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Background Several performance-based financing (PBF) evaluations have been undertaken in low-income countries, yet few have examined community perspectives of care amid PBF programme implementation. We assessed community members’ perspectives of Support for Service Delivery Integration – Performance-Based Incentives (‘SSDI-PBI’), a PBF intervention in Malawi, and explored some of the unintended effects that emerged amid implementation. Methods We conducted 30 focus group discussions: 17 with community leaders and 13 with mothers within catchment areas of SSDI-PBI implementing facilities. We analysed data using the framework approach. Results Community leaders and women had mixed impressions regarding the effect of SSDI-PBI on service delivery in facilities. They highlighted several improvements (including improved dialogue between staff and community, and cleaner, better-equipped facilities with enhanced privacy), but also persisting challenges (including inadequate and overworked staff, overcrowded facilities and long distances to facilities) related to services in SSDI-PBI-implementing facilities. Further, respondents described how four targeted service indicators related to maternal risk factor management, antenatal care (ANC) in the first trimester, skilled birth attendance and couple’s HIV testing sparked unintended negative effects as experienced by women and communities. The unintended effects included women returning home for delivery, women feeling uncertain about their pregnancy status, women feeling betrayed or frustrated by the quality of care provided and partnerless women being denied ANC. Conclusion PBF programmes such as SSDI-PBI may improve some aspects of service delivery. However, to achieve system improvement, not only should necessary tools (such as medicines, equipment and human resources) be in place, but also programme priorities must be congruent with cultural expectations. Finally, facilities must be better supported to expect and then address increases in client load and heightened expectations in relation to services.
Malawi is a low-income country with an economy largely dependent on agriculture, and a health system largely dependent on foreign aid.31 One quarter of the country’s estimated 17.5 million citizens live in extreme poverty.31 Health institutions are either government-owned or faith-based organisations, with only a minority being managed by for-profit private institutions.32 Across all districts, implementation of health interventions is guided by the health sector strategic plan, which emphasises improving service coverage via an essential healthcare package (EHP).32 The EHP states a stipulated set of health services covering the most common conditions be delivered free of charge at point-of-use in public facilities and in private facilities contracted via service-level agreements.32 Utilisation of healthcare services is relatively high, but EHP services are often inadequately provided33 due to a shortage of human resources, poor infrastructure, lack of medical equipment and supplies and inadequate financing.34 This situation has resulted in slow progress towards reduction of morbidity and mortality in the country.35 In trying to address these challenges, the government of Malawi explored PBF as a means to improve access to health services of high quality. The country recently concluded the implementation of two PBF-specific programs entitled ‘Results Based Financing for Maternal and Neonatal Health’ (RBF4MNH),36 and ‘Support for Service Delivery Integration – Performance-Based Incentives’ (SSDI-PBI).37 The focus of this paper is the latter programme, SSDI-PBI, implemented in 17 facilities across three districts: Mangochi, Nkhotakota and Chitipa. The SSDI-PBI programme and its implementation processes have been described in detail elsewhere.37 The programme, which lasted 2 years, was introduced in 2014 into a context where: funding for health resources was largely input based; financial autonomy was held at district and higher organisational levels (with health facilities holding limited control over their own resources); accountability of health facilities to the health system or communities was largely informal and inconsistent and severe general shortages in human and material resources persist.33 38 SSDI-PBI is similar to other PBF programs in that rewards were provided to health facilities on provision of a predefined set of health services stipulated in a service contract. In SSDI-PBI, improved service provision aimed to increase utilisation rates (also called ‘quantity indicators’ (online supplementary file appendix 2)) across the maternal health continuum (during antenatal, delivery and postpartum periods), newborn and child health and HIV and AIDS care and treatment. Quality indicators emphasised improvements in both the facility environment (eg, clean rooms that offered privacy) and how care was provided (eg, medical equipment was available and functioning), see online supplementary file appendix 2. In addition, the programme relied on an explicit community assessment of quality of service provision (via community meetings defined as ‘community scorecards’ and exit interviews). Payouts to facilities were made based on the joint assessment of quantity indicators, quality indicators and the community scores. bmjgh-2019-001894supp001.pdf bmjgh-2019-001894supp002.pdf