Measuring and paying for quality of care in performance-based financing: Experience from seven low and middle-income countries (Democratic Republic of Congo, Kyrgyzstan, Malawi, Mozambique, Nigeria, Senegal and Zambia)

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.

Implementing two national responsibilities of the revised UNICEF/WHO Baby-Friendly Hospital Initiative: A two-country case study

The 2018 implementation guidance for the Baby-Friendly Hospital Initiative (BFHI) recommends institutionalising the ten Steps through nine national responsibilities for universal coverage and sustainability. As countries adapt BFHI programmes to this paradigm shift away from traditional designation programmes, documenting and sharing policy and programme experience are critical and currently sparse. This qualitative case study included desk reviews of published and grey literature on BFHI programming, national plans and policy documents specific to the selected national responsibilities for universal coverage and key informant (KI) interviews across a range of actors. In the Kyrgyz Republic, the case study explored responsibility 5, development and implementation of incentives and/or sanctions, and responsibility 6 in Malawi, providing technical assistance (TA). In both countries, the three sustainability responsibilities (national monitoring [7] communication and advocacy [8] and financing [9]) as they relate to the universal coverage of the targeted responsibilities were also explored. Thirty-eight respondents in the Kyrgyz Republic described approaches that were used in the health system, including BFHI designation plaques, performance-based financing and financial sanctions. However, currently, there are no formal incentives and sanctions. In Malawi, TA was utilised for national planning and to introduce quality improvement processes. Forty-seven respondents mostly described provisions of TA in building and strengthening the capacity of providers. More programmatic evidence to demonstrate which types of incentives or sanctions can be effective and sustained and more documentation of how TA is provided across multiple aspects of implementation are needed as countries institutionalise BFHI.

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.

Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania

BACKGROUND

The success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes.

METHODS

We conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change.

RESULTS

Programme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding.

CONCLUSION

Our study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.

Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India

Introduction

We evaluated the impact of a ‘Team-Based Goals and Incentives’ (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.

Methods

This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention’s team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.

Results

The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial’s goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.

Conclusion

Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW–beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.

Trial registration number

NCT03406221