The effect of a performance-based financing program on HIV and maternal/child health services in Mozambique—an impact evaluation

Abstract

Performance-based financing (PBF) is a mechanism by which health providers are paid on the basis of outputs or results delivered. A PBF program was implemented on the provision of HIV, prevention of mother-to child HIV transmission (PMTCT), and maternal/child health (MCH) services in two provinces of Mozambique. A retrospective case–control study design was used in which PBF provinces were matched with control provinces to evaluate the impact of PBF on 18 indicators. Due to regional heterogeneity, we evaluated the intervention sites (North and South) separately. Beginning January 2011, 11 quarters (33 months or 2.75 years) of data from 134 facilities after matching (84 in the North and 50 in the South) were used. Our econometric framework employed a multi-period, multi-group difference-in-differences model on data that was matched using propensity scoring. The regression design employed a generalized linear mixed model with both fixed and random effects, fitted using the seemingly unrelated regression technique. PBF resulted in positive impacts on MCH, PMTCT and paediatric HIV program outcomes. The majority of the 18 indicators responded to PBF (77% in the North and 66% in the South), with at least half of the indicators demonstrating a statistically significant increase in average output of more than 50% relative to baseline. Excluding pregnant women, the majority of adult HIV treatment indicators did not respond to PBF. On average, it took 18 months (six quarters) of implementation for PBF to take effect, and impact was generally sustained thereafter. Indicators were not sensitive to price, but were inversely correlated to the level of effort associated with marginal output. No negative impacts on incentivized indicators nor spill-over effects on non-incentivized indicators were observed. The PBF program in Mozambique has produced large, sustained increases in the provision of PMTCT, paediatric HIV and MCH services. Our results demonstrate that PBF is an effective strategy for driving down the HIV epidemic and advancing MCH care service delivery as compared with input financing alone.

The effects of performance-based financing on neonatal health outcomes in Burundi, Lesotho, Senegal, Zambia and Zimbabwe

“…Fourth, we were unable to look at a longer time frame beyond 2 years because of PBF implementation in the control areas in some of the countries at that time. Although neonatal mortality can be responsive to changes in the health system ( Magge et al , 2020 ), it may take longer than this period to see an effect particularly if there were delays in signing contracts or delivering payments ( Rajkotia et al , 2017 ; Ridde et al , 2018 ). Finally, we were unable to look at treatment heterogeneity at levels lower than the country because of limited sample sizes.…”

Cost–effectiveness of results-based financing, Zambia: a cluster randomized trial

“…5 Despite mixed results, 6 , 7 results-based financing has generally shown promise as a way to address maternal and child health concerns and catalyse health-care reforms. 8 – 13 These findings prompted Zambia to initiate a results-based financing programme. With partial funding from the World Bank, Zambia implemented a project in 2008 in Katete district as a pre-pilot site, trying to realign payment to outputs rather than inputs.…”

Evidence on result-based financing in maternal and child health in low- and middle-income countries: a systematic review

“…Only two out of the 13 reports in this review included a discussion on sustainability. In Mozambique, on average, it took 18 months of implementation for PBF to show effects, and the impact was generally sustained thereafter [25]. The mobilization of domestic financial resources was central to the sustainability of Burundi's program [22].…”