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GLOBVAC-Global helse- og vaksin.forskn

Evaluation of the implementation and long-term impact of performance based financing of health services in Tanzania

Alternative title: Evaluering av implementering og langtidsvirkninger av resultatbasert finansiering av heletjenester i Tanzania

Awarded: NOK 17.5 mill.

Results-based financing is used to a greater extent than before to increase the use and raise the quality of health services in low- and middle-income countries. This project has studied the implementation and effects of results-based financing of health services in Tanzania. Results-based financing means that health clinics and / or health workers receive cash payments in relation to the results they achieve. The results can, for example, be measured as the number of patients who have received a service, the extent to which the health clinic meets quality standards, etc. Results-based financing also entails greater autonomy of health facilities, while there are also increased reporting requirements. The idea is that these reforms will stimulate increased creativity and efforts to raise the quality of health services and increase the use of health services . This project has studied the effects of two different versions of results-based financing; one model was implemented in Pwani region from 2012, and the other was implemented in Mwanza region from 2016. Results: After one year of performance-based financing in the Pwani region, we found an increase in two of eight performance indicators; the proportion who gave birth in a health clinic increased by 8 per cent, and the proportion who received malaria prophylaxis during pregnancy increased by 10 per cent. We found no increase in vaccination coverage. The proportion who had to pay to give birth at a health clinic fell by 5 per cent. After three years of performance-based financing in Pwani, we found that the effects were smaller than after one year. The increase in the proportion who gave birth at a health clinic was then 4 per cent. This is despite the fact that the proportion who gave birth in a clinic continued to increase in Pwani. However, the increase was even stronger in the control region. Thus, the entire increase cannot be attributed to results-based financing. Taken together, our findings suggest that performance-based funding has helped accelerate the trend towards increased use of these health services. Preliminary analyzes of the effects of performance-based financing in Mwanza indicate that mothers went for check-ups earlier in the pregnancy and that they had several pregnancy check-ups. It also led to several follow-ups visits in the first days after birth. However, results-based financing did not lead to a statistically significant increase in the proportion who received such follow-up visits. This suggests that the incentives pull in the direction of offering more follow-up visits to those who have already received it, rather than offering follow-up visits to those who did not. We also find no effect on the proportion who gave birth in a clinic. The share has admittedly increased sharply over time, but since the same has happened in the Mara control region, we cannot conclude that the increase in Mwanza is due to results-based financing. Several other performance indicators show a similar pattern; health service use is increasing both in Mwanza and in the control region. A clear result, however, is that results-based financing has led to perceived higher quality of the health services, both structurally and at the interpersonal level. A larger proportion of mothers who recently gave birth say that medicines were available at the health clinic and that the health workers were listening carefully and talking to the patients without using harsh language. In summary, we find that results-based financing has led to a positive development in the use and quality of several health services related to pregnancy and childbirth. The in-charges of health clinics claim that these changes are due to the fact that results-based financing has 1) increased access to resources, 2) provided clear incentives, 3) strengthened performance measurement, and 4) strengthened the autonomy of the health clinics. This has raised the morale of the health workers and enabled them to do a good job, made them more responsive to patients, reduced absenteeism, and strengthened teamwork. Possible impacts: The results of the project are highly relevant for the ongoing discussions about health financing reforms in Tanzania, as well as in and other low- and middle-income countries. The primary users of the results will be the Government of Tanzania, the World Bank and other international donors in Tanzania. At the moment, the government?s preference seems to be for another performance-based system than the one that we evaluated, but the insights from our research can also inform the design of this other financing system. Partners: The project has been implemented by an interdisciplinary team in a partnership between Chr. Michelsen Institute, Ifakara Health Institute, and London School of Hygiene and Tropical Medicine.

Outcomes: - PhD - IHI a leading research intitute on RBF, several researchers - CMI has built competence - Dialogue established with the Government of Tanzania, WB, Power of Nutrition, and other stakeholders. - A platform for mobilising additional funding from WB. - A basis for research application for new project funding from Horizon 2020. Impacts: - International research collaboration with LSHTM and IHI. - Collaboration with the World Bank on additional projects related to RBF. - Intermediate results obtained through repeated process evaluations have informed the RBF implementation process. - Anticipate that the final results will inform ongoing discussions about how to continue the health financing reform process in Tanzania. (More about decentralized funding through DHFF?)

The project will study the implementation and impact of performance based financing of health care in Tanzania. It will add to the limited evidence base regarding the implementation process, cost and long-term impact of performance based financing in the health sector. Our project is novel in several ways: a) We will collect data over a long period to assess the enduring adaptation to, and impact of, performance incentives in health service provision. b) We will measure non-intended (positive and negati ve) effects of incentivising professional work. Our long-term perspective will enable us to say something about whether the potential dysfunctional effects aggravate or dissipate over time. In the second phase of this project we will study the national scale up of PBF in Tanzania. Tanzania is the first large country to implement performance based financing of health services at a national level. This is a major reform and it is of foremost importance to evaluate the process around the design and implem entation of such a program.

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GLOBVAC-Global helse- og vaksin.forskn