Abstract
ABSTRACT Heterogeneity of effects produced by performance-based incentives (PBIs) at different levels of care provision is not well understood. This study analyzes effect heterogeneities between different facility types resulting from a PBI program in Malawi. Identical PBIs were applied to both district hospitals and health centers to improve the performance of essential health services provision. We conducted two complementary quasi-experiments comparing all 17 interventions with 17 matched independent control facilities (each 12 health centers, five hospitals). A pre- and post-test design with difference-in-differences analysis was used to estimate effects on 14 binary quality indicators; interrupted time series analysis of monthly routine data was used to estimate effects on 11 continuous quantity indicators. Effects were estimated separately for health centers and hospitals. Most quality indicators performed high at baseline, producing ceiling effects on further measurable improvements. Significant positive effects were observed for stocks of iron supplements (hospitals) and partographs (health centers). Four quantity indicators showed similar positive trend improvements across facility types (first-trimester antenatal visits, voluntary HIV-testing of couples, iron supplementation in pregnancy, vitamin A supplementation of children); two showed no change for either type of facility (skilled birth attendance, fully immunized one-year-olds); five indicators revealed different effect patterns for health centers and hospitals. In both health centers and hospitals, the largely positive PBI effects on antenatal care included resilience against interrupted supply chains and improvements in attendance rates. Observed heterogeneity might have been influenced by the availability of specific resources or the redistribution of service use.
Highlights
Performance-based incentives (PBIs) entail the payment of financial and in-kind rewards to health system actors upon the achievement of pre-defined quantity and/or quality performance outputs.[1]
We focus on aspects related to the micro-context — namely the extent to which Performance-Based Financing (PBF) effects differ between sub-district level health centers and district-level hospitals—in the case of the Support for Service Delivery Integration Performance-Based Incentives (SSDI-PBI) program in Malawi
SSDI-PBI effects were more pronounced or statistically significant on quantity compared to quality indicators of service provision
Summary
Performance-based incentives (PBIs) entail the payment of financial and in-kind rewards to health system actors upon the achievement of pre-defined quantity and/or quality performance outputs.[1]. Recent reviews on PBF implementation in SSA have shown mixed effects in terms of expected changes in both the quantity and quality of service delivery.[4,5] This evidence suggests that PBF success depends on a number of factors related to both the health system macro-context (e.g. status quo of key health indicators, political stewardship, governance, decentralization, financial flows, existing purchasing structures) and the service provision micro-context (e.g. choice of performance indicators, type of service providers, degree of provider’s financial autonomy, verification mechanisms, implementation capacities).[6]. While evidence generalization is often limited given the uniqueness of each PBF program within its specific context, individual program evaluations still offer opportunities to generate specific knowledge on the effect of individual PBF designs within their given macro- or micro-contexts
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