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Background: Results Based Financing (RBF) interventions have recently gained significant momentum, especially in sub-Saharan Africa. However, most of the research has focused on the evaluation of the impacts of this approach, providing little insight into how the contextual circumstances surrounding the implementation have contributed to its success or failure. This study aims to fill a void in the current literature on RBF by focusing explicitly on the process of implementing a RBF intervention rather than on its impact. Specifically, this study focuses on the acceptability and adoption of the RBF intervention’s implementation among local and international key stakeholders with the aim to inform further implementation. Methods: The Results Based Financing for Maternal and Neonatal Health (RBF4MNH) Initiative is currently being implemented in Malawi. Our study employed an exploratory cross-sectional qualitative design to explore the factors affecting the acceptability and adoption of the intervention’s implementation. Purposeful sampling techniques were used to identify each key stakeholder who participated in all or parts of the implementation process. In-depth interviews were conducted and analyzed using a deductive open coding approach. The final interpretation of the findings emerged through active discussion among the co-authors. Results: Despite encountering several challenges, such as delay in procurement of equipment and difficulties in arranging local bank accounts, all stakeholders responded positively to the RBF4MNH Initiative. Stakeholders’ acceptance of the RBF4MNH Initiative grew stronger over time as understanding of the intervention improved and was supported by early inclusion during the design and implementation process. In addition, stakeholders took on functions not directly incentivized by the intervention, suggesting that they turned adoption into actual ownership. All stakeholders raised concerns that the intervention may not be sustainable after its initial program phase would end, which contributed to hesitancy in fully accepting the intervention. Conclusions: Based on the results of this study, we recommend the inclusion of local stakeholders into the intervention’s implementation process at the earliest stages. We also recommend setting up continuous feedback mechanisms to tackle challenges encountered during the implementation process. The sustainability of the intervention and its incorporation into national budgets should be addressed from the earliest stages.
Our study took place in Malawi, a low-income country in Southern Africa, which has high maternal and child mortality rates. Similar to most countries in sub-Saharan Africa, Malawi is not on track to achieve Millennium Development Goal 5 to reduce maternal mortality, in spite of recent progress showing the Maternal Mortality Ratio steadily decreasing from 1120/100,000 in the year 2000 to a figure of 510/100,000 in 2013 [9]. Surveys performed by the Ministry of Health indicated that several factors contribute to high maternal and neonatal mortality, including low quality of care, poor staff attitude, inadequate supplies, and difficulty obtaining or paying for transport to a health facility [10]. In 2004, an Essential Health Package was implemented in Malawi which delivers basic health services free of charge, through tax revenues and donor funds, but inadequate quality and access to services persist [11–13]. In addition, Malawi relies on a large amount of donor support to finance its health sector, accounting for 66 % of total health spending in 2008–2009 [14]. In line with the Millenium Development Goals and national health strategy, the Results Based Financing for Maternal and Neonatal Health (RBF4MNH) Initiative is currently being implemented in Malawi to improve the quality and access to maternal and neonatal health services [15, 16]. The Reproductive Health Directorate of the Ministry of Health (MoH) is implementing the intervention with technical support from Options Consultancy Services Ltd., a UK-based consultancy firm. The German Development Bank (KfW) and the Government of Norway, represented by the Royal Norwegian Embassy (RNE), are providing financial support. The intervention combines supply-side incentives typical of PBF schemes with demand-side incentives in the form of conditional cash transfers. The supply-side incentives are provided based on quality-performance contracts between district and local health facility teams and the Ministry of Health and include performance indicators consistent with emergency obstetric care standards (Table 1). The demand-side incentives consist of cash reimbursements to pregnant women to compensate for transport to a health facility for delivery and stay for 48 h after delivery (Table 2). Before and during the intervention, direct investments were made to upgrade buildings and provide equipment to guarantee minimum standards needed to provide quality maternal and neonatal health care services. The intervention is being implemented in the four districts of Balaka, Ntcheu, Dedza, and Mchinji. After months of preparation, the supply-side component began in April 2013 with verification and reward cycles occurring every 6 months. The demand-side component launched in different districts between November 2013 and June 2014. Data for this study was collected in June 2014, shortly after providers had received the second round of incentive payments. Supply