months.

RESULTS

No significant effect was observed, on utilisation trends for any of the three services during the first 2.5 years of intervention. In the following 2.5 years after full implementation, we observed a small positive increase for facility-based childbirths (+0.62 childbirths/month/facility) and decrease for PNC (-0.55 consultations/month/facility) trends of utilisation respectively. After withdrawal, facility-based childbirths and ANC consultations dropped both in immediate volume after removal (-10.84 childbirths/facility and -20.66 consultations/facility, respectively), and in trends of utilisation over time (-0.27 childbirths/month/facility and -1.38 consultations/month/facility, respectively). PNC utilisation levels seemed unaffected in intervention districts against a decline in the rest of the country.

CONCLUSIONS

Concurrent with wider literature, our results suggest that effects of complex health financing interventions, such as RBF4MNH, can take a long time to be seen. They might not be sustained beyond the implementation period if measures are not adopted to reform existing health financing structures.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

Discontinuation of performance-based financing in primary health care: impact on family planning and maternal and child health

Performance-based financing (PBF) is advocated as an effective means to improve the quality of care by changing healthcare providers' behavior. However, there is limited evidence on its effectiveness in low- and middle-income countries and on its implementation in primary care settings. Evidence on the effect of discontinuing PBF is even more limited than that of introducing PBF schemes. We estimate the effects of discontinuing PBF in Egypt on family planning, maternal health, and child health outcomes. We use a difference-in-differences (DiD) model with fixed effects, exploiting a unique dataset of six waves of spatially constructed facility-level health outcomes. We find that discontinuing performance-based incentives to providers had a negative effect on the knowledge of contraceptive methods, iron supplementation during pregnancy, the prevalence of childhood acute respiratory infection, and, more importantly, under-five child mortality, all of which were indirectly targeted by the PBF scheme. No significant effects are reported for directly targeted outcomes. Our findings suggest that PBF can induce permanent changes in providers' behavior, but this may come at the expense of non-contracted outcomes.

Exploring the roles of players in strategic purchasing for healthcare in Africa-a scoping review

Following the World Health Organization (WHO) guidance on strategic purchasing in 2000, low- and middle-income countries (LMICs) are trying to shift from passive purchasing (using fixed budgets) to strategic purchasing of healthcare which ties reimbursement to outcomes. However, there is limited evidence on strategic purchasing in Africa. We conducted a scoping literature review aimed at summarizing the roles played by governments, purchasers and providers in relation to citizens/population in strategic purchasing in Africa. The review searched for scientific journal articles that contained data on strategic purchasing collected from Africa. The literature search identified 957 articles of which 80 matched the inclusion criteria and were included in the review. The study revealed that in some countries strategic purchasing has been used as a tool for healthcare reforms or for strengthening systems that were not functional under fixed budgets. However, there was some evidence of a lack of government commitment in taking leading roles and funding strategic purchasing. Further, in some countries the laws need to be revised to accommodate new arrangements that were not part of fixed budgets. The review also established that there were some obstacles within the public health systems that deterred purchasers from promoting efficiency among providers and that prevented providers from having full autonomy in decision making. As African countries strive to shift from passive to strategic purchasing of healthcare, there is need for full government commitment on strategic purchasing. There is need to further revise appropriate legal frameworks to support strategic purchasing, conduct assessments of the healthcare systems before designing strategic purchasing schemes and to sensitize the providers and citizens on their roles and entitlements respectively.

How much does it cost to combine supply-side and demand-side RBF approaches in a single intervention? Full cost analysis of the Results Based Financing for Maternal and Newborn Health Initiative in Malawi

OBJECTIVE

To estimate the economic cost associated with implementing the Results Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi. No specific hypotheses were formulated ex-ante.

SETTING

Primary and secondary delivery facilities in rural Malawi.

PARTICIPANTS

Not applicable. The study relied almost exclusively on secondary financial data.

INTERVENTION

The RBF4MNH Initiative was a results-based financing (RBF) intervention including both a demand and a supply-side component.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cost per potential and for actual beneficiaries.

RESULTS

The overall economic cost of the Initiative during 2011-2016 amounted to €12 786 924, equivalent to €24.17 per pregnant woman residing in the intervention districts. The supply side activity cluster absorbed over 40% of all resources, half of which were spent on infrastructure upgrading and equipment supply, and 10% on incentives. Costs for the demand side activity cluster and for verification were equivalent to 14% and 6%, respectively of the Initiative overall cost.

CONCLUSION

Carefully tracing resource consumption across all activities, our study suggests that the full economic cost of implementing RBF interventions may be higher than what was previously reported in published cost-effectiveness studies. More research is urgently needed to carefully trace the costs of implementing RBF and similar health financing innovations, in order to inform decision-making in low-income and middle-income countries around scaling up RBF approaches.

