Credit: Evidence for Action/Malawi

Improving maternal and newborn health using results-based financing

In Malawi, considerable progress has been made in improving maternal, newborn and child health. More women are delivering in health facilities than ever before and access to modern family planning continues to increase. However, an estimated two of every 100 women still die from largely preventable maternal causes during their reproductive lifetimes, and maternal and newborn mortality remain among the highest in sub-Saharan Africa. The Results-based Financing (RBF) for Maternal and Newborn Health Initiative supported the Malawi government in addressing factors contributing to high numbers of maternal and newborn deaths using innovative approaches to health financing.

The RBF Initiative, known locally as Uchembere wa Ngwiro, combined performance-based and demand-side financing in an approach which reflected the complex challenges facing Malawi’s health sector. The programme rewarded the provision of better quality care, as well as health system improvements. Payments were made both to individual staff members as well as directly to the facility for investment, providing a powerful incentive for facility staff to work together to improve the quality of care provided. Many poor women and their families struggle to find cash to pay for transport and other costs of delivering in a health facility. The RBF programme provided small cash payments to women who deliver in an RBF facility and remain there during the critical period immediately after giving birth. Investments in infrastructure and equipment aimed to bring participating facilities up to a minimum operating standard for providing emergency obstetric care.

The programme’s goal was to enable more women, particularly from poor rural areas, to deliver in health facilities, and for those facilities to offer better quality maternal and neonatal care services. The RBF Initiative contributed to an increase in assisted deliveries and an increase in the number of health facilities offering maternal and newborn health services that meet national standards. Importantly, there was a significant reduction in maternal mortality during the programme period in the districts where RBF was introduced, compared with those where RBF was not implemented.

Options worked with the Reproductive Health Directorate within the Ministry of Health to manage and implement the Initiative, which was financed by the governments of Germany and Norway. The programme was implemented in a total of 33 health facilities in four districts (Mchinji, Dedza, Ntcheu and Balaka), including four district hospitals and five facilities owned by the Christian Health Association of Malawi, and reached over three-quarters of the population in each district.

Project achievements

  • A significant reduction in maternal mortality in RBF versus non-RBF districts: 4.8 fewer maternal deaths per 100,000 deliveries per month
  • Improved infrastructure and availability of equipment, drugs and supplies, meant facilities were able to provide better quality care
  • RBF facilities were able to maintain stocks of essential drugs during a period of severe economic instability, which saw non-RBF (control) facilities suffer worsening stock-outs
  • Healthcare workers were motivated by positive changes in their working environment, related to improvements in infrastructure, equipment, drugs and supplies

Results

  • The percentage of women delivering without complications, remaining at the health facility for 48 hours post-delivery (when the majority of neonatal deaths occur) increased from 40% at baseline to 90% in December 2017;
  • 95% of neonatal deaths and 100% of maternal deaths were audited according to national standards, from a baseline of zero;
  • By March 2018, 93,712 women who delivered in participating RBF health facilities had received cash transfers, against a target of 64,000.
Programme

Results

95% of neonatal deaths and 100% of maternal deaths were audited according to national standards, from a baseline of zero

By March 2018, 93,712 women who delivered in participating RBF health facilities had received cash transfers, against a target of 64,000.

An increase from 40% to 90% in women delivering without complications and remaining at a health facility for 48 hours after delivery by December 2017

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