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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 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).

SUBMITTER: Nimpagaritse M

PROVIDER: S-EPMC6957191 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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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.

Nimpagaritse Manassé M Korachais Catherine C Meessen Bruno B

PloS one 20200113 1

<h4>Background</h4>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.<h4>Methods</h4>With a mul ...[more]

PMID: 31929554

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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: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.

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:BackgroundTo keep a high quality of assistance it is important for hospitals to invest in health technologies (HTs) that have the potential of improving health outcomes. Even though guidance exists on how HTs should be introduced, used and dismissed, there is a surprising gap in literature concerning the awareness of hospitals in the actual utilization of HTs.MethodsWe performed a systematic literature review of qualitative and quantitative studies aimed at investigating hospital contextual factors that influence the actual utilization of HTs. PubMed, Scopus, Web of Science, Econlit and Ovid Medline electronic databases were searched to retrieve articles published in English and Italian from January 2000 to January 2019. The quality of the included articles was assessed using the Critical Appraisal Skills Programme checklist for qualitative studies, Newcastle-Ottawa Scale for the cross-sectional studies and the Mixed Methods Appraisal Tool for mixed method studies.ResultsWe included 33 articles, which were of moderate to high methodological quality. The included articles mostly addressed the contextual factors that impact the implementation of information and communication technologies (ICTs). Overall, for all HTs, the hospital contextual factors were part of four categories: hospital infrastructure, human resource management, financial resources and leadership styles.ConclusionOur systematic review reported that the contextual factors influencing the HTs utilization at hospital level are mainly explored for ICTs. Several factors should be considered when planning the implementation of a new HTs at hospital level. A potential publication bias might be present in our work, since we included articles published only in English and Italian Language, from January 2000 to January 2019. There remains a gap in the literature on the facilitators and barriers influencing the implementation and concrete utilization of medical and surgical HTs, suggesting the need for further studies for a better understanding.

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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.

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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.

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