Photo Credit: World Bank
Burkina Faso is experiencing a rapid population growth rate which is impeding its capacity to complete its demographic transition and to harness its economic potential. At the heart of this population growth is reproductive health: the 2010 Demographic and Health Survey indicates a high total fertility rate (i.e. 6 children per woman), high adolescent birth rate (i.e. 11 percent) and low contraceptive prevalence rate (15 percent). This is further compounded by poor child survival rates with only one in five children reaching the age of five, and by poor maternal outcomes, with only 17 percent of pregnant women completing four antenatal care visits (Annuaire Statistique, 2009). Further, there are large variations in access to services and health outcomes between urban and rural areas, and between the wealthiest 20 percent and the poorest 20 percent of the population. Doctors and midwives remain disproportionately concentrated in urban areas, and service quality is undermined by the inadequate motivation of public sector health workers due to low salaries, poorly developed career structures, and limited accountability for performance.
RBF AT A GLANCE
The Reproductive Health Project uses Performance-Based Financing (PBF) to concurrently improve the delivery and quality of Packages of Basic Health Care (PBHS) and stimulate demand at the community level. On the supply side, the Ministry of Health contracts health facilities to deliver a predefined package of services based on agreed indicators and targets. Upon the achievement and verification of results, each contracted facility receives a payment in partial reimbursement for the PBHS delivered. These quarterly PBF payments are disbursed based on the unit price of the service delivered and are adjusted for the quality of care. They are typically used by health personnel to increase both the demand for and the supply of reproductive health services.
The RBF verification function is led by an international firm contracted to independently verify achieved results. Specifically, this entity assesses the quality of services delivered through regular quality audits and patient satisfaction surveys. It oversees the quarterly verification of both quantity and quality carried out by external reviewers using routine performance data and survey results. The international firm also subcontracts community-based organizations to conduct targeted household surveys and exit patient surveys.
Status and Achievements – Fiscal Year 2016
Despite political turmoil, the PBF component continues to yield encouraging results.
The PBF pilot implemented from 2011 to 2013 in three districts has been instrumental in improving project design and ensuring a successful expansion to 15 districts. This underlines that the implementation of PBF should be gradual. It also highlights the decisive nature of piloting and learning for a successful scale-up.
EVALUATION AT A GLANCE
The impact evaluation tests combinations of PBF with pro-poor financing mechanisms such as community-based targeting of the poor for subsidized health care, and community-based health insurance. The baseline survey was completed in March 2014, and a report was presented and validated in November 2014. Implementation of PBF began in April 2014 and the targeting and insurance mechanisms were rolled out through randomized assignment in mid-2015. The endline survey is planned for January-April 2017. The impact evaluation also includes a “lab-in-the-field experiment” to test the effects of different incentive mechanisms on provider behavior in a lab-type setting.