Article Text
Abstract
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.
- public health
- qualitative study
- intervention study
- health systems
- health economics
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Footnotes
Handling editor Seye Abimbola
Twitter @shannonamcmahon
CP and SM contributed equally.
Contributors The first (C Petross) and second (S McMahon) authors contributed equally to this article. All authors contributed to the writing of this manuscript.
Funding This research project is made possible through Translating Research into Action, TRAction, which is funded by United States Agency for International Development (USAID) under cooperative agreement number No. GHSA-00-09-00015-00. The project team includes the University of Heidelberg as prime recipient and the University of Malawi at the College of Medicine in Malawi as a sub-recipient. Dr McMahon is supported via an Olympia Morata Program Grant from Heidelberg University.
Competing interests Both the implementation team and the evaluation team are funded by USAID through two independent funding streams for implementation and evaluation efforts, respectively.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Patient consent for publication Not required.
Ethics approval This study received ethical approval from the College of Medicine in Malawi (ethical approval code: P.09/15/1803) and the University of Heidelberg in Germany (ethical approval code: S-385/2015).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.