Good while it lasted? Estimating the long-term and withdrawal effects of results-based financing in Malawi on maternal care utilisation using routine data.

OBJECTIVES: This study aimed to evaluate the effect of introduction and subsequent withdrawal of the Results-based Financing for Maternal and Newborn Health Initiative (RBF4MNH) in Malawi on utilisation of facility-based childbirths, antenatal care (ANC) and postnatal care (PNC). DESIGN: A controlled interrupted time series design was used with secondary data from the Malawian Health Management Information System. SETTING: Healthcare facilities at all levels identified as providing maternity services in four intervention districts and 20 non-intervention districts in Malawi. PARTICIPANTS: Routinely collected, secondary data of total monthly service utilisation of facility-based childbirths, ANC and PNC services. INTERVENTIONS: The intervention is the RBF4MNH initiative, introduced by the Malawian government in 2013 to improve maternal and infant health outcomes and withdrawn in 2018 after ceasing of donor funding. OUTCOME MEASURES: Differences in total volume and trends of utilisation of facility-based childbirths, ANC and PNC services, compared between intervention versus non-intervention districts, for the study period of 90 consecutive months. RESULTS: No significant effect was observed, on utilisation trends for any of the three services during the first 2.5 years of intervention. In the following 2.5 years after full implementation, we observed a small positive increase for facility-based childbirths (+0.62 childbirths/month/facility) and decrease for PNC (-0.55 consultations/month/facility) trends of utilisation respectively. After withdrawal, facility-based childbirths and ANC consultations dropped both in immediate volume after removal (-10.84 childbirths/facility and -20.66 consultations/facility, respectively), and in trends of utilisation over time (-0.27 childbirths/month/facility and -1.38 consultations/month/facility, respectively). PNC utilisation levels seemed unaffected in intervention districts against a decline in the rest of the country. CONCLUSIONS: Concurrent with wider literature, our results suggest that effects of complex health financing interventions, such as RBF4MNH, can take a long time to be seen. They might not be sustained beyond the implementation period if measures are not adopted to reform existing health financing structures.

The impact of international health worker migration and recruitment on health systems in source countries: Stakeholder perspectives from Colombia, Indonesia, and Jordan.

INTRODUCTION: To address domestic shortages, high-income countries are increasingly recruiting health workers from low- and middle-income countries. This practice is much debated. Proponents underline benefits of return migration and remittances. Critics point in particular to the risk of brain drain. Empirical evidence supporting either position is yet rare. This study contributes to filling this gap in knowledge by reporting high-level stakeholders' perspectives on health system impacts of international migration in general, and active recruitment of health workers in specific, in Colombia, Indonesia, and Jordan. METHOD: We used a multiple case study methodology, based on qualitative methods integrated with information available in the published literature. RESULTS: All respondents decried a lack of robust and detailed data as a serious challenge in ascertaining their perspectives on impacts of health worker migration. Stakeholders described current emigration levels as not substantially aggravating existing health workforce availability challenges. This is due to the fact that all three countries are faced with health worker unemployment grounded in unwillingness to work in rural areas and/or overproduction of certain cadres. Respondents, however, pleaded against targeting very experienced and specialised individuals. While observing little harm of health worker migration at present, stakeholders also noted few benefits such as brain gain, describing how various barriers to skill enhancement, return, and reintegration into the health system hamper in practice what may be possible in theory. CONCLUSION: Improved availability of data on health worker migration, including their potential return and reintegration into their country of origin's health system, is urgently necessary to understand and continuously monitor costs and benefits in dynamic national and international health labour markets. Our results imply that potential benefits of migration do not come into being automatically, but need in-country supportive policy and programming, such as favourable reintegration policies or programs targeting engagement of the diaspora.

Depressive symptoms and their association with age, chronic conditions and health status among middle-aged and elderly people in peri-urban Tanzania.

