Effects in spite of tough constraints - A theory of change based investigation of contextual and implementation factors affecting the results of a performance based financing scheme extended to malnutrition in Burundi

Abstract

Background From January 2015 to December 2016, the health authorities in Burundi piloted the inclusion of child nutrition services into the pre-existing performance-based financing free health care policy (PBF-FHC). An impact evaluation, focused on health centres, found positive effects both in terms of volume of services and quality of care. To some extent, this result is puzzling given the harshness of the contextual constraints related to the fragile setting. Methods With a multi-methods approach, we explored how contextual and implementation constraints interacted with the pre-identified tracks of effect transmission embodied in the intervention. For our analysis, we used a hypothetical Theory of Change (ToC) that mapped a set of seven tracks through which the intervention might develop positive effects for children suffering from malnutrition. We built our analysis on (1) findings from the facility surveys and (2) extra qualitative data (logbooks, interviews and operational document reviews). Findings Our results suggest that six constraints have weighted upon the intervention: (1) initial low skills of health workers; (2) unavailability of resources (including nutritional dietary inputs and equipment); (3) payment delays; (4) suboptimal information; (5) restrictions on autonomy; and (6) low intensity of supervision. Together, they have affected the intensity of the intervention, especially during its first year. From our analysis of the ToC, we noted that the positive effects largely occurred as a result of the incentive and information tracks. Qualitative data suggests that health centres have circumvented the many constraints by relying on

Impact of the extension of a performance-based financing scheme to nutrition services in Burundi on malnutrition prevention and management among children below five: A cluster-randomized control trial

“…Nevertheless, the intervention occurred and HCs in the intervention group were paid accordingly to their performance in nutrition activities. More details on the implementation and on the context can be found in the endline report and in other papers [ 21 , 25 , 27 ].…”

“…sets of anthropometrics’ equipment -with scales, measuring boards, WHZ tables, etc.- were not fully available and functional in most of the HCs), at least not within the two-year period of the study. The discontinuation of the MAM treatment supply as well as the political and financial instability also hindered the PBF-N to operate [ 21 , 24 , and S8 File ].…”

“…A chain of expected results can be found in S1 Fig . In another paper, recently published, we report on more extensively our findings as for the theory of change [ 21 ]. Qualitative data suggest that the most influencing mechanisms related to PBF-N were incentives as well as information provided in the contract and during the initial training (stating clearly the service performance indicators).…”

Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research

“…10,14 Mechanisms and Spillovers Understanding the mechanisms through which P4P operates is also important to answer questions on the appropriate use of P4P schemes. [15][16][17] Key questions include when and for which policy objectives P4P schemes can be applied, as well as which design features can be chosen by policy-makers to obtain long-term, sustainable changes. For example, schemes may be associated with improvements in care processes and care use, but not associated with improved health outcomes.…”

“…9,38 As a result some of the LMIC research has sought to examine the interactions between P4P and the broader health system building blocks involved in the achievement of these targets. [15][16][17]39 However, in HIC P4P does not typically require broader reforms to the health system, and hence system level effects of P4P are less commonly studied. In England, for example, the interaction between P4P schemes and the way public funding is managed (ie, how budgets are allocated to different sectors and public institutions, and then executed to deliver services) has rarely been examined.…”