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International Health Economics Association (iHEA) 2017

Saturday, July 8, 2021 to Tuesday, July 11, 2021

Five presentations occurred at iHEA 2017 from two TRAction-supported performance-based incentive projects:

  1. Assessing Quality of Care in Malawi's Support for Service Delivery and Integration (SSDI) Project's Performance Based Incentives Intervention, and 
  2. Results Based Financing for Maternal Neonatal Health (RBF4MNH)

 

Abstract Presentations:

Abstract Presentation #1
Presentation Title: Cost-Effectiveness of Results-Based Financing For Reducing Maternal and Perinatal Mortality: Evidence From a Decision Tree Model
Presenter: Jobida Chinkhumba
Date and Time: Monday, July 10th, 2017 at 8:00am
Session: 285804- Insurance and Financing 
Room: HAR-220
 
Abstract Presentation #2
Presentation Title: Results-Based Financing and its Impact on Effective Coverage of Pregnant Women: Findings from the RBF4MNH Evaluation in Malawi
Presenter: Stephan Brenner
Institute of Public Health, Heidelberg University, INF 130.3, Heidelberg, Germany
Heidelberg University, Senior Research Fellow
Date and Time: Monday, July 10th, 2017 at 11:45am
Session: 285630 - Evaluation of Changes in Financing and Delivery of Care
Room: Kenmore
 

Abstract:

Primary Field: Evaluation of policy, programs and health system performance
 
Background: Effective population coverage represents a comprehensive metric identifying what proportion of a target population is provided with health services of a high (i.e. effective) level of quality. We assessed effective coverage of pregnant women provided with facility-based delivery (FBD) services at emergency obstetric care (EmOC) facilities to measure the impact of the Results-Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi.
 
Methods: A non-randomized controlled pre-post-test design was used to evaluate the combined effects of performance incentives to maternal care providers (service quality) and conditional cash transfers to pregnant women (service utilization). The study sample included 33 health facilities (18 intervention and 15 control facilities) with their individual catchment areas across four districts. Data were collected before, and at one and two years after intervention start. We surveyed 5,349 recently pregnant women living in the catchment areas to estimate crude coverage based on women’s health-seeking behavior in respect to their place of delivery. At each facility we conducted inventories and observed a total of 401 obstetric cases to estimate service quality based on a) facilities’ availability of tracer items essential to labor and delivery and on b) birth attendants’ adherence to clinical obstetric care guidelines. Descriptive statistics and difference-in-differences regression models were used to analyze effects of the RBF4MNH on both crude and effective coverage.
 
Results: Although effective coverage remained far below crude coverage, both parameters increased across study arms, however more so in RBF compared to control areas. Between baseline and endline, the proportion of pregnant women utilizing FBD services at EmOC facilities (crude coverage) increased from 84.4% to 89.2% in the RBF and from 81.0% to 82.7% in the control arm. Once adjusted for service quality, the proportion of pregnant women effectively covered by FBD services improved from 62.4% to 77.0% in the RBF and from 68.2% to 69.5% in the control arm. During the two-year study period and for both RBF and control facilities, the gap between crude and effective coverage was widest with approximately 20-21%-points after the first year and reduced to baseline levels at approximately 12-13%-points after the second year, indicating an initial increase in crude coverage followed by a relatively delayed increase in effective coverage later on. While the estimated overall effect of the RBF4MNH on crude coverage was insignificant with -1.1%- points (95%CI: -5.5−3.2%-points, p=0.61), the RBF4MNH substantially increased effective coverage by 10.5%-points (95%CI: 8.9−12.1%-points, p=<0.01).
 
Discussion: While crude coverage with FBD at EmOC facilities is relatively high among pregnant women in Malawi, the quality of these services still lags behind. The RBF4MNH contributed minimally to the Increases in crude coverage, but had significant effects on improving service quality and thus effective coverage of pregnant women in the study area after the initial intervention year. While we were unable to separate individual effects of the two RBF components, it nevertheless appears that cash transfers as means to direct women towards EmOC based deliveries was less pronounced in this RBF example compared to the effects of provider incentives on service quality.
 
Declaration Conflicts of Interest: The authors declare no conflict of interest
 
Funding sources: This study was funded by the United States Agency for International Development under Translating Research into Action, Cooperative Agreement No.GHS-A-00- 09-00015-00.
 