Background: Depression is a global mental health challenge. We assessed the prevalence of depressive symptoms and their association with age, chronic conditions, and health status among middle-aged and elderly people in peri-urban Dar es Salaam, Tanzania. Methods: Depressive symptoms were measured in 2,220 adults aged over 40 years from two wards of Dar es Salaam using the ten-item version of the Center of Epidemiologic Studies Depression Scale (CES-D-10) and a cut-off score of 10 or higher. The associations of depressive symptoms with age, 13 common chronic conditions, multimorbidity, self-rated health and any limitation in six activities of daily living were examined in univariable and multivariable logistic regressions. Results: The estimated prevalence of depressive symptoms was 30.7% (95% CI 28.5-32.9). In univariable regressions, belonging to age groups 45-49 years (OR 1.35 [95% CI 1.04-1.75]) and over 70 years (OR 2.35 [95% CI 1.66-3.33]), chronic conditions, including ischemic heart disease (OR 3.43 [95% CI 2.64-4.46]), tuberculosis (OR 2.42 [95% CI 1.64-3.57]), signs of cognitive problems (OR 1.90 [95% CI 1.35-2.67]), stroke (OR 1.56 [95% CI 1.05-2.32]) and anemia (OR 1.32 [95% CI 1.01-1.71]) and limitations in activities of daily living (OR 1.35 [95% CI 1.07-1.70]) increased the odds of depressive symptoms. Reporting good or very good health was associated with lower odds of depressive symptoms (OR 0.48 [95% CI 0.35-0.66]). Ischemic heart disease and tuberculosis remained independent predictors of depressive symptoms in multivariable regressions. Conclusion: Depressive symptoms affected almost one in three people aged over 40 years. Their prevalence differed across age groups and was moderated by chronic conditions, health status and socioeconomic factors.

To What Extent Do Free Healthcare Policies and Performance-Based Financing Reduce Out-of-Pocket Expenditures for Outpatient services? Evidence From a Quasi-experimental Study in Burkina Faso.

BACKGROUND: Burkina Faso has been implementing financing reforms towards universal health coverage (UHC) since 2006. Recently, the country introduced a performance-based financing (PBF) program as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under 5. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPEs) for outpatient services. METHODS: Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program's impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under 5 and individuals above 5 to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM). RESULTS: The proportion of children under 5 incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our difference in differences estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude. CONCLUSION: User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supply-side intervention, PBF appears to have limited effects on reducing financial burden.

Improving the readiness and clinical quality of antenatal care - findings from a quasi-experimental evaluation of a performance-based financing scheme in Burkina Faso.

BACKGROUND: While maternal mortality has declined globally, it remains highest in low-income countries. High-quality antenatal care (ANC) can prevent or decrease pregnancy-related complications for mothers and newborns. The implementation of performance-based financing (PBF) schemes in Sub-Saharan Africa to improve primary healthcare provision commonly includes financial indicators linked to ANC service quality indicators. In this study, we examine changes in ANC provision produced by the introduction of a PBF scheme in rural Burkina Faso. METHODS: This study followed a quasi-experimental design with two data collection points comparing effects on ANC service quality between primary health facilities across intervention and control districts based on difference-in-differences estimates. Performance scores were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision related to screening and prevention pertaining to first and follow-up ANC visits. RESULTS: We found a statistically significant increase in performance scores by 10 percent-points in facilities' readiness to provide ANC services. The clinical care provided to different ANC client groups scored generally low, especially with respect to preventive care measures, we failed to observe any substantial changes in the clinical provision of ANC care attributable to the PBF. CONCLUSION: The observed effect pattern reflects the incentive structure implemented by the scheme, with a stronger focus on structural elements compared with clinical aspects of care. This limited the scheme's overall potential to improve ANC provision at the client level after the observed three-year implementation period. To improve both facility readiness and health worker performance, stronger incentives are needed to increase adherence to clinical standards and patient care outcomes.

Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study.

In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health.

Can Combining Performance-Based Financing With Equity Measures Result in Greater Equity in Utilization of Maternal Care Services? Evidence From Burkina Faso.

