Abstract
BackgroundResults-based financing (RBF) describes health system approaches addressing both service quality and use. Effective coverage is a metric measuring progress towards universal health coverage (UHC). Although considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied.MethodsMalawi introduced the Results-Based Financing For Maternal and Neonatal Health (RBF4MNH) Initiative in 2013 to improve quality of maternal and newborn health services at emergency obstetric care facilities. Using a quasi-experimental design, we examined the impact of the RBF4MNH on both crude and effective coverage of pregnant women across four districts during the two years following implementation.ResultsThere was no effect on crude coverage. With a larger proportion of women in intervention areas receiving more effective care over time, the overall net increase in effective coverage was 7.1%-points (p = 0.07). The strongest impact on effective coverage (31.0%-point increase, p = 0.02) occurred only at lower cut-off level (60% of maximum score) of obstetric care effectiveness. Design-specific and wider health system factors likely limited the program’s potential to produce stronger effects.ConclusionThe RBF4MNH improved effective coverage of pregnant women and seems to be a promising reform approach towards reaching UHC. Given the short study period, the full potential of the current RBF scheme has likely not yet been reached.
Highlights
Results-based financing (RBF) describes health system approaches addressing both service quality and use
Significant differences in two-sample t-tests between group means existed for household socioeconomic status (p = 0.01 at baseline), with women in the intervention arm on average residing in poorer households
Between 88.6 and 97.0% of women depending on study arm and time point reported facility-based service use, while delivery at any or at catchment area specific emergency obstetric care (EmOC) facilities was much lower
Summary
Results-based financing (RBF) describes health system approaches addressing both service quality and use. Considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied. Brenner et al BMC Health Services Research (2018) 18:791 more efficiently and effectively, improving both the quantity and quality of healthcare services used by the targeted population). To reflect this complexity, RBF evaluations often assess impact along a number of different dimensions (i.e. health worker motivation, quality of care, service use, crude population coverage) [7,8,9,10]. Given RBF programs’ theoretical impact on both service quality and population coverage, approaches measuring aggregated outcomes that frame broader concepts might be useful adjuncts in gaining additional understanding of the role RBF plays in the achievement of UHC
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