SSM – Population Health 3 (2017) 179–184 Contents lists available at ScienceDirect SSM – Population Health journal homepage: www.elsevier.com/locate/ssmph Article Performance-based financing to increase utilization of maternal health MARK services: Evidence from Burkina Faso☆ ⁎ Maria Steenlanda, , Paul Jacob Robynb, Philippe Compaorec, Moussa Kaborec, Boukary Tapsobac, Aloys Zongoc, Ousmane Diadie Haidarad, Günther Finka a Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA b Health, Nutrition and Population Global Practice, The World Bank, 701 18th St NW, Washington, DC 20006, USA c Direction Générale des Etudes et des Statistiques Sectorielles, Ministère de la Santé de Burkina Faso, 01 BP 7009 Ouagadougou 01, Burkina Faso d Health, Nutrition and Population Global Practice, The World Bank, 179 Av. President Saye ZERBO, 01BP 622, Ouagdougou 01, Burkina Faso A R T I C L E I N F O A BS T RAC T Keywords: Performance-based financing (PBF) programs are increasingly implemented in low and middle-income Performance-based financing countries to improve health service quality and utilization. In April 2011, a PBF pilot program was launched Results-based financing in Boulsa, Leo and Titao districts in Burkina Faso with the objective of increasing the provision and quality of Health services maternal health services. We evaluate the impact of this program using facility-level administrative data from Provider incentives the national health management information system (HMIS). Primary outcomes were the number of antenatal Burkina Faso care visits, the proportion of antenatal care visits that occurred during the first trimester of pregnancy, the number of institutional deliveries and the number of postnatal care visits. To assess program impact we use a difference-in-differences approach, comparing changes in health service provision post-introduction with changes in matched comparison areas. All models were estimated using ordinary least squares (OLS) regression models with standard errors clustered at the facility level. On average, PBF facilities had 2.3 more antenatal care visits (95% CI [0.446–4.225]), 2.1 more deliveries (95% CI [0.034–4.069]) and 9.5 more postnatal care visits (95% CI [6.099, 12.903]) each month after the introduction of PBF. Compared to the service provision levels prior to the interventions, this implies a relative increase of 27.7 percent for ANC, of 9.2 percent for deliveries, and of 118.7 percent for postnatal care. Given the positive results observed during the pre-pilot period and the limited resources available in the health sector, the PBF program in Burkina Faso may be a low-cost, high impact intervention to improve maternal and child health. 1. Introduction of children were not delivered at a health facility (ICF International, 2012). The situation is similar in rural Burkina Faso, where 69% of Reducing maternal and child mortality remains a priority of the women did not receive four or more antenatal visits and almost 40% of international development community as demonstrated by the 2015 women gave birth at home as of 2010 (ICF International, 2012). launch of the Global Strategy for Women’s, Children’s and Adolescents’ The reasons for continued low maternal health service use are Health (Kuruvilla et al., 2016). Despite recent increases in the use of complex, but appear to include high user fees and poor quality of care maternal health services as well as recent improvements in maternal in many settings (Hatt, Makinen, Madhavan, & Conlon, 2013; Nair and child health, reaching targeted coverage for key health services et al., 2014). A wide-variety of programs have been introduced to such as deliveries or early antenatal care remains challenging in many address these barriers including interventions focused on changing countries (The World Health Organization & UNICEF, 2014; United demand (conditional-cash transfers, vouchers, user-fee exemptions, Nations, 2014). According to the most recent Demographic and Health health insurance) and supply-side interventions (financing, targeted Survey data from Sub-Saharan Africa data, only 50% of women subsidies) (The AIDSTAR-Two Project, 2011). Performance-Based received the recommended four ANC visits per pregnancy, and 42% Financing (PBF) has been implemented in an increasingly large ☆ The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. We wish to thank our partners in the Ministry of Health in Burkina Faso for helping develop the study methodology and tools, and facilitating data collection. ⁎ Corresponding author. E-mail address: mws475@mail.harvard.edu (M. Steenland). http://dx.doi.org/10.1016/j.ssmph.2017.01.001 Received 28 July 2016; Received in revised form 6 January 2017; Accepted 9 January 2017 2352-8273/ © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). M. Steenland