BACKGROUND: As countries reform health financing systems towards universal health coverage, increasing concerns emerge on the need to ensure inclusion of the most vulnerable segments of society, working to counteract existing inequities in service coverage. To this end, selected countries in sub-Saharan Africa have decided to couple performance-based financing (PBF) with demand-side equity measures. Still, evidence on the equity impacts of these more complex PBF models is largely lacking. We aimed at filling this gap in knowledge by assessing the equity impact of PBF combined with equity measures on utilization of maternal health services in Burkina Faso. METHODS: Our study took place in 24 districts in rural Burkina Faso. We implemented an experimental design (clusterrandomized trial) nested within a quasi-experimental one (pre- and post-test design with independent controls). Our analysis relied on self-reported data on pregnancy history from 9999 (baseline) and 11 010 (endline) women of reproductive age (15-49 years) on use of maternal healthcare and reproductive health services, and estimated effects using a difference-in-differences (DID) approach, purposely focused on identifying program effects among the poorest wealth quintile. RESULTS: PBF improved the utilization of few selected maternal health services compared to status quo service provision. These benefits, however, were not accrued by the poorest 20%, but rather by the other quintiles. PBF combined with equity measures did not produce better or more equitable results than standard PBF, with specific differences only on selected outcomes. CONCLUSION: Our findings challenge the notion that implementing equity measures alongside PBF is sufficient to produce an equitable distribution in program benefits and point at the need to identify more innovative and contextsensitive measures to ensure adequate access to care for the poorest. Our findings also highlight the importance of considering changing policy environments and the need to assess interferences across policies.

No impact of performance-based financing on the availability of essential medicines in Burkina Faso: A mixed-methods study.

Access to safe, effective, and affordable essential medicines (EM) is critical to quality health services and as such has played a key role in innovative health system strengthening approaches such as Performance-based Financing (PBF). Available literature indicates that PBF can improve EM availability, but has not done so consistently in the past. Qualitative explorations of the reasons are yet scarce. We contribute to expanding the literature by estimating the impact of PBF on EM availability and stockout in Burkina Faso and investigating mechanisms of and barriers to change. The study used an explanatory mixed methods design. The quantitative study component followed a quasi-experimental design (difference-in-differences), comparing how EM availability and stockout had changed three years after implementation in 12 PBF and in 12 control districts. Qualitative data was collected from purposely selected policy and implementation stakeholders at all levels of the health system and community, using in-depth interviews and focus group discussions, and explored using deductive coding and thematic analysis. We found no impact of PBF on EM availability and stockouts in the quantitative data. Qualitative narratives converge in that EM supply had increased as a result of PBF, albeit not fully satisfactorily and sustainably so. Reasons include persisting contextual challenges, most importantly a public medicine procurement monopoly; design challenges, specifically a disconnect and disbalance in incentive levels between service provision and service quality indicators; implementation challenges including payment delays, issues around performance verification, and insufficient implementation of activities to strengthen stock management skills; and concurrently implemented policies, most importantly a national user fee exemption for children and pregnant women half way through the impact evaluation period. The case of PBF and EM availability in Burkina Faso illustrates the difficulty of incentivizing and effecting holistic change in EM availability in the presence of strong contextual constraints and powerful concurrent policies.

Implementation of a performance-based financing scheme in Malawi and resulting externalities on the quality of care of non-incentivized services.

BACKGROUND: Countries in Africa progressively implement performance-based financing schemes to improve the quality of care provided by maternal, newborn and child health services. Beyond its direct effects on service provision, evidence suggests that performance-based financing can also generate positive externalities on service utilization, such as increased use of those services that reached higher quality standards after effective scheme implementation. Little, however, is known about externalities generated within non-incentivized health services, such as positive or negative effects on the quality of services within the continuum of maternal care. METHODS: We explored whether a performance-based financing scheme in Malawi designed to improve the quality of childbirth service provision resulted positive or negative externalities on the quality of non-targeted antenatal care provision. This non-randomized controlled pre-post-test study followed the phased enrolment of facilities into a performance-based financing scheme across four districts over a two-year period. Effects of the scheme were assessed by various composite scores measuring facilities' readiness to provide quality antenatal care, as well as the quality of screening, prevention, and education processes offered during observed antenatal care consultations. RESULTS: Our study did not identify any statistically significant effects on the quality of ANC provision attributable to the implemented performance-based financing scheme. Our findings therefore suggest not only the absence of positive externalities, but also the absence of any negative externalities generated within antenatal care service provision as a result of the scheme implementation in Malawi. CONCLUSIONS: Prior research has shown that the Malawian performance-based financing scheme was sufficiently effective to improve the quality of incentivized childbirth service provision. Our findings further indicate that scheme implementation did not affect the quality of non-incentivized but clinically related antenatal care services. While no positive externalities could be identified, we also did not observe any negative externalities attributable to the scheme's implementation. While performance-based incentives might be successful in improving targeted health care processes, they have limited potential in producing externalities - neither positive nor negative - on the provision quality of related non-incentivized services.