Side Initiatives Demand Side Initiatives Our study focused specifically on acceptability and adoption of the RBF4MNH Initiative among key stakeholders during its early implementation stages. Acceptability and adoption were selected as the focus of our analysis, since these two factors are critical to the initial stages of implementation of health interventions. We define acceptability as “the perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory” [17]. This includes any factors related to acceptability such as comfort or credibility of the intervention [18], which are particularly important during an intervention’s initial phase. We define adoption as “the intention, initial decision, or action to employ an innovation or evidence-based practice” [17]. Adoption refers to the uptake or intention to try a new intervention among stakeholders [18]. In addition, the sustainability of an intervention influences a stakeholder’s decision to fully invest in an intervention. These definitions of acceptability and adoption, along with the intervention’s design and sustainability, were used as a conceptual framework to assess the RBF4MNH Initiative implementation process. Since the RBF4MNH Initiative is the first health intervention in Malawi employing RBF, an exploratory cross-sectional qualitative design was selected to explore possible factors affecting the implementation and to allow for a better understanding of key issues encountered during this process. This study examined the implementation process from the design phase beginning in November 2011 through part of the initial implementation phase from April 2013 to June 2014. The authors were part of an independent research team set to evaluate the impact of the RBF4MNH Initiative on service use and quality of healthcare services [8]. Within the framework of this independent evaluation, the authors established frequent contact and information exchange with all concerned policy and implementation stakeholders. It is due to this constant exchange that the study team could identify all relevant stakeholders to be interviewed. The final study population consisted of 24 individuals, purposely selected to represent the totality of key policy and implementing stakeholders in the country. The sample included three representatives of the external project funders (one German Development Bank (KfW) technical expert, one Royal Norwegian Embassy (RNE) local health officer and deputy ambassador) and five central-level MoH representatives (the director of the Reproductive Health Directorate, the director of Planning and Policy, the former and current directors of the Sector Wide Approach Program (SWAp), and the zonal supervisor for the project area) who were responsible for aligning the intervention with national health priorities. Seven key representatives were selected from the implementation team, which included the Reproductive Health Directorate’s Chief Health officer, three external and three local technical consultants hired through Options Consultancy Services, Ltd. In addition, eight representatives from the District Health Management Teams (DHMT) were interviewed consisting of District Health Officers and District Nursing Officers in each of the four districts, who were actively involved in the implementation process and also direct beneficiaries of the rewards. Lastly, an interview was conducted with the local Health Program Director of the German Malawian Health Program (Deutsche Gesellschaft für Internationale Zusammenarbeit or GIZ) who provided additional technical support. Data was collected through individual interviews with all respondents. Interviews were conducted directly by the first author either in person or via Skype. A total of seven semi-structured interview guides, each one specifically tailored to a different respondent group, were used as an aid during interviews (See Additional file 1). The interview guides were developed by the first author with the support of the co-authors and explored relevant factors related to acceptability and adoption of the RBF4MNH Initiative during the design and early implementation phases. Questions addressed the overall concepts of acceptability and adoption and specific probes investigated the motivation behind the initial responses. Interview guides were revised as the interviews proceeded to accommodate any additional emerging theme. All interviews were digitally-recorded. Written informed consent was obtained from the respondents prior to each interview. Each respondent was instructed that interviews could be declined or stopped at any time without consequences. Anonymity was provided to the greatest extent possible by referencing quotes to a particular stakeholder group instead of an individual’s specific position. The first author verbatim transcribed all digital interview recordings was responsible for the initial coding and analysis with support from the last author. Analysis began by organizing the transcribed material into meaningful units using a deductive open coding approach, with codes emerging as reading of the text progressed [19]. Once the initial coding was completed, the first and last author engaged in an iterative process to further organize coded text into overarching themes and to elucidate relationships between themes. The final interpretation of the findings, as presented in this manuscript, emerged through active discussion among the co-authors. Analysis was completed with the support of the software Nvivo.