et al. SSM – Population Health 3 (2017) 179–184 number of low- and middle income countries to strengthen health were a total of 2495 district level primary care facilities (Centres de systems and increase service provision (The AIDSTAR-Two Project, Santé et de Promotion Sociale – CSPS), and CSPS staffed with 2011). PBF is a form of supply-side Results-Based Financing that uses physicians (Centre Medical – CM). Secondary care facilities or district fee-for-service contracts with a service quality component (Fritsche, hospitals (Centre médical avec antenne chirurgicale – CMA) exist in Soeters, & Meessen, 2014). PBF aims to improve health service each health district as well. provision and quality by increasing staff motivation, reducing provider absenteeism, and increasing the financial independence of facilities, 2.2. Study design which can allow them to improve the quality of their services, and also potentially reduce users fees (The World Bank, 2012). Recent PBF The PBF pilot began in Boulsa, Leo and Titao health districts in programs have introduced additional demand-side interventions such April 2011. We use a difference-in-differences design to assess the as using household visits by health workers to stimulate demand, impact of the PBF program on the provision of essential maternal referrals by community health workers, and the removal of user and health services. The three intervention districts were chosen in 2010 by drug fees for the poor and vulnerable. While the term PBF first the Ministry of Health (MoH) for the PBF program; these districts were originated in Rwanda, early programs with some of the same tenets selected based on their health indicators for priority services, their as PBF such as contracting and decentralization emerged in the 1990s poverty level, their distance from Ouagadougou ( < 300 km), and their in Zambia and Cambodia (Bossert, Chitah, & Bowser, 2003; Soeters & health system characteristics (having a functioning district hospital and Griffiths, 2003). Since the mid-2000s, and in particular after the having between 15 and 30 primary health care centers). The study area positive results from the Rwanda program (Basinga et al., 2010), there includes three regions in Burkina Faso: North (Titao), Center-North has been a rapid increase in the number of countries integrating (Boulsa), and Center-West (Leo). For each intervention health district performance-based financing into their health system. As of 2013, over we selected a comparison health district in the same region with 40 countries have either planned or begun to implement some form of comparable health, health system and socio-economic characteristics. PBF (Fritsche et al., 2014). A somewhat controversial Cochrane review published in 2012 2.3. The intervention package analyzed nine studies on PBF, and concluded that the existing evidence base was too weak to draw any general conclusions (Meessen, 2012; Before PBF, health facilities in Burkina Faso were financed primar- Witter, Fretheim, Kessy, & Lindahl, 2012). More recent PBF programs ily through funding provided from the Ministry of Health for specific have generally incorporated more rigorous evaluation designs and health care resources outlined in annual health facility action plans, several randomized or quasi-experimental studies published since and from revenue generated from user fees and drug sales (Robyn 2010 have increased the quality of available evidence considerably. et al., 2014). The pilot program changed the previous financing system While a study conducted in the Democratic Republic of the Congo by defining a package of key health services to be targeted at contracted found no effect of PBF on health service utilization (Huillery and primary- (CSPS, CM) and secondary-level (CMA) health facilities, and Seban, 2014), studies conducted in Rwanda, the Philippines and issuing payments based on quantity and quality for these services. Tanzania found that PBF increased several, but not all, of the health Health facilities included in the pilot signed contracts with the central services examined in these studies (Basinga et al., 2010; Binyaruka level of the Ministry of Health to provide these packages of services. A et al., 2015; Peabody et al., 2014). Three studies conducted in Burundi checklist which included items such as how well patient documentation found mixed results with findings differing between studies (Bonfrer was completed, the availability of health supplies equipment, and et al., 2014; Bonfrer, Van de Poel, & Van Doorslaer, 2014; Falisse, essential medicines, and adherence to national standards defining Ndayishimiye, Kamenyero, & Bossuyt, 2014). While two of the three quality of care was used to create a quality score. The total payment studies from