Academic journal article Journal of Health Population and Nutrition

Performance-Based Incentives to Improve Health Status of Mothers and Newborns: What Does the Evidence Show?

Academic journal article Journal of Health Population and Nutrition

Performance-Based Incentives to Improve Health Status of Mothers and Newborns: What Does the Evidence Show?

Article excerpt

INTRODUCTION

Health financing strategies that incorporate performance-based incentives (PBIs) are being applied in many developing countries, often with improvements in the health of mothers and newborns as the central goal. Defined as "any program that rewards the delivery of one or more outputs or outcomes by one or more incentives, financial or otherwise, upon verification that the agreed-upon result has actually been delivered" (1), PBI is being implemented to strengthen the linkages between funding for health and health outcomes and to stimulate actions by households, providers, and other health system actors to overcome obstacles in order to achieve health outcomes. This paper focuses on the impact of PBI initiatives that pay providers (individuals and facilities) and their supervisors (at subnational levels of government) if they achieve predetermined performance measures of the health of mothers and newborns. It is based, in part, on lessons that emerged from the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives, which took place in Washington, DC in April 2012. While evidence of the impact of PBI is not fully clear, this paper will argue that lack of evidence may be due to a dearth of quality studies rather than weak programmes or inadequate impact of PBI schemes. We present the available evidence and suggest options for enhancing the global evidence base.

The imperative to reduce maternal mortality in the developing world has increased political and financial commitments and spurred momentum around Millennium Development Goal 5 (MDG 5), which calls for reduction by three-fourths the maternal mortality ratio and achieving universal access to reproductive health services between 1990 and 2015. In total, 287,000 women die each year from complications of childbirth, the vast majority of whom live in developing countries. In sub-Saharan Africa, women have a lifetime risk of maternal death of 1 in every 39 compared to 1 in every 3,800 in developed regions of the world--the largest difference between poor and the rich countries of any health indicator (2). Much good has been done but experience has shown that health systems continue to underprovide proven cost-effective interventions and fail to reach the poorest populations. PBI is a promising intervention that, by changing incentives for many people who together comprise a health system, may contribute to reducing maternal mortality.

Ensuring maternal wellbeing and survival requires knowledge of and demand for services by women and multiple interactions with a functioning health system capable of delivering quality reproductive and specifically maternal health services. Individuals must know when to seek care and demand services; health workers must be motivated to deliver care of sufficient quality; and the institutions they work for must be encouraged and enabled to make the systemic changes required to achieve the health goals for mothers and newborns. While maternal mortality is partly caused by insufficient inputs, such as equipment, supplies, facilities, trained health workers, and a coordinated referral system, it is also driven by disincentives in the health system that can hinder delivery of interventions that improve the health of women and their babies. The choices providers and their supervisors make depend on what they have (that is, on inputs), what they know, and, critically, on what influences and motivates them. PBI initiatives aim to counteract dysfunctional incentives and drive changes that strengthen health systems and improve outcomes.

Translating funding into health outputs or outcomes requires many actions by a large number of people that span from the national to the community level, from officials in the national ministry of health to people who work on the supply chain for lifesaving commodities and to health workers and their supervisors at the district level and in communities. …

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