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The widening gap between improving healthcare coverage rates and stagnating health outcomes across low-income and middle-income countries highlights the need for investments in quality of care, in addition to access. New research, presented in a World Bank report, examines one type of relevant policy reform: performance-based financing (PBF), which is a package reform that always includes performance pay to front-line health workers and often also provides facility autonomy, transparency and community engagement. A large body of rigorous studies and new analysis show that in under-resourced, centralised health systems, PBF can result in gains to service utilisation, but only has limited impacts on quality. Even the relative benefits of PBF on service utilisation are less clear when compared with (1) direct facility financing which provides front-line facilities with operating budgets and provider autonomy, but not performance pay and (2) demand-side financial support for health services (ie, conditional cash transfers and vouchers). Thus, the central component of PBF—the performance pay—appears to add little value over flexible payment systems and provider autonomy. The analysis shows that this lack of impact is unsurprising because most of the constraints to improving quality do not lie with the health worker in these settings. While PBF was conceived as a complex package ‘blueprint’, we review the evidence to conclude that only some elements seem to make sense. To improve quality of care, health financing should pivot from performance pay while retaining the elements of direct facility financing, autonomy, transparency and community engagement.

Background After neonatal conditions, the leading causes of child mortality in sub-Saharan Africa are malaria, lower respiratory infections, and dehydration. Many of these deaths could be averted with basic and widely-available health interventions, but quality of care remains low. We aimed to assess adherence to clinical guidelines for these conditions in Burundi, the Democratic Republic of the Congo (DRC), and Nigeria, and estimate the proportion of guideline non-adherence that is explained by gaps in health care provider knowledge versus other factors. Methods We conducted an observational study in randomly-sampled health facilities in each study country, linking data from direct observations of under-5 sick child visits, knowledge assessments of the treating health care providers, and interviews with caregivers. For children diagnosed with malaria, severe respiratory infection, or dehydration, we defined the “adherence gap” as the percentage who did not receive correct treatment, and the “know-do gap” as the percentage who received incorrect care despite the provider knowing the correct treatment. We evaluated the portions of overall adherence gaps that were explained by know-do gaps, and described factors associated with know-do gaps. Results A total of 2,212 sick child visits treated by 852 providers were analyzed. In the pooled sample, 87%, 75%, and 77% percent of providers were familiar with the main treatment recommendations for malaria, pneumonia, and dehydration, respectively. When observed by survey staff during consultations with sick children, compliance with the same guidelines was 76%, 74%, and 51%. Knowledge gaps explained between 0% of the total adherence gap for pneumonia treatment in Burundi and 40% of the gap for pneumonia treatment in the DRC. Conclusions To improve quality of care, it is critical to understand why providers do not consistently follow clinical guidelines. Our findings suggest that adherence to protocols is low, but that knowledge is not the primary barrier. Interventions to improve quality must go beyond improving knowledge to also address other drivers of provider behavior such as motivation, workload, and systemic constraints.

Background Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. Methods We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. Results PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual ( p <0.01). PBF and DFF were more effective than business-as-usual for Penta3 ( p <0.05 and p <0.01, respectively); PBF also for mCPR ( p <0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual ( p <0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF ( p <0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution ( p <0.05). Conclusions Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. Trial registration ClinicalTrials.gov NCT03890653 ; May 8, 2017. Retrospectively registered.

The COVID-19 pandemic brought to the fore long-standing inequities that resulted in certain already-vulnerable groups bearing a disproportionate burden of the disease. The poor have worse health outcomes and access to care, and live and work in inferior conditions, leading to a greater risk of severe illness and death.

