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

PLOS Glob Public Health

Brenner

Koulidiati

et al. 2022

Self Cite

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.

Section: Plos Global Public Healthsupporting

confidence: 64%

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

PLOS Glob Public Health

Brenner

Koulidiati

et al. 2022

Self Cite

“…A recent study on the free healthcare policy in Burkina showed that prior to this policy, there were significant positive effects of the PBF on maternal and child service utilisation. After the introduction of the free healthcare policy, however, PBF no longer impacted service utilisation in intervention compared with control facilities [34]. Given these observed changes in service utilisation at the facility level in response to the free healthcare policy, it might be likely a similar trend pattern occurred with respect to service use at the level of households in the respective catchment areas.…”

Section: Discussionmentioning

confidence: 99%

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

Koulidiati

Allegri

Tropical Med Int Health

et al. 2021

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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.

“…To estimate the effect of PBF on the different ANC quality outcomes, we used a difference-in-differences approach based on linear regression. The assumption of parallel trends prior to intervention was con rmed using routine data from these study facilities for selected ANC indicators (41). As treatment assignment occurred at district level, we clustered standard errors at that level.…”

Section: Analytical Approachmentioning

confidence: 99%

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

Appel

Allegri

et al. 2022

Preprint

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Background: While maternal mortality has declined globally, it remains highest in low-income countries. High-quality antenatal care (ANC) can control 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 mechanisms targeting ANC service quality. 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. Outcome variables were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision (i.e. screening, prevention) for two different client groups (i.e. first ANC visits, follow-up visits).Results: We found a statistically significant increase of 10 percent-points in facilities’ readiness to provide ANC services. Although clinical care provided to different ANC client groups was 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 seems largely to reflect the incentive structure implemented by the scheme, with a stronger focus on structural elements compared with clinical aspects of care. This might have 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 might be needed to increase adherence to technical standards and technical patient care outcomes.