Co-author Information:
Danielle Wilhelm
Institute of Public Health, Heidelberg University, INF 130.3, Heidelberg, Germany
+49 6221 5635039
Heidelberg University, PHD Student
 
Terhi J. Lohela
Department of Public Health, P.O. Box 20, FI-00014 University of Helsinki, Helsinki, Finland
+358 40 768 0891
University of Helsinki, resident anesthesiology and intensive care medicine / PhD student
 
Jobiba Chinkhumba
University of Malawi, College of Medicine, Blantyre, Malawi
+265 999 775 520
University of Malawi, Honorary Lecturer
 
Adamson S. Muula
Department of Public Health, School of Public Health and Family Medicine, University of
Malawi, Blantyre, Malawi
+265 884 233 486
University of Malawi, Professor
 
Manuela De Allegri
Institute of Public Health, Heidelberg University, INF 130.3, Heidelberg, Germany
+ 49 6221 5635056
Heidelberg University, Associate Professor
 
Abstract Presentation #3:
Presentation Title: Estimating the Costs of Performance-Based Financing Interventions in Low and Middle Income Countries: Evidence from Malawi
Presenter: Aleksandra Torbica
Department of Policy Analysis and Public Management
Centre for Research in Health and Social Care Management (CERGAS)
Bocconi University, Via Roentgen 1, 20136 Milano, Italy
Bocconi University, Associate Professor
Date and Time: Monday, July 10th, 2017 at 11:45am
Session: 284760 - Performance
Room: HAR-408
 
Abstract:
 
Primary field: healthcare financing
 
Background: Performance-based financing (PBF) has proliferated across sub-Saharan Africa (SSA). Our work situates itself within a context characterized by the almost complete absence of comprehensive cost analysis of PBF interventions. The complexity which characterizes these interventions poses a challenge in tracing economic costs at all relevant levels, but is essential to offer insights to policy proponents on their actual economic impact..
 
Objective: Our analysis aimed to estimate the full economic costs of all activities related to the implementation of the Service Delivery Integration Performance- Based Incentives (SSDI-PBI) program, a PBF intervention nested within the USAID-funded SSDI project, which supports health service delivery, health systems strengthening, and health communications in 15 districts in Malawi. Study setting: The SSDI-PBI intervention was launched 2014 in a total of 17 facilities across three districts. Facilities were eligible to receive performance based incentives (PBI) upon attainment of a pre-defined set of service quantity and quality indicators. Incentives could not be redistributed among staff, but were instead reinvested fully towards facilities infrastructure upgrades.
 
Methods: The full costs associated with SSDI-PBI included the following cost categories: i) personnel costs; ii) design costs (design of program, training, initial dissemination); iii) implementation costs (including verification and counter verification); iv) the cost of incentives themselves. To estimate the full cost of SSDI-PBI, we relied on a mixture of secondary and primary data collection strategies. We collected data from the financial statements of the two implementing agencies (JPHIEGO and Abt Consultants) and we used project reports and documents to identify all activities to which MoH and USAID staff had participated. To estimate the total value of the time committed by MoH and USAID personnel, we used the human capital approach. We used the value of the incentives (measured in relation to what was “earned” by the single facilities and not what was effectively “spent”) to measure the economic value of the additional effort needed to produce an increase in quantity and quality of service provision. Our evaluation stretches from Sept 2012 to Dec 2015, but distinguishes between the SSDI-PBI design (Sept 2012 to July 2014) and the implementation phase (Aug 2014 to Dec 2015). All costs were computed in US dollars adjusted for inflation from the year in which the costs were incurred to the year 2015.
 
Results: Counting the period Sept 2012 to Dec 2015, the economic value of the SSDI-PBI intervention amounts to USD 3,402,187, with about one third (USD 1,161,332) being absorbed by the design phase. With an estimated value of USD 1,140,436, the incentives represent about one third of the total value of the intervention and about half the value of the implementation costs. With a value of USD 1,605,178, personnel represent the single most relevant cost of the SSDI-PBI intervention. It is worth noting that the economic value of personnel was substantially higher during the design (USD 934,045) than during the implementation phase monitored in our analysis (USD 671,133). The high personnel costs during the design phase are driven by a high time commitment on the part of USAID staff, who were advising on the development of the intervention. The most relevant costs incurred by personnel (47.2%) and cost of incentives (33.5%). All remaining costs accounted for slightly less than 20% of total costs.
 
