Boosting facility deliveries with results-based financing: a mixed-methods evaluation of the government midwifery incentive scheme in Cambodia

Abstract

BackgroundIncreasing the coverage of skilled attendance at births in a health facility (facility delivery) is crucial for saving the lives of mothers and achieving Millennium Development Goal five. Cambodia has significantly increased the coverage of facility deliveries and reduced the maternal mortality ratio in the last decade. The introduction of a nationwide government implemented and funded results-based financing initiative, known as the Government Midwifery Incentive Scheme (GMIS), is considered one of the most important contributors to this. We evaluated GMIS to explore its effects on facility deliveries and the health system.MethodsWe used a mixed-methods design. An interrupted time series model was applied, using routine longitudinal data on reported deliveries between 2006 and 2011 that were extracted from the health information system. In addition, we interviewed 56 key informants and performed 12 focus group discussions with 124 women who had given birth (once or more) since 2006. Findings from the quantitative data were carefully interpreted and triangulated with those from qualitative data.ResultsWe found that facility deliveries have tripled from 19 % of the estimated number of births in 2006 to 57 % in 2011 and this increase was more substantial at health centres as compared to hospitals. Segmented linear regressions showed that the introduction of GMIS in October 2007 made the increase in facility deliveries and deliveries with skilled attendants significantly jump by 18 and 10 % respectively. Results from qualitative data also suggest that the introduction of GMIS together with other interventions that aimed to improve access to essential maternal health services led to considerable improvements in public health facilities and a steep increase in facility deliveries. Home deliveries attended by traditional birth attendants decreased concomitantly. We also outline several operational issues and limitations of GMIS.ConclusionsThe available evidence strongly suggests that GMIS is an effective mechanism to complement other interventions to improve health system performance and boost facility deliveries as well as skilled birth attendance; thereby contributing to the reduction of maternal mortality. Our findings provide useful lessons for Cambodia to further improve GMIS and for other low-income countries to implement similar results-based financing mechanisms.

Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries

“…In Cambodia, no formal program about home SBA is reported in the literature. According to Por et al, home SBA deliveries are driven by economic interest from government health personnel, who can charge women for the delivery at home, but not in a public facility [ 53 , 54 ]. In Tajikistan, health care has deteriorated dramatically since 1991 [ 55 , 56 ], and most rural maternities are operating without the basic conditions such as heat or running water.…”

Factors associated with misreporting in performance‐based financing in Burkina Faso: Implications for risk‐based verification

“…Performance‐based financing (PBF) has been piloted in many low‐ and middle‐income countries (LMICs) in the last decade with the aim of improving both the quantity and the quality of health services delivery. Through the provision of performance‐conditional financial incentives and greater autonomy in facility management, PBF is expected to motivate and enable health workers to facilitate access to health care, strengthen health worker productivity, and improve service quality.…”

Administrative reform and pay‐for‐performance methods of primary health service delivery: A comparison of 3 health districts in Cambodia, 2006‐2012

“…The findings are indicative of the SOA experience but cannot be taken as representative of all SOA districts. The data for deliveries by trained staff were complex, as it measured both access to services and utilization of services, it involved deliveries in hospitals as well as in health centres, and it was affected by the nationwide midwife bonus 24 as well as positive changes in community attitudes toward facility-based birthing. 25 Even so, we…”