Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi

Chisomo Petross; Shannon McMahon; Julia Lohmann; Rachel P Chase; Adamson S Muula; Manuela De Allegri

doi:10.1136/bmjgh-2019-001894

Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi

BMJ Glob Health. 2020 Apr 1;5(4):e001894. doi: 10.1136/bmjgh-2019-001894. eCollection 2020.

Authors

Chisomo Petross^#^{1

2}, Shannon McMahon^#², Julia Lohmann^{2

3}, Rachel P Chase², Adamson S Muula^{4

5}, Manuela De Allegri²

Affiliations

¹ University of Malawi, Kamuzu College of Nursing, Private Bag 1, Lilongwe, Malawi.
² Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany.
³ Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, Keppel Street, London WC1E 7HT, UK.
⁴ Department of Public health, University of Malawi, College of Medicine, Blantyre 3, Malawi.
⁵ Africa Center of Excellence in Public Health, University of Malawi, College of Medicine, Blantyre, Malawi.

^# Contributed equally.

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.

Keywords: health economics; health systems; intervention study; public health; qualitative study.

Publication types

Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

Female
Humans
Malawi
Pregnancy
Prenatal Care*