Impact of Performance-Based Financing on effective coverage for curative child health services in Burkina Faso: Evidence from a quasi-experimental design.

OBJECTIVE: To evaluate the impact of Performance-Based Financing (PBF) on effective coverage of child curative health services in primary healthcare facilities in Burkina Faso. METHODS: An impact evaluation of a PBF pilot programme, using an experiment nested within a quasi-experimental design, was carried out in 12 intervention and 12 comparison districts in six regions of Burkina Faso. Across the 24 districts, primary healthcare facilities (537 both at baseline and endline) and households (baseline = 7978 endline = 7898) were surveyed. Within these households, 12 350 and 15 021 under-five-year-olds caretakers were interviewed at baseline and endline respectively. Linking service quality to service utilisation, we used difference-in-differences to estimate the impact of PBF on effective coverage of curative child health services. RESULTS: Our study failed to detect any effect of PBF on effective coverage. Looking specifically into quality of care indicators, we detected a positive effect of PBF on structural elements of quality of care related to general service readiness, but not on the overall facility quality score, capturing both service readiness and the content of childcare. CONCLUSION: The current study makes a unique contribution to PBF literature, as this is the first study assessing PBF impact on effective coverage for curative child health services in low-income settings. The absence of any significant effects of PBF on effective coverage suggests that PBF programmes require a stronger design focus on quality of care elements especially when implemented in a context of free healthcare policy.

Does the gap between health workers' expectations and the realities of implementing a performance-based financing project in Mali create frustration?

BACKGROUND: Performance-Based Financing (PBF), an innovative health financing initiative, was recently implemented in Mali. PBF aims to improve quality of care by motivating health workers. The purpose of this research was to identify and understand how health workers' expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this experience affected their motivation and sentiments towards the intervention. We pose the research question, "how does the process of PBF subsidies impact the motivation of health workers in Mali?" METHODS: We adopted a qualitative approach using multiple case studies. We chose three district hospitals (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation; we used 53 semi-directive interviews conducted with health workers (to follow the principle of saturuation), field notes, and documents relating to the distribution grids of subsidies for each DH. We analyzed data in a mixed deductive and inductive manner. RESULTS: The results show that the PBF subsidies led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work more efficiently. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention. CONCLUSION: The PBF implementation in Mali left health workers frustrated. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive nor negative. This underlines how short-term interventions might not just lack impact, but instil negative sentiments likely to carry on into the future.

"It Depends on What They Experience in Each Health Facility. Some Are Satisfied, Others Are Not." A MixedMethods Exploration of Health Workers' Attitudes Towards Performance-Based Financing in Burkina Faso.

BACKGROUND: Evidence emerging from qualitative studies suggests the existence of substantial variation in how health workers experience performance-based financing (PBF) within the same setting. To date, however, no study has quantified or systematically explored this within-setting heterogeneity. Considering that differences in health workers' affective reactions to PBF likely constitute an important element mediating the effectiveness of PBF in improving health service delivery, systematic and tangible information will be highly valuable to policy-makers and program managers who aim to maximize positive impacts of PBF. Our study aimed at contributing to filling this gap in knowledge by quantifying health workers' knowledge of, satisfaction with, and perceptions of PBF in Burkina Faso, and exploring factors associated with heterogeneity therein. METHODS: The study employed a post-intervention cross-sectional explanatory mixed methods study design with a dominant quantitative component - a structured survey to a total of 1314 health workers from 396 intervention health facilities - and a small and focused qualitative component - key informant interviews with 5 program managers - to triangulate and further elucidate the quantitative findings. Quantitative data were analyzed descriptively as well as using 3-level mixed-effects models. Qualitative data were analyzed in a largely deductive process along the quantitative variables and results. RESULTS: Health workers were on average moderately satisfied with PBF overall, with a slight tendency towards the positive and large variation between individuals. Two-thirds of health workers did not have adequate basic knowledge of key PBF elements. Perceived fairness of the performance evaluation process, of the bonus distribution process, and satisfaction with the individual financial bonuses varied dramatically between respondents. Factors associated with heterogeneity in knowledge, satisfaction, and fairness perceptions included responsibility at the facility, general work attitudes, management factors, and training in and length of exposure to PBF. CONCLUSION: Findings imply that investments into staff training on PBF and manager training on organizational change processes might be beneficial to positive staff attitudes towards PBF, which in turn would likely contribute to improving the effectiveness of PBF.

