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    • The reasons for continued low maternal health

    2018-10-24

    The reasons for continued low maternal health service use are complex, but appear to include high user fees and poor quality of care in many settings (Hatt, Makinen, Madhavan, & Conlon, 2013; Nair et al., 2014). A wide-variety of programs have been introduced to address these barriers including interventions focused on changing demand (conditional-cash transfers, vouchers, user-fee exemptions, health insurance) and supply-side interventions (financing, targeted subsidies) (The AIDSTAR-Two Project, 2011). Performance-Based Financing (PBF) has been implemented in an increasingly large number of low- and middle income countries to strengthen health systems and increase service provision (The AIDSTAR-Two Project, 2011). PBF is a form of supply-side Results-Based Financing that uses fee-for-service contracts with a service quality component (Fritsche, Soeters, & Meessen, 2014). PBF aims to improve health service provision and quality by increasing staff motivation, reducing provider absenteeism, and increasing the financial independence of facilities, which can allow them to improve the quality of their services, and also potentially reduce users fees (The World Bank, 2012). Recent PBF programs have introduced additional demand-side interventions such as using household visits by health workers to stimulate demand, referrals by crm1 health workers, and the removal of user and drug fees for the poor and vulnerable. While the term PBF first originated in Rwanda, early programs with some of the same tenets as PBF such as contracting and decentralization emerged in the 1990s in Zambia and Cambodia (Bossert, Chitah, & Bowser, 2003; Soeters & Griffiths, 2003). Since the mid-2000s, and in particular after the positive results from the Rwanda program (Basinga et al., 2010), there has been a rapid increase in the number of countries integrating performance-based financing into their health system. As of 2013, over 40 countries have either planned or begun to implement some form of PBF (Fritsche et al., 2014). A somewhat controversial Cochrane review published in 2012 analyzed nine studies on PBF, and concluded that the existing evidence base was too weak to draw any general conclusions (Meessen, 2012; Witter, Fretheim, Kessy, & Lindahl, 2012). More recent PBF programs have generally incorporated more rigorous evaluation designs and several randomized or quasi-experimental studies published since 2010 have increased the quality of available evidence considerably. While a study conducted in the Democratic Republic of the Congo found no effect of PBF on health service utilization (Huillery and Seban, 2014), studies conducted in Rwanda, the Philippines and Tanzania found that PBF increased several, but not all, of the health services examined in these studies (Basinga et al., 2010; Binyaruka et al., 2015; Peabody et al., 2014). Three studies conducted in Burundi found mixed results with findings differing between studies (Bonfrer et al., 2014; Bonfrer, Van de Poel, & Van Doorslaer, 2014; Falisse, Ndayishimiye, Kamenyero, & Bossuyt, 2014). While two of the three studies from Burundi found an increase in institutional deliveries and antenatal care, none of the three studies found an increase in vaccinations and only one of the two studies that examined contraception found an increase in this outcome. Three studies from the Philippines, Haiti and Cambodia found positive results for all health services they examined though one of these studies focused exclusively on institutional deliveries (Gertler & Giovagnoli, 2014; Ir et al., 2015; Zeng, Cros, Wright, & Shepard, 2013). Most of these studies focus on maternal and child health service use and few examine health outcomes or quality of the health services provided. In this paper we examine the effect of a pilot project that introduced Performance-Based Financing from 2011 to 2013 in Burkina Faso. We focus on provision of maternal health services as a key strategy to improve maternal and child health outcomes in the country and globally (Jones et al., 2003; Rosenfield, Maine, & Freedman, 2006).