The global incidence of very intense cyclones has increased in recent decades with climate projections signaling that this trend will intensify. To what degree can vulnerability to extreme weather events be mitigated by access to a rural livelihoods program, particularly with regard to the impacts on women? This paper addresses this question through a natural experiment arising from two independent but overlapping sources of variation: exposure to a devastating cyclone that occurred in the Bay of Bengal region of India and the staggered rollout of a rural livelihoods intervention. Comparisons from household surveys across communities more or less exposed to the storm before and after the introduction of the program reveal that the storm led to significant reductions in overall household expenditure, and that these reductions were indeed the largest for women, adding to the emerging evidence for the frequently-posed hypothesis that women bear the brunt of the effects of disasters on overall household consumption. Participation in the livelihoods program mitigated some of the reductions in household nonfood expenditure and women’s consumption, but not on food expenditure. These results from a densely populated region whose topography makes it particularly vulnerable to storms can inform future policy approaches and aid in modeling the impact of these policies on the effects of climate change.

This Policy Research Report examines one specific policy approach to improving effective coverage: financial incentives in the form of performance-based financing (PBF) or financial incentives to health workers on the front lines.

Could a partial subsidy for child education increase child labor? Using data from the randomized evaluation of a conditional cash transfer program (CCT) in the Philippines, we find that children who were neither in school nor work in the absence of the program not only increased school participation but also increased work for pay. We show suggestive evidence that because the cash transfer only provided a partial schooling subsidy children worked to cover the shortfall in schooling fees. Our findings contribute to the increasing evidence that the design of CCTs, in this case transfer size, matters considerably in terms of achieving program goals.

Peer networks provide their members new information about employment opportunities (Munshi and Rosenzweig 2006), shape available economic opportunities (Skoufias, Lunde, and Patrinos 2009), supply marital partners (Banerjee et al. 2009), facilitate adoption of new technologies (acite[Conley and Udry 2010]bib5; Montgomery and Casterline 1996). Montgomery and Casterline distinguish between two key effects of social networks: information and influence. In both cases, homophily-induced homogeneous networks may limit the network's ability to affect social norms or at least delay the process, since information and social norms are likely already common to the network, and may well presumably be reinforced instead of challenged by network connections. Indeed, economists have found both theoretical and empirical evidence suggesting that homophily slows social learning and therefore convergence in the adoption of new technologies (Behrman, Kohler, and Watkins 2002; Golub and Jackson 2011, 2010). Reprinted by permission of the American Agricultural Economics Association

Background Malaria continues to be a prominent global public health challenge. This study tested the effectiveness of two service delivery models for reducing the malaria burden, e.g. supportive supervision of community health workers (CHW) and community mobilization in promoting appropriate health-seeking behaviour for febrile illnesses in Odisha, India. Methods The study population comprised 120 villages from two purposively chosen malaria-endemic districts, with 40 villages randomly assigned to each of the two treatment arms, one with both supportive supervision and community mobilization and one with community mobilization alone, as well as an observational control arm. Outcome measures included changes in the utilization of bed nets and timely care-seeking for fever from a trained provider compared to the control group. Analysis was by intention-to-treat. Results Significant improvements were observed in the reported utilization of bed nets in both intervention arms (84.5% in arm A and 82.4% in arm B versus 78.6% in the control arm; p < 0.001). While overall rates of treatment-seeking were equal across study arms, treatment-seeking from a CHW was higher in both intervention arms (28%; p = 0.005 and 27.6%; p = 0.007) than in the control arm (19.2%). Fever cases were significantly more likely to visit a CHW and receive a timely diagnosis of fever in the combined interventions arm than in the control arm (82.1% vs. 67.1%; p = 0.025). Care-seeking from trained providers also increased with a substitution away from untrained providers. Further, fever cases from the combined interventions arm (60.6%; p = 0.004) and the community mobilization arm (59.3%; p = 0.012) were more likely to have received treatment from a skilled provider within 24 hours than fever cases from the control arm (50.1%). In particular, women from the combined interventions arm were more likely to have received timely treatment from a skilled provider (61.6% vs. 47.2%; p = 0.028). Conclusion A community-based intervention combining the supportive supervision of community health workers with intensive community mobilization and can be effective in improving care-seeking and preventive behaviour and may be used to strengthen the national malaria control programme.

Dans de nombreux pays à faible revenu et à revenu intermédiaire, la couverture sanitaire s'est considérablement améliorée au cours des deux dernières décennies, mais pas les résultats en matière de santé.