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Measuring and understanding the effects of a performance based financing scheme applied to nutrition services in Burundi-a mixed method impact evaluation design.

ABSTRACT: Malnutrition is a huge problem in Burundi. In order to improve the provision of services at hospital, health centre and community levels, the Ministry of Health is piloting the introduction of malnutrition prevention and care indicators within its performance based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services, as PBF has done, in Burundi and elsewhere, for several other services.This paper presents the protocol for the impact evaluation of the PBF scheme applied to malnutrition. The research design consists in a mixed methods model adopting a sequential explanatory design. The quantitative component is a cluster-randomized controlled evaluation design: among the 90 health centres selected for the study, half receive payment related to their results in malnutrition activities, while the other half get a budget allocation. Qualitative research will be carried out both during the intervention period and at the end of the quantitative evaluation. Data are collected from 1) baseline and follow-up surveys of 90 health centres and 6,480 households with children aged 6 to 23 months, 2) logbooks filled in weekly in health centres, and 3) in-depth interviews and focus group discussions. The evaluation aims to provide the best estimate of the impact of the project on malnutrition outcomes in the community as well as outputs at the health centre level (malnutrition care outputs) and to describe quantitatively and qualitatively the changes that took place (or did not take place) within health centres as a result of the program.Although PBF schemes are blooming in low in-come countries, there is still a need for evidence, especially on the impact of revising the list of remunerated indicators. It is expected that this impact evaluation will be helpful for the national policy dialogue in Burundi, but it will also provide key evidence for countries with an existing PBF scheme and confronted with malnutrition problems on the appropriateness to extend the strategy to nutrition services.ClinicalTrials.gov PRS Identifier: NCT02721160; registered March 2016.

SUBMITTER: Nimpagaritse M

PROVIDER: S-EPMC4908705 | biostudies-literature | 2016 Jun

REPOSITORIES: biostudies-literature

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Measuring and understanding the effects of a performance based financing scheme applied to nutrition services in Burundi-a mixed method impact evaluation design.

Nimpagaritse Manassé M Korachais Catherine C Roberfroid Dominique D Kolsteren Patrick P Zine Eddine El Idrissi Moulay Driss MD Meessen Bruno B

International journal for equity in health 20160614

<h4>Background</h4>Malnutrition is a huge problem in Burundi. In order to improve the provision of services at hospital, health centre and community levels, the Ministry of Health is piloting the introduction of malnutrition prevention and care indicators within its performance based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services, as PBF has done, in Burundi and elsewhere, for several ot ...[more]

PMID: 27301741

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Project description:Malnutrition is a huge problem in Burundi. In order to improve the health system response, the Ministry of Health piloted the introduction of malnutrition prevention and care indicators within its performance-based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services. The objective of this study is to assess the impacts of this intervention, on both child acute malnutrition recovery rates at health centre level and prevalence of chronic and acute malnutrition among children at community level. This study follows a cluster-randomized controlled evaluation design: 90 health centres (HC) were randomly selected for the study, 45 of them were randomly assigned to the intervention and received payment related to their performance in malnutrition activities, while the other 45 constituted the control group and got a simple budget allocation. Data were collected from baseline and follow-up surveys of the 90 health centres and 6,480 households with children aged 6 to 23 months. From the respectively 1,067 and 1,402 moderate and severe acute malnutrition transcribed files and registers, findings suggest that the intervention had a positive impact on moderate acute malnutrition recovery rates (OR: 5.59, p = 0.039 -at the endline, 78% in the control group and 97% in the intervention group) but not on uncomplicated severe acute malnutrition recovery rate (OR: 1.16, p = 0.751 -at the endline, 93% in the control group and 92% in the intervention group). The intervention also had a significant increasing impact on the number of children treated for acute malnutrition. Analyses from the anthropometric data collected among 12,679 children aged 6-23 months suggest improvements at health centre level did not translate into better results at community level: prevalence of both acute and chronic malnutrition remained high, precisely at the endline, acute and chronic malnutrition prevalence were resp. 8.80% and 49.90% in the control group and 8.70% and 52.0% in the intervention group, the differences being non-significant. PBF can contribute to a better management of malnutrition at HC level; yet, to address the huge problem of child malnutrition in Burundi, additional strategies are urgently required.

Project description:BackgroundCountries in Africa progressively implement performance-based financing schemes to improve the quality of care provided by maternal, newborn and child health services. Beyond its direct effects on service provision, evidence suggests that performance-based financing can also generate positive externalities on service utilization, such as increased use of those services that reached higher quality standards after effective scheme implementation. Little, however, is known about externalities generated within non-incentivized health services, such as positive or negative effects on the quality of services within the continuum of maternal care.MethodsWe explored whether a performance-based financing scheme in Malawi designed to improve the quality of childbirth service provision resulted positive or negative externalities on the quality of non-targeted antenatal care provision. This non-randomized controlled pre-post-test study followed the phased enrolment of facilities into a performance-based financing scheme across four districts over a two-year period. Effects of the scheme were assessed by various composite scores measuring facilities' readiness to provide quality antenatal care, as well as the quality of screening, prevention, and education processes offered during observed antenatal care consultations.ResultsOur study did not identify any statistically significant effects on the quality of ANC provision attributable to the implemented performance-based financing scheme. Our findings therefore suggest not only the absence of positive externalities, but also the absence of any negative externalities generated within antenatal care service provision as a result of the scheme implementation in Malawi.ConclusionsPrior research has shown that the Malawian performance-based financing scheme was sufficiently effective to improve the quality of incentivized childbirth service provision. Our findings further indicate that scheme implementation did not affect the quality of non-incentivized but clinically related antenatal care services. While no positive externalities could be identified, we also did not observe any negative externalities attributable to the scheme's implementation. While performance-based incentives might be successful in improving targeted health care processes, they have limited potential in producing externalities - neither positive nor negative - on the provision quality of related non-incentivized services.

