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

Abstract

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.

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

“…In line with prior literature [7,21,[62][63][64], not all services experienced an increase following the introduction of PBF. In particular, contrary to the primary IE [33], we did not identify an effect of PBF on the use of facility-based delivery. While likely due to the different modelling approaches adopted by the two studies, the discrepancy between our findings and the findings from the primary IE remains to be explored and understood through further qualitative inquiry in order to be able to inform prospective policy formulation.…”

“…In this study, we do not differentiate facilities according to whether they did or did not implement an equity measure as we focus on the supply-side intervention to establish whether PBF produced changes in quantity and mix of service provision, irrespective of the distributional incidence of these changes which is addressed by a parallel study [33].…”

How could patient navigation help promote health equity in sub-Saharan Africa? A qualitative study among public health experts

“…While there have been long-standing pleas to take into account the indigents (2), and policies for universal health coverage are supposed to be designed with the idea of ‘leaving no one behind’, little has actually been done to address their specific needs. The user fee exemption alone, as well as programs linking performance-based financing and equity measures, have shown their inadequacy in increasing the use of health services for the indigents (5,6,18). There is a need to design and test interventions that are better adapted to their situation and that include support throughout their care pathway.…”

Digital Transformation and Global Health in Africa

“…This shows that Uganda is taking active measures to incorporate digital technologies in various healthcare programs. The use of a toll-free telephone service also proved to be important in improving communication with the healthcare provider (Mwase et al 2020). This shows that even mundane tasks in the health sector can be digitalized to improve services.…”