Patterns of healthcare seeking among people reporting chronic conditions in rural sub-Saharan Africa: findings from a population-based study in Burkina Faso.

OBJECTIVE: Non-communicable diseases are rapidly becoming one of the leading causes of morbidity and mortality in sub-Saharan Africa. Yet, little is known about patterns of healthcare seeking among people with chronic conditions in these settings. We aimed to explore determinants of healthcare seeking among people who reported at least one chronic condition in rural Burkina Faso. METHODS: Data were drawn from a cross-sectional population-based survey conducted across 24 districts on 52 562 individuals from March to June 2017. We used multinomial logistic regression to assess factors associated with seeking care at a formal provider (facility-based care) or at an informal provider (home and traditional treatment) compared to no care. RESULTS: 1124 individuals (2% of all respondents) reported at least one chronic condition. Among those, 22.8% reported formal care use, 10.6% informal care use, and 66.6% no care. The presence of other household members reporting a chronic condition (RRR = 0.57, 95%-CI [0.39, 0.82]) was negatively associated with seeking formal care. Wealthier households (RRR = 2.14, 95%-CI [1.26, 3.64]), perceived illness severity (RRR = 3.23, 95%-CI [2.22, 4.70]) and suffering from major chronic conditions (RRR = 1.54, 95%-CI [1.13, 2.11]) were positively associated with seeking formal care. CONCLUSION: Only a minority of individuals with chronic conditions sought formal care, with important differences due to socio-economic status. Policies and interventions aimed at increasing the availability and affordability of services for early detection and management in peripheral settings should be prioritised.

OBJECTIF: Les maladies non transmissibles deviennent rapidement l'une des principales causes de morbidité et de mortalité en Afrique subsaharienne. Pourtant, on en sait peu sur les profils de recherche de soins de santé chez les personnes atteintes de maladies chroniques dans ces milieux. Nous visions à explorer les déterminants de la recherche de soins de santé chez les personnes qui ont déclaré au moins une maladie chronique dans les régions rurales du Burkina Faso. MÉTHODES: Les données ont été tirées d'une enquête transversale de population menée dans 24 districts auprès de 52.562 personnes de mars à juin 2017. Nous avons utilisé une régression logistique multinomiale pour évaluer les facteurs associés à la recherche de soins chez un prestataire formels (soins en établissement) ou chez un prestataire informel (traitement à domicile et traditionnel) par rapport à l'absence de soins. RÉSULTATS: 1.124 personnes (2% de tous les répondants) ont déclaré au moins une maladie chronique. Parmi ceux-ci, 22,8% ont déclaré avoir recours à des soins formels, 10,6% à des soins informels et 66,6% à aucun soin. La présence d'autres membres du ménage déclarant une maladie chronique (RRR = 0,57, IC95%: 0,39, 0,82) était associée négativement à la recherche de soins formels. Les ménages plus riches (RRR = 2,14; IC95%: 1,26-3,64), la sévérité perçue de la maladie (RRR = 3,23 ; IC95%: 2,22-4,70) et souffrir de maladies chroniques majeures (RRR = 1,54 ; IC95%: 1,13-2,11) étaient positivement associés à la recherche de soins formels. CONCLUSION: Seule une minorité de personnes atteintes de maladies chroniques ont recherché des soins formels, avec des différences importantes en raison du statut socioéconomique. Les politiques et interventions visant à accroître la disponibilité et l'accessibilité des services de détection précoce et de prise en charge dans les régions périphériques doivent être prioritaires.

What happens when performance-based financing meets free healthcare? Evidence from an interrupted time-series analysis.

In spite of the wide attention performance-based financing (PBF) has received over the past decade, no evidence is available on its impacts on quantity and mix of service provision nor on its interaction with parallel health financing interventions. Our study aimed to examine the PBF impact on quantity and mix of service provision in Burkina Faso, while accounting for the parallel introduction of a free healthcare policy. We used Health Management Information System data from 838 primary-level health facilities across 24 districts and relied on an interrupted time-series analysis with independent controls. We placed two interruptions, one to account for PBF and one to account for the free healthcare policy. In the period before the free healthcare policy, PBF produced significant but modest increases across a wide range of maternal and child services, but a significant decrease in child immunization coverage. In the period after the introduction of the free healthcare policy, PBF did not affect service provision in intervention compared with control facilities, possibly indicating a saturation effect. Our findings indicate that PBF can produce modest increases in service provision, without altering the overall service mix. Our findings, however, also indicate that the introduction of other health financing reforms can quickly crowd out the effects produced by PBF. Further qualitative research is required to understand what factors allow healthcare providers to increase the provision of some, but not all services and how they react to the joint implementation of PBF and free health care.