Impact of a maternal and newborn health results-based financing intervention (RBF4MNH) on stillbirth: a cross-sectional comparison in four districts in Malawi

BACKGROUND

Malawi implemented a Results Based Financing (RBF) model for Maternal and Newborn Health, "RBF4MNH" at public hospitals in four Districts, with the aim of improving health outcomes. We used this context to seek evidence for the impact of this intervention on rates of antepartum and intrapartum stillbirth, taking women's risk factors into account.

METHODS

We used maternity unit delivery registers at hospitals in four districts of Malawi to obtain information about stillbirths. We purposively selected two districts hosting the RBF4MNH intervention and two non-intervention districts for comparison. Data were extracted from the maternity registers and used to develop logistic regression models for variables associated with fresh and macerated stillbirth.

RESULTS

We identified 67 stillbirths among 2772 deliveries representing 24.1 per 1000 live births of which 52% (n = 35) were fresh (intrapartum) stillbirths and 48% (n = 32) were macerated (antepartum) losses. Adjusted odds ratios (aOR) for fresh and macerated stillbirth at RBF versus non-RBF sites were 2.67 (95%CI 1.24 to 5.57, P = 0.01) and 7.27 (95%CI 2.74 to 19.25 P < 0.001) respectively. Among the risk factors examined, gestational age at delivery was significantly associated with increased odds of stillbirth.

CONCLUSION

The study did not identify a positive impact of this RBF model on the risk of fresh or macerated stillbirth. Within the scientific limitations of this non-randomised study using routinely collected health service data, the findings point to a need for rigorously designed and tested interventions to strengthen service delivery with a focus on the elements needed to ensure quality of intrapartum care, in order to reduce the burden of stillbirths.

Paying for performance to improve the delivery of health interventions in low- and middle-income countries

BACKGROUND

There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low- and middle-income countries (LMICs) is lacking; this is an update of the 2012 review on this topic.

OBJECTIVES

To assess the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.'

SELECTION CRITERIA

We included randomized or non-randomized trials, controlled before-after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use.

DATA COLLECTION AND ANALYSIS

We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta-analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design.

MAIN RESULTS

We included 59 studies: controlled before-after studies (19), non-randomized (16) or cluster randomized trials (14);  and interrupted time-series studies (9). One study included both an interrupted time series and a controlled before-after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities (54 studies). P4P was assessed predominantly at health facility level, though districts and other levels were also involved. Most studies assessed the effects of P4P against a status quo control (49 studies); however, some studies assessed effects against comparator interventions (predominantly enhanced financing intended to match P4P funds (17 studies)). Four studies reported intervention effects against both comparator and status quo. Controlled before-after studies were at higher risk of bias than other study designs. However, some randomised trials were also downgraded due to risk of bias. The interrupted time-series studies provided insufficient information on other concurrent changes in the study context. P4P compared to a status quo control For health services that are specifically targeted, P4P may slightly improve health outcomes (low certainty evidence), but few studies assessed this. P4P may also improve service quality overall (low certainty evidence); and probably increases the availability of health workers, medicines and well-functioning infrastructure and equipment (moderate certainty evidence). P4P may have mixed effects on the delivery and use of services (low certainty evidence) and may have few or no distorting unintended effects on outcomes that were not targeted (low-certainty evidence), but few studies assessed these. For secondary outcomes, P4P may make little or no difference to provider absenteeism, motivation or satisfaction (low certainty evidence); but may improve patient satisfaction and acceptability (low certainty evidence); and may positively affect facility managerial autonomy (low certainty evidence). P4P probably makes little to no difference to management quality or facility governance (low certainty evidence). Impacts on equity were mixed (low certainty evidence). For health services that are untargeted, P4P probably improves some health outcomes (moderate certainty evidence); may improve the delivery, use and quality of some health services but may make little or no difference to others (low certainty evidence); and may have few or no distorting unintended effects (low certainty evidence). The effects of P4P on the availability of medicines and other resources are uncertain (very low certainty evidence). P4P compared to other strategies For health outcomes and services that are specifically targeted, P4P may make little or no difference to health outcomes (low certainty evidence), but few studies assessed this. P4P may improve service quality (low certainty evidence); and may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines (low certainty evidence). For health outcomes and services that are untargeted, P4P may make little or no difference to health outcomes and to the delivery and use of health services (low certainty evidence). The effects of P4P on service quality, resource availability and unintended effects are uncertain (very low certainty evidence). Findings of subgroup analyses Results-based aid, and schemes using payment per output adjusted for service quality, appeared to yield the greatest positive effects on outcomes. However, only one study evaluated results-based aid, so the effects may be spurious. Overall, schemes adjusting both for quality of service and rewarding equitable delivery of services appeared to perform best in relation to service utilization outcomes.

AUTHORS' CONCLUSIONS

The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. P4P schemes may have mixed effects on outcomes of interest, and there is high heterogeneity in the types of schemes implemented and evaluations conducted. P4P is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g., who receives payments ), the amount of additional funding,  ancillary components (such as technical support) and contextual factors (including organizational context).