Project description: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 a community-based recruitment strategy and a better management of inputs at the level of the facility and the patient himself. CONCLUSION:Frontline actors have agency: when incentives are right, they take the initiative and find solutions. However, they cannot perform miracles: Burundi needs a holistic societal strategy to resolve the structural problem of child malnutrition. TRIAL REGISTRATION:Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

Project description:BACKGROUND:Globally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania. METHODS:An evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients' experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness. DISCUSSION:This evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.

Project description:BACKGROUND:The Dutch Ministry of Health has formulated ambitious goals concerning the use of telehealth, leading to subsequent changes compared with the current health care situation, in which 93% of care is delivered face-to-face. Since most care is delivered to older people, the prospect of telehealth raises the question of whether this population is ready for this new way of receiving care. To study this, we created a theoretical framework consisting of 6 factors associated with older people's intention to use technology. OBJECTIVE:The objective of this study was to understand community-dwelling older people's readiness for receiving telehealth by studying their intention to use videoconferencing and capacities for using digital technology in daily life as indicators. METHODS:A mixed-method triangulation design was used. First, a cross-sectional survey study was performed to investigate older people's intention to use videoconferencing, by testing our theoretical framework with a multilevel path analysis (phase 1). Second, for deeper understanding of older people's actual use of digital technology, qualitative observations of older people executing technological tasks (eg, on a computer, cell phone) were conducted at their homes (phase 2). RESULTS:In phase 1, a total of 256 people aged 65 years or older participated in the survey study (50.0% male; median age, 70 years; Q1-Q3: 67-76). Using a significance level of .05, we found seven significant associations regarding older people's perception of videoconferencing. Older people's (1) intention to use videoconferencing was predicted by their performance expectancy (odds ratio [OR] 1.26, 95% CI 1.13-1.39), effort expectancy (OR 1.23, 95% CI 1.07-1.39), and perceived privacy and security (OR 1.30, 95% CI 1.17-1.43); (2) their performance expectancy was predicted by their effort expectancy (OR 1.38, 95% CI 1.24-1.52); and (3) their effort expectancy was predicted by their self-efficacy (OR 1.55, 95% CI 1.42-1.68). In phase 2, a total of 6 men and 9 women aged between 65 and 87 years participated in the qualitative observation study. Of the primary themes, 5 themes were identified that could provide greater understanding of older people's capacities and incapacities in using digital technology: (1) "self-efficacy and digital literacy," (2) "obstacles to using technology," (3) "prior experience and frequency of use," (4) "sources of support and facilitating conditions," and (5) "performance expectancy." These 5 themes recurred in all 15 observations. CONCLUSIONS:Performance expectancy, effort expectancy, and perceived privacy and security are direct predictors of older people's intention to use videoconferencing. Self-efficacy appeared to play a role in both older people's intention to use, as well as their actual use of technology. The path analysis revealed that self-efficacy was significantly associated with older people's effort expectancy. Furthermore, self-efficacy and digital literacy appeared to play a major role in older people's capacities to make use of digital technology.

Project description:IntroductionHealth financing systems have a key role in achieving universal health coverage (UHC) across the globe. However, little is known about how best to monitor health financing system progress towards UHC, especially in low- and middle-income countries. This is a protocol of a study that will aim to assess health financing system progress towards achieving UHC in Iran.MethodsAn explanatory mixed-method approach will be used in two phases. In the quantitative phase, the performance of the Iranian health financing system will be assessed using a well-established set of indicators to draw on progress over 5-year intervals starting in the year 2000 up to the present. Data will be extracted from the global health expenditure database using a specific form and will be classified in accordance with each indicator. A qualitative phase will then take place considering the Kutzin et al. framework and by using health financing progress matrices. The qualitative phase will consist of two successive stages; first, a descriptive overview on the major health coverage schemes along with key attributes of each scheme. This initial mapping will be the underlying background for the second stage. In the second stage, the matrices comprised of a series of questions and relevant to the core functions of health financing and cross-cutting options will be invested in enhancing the evaluation of the ongoing reforms or policies. In this phase, data will be collected by reviewing national policy documents and in-depth interviews with key informants who will be recruited using purposive sampling. Finally, a policy discussion with key stakeholders will be held in order to review and verify the consistency between the current health financing policy and UHC goals.DiscussionThis study will provide a comprehensive image about the current status of the national health financing system progress towards achieving UHC in Iran. Such assessment will give detailed insight about the performance of the current financing system through identifying encountered challenges. Furthermore, some other defects in the design of the financing system are expected to appear. In all likelihood, the results will be fruitful enough to make informed decisions about interventions and policies in relation to UHC.Ethics and disseminationThe study protocol has been approved by the Ethics Committee for Research at Tehran University of Medical Sciences. Informed consent will be obtained from all key informants and the data will be collected and transcribed anonymously in order to maintain utmost confidentiality. The results will be disseminated in peer-reviewed journals and presented in national and international conferences and meetings.

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Measuring and understanding the effects of a performance based financing scheme applied to nutrition services in Burundi-a mixed method impact evaluation design.

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Measuring and understanding the effects of a performance based financing scheme applied to nutrition services in Burundi-a mixed method impact evaluation design.

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