Photo credit: World Bank/Dominic Chavez
Although progress has been made in the health sector, maternal and child health indicators continue to perform poorly in Haiti. Under-five mortality remains high with 87 deaths per 1,000 live births and children under five facing high risks of morbidity from preventable illnesses, including diarrheal diseases and pneumonia. In addition, the maternal mortality ratio also continues to be high with 372 deaths per 100,000 live births (World Bank, 2012) and women facing the compounded effects of poor maternal nutrition, high incidences of home deliveries, limited post-natal care and poor access to family planning. Further, significant economic disparities persist, creating wide variations in terms of both access and in terms of the quality of care. While more that 65 percent of women among the wealthiest quintile delivered with a trained medical professional, only 6 percent of women in the poorest wealth quintile were professionally assisted during delivery. Conversely, while nine out of ten women in the wealthier quintile had a blood or/urine sample collected during an antenatal care visit, less than 50 percent of women in the poorest wealth quintile benefited from these standard tests (DHS, 2012).
RBF AT A GLANCE
The project entitled “Improving Maternal and Child Health through Integrated Service Delivery” uses a supply-side performance-based financing (PBF) scheme to improve the quality and utilization of maternal and child health services across Haiti. Under this scheme, the Ministry of Public Health and Population (MSPP) contracts first line and second line primary healthcare facilities to deliver a predefined package of services. Based on a fee-for-service mechanism, contracted facilities are paid quarterly by the Directorate for Administration and Budget. PBF payments are disbursed based on the quantity, quality and equity of the maternal and child health and nutrition services provided. Health facilities can use these payments with a substantial level of autonomy to respond to context specific issues and incentives health care professionals.
An external independent agency is contracted to lead the RBF verification function. Specifically, it conducts quarterly assessments of the quantity of services delivered using health facility reports and registries. These assessments are supplemented by community surveys which are implemented quarterly to both trace patients in communities and ascertain that services were delivered as reported. These verifications of quantity are supplemented by the quarterly administration of a quality checklist at health facility.
Status and achievements
The PBF project was initially piloted for 16 months the Northeastern Department of Haiti. Operational results indicate that the project impelled significant increases in service utilization, with surges of 41 percent in nutritional screenings, 65 percent in under-five immunizations, 40 percent in institutional deliveries, and 23 percent in contraceptive use. Further, these results highlight a significant improvement in the quality of care with quality scores rising from 50 to 90 percent across health facilities over the piloting period.
Based on these encouraging results, the PBF project was scaled up to three additional Departments (i.e. Central, Southern and Northern Departments) in June 2016. Implementation has, however, been impeded by various external factors including disputed elections, a lengthy strike in the health sector, reduced external health financing, and natural disasters (i.e. Hurricane Matthew).
The medium and long-term financial sustainability of PBF should be considered at the project’s onset/during project design.
EVALUATION AT A GLANCE
The Impact Evaluation will compare performance – measured in terms of health outcome and output variables – in three different groups, which will be selected in a randomized fashion:
- A treatment group receiving PBF payments and technical support;
- A comparison group only receiving technical support;
- A control group receiving neither PBF payments nor technical support.
A baseline household survey and a baseline health facility survey were conducted from January to March 2016 with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Tuberculosis and Malaria, USAID and the World Bank.