Abstract
ObjectiveTo evaluate the cost–effectiveness of results-based financing and input-based financing to increase use and quality of maternal and child health services in rural areas of Zambia.MethodsIn a cluster-randomized trial from April 2012 to June 2014, 30 districts were allocated to three groups: results-based financing (increased funding tied to performance on pre-agreed indicators), input-based financing (increased funding not tied to performance) or control (no additional funding), serving populations of 1.33, 1.26 and 1.40 million people, respectively. We assessed incremental financial costs for programme implementation and verification, consumables and supervision. We evaluated coverage and quality effectiveness of maternal and child health services before and after the trial, using data from household and facility surveys, and converted these to quality-adjusted life years (QALYs) gained.FindingsCoverage and quality of care increased significantly more in results-based financing than control districts: difference in differences for coverage were 12.8% for institutional deliveries, 8.2% postnatal care, 19.5% injectable contraceptives, 3.0% intermittent preventive treatment in pregnancy and 6.1% to 29.4% vaccinations. In input-based financing districts, coverage increased significantly more versus the control for institutional deliveries (17.5%) and postnatal care (13.2%). Compared with control districts, 641 more lives were saved (lower–upper bounds: 580–700) in results-based financing districts and 362 lives (lower–upper bounds: 293–430) in input-based financing districts. The corresponding incremental cost–effectiveness ratios were 809 United States dollars (US$) and US$ 413 per QALY gained, respectively.ConclusionCompared with the control, both results-based financing and input-based financing were cost–effective in Zambia.
Highlights
Over the last two decades, Zambia’s health indicators have improved substantially
This study aimed to evaluate both the cost and health outcomes of Zambia’s results-based financing programme against two counterfactual policies: enhanced financing not explicitly tied to performance and the existing system of funding without additional financing
To examine the uncertainty of incremental cost–effectiveness ratios, we focused on the uncertainty of the impact of results-based financing on use of health services
Summary
Over the last two decades, Zambia’s health indicators have improved substantially. Between 1990 and 2013, the underfive mortality rate dropped from 193 to 87 deaths per 1000 live births, and the maternal mortality rate fell from 580 to 280 deaths per 100 000 births.[1] There has been a substantial reduction in mortality from human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) and malaria.[2]. Despite these improvements, the under-five mortality rate and maternal mortality rate in Zambia (population 15.15 million in 2013) remain high by regional and international standards. The country faces great challenges in financing the health system, and delivering quality and equitable health services.[3,4]
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