Abstract
Most evidence on Performance Based Financing (PBF) in low-income settings has focused on services delivered by providers in targeted health administrations, with limited understanding of how effects on health and care vary within them. We evaluated the population effects of a program implemented in two provinces in Mozambique, focusing on child, maternal and HIV/AIDS care and knowledge. We used a difference-in-difference estimation strategy applied to data on mothers from the Demographic Health Surveys, linked to information on their closest health facility. The impact of PBF was limited. HIV testing during antenatal care increased, particularly for women who were wealthier, more educated, or residing in Gaza Province. Knowledge about transmission of HIV from mother-to-child, and its prevention, increased, particularly for women who were less wealthy, less educated, or residing in Nampula Province. Exploiting the roll-out by facility, we found that the effects were concentrated on less wealthy and less educated women, whose closest facility was in the referral network of a PBF facility. Results suggest that HIV testing and knowledge promotion increased in the whole district, as a strategy to boost referral for highly incentivized HIV services delivered in PBF facilities. However, demand-side constraints may prevent the use of those services.
| Original language | English |
|---|---|
| Pages (from-to) | 1525-1549 |
| Number of pages | 25 |
| Journal | Health Economics |
| Volume | 32 |
| Issue number | 7 |
| Early online date | 27 Mar 2023 |
| DOIs | |
| Publication status | Published - 31 Jul 2023 |
Bibliographical note
The data used are publicly available from The DHS program website or upon request from the National Institute of Health of Mozambique (INS).
Funding
We are grateful to Josephine Borghi, Søren Rud Kristensen, Garret Brown, Neide Canana, Laurentino Cumbi, Armindo Nhanombe, Neha Singh, Roxanne Kovacs, Gwati Gwati, Artwell Kadungure, Rene Loewenson, EGPAF Mozambique, and two anonymous reviewers. All remaining errors are ours. Laura Anselmi was funded by UKRI‐MRC grant [MR/S022554/1]. Julius Ohrnberger was funded by UKRI‐MRC grant [MR/T025409/1]). All authors were funded by the HSRI Grant MR/P014429/1 “Strengthening health system delivery and quality: Mechanisms and Effects of Performance Based Financing in the Sub‐Saharan context”. The PBF program was funded by the United States President's Emergency Plan for AIDS Relief (PEPFAR) through the Center for Disease Control (CDC) and was implemented by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). The CDC was already actively supporting Gaza and Nampula provinces in providing HIV/AIDS care. The health facilities enrolled in the program were selected from those serving a large population and offering HIV/AIDS services, including adult or pediatric ART and PMTCT. Those facilities had to meet minimum staffing requirements and, either have a bank account, or be under the financial supervision of the SDSMAS. The PBF scheme was rolled‐out over four periods: Phase 1 starting in January 2011 (30 facilities in Nampula and in 18 Gaza); Phase 2 in March 2012 (41 facilities in Nampula and in 23 Gaza), Phase 3 in September 2013 (15 facilities in Nampula and 25 in Gaza) and Phase 4 in September 2014 (no facilities in Nampula and 21 in Gaza). No new districts were enrolled from September 2013 onwards (Figures A2 and A3 in Appendix). No change was implemented in the remaining facilities as part of the scheme.
| Funders | Funder number |
|---|---|
| UKRI-MRC | |
| UKRI‐MRC | MR/T025409/1, MR/S022554/1 |
| United States President's Emergency Plan for AIDS Relief | |
| Centers for Disease Control and Prevention | |
| Elizabeth Glaser Pediatric AIDS Foundation | |
| U.S. President’s Emergency Plan for AIDS Relief | |
| Health Systems Research Institute | MR/P014429/1 |
