Publication: Performance-Based Financing to Increase Utilization of Maternal Health Services: Evidence from Burkina Faso
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Date
2017-12
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2352-8273
Published
2017-12
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Abstract
Performance-based financing (PBF) programs are increasingly implemented in low and middle-income countries to improve health service quality and utilization. In April 2011, a PBF pilot program was launched in Boulsa, Leo and Titao districts in Burkina Faso with the objective of increasing the provision and quality of maternal health services. We evaluate the impact of this program using facility-level administrative data from the national health management information system (HMIS). Primary outcomes were the number of antenatal care visits, the proportion of antenatal care visits that occurred during the first trimester of pregnancy, the number of institutional deliveries and the number of postnatal care visits. To assess program impact we use a difference-in-differences approach, comparing changes in health service provision post-introduction with changes in matched comparison areas. All models were estimated using ordinary least squares (OLS) regression models with standard errors clustered at the facility level. On average, PBF facilities had 2.3 more antenatal care visits (95% CI [0.446–4.225]), 2.1 more deliveries (95% CI [0.034–4.069]) and 9.5 more postnatal care visits (95% CI [6.099, 12.903]) each month after the introduction of PBF. Compared to the service provision levels prior to the interventions, this implies a relative increase of 27.7 percent for ANC, of 9.2 percent for deliveries, and of 118.7 percent for postnatal care. Given the positive results observed during the pre-pilot period and the limited resources available in the health sector, the PBF program in Burkina Faso may be a low-cost, high impact intervention to improve maternal and child health.
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Publication Looking into the performance-based financing black box(Oxford University Press, 2021-07)Performance-based financing (PBF) is a complex health systems intervention aimed at improving the coverage and quality of care. Several studies have shown a positive impact of PBF on health service coverage, often coupled with improvements in quality, but relatively little is known about the mechanisms driving those results. This article presents results of a randomized impact evaluation in Cameroon designed to isolate the role of specific components of the PBF approach with four study groups: (i) PBF with explicit financial incentives linked to results, (ii) direct financing with additional resources available for health providers not linked to performance, (iii) enhanced supervision and monitoring without additional resources and (iv) a control group. Overall, results indicate that, when compared with the pure control group, PBF in Cameroon led to significant increases in utilization for several services (child and maternal vaccinations, use of modern family planning), but not for others like antenatal care visits and facility-based deliveries. In terms of quality, PBF increased the availability of inputs and equipment, qualified health workers, led to a reduction in formal and informal user fees but did not affect the content of care. However, for many positively impacted outcomes, the differences between the PBF group and the group receiving additional financing not linked to performance are not significant, suggesting that additional funding rather than the explicit incentives might be driving improvements. In contrast, the intervention group offering enhanced supervision, coaching and monitoring without additional funding did not experience significant impacts compared to the control group.Publication Looking into the Performance-Based Financing Black Box(World Bank, Washington, DC, 2017-08)Performance-based financing is a complex health system intervention aimed at improving coverage and quality of care. This paper presents the results of an impact evaluation in Cameroon that seeks to isolate the role of specific components of the performance-based financing approach on outcomes of interest, such as explicit financial incentives linked to results, additional resources available at the point of service delivery (not linked to performance), and enhanced supervision, coaching, and monitoring. Four evaluation groups were established to measure the effects of each component that was studied. In general, the results indicate that performance-based financing in Cameroon is an efficient mechanism to channel payments and funding to the provider level, leading to significant increases in utilization in the performance-based financing arm for several services (child and maternal vaccinations and use of modern family planning), but not for others, such as antenatal care visits and facility-based deliveries. However, for many of those outcomes, the differences between the performance-based financing group and the additional financing group are not significant. In terms of quality, performance-based financing was found to have a significant impact on the availability of essential inputs and equipment, qualified health workers, reduction in formal and informal user fees, and increased satisfaction among patients and providers. However, there was a clear effect of additional financing, irrespective of whether it was linked to incentives, in combination with reinforced supervision through performance-based financing. This result suggests that enhanced supervision and monitoring on their own are not sufficient to improve maternal and child health outcomes.Publication Impacts of Performance‑Based Financing on Health System Performance(BMC Medicine, 2023-10-10)Health systems’ weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such programs introduced in LMICs to date. We used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021–2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers’ satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain. 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However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals.Publication Performance-Based Financing Toolkit(Washington, DC: World Bank, 2014-02-26)Performance-based financing (PBF) approaches have expanded rapidly in lower-and middle income countries, and especially in Africa. The number of countries has grown from three in 2006 to 32 in 2013. PBF schemes are flourishing and cause considerable demand for technical assistance in executing these health reforms in a rational and accountable manner. Currently there is a lack of knowledge among many health reformers of how to implement performance-based financing pilot projects, and scale them up intelligently. In a context of tremendous demand for solid design and implementation experience and given the rapid expansion of results-based financing (RBF) programs, there is an urgent need to build capacity in designing and implementing PBF programs. As yet there has been little attempt to gather the learning from these experiences together in one volume and, moreover, in a form that serves as a guide to implementers. This toolkit answers the most pressing issues related to the supply-side RBF programs of which PBF forms part.Publication Transferring the Purchasing Role from International to National Organizations During the Scale-Up Phase of Performance-Based Financing in Cameroon(Taylor and Francis, 2017-04-13)The World Bank and the government of Cameroon launched a performance-based financing (PBF) program in Cameroon in 2011. To ensure its rapid implementation, the performance purchasing role was sub-contracted to a consultancy firm and a nongovernmental organization, both international. 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Other factors hindered the transfer, such as the lack of a legal act clarifying the conditions of the transfer and the lack of post-transition support agreements. The Cameroonian experience suggests that key components of a successful transfer of PBF functions from international to national organizations may include clear guidelines, co-ownership and planning of the transition by all parties, and post-transition support to new actors.
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