Credit: Evidence for Action/Malawi

Improving maternal and newborn health using results-based financing

In Malawi, considerable progress has recently been made in improving child health, increasing the numbers of women delivering in a facility and promoting the use of family planning. However, Malawi still has one of the highest rates of maternal mortality in Africa with 460 deaths per 100,000 live births. The Results-based Financing (RBF) for Maternal and Newborn Health Initiative supports 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, uses performance-based and demand-side financing approaches. In participating facilities, the programme funds minor infrastructure and rehabilitation improvements to bring the buildings and equipment up to a minimum standard. The number of services provided, and the quality of those services, are monitored and provision of high quality services is rewarded with financial payments disbursed direct to the facility. This provides a powerful incentive for facility staff to improve the quality of care provided. Many women struggle to find cash to pay for transport or other costs of delivering in a health facility. The programme is overcoming this by providing a cash payment to women who deliver in a facility and remain there for 48 hours after having their baby.

Our goal is for more women, particularly from poor rural areas, to deliver in health facilities, and for those facilities to be offering high quality maternal and neonatal services. The RBF Initiative is contributing to an increase in assisted deliveries, an increase in the number of health facilities offering maternal and newborn health services that meet national standards, and an increase in patients’ satisfaction with service delivery.

Options is working with the Reproductive Health Directorate within the Ministry of Health to manage and implement the initiative, which is financed by the German government (KfW) and the Royal Norwegian Embassy.

We are currently working in four districts (Mchinji, Dedza, Ncheu and Balaka), supporting 28 facilities including four owned by the Christian Health Association of Malawi. We are planning to contract a further five facilities to ensure that we are able to reach over three-quarters of the population in each district. The initiative includes building understanding amongst Ministry of Health and other government staff, civil society organisations and traditional leaders about the RBF approach. We are also training health providers to upgrade skills in providing maternal and newborn health care, and supporting supervision and monitoring at the district level. Building on strong support within the Ministry of Health, we are working towards the creation of a national RBF Steering Committee to replicate the approach across other districts in Malawi.

Project achievements

  • Institutional delivery rates in participating facilities have increased from 54 per cent in 2012/13 to 63 per cent in 2013/14, and a total of 60,903 women have delivered safely in an RBF facility since the beginning of the initiative
  • Ninety-five per cent of neonatal deaths and 100 per cent of maternal deaths are now audited according to national standards, from a baseline of zero
  • The percentage of women delivering without complications remaining at the health facility for 48 hours post-delivery (when the majority of neonatal deaths occur) has increased from 0 per cent at baseline to 83 per cent in March 2015
  • The stock-out of drugs and supplies has greatly decreased: for example, the average number of stock-out days for HIV testing kits during each reward cycle has decreased from 14 at baseline, to 10 in 2012/13, to just one in the period from April 2013 to March 2014
  • Use of stock cards for medicines and supplies improved from 0 per cent at baseline to 84 per cent in March 2015
  • As of March 2015, 16,283 women have received cash transfers since the introduction of the cash transfer in September 2013.


60,903 women have delivered their babies safely in a RBF facility

An increase from 0% to 83% in women delivering without complications and remaining at a health facility for 48 hours after delivery by March 2015

98,055 women received cash transfers by June 2017

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