Effect Heterogeneity in Responding to Performance-Based Incentives: A Quasi-Experimental Comparison of Impacts on Health Service Indicators Between Hospitals and Health Centers in Malawi.

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.

Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi.

Background: Several performance-based financing (PBF) evaluations have been undertaken in low-income countries, yet few have examined community perspectives of care amid PBF programme implementation. We assessed community members' perspectives of Support for Service Delivery Integration - Performance-Based Incentives ('SSDI-PBI'), a PBF intervention in Malawi, and explored some of the unintended effects that emerged amid implementation. Methods: We conducted 30 focus group discussions: 17 with community leaders and 13 with mothers within catchment areas of SSDI-PBI implementing facilities. We analysed data using the framework approach. Results: Community leaders and women had mixed impressions regarding the effect of SSDI-PBI on service delivery in facilities. They highlighted several improvements (including improved dialogue between staff and community, and cleaner, better-equipped facilities with enhanced privacy), but also persisting challenges (including inadequate and overworked staff, overcrowded facilities and long distances to facilities) related to services in SSDI-PBI-implementing facilities. Further, respondents described how four targeted service indicators related to maternal risk factor management, antenatal care (ANC) in the first trimester, skilled birth attendance and couple's HIV testing sparked unintended negative effects as experienced by women and communities. The unintended effects included women returning home for delivery, women feeling uncertain about their pregnancy status, women feeling betrayed or frustrated by the quality of care provided and partnerless women being denied ANC. Conclusion: PBF programmes such as SSDI-PBI may improve some aspects of service delivery. However, to achieve system improvement, not only should necessary tools (such as medicines, equipment and human resources) be in place, but also programme priorities must be congruent with cultural expectations. Finally, facilities must be better supported to expect and then address increases in client load and heightened expectations in relation to services.

What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo.

BACKGROUND: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF. METHODS: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF. RESULTS: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community. CONCLUSION: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

Correction to: Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso.

Due to an error introduced during copyediting of this article [1], there are two corrections about the Figs. 1. The caption of Fig. 1 should be changed to "Study design". 2. The Fig. 2 is missing.

Psychological wellbeing in a resource-limited work environment: examining levels and determinants among health workers in rural Malawi.

BACKGROUND: A competent, responsive, and productive health workforce is central to a well-performing health system capable of providing universal access to high-quality care. Ensuring health workers' psychological wellbeing is critical to sustaining their availability and productivity. This is particularly true in heavily constrained health systems in low- and lower-middle-income countries. Research on the issue, however, is scarce. This study aimed to contribute to filling the gap in knowledge by investigating levels of and factors associated with psychological wellbeing of mid-level health workers in Malawi. METHODS: The study relied on a cross-sectional sample of 174 health workers from 33 primary- and secondary-level health facilities in four districts of Malawi. Psychological wellbeing was measured using the WHO-5 Wellbeing Index. Data were analyzed using linear and logistic regression models. RESULTS: Twenty-five percent of respondents had WHO-5 scores indicative of poor psychological wellbeing. Analyses of factors related to psychological wellbeing showed no association with sex, cadre, having dependents, supervision, perceived coworker support, satisfaction with the physical work environment, satisfaction with remuneration, and motivation; a positive association with respondents' satisfaction with interpersonal relationships at work; and a negative association with having received professional training recently. Results were inconclusive in regard to personal relationship status, seniority and responsibility at the health facility, clinical knowledge, perceived competence, perceived supervisor support, satisfaction with job demands, health facility level, data collection year, and exposure to performance-based financing. CONCLUSIONS: The high proportion of health workers with poor wellbeing scores is concerning in light of the general health workforce shortage in Malawi and strong links between wellbeing and work performance. While more research is needed to draw conclusions and provide recommendations as to how to enhance wellbeing, our results underline the importance of considering this as a key concern for human resources for health.