Supporting performance based financing to enhance maternal health services in Kenya

In 2015, performance based financing (PBF) was introduced in Bungoma, Kenya to incentivise health workers to improve maternal and newborn health services. This means that health facilities and staff qualify for financial rewards based on the number and quality of maternal health services provided.

The PBF scheme is supported by the Maternal and Newborn Improvement (MANI) project in partnership with the County Health Management Team, and has contributed to improving access to quality maternal and newborn health services in 37 facilities across the six sub-counties where MANI operates. One of the facilities that has benefited from PBF is Sikulu Dispensary which offers preventative, promotive and curative health services to the local community. Since its establishment in 2005, the dispensary has grown from strength to strength; it has recruited more staff, built additional outpatient rooms, built a maternity wing and in 2011 began conducting deliveries.

In 2016, Sikulu Dispensary joined the PBF scheme. At the time, the facility only had two nurses and convincing women to deliver at the facility was a major challenge. With financial incentives from the scheme, the facility staff gained the resources and the motivation to change this, and since then has seen a dramatic improvement to both the quantity and quality of services.

Together the two nurses reached out to their 20 community health volunteers to generate demand for maternity services and arranged for someone to be on call at night. The results were outstanding.  While the number of deliveries conducted by the facility showed a gradual increase from 2011 – 2016, between 2016 and 2017 there was an almost three-fold increase from 243 to 681 deliveries per year due to PBF support.

“We have improved and even surpassed our targets as a facility. That means as a facility we are able to reach the population that we are supposed to serve; they are getting skilled attendance right from antenatal care and up to delivery and even past delivery”, Nurse in charge, Sikulu Dispensary.

Alongside increasing the number of women using the dispensary, PBF has contributed to improving the quality of care provided. The PBF’s monitoring and verification process requires facilities to have a score of 60% or over to qualify for a quality reward. With the help of the scheme, Sikulu Dispensary achieved an average score of 90% for the last 18 months, which is a significant improvement from its baseline score of 37%.

PBF has improved performance by promoting facility autonomy and placing health workers at the centre of decision making. Decisions such as whether they should purchase supplies, undertake facility renovations, reward community level work, or source casual staff are made by health workers at the facility:

“PBF has assisted us so much… we were having a shortage of supplies like non-pharmaceuticals. We were able to sit down as staff and committee and prioritise our needs… so we were able to budget for the non-pharms and drugs”, Sikulu Dispensary staff.

The PBF scheme has demonstrated that motivation of health workers improves how services at the facility are offered and has helped motivate staff who are operating in difficult circumstances. The staff at Sikulu said they feel more motivated and have cultivated a sense of team work. 

“It has improved my spirit…. when I wake up in the morning I am motivated that I need to do ABCD…There is a lot of teamwork, everybody wants to work and everybody is punctual to her place of work because at the end of the day they know there is something they are expecting”, Sikulu Dispensary staff.

With the implementation of PBF, it has allowed health facilities to access other revenue channels from other performance based financing interventions. For example, since January 2018, 72 mothers have been registered under Linda Mama (the free maternity programme funded by the national government)  and 24 women have delivered under the scheme.

Ultimately, the Performance Based Financing scheme has helped the delivery of priority, life-saving interventions, and by increasing the autonomy of health facilities PBF has empowered facility managers and their staff to deliver better quality of services.