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Results-Based Financing for Maternal Neonatal Health (RBF4MNH)

Health provider cares for mother and newborn at a health center in Dedza District, Malawi. Photo Credit: Uchembere Wangwiro Program.

Research Overview

Scaling-up of results-based financing (RBF) schemes across sub-Saharan Africa has developed rapidly over the past few years. Although studies in several countries have suggested that RBF can play a role in improving service coverage, a substantial knowledge gap remains as to how various RBF interventions affect quality of care of Essential Obstetric and Newborn Care (EONC).

The Results-Based Financing for Maternal Neonatal Health (RBF4MNH) study sets to fill this gap in knowledge by providing an independent scientific assessment of both the expected and unexpected effects on quality of maternal care services of a series of RBF interventions being implemented in Malawi.


Project Location

The study takes place in 33 facilities and their catchment areas in four districts in Malawi: Balaka, Dedza, Mchinji, and Ntcheu

Research Objectives

The purpose of this study is to assess the implementation and impact of the RBF4MNH intervention on quality of care in Malawi. Research questions include:

  • What is the effect of the RBF4MNH intervention on quality of care (QoC) delivered in labor & delivery, antenatal and post-natal care services?
  • What is the effect of the intervention on women’s utilization of labor & delivery, antenatal and post-natal care services?
  • Does the intervention have an effect on provider’s, motivation and job satisfaction?
  • To what extent did the actual implementation process follow the initial implementation design aims to assess the quality impact both on the interventions directly targeted by the RBF program (i.e. obstetric services) and on the complete range of other relevant maternal and newborn care services (antenatal, postnatal, and newborn services).

Study Approach

This study examines the quality impact of the intervention on services directly targeted by the PBI program (i.e. obstetric services), as well as on essential antenatal and newborn care to determine if intervention effects spillover into these other service areas. The study also examines the effect of the intervention on service utilization, provider motivation and job satisfaction, as well as the implementation of the intervention. Quantitative data has been collected at three time points and qualitative data at two time points over a two-years period to compare changes in intervention and control facilities. 
The study has produced quantitative data on quality of care (QoC) including: a) structural quality indicators measured through facility assessments; b) provider knowledge measured through vignettes, and c) process indicators measured through systematic observation of clinical encounters as well as client exit interviews and facility record review. Utilization of care was measured through household surveys among women who had completed a pregnancy in the past twelve months.
Qualitative data has been collected via in-depth interviews with providers and implementers and via community-based focus group discussions with women living in the catchment areas under study who had completed a pregnancy in the past twelve months. 

Preliminary Findings

While endline data analysis is still underway, preliminary study findings based on the midline assessment include:
  • The effect of the intervention on QoC was mixed, with significant improvement on some indicators, such as availability of infection prevention supplies and functioning of newborn resuscitation equipment. For other indicators, such as availability of skilled birth attendants and emergency obstetric care equipment, no intervention effect was detected. 
  • Providers perceived improvements in the work environment stemming from the intervention, including increased supervisor support, increased influence over facility decisions, increased understanding of work expectations, and better cooperation among staff. Interviews with stakeholders identified both facilitators and challenges to implementing the RBF intervention.

Policy Briefs

Research Into Action

Findings from this study will be shared with the Ministry of Health throughout the duration of the project to enable implementation adjustments and to help inform policy decisions as the program scales up. This study will also help to fill the evidence gap related to the effects of RBF on quality of care. Research in this area is currently lacking, and the findings of this study can contribute to RBF policy formation in Malawi and elsewhere.

Research Partner


Principal Investigator

Manuela De Allegri, University of Heidelberg 

Project Status

Country / Countries: