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      Performance-based financing to increase utilization of maternal health services: Evidence from Burkina Faso

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          Abstract

          Performance-based financing (PBF) programs are increasingly implemented in low and middle-income countries to improve health service quality and utilization. In April 2011, a PBF pilot program was launched in Boulsa, Leo and Titao districts in Burkina Faso with the objective of increasing the provision and quality of maternal health services. We evaluate the impact of this program using facility-level administrative data from the national health management information system (HMIS). Primary outcomes were the number of antenatal care visits, the proportion of antenatal care visits that occurred during the first trimester of pregnancy, the number of institutional deliveries and the number of postnatal care visits. To assess program impact we use a difference-in-differences approach, comparing changes in health service provision post-introduction with changes in matched comparison areas. All models were estimated using ordinary least squares (OLS) regression models with standard errors clustered at the facility level. On average, PBF facilities had 2.3 more antenatal care visits (95% CI [0.446–4.225]), 2.1 more deliveries (95% CI [0.034–4.069]) and 9.5 more postnatal care visits (95% CI [6.099, 12.903]) each month after the introduction of PBF. Compared to the service provision levels prior to the interventions, this implies a relative increase of 27.7 percent for ANC, of 9.2 percent for deliveries, and of 118.7 percent for postnatal care. Given the positive results observed during the pre-pilot period and the limited resources available in the health sector, the PBF program in Burkina Faso may be a low-cost, high impact intervention to improve maternal and child health.

          Highlights

          • PBF increased provision of three key reproductive health services in Burkina Faso.

          • Future research should examine the mechanisms through which PBF increases service provision.

          • PBF in Burkina Faso may be a low-cost, high impact intervention to improve maternal and child health.

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          Being a bridge: Swedish antenatal care midwives’ encounters with Somali-born women and questions of violence; a qualitative study

          Background Violence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence. Methods Qualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis. Results The midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women’s’ strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman’s access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women. Conclusion Focus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives’ ability to identify Somali born woman’s resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.
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            The Global strategy for women’s, children’s and adolescents’ health (2016–2030): a roadmap based on evidence and country experience

            The Global strategy for women’s, children’s and adolescents’ health (2016–2030) provides a roadmap for ending preventable deaths of women, children and adolescents by 2030 and helping them achieve their potential for and rights to health and well-being in all settings. 1 The global strategy has three objectives: survive (end preventable deaths); thrive (ensure health and well-being); and transform (expand enabling environments). These objectives are aligned with 17 targets within nine of the sustainable development goals (SDGs), 2 including SDG 3 on health and other SDGs related to the political, social, economic and environmental determinants of health and sustainable development. Like the SDGs, the global strategy is universal in scope and multisectoral in action, aiming for transformative change across numerous challenging areas for health and sustainable development (Box 1). 1 The strategy was developed through evidence reviews and syntheses and a global stakeholder consultation, 3 , 4 and draws on new thinking about priorities and approaches for health and sustainable development. 4 Particular attention was given to experience gained and lessons learnt by countries during implementation of the previous Global strategy for women’s and children’s health (2010–2015) 5 and achieving the millennium development goals (MDGs). 6 , 7 A five-year operational framework with up-to-date technical resources has also been developed to support country-led implementation of the global strategy. This framework will be regularly updated until 2030. 1 , 3 Box 1 The Global strategy for women’s, children’s and adolescents’ health (2016–2030) Objectives of the global strategy: Survive: end preventable mortality; Thrive: promote health and well-being; and Transform: expand enabling environments. Five drivers of change to achieve the objectives based on the global strategy action areas: People: individual potential and community engagement; Political effectiveness: country leadership, financing, accountability; Programmes: health system, multisector, humanitarian, research and innovation; Partnerships: Every Woman Every Child Partnerships, including the Global Financing Facility, the United Nations and multilateral H6 partnership, Unified Accountability Framework and Independent Accountability Panel, Innovation Marketplace and other national, regional and global partnerships; and Principles: country-led, universal, sustainable, human-rights based, equity-driven, gender-responsive, evidence-informed, partnership-driven, people-centred, community-owned, accountable, aligned with development effectiveness and humanitarian norms. Evidence shows that progress is required across a set of overlapping and mutually reinforcing areas to improve the health, dignity and well-being of women, children and adolescents. 4 , 7 , 8 Key areas for action were set out in the first global strategy (2010–2015), including health financing; the health system and workforce; access to essential interventions and life-saving commodities; national leadership; and accountability. 5 Based on emergent evidence, sociopolitical and environmental changes and the SDGs, the current global strategy (2016–2030) includes new strategic areas, for example adolescent health; humanitarian and fragile settings; an integrated life-course approach to health recognizing the links across different stages; multisector approaches; and guiding principles such as universality, human rights, equity and development effectiveness. 1 Evidence indicates that countries can accelerate progress in health and sustainable development through integrated action within the health sector and across social, economic and environmental sectors. 7 , 9 For example, through investments across sectors, the Chinese government lifted 439 million people out of poverty between 1990 and 2015, reduced child and maternal mortality by over 80% and 72%, respectively, and raised secondary school enrolment to over 99%, with equal numbers of boys and girls enrolled. Rural access to clean water and sanitation also improved to over 85% and 74%, respectively. 10 – 12 In Ethiopia, a similar approach reduced poverty from 48% in 1990 to 23% in 2015, and the country experienced improvements in education, roads, water, sanitation and hygiene. Over the same period, child and maternal mortality declined by 71% and 72%, respectively. 7 , 11 , 12 The actions and approaches required to achieve the objectives of the global strategy (2016–2030) 1 converge around five main drivers of change: people; political effectiveness; programmes; partnerships; and principles. The following sections highlight how some countries have already begun achieving these transformative changes (Box 1). The global strategy (2016–2030) emphasizes the importance of measures to help all women, children and adolescents to realize their rights and full potential for health and well-being. These measures include policies and programmes for early childhood development and adolescent health. Removing barriers to enjoyment of rights– such as those to gender-equality and women’s socioeconomic and political participation are also important measures. 1 Evidence shows that early childhood development programmes have significant long-term health and socioeconomic advantages. Parenting resources for early childhood development, school-community outreach and health services have measureable physical, intellectual and socioeconomic benefits for children, their families and communities. Such actions can reduce health, special schooling and criminal justice expenditures. 13 Healthy, educated adolescents can better realize their potential, contribute to the demographic dividend and economic growth, as seen in east Asia in the 1980s and 1990s. 14 Evidence shows that with investment and political commitment for adolescent health and development, rapid progress can be made. 15 Now, countries such as Argentina, Colombia, Estonia, Ethiopia, India, the Republic of Moldova, Senegal and Uganda are investing in large-scale adolescent health and development programmes to gain similar dividends. Investments could help countries in sub-Saharan Africa realize annual dividends of at least 500 billion United States dollars (US$), equal to about one third of the region’s current gross domestic product, for as many as 30 years. 14 Women’s social, political and economic participation is associated with better health outcomes for women and children. 7 In Rwanda, where 64% of parliamentarians are women and where the parliament has committed to and invested in health and development, maternal and child mortality declined by 78% and 72%, respectively, between 1990 and 2015. 7 , 12 At community level, women’s groups in Bangladesh, India, Malawi and Nepal contributed to better access to quality health services and improved maternal and newborn health. 16 Leadership at all levels of society is a proven prerequisite for progress. 1 , 4 , 7 In Kyrgyzstan, committed political leadership, clear policy, management capacity and low staff turnover in the health ministry contributed to sustained financing, improved health services and a reduction of child mortality by almost two thirds since 1990. 11 , 17 Political effectiveness can also drive cross-sector action to address diverse determinants of health. Collaboration across sectors during the MDG era helped some countries to accelerate progress to reduce mortality, malnutrition and gender inequality, to strengthen health and education systems and to improve water quality, sanitation and infrastructure. 18 Robust data and analysis are essential to enable accountability through a cycle of monitoring, independent review and action to ensure that programmes and policies are achieving their desired objectives. For example, in Mozambique a coalition of partners invested in the country’s civil registration and vital statistics system, increasing registered deaths by 18% from 2012 to 2014 and enabling routine reporting of causes of death by sex and age for the first time since 1975 (Commission on Information and Accountability, Mozambique, unpublished data, December 14, 2015). To strengthen accountability, at least 50 countries with a high burden of maternal and child mortality had regular national health sector review processes that met basic accountability criteria in 2015, and another 36 countries had adopted the good governance for medicines approach to battle corruption. 19 , 20 Quality programmes in health and other sectors, and for research and innovation, can catalyse change, even in humanitarian and fragile settings. While resilient health systems and universal coverage of quality care are gold standards for women’s, children’s and adolescents’ health, catastrophic events can swiftly undo hard-won health gains, particularly where existing health systems are weak. For example, during the 2013–2016 Ebola disease outbreak in Liberia, skilled birth attendance fell from 52% to 38%, vaccination rates dropped and 64% of health facilities were not operational. 21 Experience shows that quality care is possible even under extreme circumstances. In Jordan, humanitarian and development partners have collaborated to give all residents of Za’atari refugee camp access to maternal and child health centres, while additional health centres serve Syrian refugees who are not living in camps. 22 The global strategy (2016–2030) highlights the importance of expanding such collaborative practices and improving emergency preparedness at all levels of the health system. While the health sector remains central for people’s health, there is evidence that in low- and middle-income countries about 50% of gains in women’s and children’s health since 1990 have resulted from progress in non-health sectors. 4 , 23 , 24 Investments in nutrition, water and sanitation were essential in eradicating polio in India, which was certified as polio-free in 2014. Previous efforts, focused on vaccination alone, were insufficient because malnourishment and diarrhoea from unsafe water and inadequate sanitation limited vaccine effectiveness. 25 Education is also critical to improving health and well-being. In Malawi, conditional cash transfers to encourage school attendance by girls were associated with reductions in teenage pregnancies, early marriage and human immunodeficiency virus infections. Evidence shows that knowledge and innovation are at least as important as economic resources in improving health and well-being and driving development. Research to help countries understand and overcome barriers is required in areas such as: policy, implementation and operational research; clinical research and systematic evidence reviews; disaster risk reduction and preparedness; social, behavioural, anthropological and community research; and political and social sciences. Multistakeholder and cross-sector partnerships are critical drivers of change. In the United Republic of Tanzania, the White Ribbon Alliance for Safe Motherhood united civil society members, health professionals, academics, donors and United Nations (UN) partners in a successful three-year campaign to improve access to comprehensive emergency obstetric and newborn care at health centres. Effective global partnerships can catalyse and support country efforts. For example, the Every Woman Every Child movement attracted more than US$60 billion dollars to women’s and children’s health between 2010 and 2015, with commitments from over 300 partners. 6 The movement has spurred partnership mechanisms to support country-led implementation of the global strategy (2016–2030) – including the Global Financing Facility in support of Every Woman Every Child, the Innovation Marketplace, Unified Accountability Framework and the UN system’s health agencies’ H6 partnership. 1 The global strategy (2016–2030) recognizes that human rights and other fundamental development principles – such as equity, community ownership and development effectiveness – are drivers of transformative change. 1 In Peru, principles of equity underpinned a programme of poverty mapping to identify and prioritize reaching poor, rural and indigenous populations with social protection programmes and culturally appropriate, affordable care. 7 In Kenya, the institutionalization of human rights principles is benefiting women’s health following complaints alleging systematic violation of women’s reproductive health rights in health facilities. The global strategy (2016–2030) provides knowledge for integrated actions both within the health sector and with other sectors, based on country experience and current evidence. With its accompanying operational framework, the strategy serves as a roadmap for collective action to advance the health and well-being of women, children and adolescents, which will be central to achieving the SDGs.
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              The effects of performance incentives on the utilization and quality of maternal and child care in Burundi.

              Africa's progress towards the health related Millennium Development Goals remains limited. This can be partly explained by inadequate performance of health care providers. It is therefore critical to incentivize this performance. Payment methods that reward performance related to quantity and quality, called performance based financing (PBF), have recently been introduced in over 30 African countries. While PBF meets considerable enthusiasm from governments and donors, the evidence on its effects is still limited. In this study we aim to estimate the effects of PBF on the utilization and quality of maternal and child care in Burundi. We use the 2010 Burundi Demographic and Health Survey (August 2010-January 2011, n = 4916 women) and exploit the staggered rollout of PBF between 2006 and 2010, to implement a difference-in-differences approach. The quality of care provided during antenatal care (ANC) visits improved significantly, especially among the better off, although timeliness and number of ANC visits did not change. The probability of an institutional delivery increased significantly with 4 percentage points among the better off but no effects were found among the poor. PBF does significantly increase this probability (with 5 percentage points) for women where PBF was in place from the start of their pregnancy, suggesting that women are encouraged during ANC visits to deliver in the facility. PBF also led to a significant increase of 4 percentage points in the probability of a child being fully vaccinated, with effects more pronounced among the poor. PBF improved the utilization and quality of most maternal and child care, mainly among the better off, but did not improve targeting of unmet needs for ANC. Especially types of care which require a behavioral change of health care workers when the patient is already in the clinic show improvements. Improvements are smaller for services which require effort from the provider to change patients' utilization choices.
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                Author and article information

                Contributors
                Journal
                SSM Popul Health
                SSM Popul Health
                SSM - Population Health
                Elsevier
                2352-8273
                10 January 2017
                December 2017
                10 January 2017
                : 3
                : 179-184
                Affiliations
                [a ]Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
                [b ]Health, Nutrition and Population Global Practice, The World Bank, 701 18th St NW, Washington, DC 20006, USA
                [c ]Direction Générale des Etudes et des Statistiques Sectorielles, Ministère de la Santé de Burkina Faso, 01 BP 7009 Ouagadougou 01, Burkina Faso
                [d ]Health, Nutrition and Population Global Practice, The World Bank, 179 Av. President Saye ZERBO, 01BP 622, Ouagdougou 01, Burkina Faso
                Author notes
                [* ]Corresponding author. mws475@ 123456mail.harvard.edu
                Article
                S2352-8273(17)30005-8
                10.1016/j.ssmph.2017.01.001
                5769027
                24ad4149-197c-45a3-b478-8cf202d4b160
                © 2017 The Authors. Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Categories
                Article

                performance-based financing,results-based financing,health services,provider incentives,burkina faso

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