Discussion: Our analysis is one of the first comprehensive PBF cost assessments. Despite limitations, mainly due to the lack of adequate data, our study offers valuable insights to the policy makers by providing solid evidence on the amount of resources consumed to design and implement such a scheme and contributes methodologically to research on PBF economic evaluation.
 
The authors declare no conflict of interest
 
Funding sources for research: This research project is made possible through Translating Research into Action, TRAction, which is funded by United States Agency for International Development (USAID) under cooperative agreement number No. GHS-A-00-09-00015-00.
 
Co-Authors:
 
Christopher Makwero
 
Manuela De Allegri
• Institute of Public Health, Heidelberg University, INF 130.3, Heidelberg,
Germany
• + 49 6221 5635056
• Heidelberg University, Associate Professor

 

Abstract Presentation #4:
Presentation Title: Can Results-Based Financing Lead to Reductions in Maternal Mortality? Evidence from a Quasi-Experimental Study in Rural Malawi
Presenter: Manuela De Allegri
Institute of Public Health, Heidelberg University, INF 130.3, Heidelberg, Germany
+ 49 6221 5635056
Heidelberg University, Associate Professor
Date and Time: Monday, July 10th, 2017 at 2:45pm
Session: 283901 - Evaluation of Innovative Programs 3
Room: HAR-304
 
Abstract:
 
Primary field: healthcare financing
 
Background: Results-Based Financing (RBF) has been the subject of multiple impact evaluations. Existing evaluations, however, focused on assessing the impact of RBF either on health service utilization or on quality of health service provision. The question remains as to whether RBF leads to changes in population health status, by measuring for instance its impact on mortality. Objective: We aimed to fill the existing gap in knowledge by assessing the impact of the Results-Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative on maternal mortality. Given the short evaluation time span (two years) and the unavailability of data on maternal deaths at the community level, we restricted our evaluation to deaths taking place at the facility (i.e. obstetric case fatality).
 
Study setting: The RBF4MNH Initiative was launched in April 2013 in four districts in rural Malawi, in response to the fact that maternal and neonatal mortality were persistently high in spite of a facility-based delivery rate approaching 90%. Performance incentives targeting quality of obstetric and early newborn care were implemented in a total of 28 Emergency Obstetric Care (EmOC) facilities. Implementation was phased and completed by late summer 2014. Conditional cash transfers were offered to women in the corresponding catchment areas to incentivize them to remain at the facility 48 hours following delivery.
 
Methods: We extracted data from the National Health Information System on number of deliveries taking place at a given facility and number of deaths occurring at that same facility for all facilities in the country for the period July 2012 to Dec 2015. We collapsed data at the district level to even out differences across levels of care. We used Interrupted Time Series to observe trends in case fatality over time and test for the existence of statistically significant differences between the RBF4MNH districts and the non-RBF4MNH districts. We conducted the analysis in Stata using the ITSA command (singe comparison group) and adjusted the model for seasonal effects. We conducted multiple sensitivity analyses (varying the comparison group and including additional covariates) to test for the robustness of the results.
 
Results: Prior to the launch of the intervention and during its first year of operation, obstetric case fatality rates were comparable across RBF4MNH and non-RBF4MNH districts. Starting in October 2014, we observed a precipitous fall in obstetric deaths in RBF4MNH districts which was not paralleled in non- RBF4MNH districts. Specifically, we measured a decline in obstetric case fatality rate of 0.00009 per month, which represents 7.5% of the total obstetric case fatality rate over the entire observation period (.00119405) and 5.2% of the RBF4MNH districts’ estimated obstetric case fatality rate at the beginning of the scale-up period in October 2014 (.0017287).
 
Discussion: Our study provides initial evidence that RBF programs with a heavy focus on improving quality of service delivery, by targeting jointly service provision and length of stay at a facility, can result in substantial and significant decreases in obstetric case fatality, making an important contribution to reducing maternal mortality in sub-Saharan Africa.
 
The authors declare no conflict of interest
 
This study was funded by the United States Agency for International
Development under Translating Research into Action, Cooperative Agreement
No.GHS-A-00-09-00015-00.
 
