Incorporating results-based financing into Malawi's draft health strategy

The Options-supported results-based financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi has been operating for nearly four years.  With 33 participating health facilities providing both basic and comprehensive emergency obstetric care in four districts, the Initiative supports improvements in quality of care and increase the number of good quality institutional deliveries.  This is achieved through a combination of performance-based payments to facility teams, district health management teams and individual health workers; cash payments for poor women to contribute towards the costs of reaching and staying at a facility for delivery; and infrastructure up-grading and equipment provision.

The project has been independently evaluated by a team led by the University of Heidelberg, with three rounds of data collection and analysis financed by jointly by USAID’s TRAction project and the Government of Norway.  Findings were presented at the RBF strategic workshop in May 2016, contributing to the decision of the Ministry of Health to incorporate performance-based financing as a health financing approach into the draft Malawi Health Sector Strategic Plan (2017 – 21).

The evaluation highlighted successes as well as important lessons that will inform the design of future RBF strategies and interventions:

• Health workers reported that they were more satisfied and felt increased professional motivation in their work. Importantly, the evaluation found no evidence that money, or other aspect of the intervention, affected the health workers’ sense of purpose and desire to serve. This is often a criticism of programmes providing financial incentives.
• Health providers described feeling more accountable to women due to an exit interview process where women are asked to describe how they were treated by providers.  Women in return reported higher satisfaction levels with the care they received.
• Facility teams were able to provide better quality of care to women as a result of being able to manage their funds locally; using RBF rewards to purchase soap and disinfectant to keep facilities clean, buying out-of-stock drugs and supplies, and making other important improvements such as putting up curtains to provide privacy for labouring women.  Maintaining stocks of medicines and supplies in the face of severely declining funds for the Malawi health sector has been an important success of the project.
• In line with national protocols and international recommendations, the project both encouraged and enabled women to remain at the health facilities for 48 hours after giving birth, which is the most dangerous time for both mother and baby.
• Despite the success of the RBC incentives, some systemic challenges remain. for example, the lack of human resources and overcrowding at district hospitals.  These have to be addressed through broader health systems strengthening efforts – RBF is an important element of such efforts, but not the whole picture.

The RBF4MNH Initiative which continues to the end of 2017 has provided many useful lessons. Together with other performance-based financing approaches we have directly contributed to the Ministry of Health’s decision to incorporate results-based financing into the policy and strategy frameworks of the health sector.

Key recommendations have recently been published in a series of Policy Briefs by the USAID TRAction project, which are available here.

A qualitative study assessing the acceptability and adoption of the approach, recently published in BMC Health Services Research, can be found here.