Photo credit: World Bank/Dominic Chavez
During the past two decades, Ghana made steady progress in maternal and child health outcomes. Child mortality decreased substantially to reach 60 deaths per 1,000 live births in 2011 (DHS, 2014); maternal mortality almost halved to reach 380 deaths per 100,000 live births (MMEIG 2014) ; and the total fertility rate (TFR) declined from 6.4 children per woman in 1988 to 4.2 children per woman in 2014. Despite this progress, large disparities remain – for instance, while 90 percent of pregnant women in urban areas deliver in health facilities, 41 percent of pregnant women in rural areas deliver at home. Furthermore, almost 80 percent of children from the lowest wealth quintile suffer from some form of iron-deficiency anemia, compared to 47 percent in urban areas (DHS, 2014).
RBF AT A GLANCE
MCHNP is currently piloting community Performance-based Financing (cPBF) in eight districts in four regions (i.e. Northern, Volta, Upper East and Upper West regions) to boost service utilization and improve maternal and child nutrition and health outcomes. The focus of the Ghana cPBF is on the Community Health Teams (CHTs), which is composed of Community Health Officers and Community Health Volunteers. CHTs operate in Community-based Health and Planning Services (CHPS) zones, from where they deliver a package of essential community maternal, child health and nutrition services to a catchment population of approximately 4500-5000 people. CHTs primarily deliver preventive services, but also basic clinical services, through static and outreach activities, including home visits and community durbars.
Incentive payments are made by the central level Ghana Health Service Finance Department (through the Regional Health Directorate) based on the validation of a set of pre-defined quantity and quality maternal, child health and nutrition indicators. CHTs invest their cPBF payments based on individual semi-annual operational plans.
The cPBF internal verification function is led by the District Health Assembly, along with the District Health Team. Validation of the quantity indicators is conducted on a monthly basis by the District Health Assembly. On a quarterly basis, the District Health Team assesses the quality of services provided through record reviews, direct observations and the administration of a quality checklist. This verification is supplemented by quarterly community surveys conducted by community-based organizations to both track patients and measure client satisfaction. Furthermore, an independent External Verification Agency (EVA) is contracted to lead counter-verification activities.
Status and achievements
The MCHNP cPBF component was pre-piloted from April to September 2015 in 16 health zones in four districts. Impeded by limited capacity, this pre-pilot experience did not provide sufficient information to evaluate the feasibility and effects of cPBF in Ghana. In this context, the cPBF Steering Committee decided on a phased piloting of cPBF to ensure continuous learning and project improvement – starting with two districts in the first phase, adding two districts in the second phase and including the last four districts in the final phase. Preparatory activities (including capacity building activities) have been underway during 2016, including technical support visits by a PBF Specialist to assist the Government to fine-tune the pilot design, and the participation of the Ghana team in the Mombasa cPBF training sponsored by SINA. Following a CHPS validation exercise conducted by GHS and the World Bank in Quarter 4 2016, it was assessed that the CHPS zones in the 2 initial districts did not have the basic equipment or human resources to adequately deliver essential services required to meet the pre-defined indicators. Start-up grants were disbursed to the CHPS zones to perform a basic equalization process. The cPBF training for the intervention zones has been confirmed for mid-February 2017 and the first quarter for cPBF indicator verification will be March-May 2017.
- Technical assistance is critical in the early stages of project design, particularly to calibrate incentives, define reliable quantity and quality measures, and establish a methodology for incentive distribution.
- It is important to match the evolving nature of an operational design with an adaptable impact evaluation design, factoring-in redesign costs to cater for this lengthier preparatory phase.
- Capacity building for key personnel should be mandatory and upfront to ensure buy-in of the operational concepts and requirements of PBF, a common understanding of impact evaluation-related concepts and objectives, and a better appreciation of how impact evaluations can inform operations and policy-making.
EVALUATION AT A GLANCE
The Impact Evaluation is a two-armed multi-site cluster randomized control trial design: it compares the impact of cPBF payments, using CHTs as treatment groups, with the impact of traditional input funding using CHPS zones as control groups. The baseline survey data collection was conducted from June-November 2016 and the baseline survey dissemination is planned for May 2017.