The specific focus of this qualitative study on maternal care arises from the fact that while SSDI-PBI did not exclusively address maternal care services, the intervention aimed to improve maternal health by increasing the quantity (service coverage rates) and quality of: antenatal care visits within the first trimester, births attended by a skilled birth attendant (a doctor, nurse or midwife), postnatal care within 7 days of delivery and patients counselled for family planning. The SSDI-PBI programme was different from many other PBF programs in at least two respects: (1) the programme did not provide any monetary incentives (in the form of salary bonuses) to individual health workers; and (2) the programme’s incentives were exclusively goods-based, with the implementing agency coordinating the procurement and distribution of supplies and equipment to facilities in line with targets and incentives set in the facility business plan.39 This qualitative study was embedded within a broader mixed-methods evaluation of SSDI-PBI.37 Since our study aimed to explore group perceptions and experiences of SSDI-PBI, we employed qualitative methods.40 41 Because the team was interested in social norms, conversational interactions and bringing to the surface perspectives of the community in relation to healthcare amid SSDI-PBI, focus group discussions (FGDs) were used. Data collectors were trained for 5 days (including pilot testing). Data collectors had previous experience collecting data to inform health interventions, and they had academic training in nursing, journalism, midwifery, social work, education, administration or medicine. The qualitative training emphasised the SSDI-PBI intervention, FGD techniques and ethics. In March 2016, we conducted 17 focus group discussions with 4 to 12 community leaders per FGD across the 17 facility catchment areas (one FGD per facility). We also conducted 13 FGDs with 5 to 10 mothers in the catchment areas of 13 facilities (FGDs were concluded on saturation of themes). Community health workers (including health surveillance assistants and volunteers) assisted in identifying participants. In addition, data collectors canvassed villages and invited those present (and eligible) to participate. Sampling was purposively focussed on gathering perspectives from those living in the catchment areas of SSDI-PBI implementing facilities who were either mothers or community leaders (village health committee members, ward councillors, chiefs, village headmen, religious leaders and traditional healers). Topics across FGDs covered impressions of facilities, changes in facilities over time and knowledge and perceptions of the SSDI-PBI programme. Techniques undertaken to collect trustworthy, high quality data followed the approach of naturalistic inquiry put forth by Lincoln and Guba (1985),42 including prolonged engagement, triangulation and reflexive dialogue (see table 1). Following each FGD, a lead researcher debriefed data collectors for information regarding emergent themes, reflexive insights and questions that could merit more deliberate follow-up in later FGDs.43 During these meetings, the research team spoke openly about their thoughts and perceptions of the programme (both positive and negative) in order to build reflexive memos that were used to further inform the conduct of later interviews and, ultimately, the coding process. Notes captured during these debriefings were also shared with the wider research team (including senior authors) and formed the basis for coding all FGDs. All FGDs were conducted in the local language (Chichewa), recorded, transcribed, translated into English and quality controlled by bilingual research assistants. FGD tools are included in online supplementary file appendix 1. Techniques to enhance the credibility and confirmability of this qualitative study as informed by Lincoln and Guba’s criteria42 The first and second author analysed the data with support from all co-authors, drawing on the framework approach outlined by Pope.44 An inductive approach was used,40 meaning that themes were mainly generated from the data that were collected. First, the lead author repeatedly read transcripts and reviewed notes in order to gain familiarity with the data and understand connections across concepts.45 Second, the first author noted emerging themes from the text and coded chunks of data representing themes.45 Third, the first and second authors explored thematic areas by displaying the relevant coded text in each category to identify key themes and inter-relationships. Finally, all co-authors interpreted findings by discussing and agreeing on key themes that addressed the research question. The process was conducted using NVivo software. Respondents were informed in writing and orally about the nature and scope of the study. Participation in the study was entirely voluntary. Informed consent was sought from all study respondents. Respondents signed or finger printed the consent forms to show that they understood the conditions of the study and had agreed to take part. Further, respondents were informed to be free to stop any time if they felt it was important for them to do so. It was also made explicit to them that doing so will not disadvantage them in any way. Neither patients nor the public were involved in the design, conduct, reporting or dissemination of our research.
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