Co-Author Information:
Rachel Chase
 
Julia Lohmann
Institute of Public Health, Heidelberg University, INF 130.3, Heidelberg, Germany
+ 49 6221 5635584
Heidelberg University, Research Fellow
 
Adamson Muula
 
Stephan Brenner
Institute of Public Health, Heidelberg University, INF 130.3, Heidelberg, Germany
+ 49 6221 5635039
Heidelberg University, Senior Research Fellow
 
Abstract Presentation #5:
Presentation Title: "The money can be a motivator, to me a Little, but mostly RBF just helps me to do better in my job." An Exploration of the Motivational Mechanisms of Performance-Based Financing for Health Workers in Malawi
Presenter: Julia Lohmann
Mailing address: Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
Email address: [email protected]
Organization and position: Heidelberg University, Institute of Public Health; Scientist
Phone number: +49 6221 56 35584
Date and Time: Monday, July 10th, 2017 at 2:45pm
Session: 286164 - Performance Based Financing in Africa Public Health Systems: Exploring the Causal Pathways
Room: SCI-113
 
Abstract:
 
Background: Performance-based financing (PBF) is assumed to improve health care delivery by motivating health workers to enhance their work performance. The exact mechanisms through which PBF exerts its motivational effect are not yet well understood, however. Although PBF schemes are renown as financial rewards awarded to health workers in most PBF schemes, a growing body of literature suggests that the motivational mechanisms triggered by PBF are complex and go far beyond such individual rewards. We used the opportunity of the introduction of PBF in Malawi to explore in-depth the various mechanisms through which PBF impacts on health workers’ work motivation.
 
Methods: We conducted in-depth interviews with a purposive sample of nurses, medical assistants, and clinical officers one (n=21) and two (n=20) years after the start of the Results-Based Financing for Maternal and Neonatal Health (RBF4MNH) Initiative in 2013. We asked respondents to describe their views of and motivational and behavioral reactions to the various elements of the intervention, including changes they had perceived in their working environment and changes they had noticed in themselves, probing specifically for causal links between these elements. Applying analyst triangulation, we used a mixture of deductive and inductive coding to analyze the transcribed material.
 
Results: Six categories of motivational mechanisms emerged from our analysis. First, RBF4MNH motivated health workers to make an effort by acting as a periodical wake-up call, opening their eyes to the discrepancies between their day-to-day practice and what they had committed themselves to when joining the health care service. Second, RBF4MNH motivated health workers by giving them previously lacking direction and goals to work towards. Third, RBF4MNH motivated health workers by strengthening their perceived ability to perform successfully in their job, and by giving them a new sense of accomplishment and purpose at work. Fourth, RBF4MNH motivated health workers by instilling in them previously lacking feelings of recognition of and appreciation for their effort in light of difficult working conditions. Fifth, RBF4MNH motivated health workers to improve their performance by altering social dynamics, including a healthy sense of competition between facilities and improved team spirit, but also social pressure to perform and interpersonal conflict resulting from the distribution of individual rewards. Last, RBF4MNH motivated health workers to work hard with a ‘nice to have’ opportunity to earn extra income. Although all six mechanisms were described by a substantial share of our sample, diverse perceived weaknesses of the intervention design (e.g. individual reward amounts), various implementation-related challenges (e.g. perceived unfairness of verification), as well as contextual constraints (e.g. shortages in human resources and drugs) fully or in part inhibited the activation of certain mechanisms for many respondents, keeping RBF4MNH from developing its full motivating potential.
 
Conclusion: Our results underline PBF’s potential to affect health workers’ motivation in ways which go far beyond the direct effect of financial incentives to individuals. We strongly recommend to
consider all motivating mechanisms of PBF more explicitly in future intervention design to fully exploit the approach’s capacity for enhancing health worker performance.
 
Declaration on potential conflicts of interest: The authors declare no conflict of interest
 
Funding sources for research: This study was funded by the United States Agency for International Development under Translating Research into Action, Cooperative Agreement No.GHS-A-00-09-00015-00.
 
Authors: Julia Lohmann, Danielle Wilhelm, Christabel Kambala, Stephan Brenner, Adamson S. Muula, Manuela De Allegri
 
 
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