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Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi
Chisomo Petross1,2, Shannon McMahon2, Julia Lohmann2,3
1University of Malawi, Kamuzu College of Nursing, Private Bag 1, Lilongwe, Malawi.
BMJ Global Health
|April 28, 2020
Summary
Community members had mixed views on the Support for Service Delivery Integration - Performance-Based Incentives (SSDI-PBI) program in Malawi. While some improvements were noted, unintended negative effects on maternal care and access were also reported.
Area of Science:
- Health Systems Strengthening
- Public Health Interventions
- Qualitative Research Methods
Background:
- Performance-based financing (PBF) evaluations are common in low-income countries, but community perspectives are often overlooked.
- The Support for Service Delivery Integration - Performance-Based Incentives (SSDI-PBI) is a PBF intervention implemented in Malawi.
- This study investigates community members' views on the SSDI-PBI program and its unintended consequences.
Purpose of the Study:
- To assess community members' perspectives on the SSDI-PBI program in Malawi.
- To explore unintended effects arising from the implementation of the SSDI-PBI intervention.
Main Methods:
- Conducted 30 focus group discussions: 17 with community leaders and 13 with mothers.
- Participants were drawn from catchment areas of SSDI-PBI implementing facilities.
- Data analysis employed the framework approach.
Main Results:
- Community leaders and women reported mixed impressions of SSDI-PBI's impact on facility service delivery.
- Noted improvements included better staff-community dialogue, enhanced facility conditions (cleanliness, equipment, privacy).
- Persistent challenges included inadequate/overworked staff, overcrowding, and long travel distances.
- Four targeted indicators (maternal risk management, early ANC, skilled birth attendance, couple's HIV testing) led to unintended negative effects, such as women delivering at home, uncertainty about pregnancy, dissatisfaction with care quality, and denial of ANC for partnerless women.
Conclusions:
- PBF programs like SSDI-PBI can improve certain service delivery aspects.
- System-wide improvement requires adequate resources (medicines, equipment, staff) and alignment of program priorities with cultural expectations.
- Facilities need support to manage increased client loads and heightened service expectations resulting from PBF interventions.
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