Burundi found an increase in institutional deliveries and was determined by multiplying the quality score by the number of each antenatal care, none of the three studies found an increase in service provided, the payment amount associated with the service, and vaccinations and only one of the two studies that examined contra- a measure of health facility characteristics. ception found an increase in this outcome. Three studies from the The program approach evaluated in the pilot did not include some Philippines, Haiti and Cambodia found positive results for all health recommended elements of performance-based-financing including services they examined though one of these studies focused exclusively demand side incentives, independent management of the PBF program on institutional deliveries (Gertler & Giovagnoli, 2014; Ir et al., 2015; administration, an increase in health facility autonomy and the Zeng, Cros, Wright, & Shepard, 2013). Most of these studies focus on introduction of improved management tools. As of 2014, the PBF maternal and child health service use and few examine health out- program approach changed to incorporate several additional design comes or quality of the health services provided. elements that are aligned with PBF guiding principles and best In this paper we examine the effect of a pilot project that introduced practices such as demand-side incentives and social marketing through Performance-Based Financing from 2011 to 2013 in Burkina Faso. We household visits (Ministere de la Sante Burkina Faso, 2013). In this focus on provision of maternal health services as a key strategy to paper we evaluate the early PBF program approach in Burkina Faso. improve maternal and child health outcomes in the country and Appendix 1 lists the services and their prices for the primary and globally (Jones et al., 2003; Rosenfield, Maine, & Freedman, 2006). secondary levels of care. A description of the methods used to determine individual provider payments is provided in Appendix 2. 2. Methods 2.4. Study population 2.1. Study setting A total of 186 health facilities were included in the study: 168 Burkina Faso remains one of the poorest countries in the world, primary health care centers (Centres de Santé et de Promotion Sociale with maternal mortality rates of 400 per 100,000 live births and under- – CSPS), 5 (Centre médical avec antenne chirurgicale), 2 (Centre 5 mortality rate of 96 per 1000 live births in 2013 (UNICEF, 2013). The Medical – CM), and 10 dispensaries (Fig. 1). health system in Burkina Faso is divided into three levels of care. At the highest level, regional hospitals (Centre Hospitalier Regional – CHR) 2.5. Data exist in each of 11 of the 13 regions in Burkina Faso (Direction Generale Ministere de la Sante Burkina Faso, 2014). Below the regional All data used for this analysis were obtained from the health level, Burkina Faso is divided into 63 health districts. In 2012 there management information system (HMIS) of Burkina Faso. The HMIS 180 M. Steenland et al. SSM – Population Health 3 (2017) 179–184 Fig. 1. Intervention and comparison health facilities. system is a national database that collects health service delivery divide the overall sample into the pre-period from January 2009 – information from all public and most private and non-governmental March 2011, and the post-period from April 2011 – December 2012. health facilities. Health facilities are responsible for completing a Our empirical analysis compares pre-post differences between health service use report each month that is transmitted to the district treated and comparison areas using a difference-in-differences regres- health office. Data from 2009 – 2012 were obtained from district- sion model. The empirical model estimated can be characterized as: specific databases. The final database included 8,074 district-month 12 observations. Several verification mechanisms existed in PBF health Yidt = α + β1timetrend t + β2Postt + β3RBFid*Postt + δid + ∑ Montht + μidt facilities taking part in the pilot: as a first-stage verification, the i =2 number of services declared by the health facility to the HMIS system where Yidt is number of services of interest provided by facility i of was checked and verified by agents on a quarterly basis by counting district d in time period t, time trend is a service-specific time trend services written in the facility registers. Second, a sample of patients capturing general trends over time, RBF is an indicator for a facility was drawn for each type of service, with sampled patients being visited being in a treated district, post captures general average monthly and interviewed (i) to ensure they received the services declared by the change compared to the pre-intervention period, RBF*post captures health facility, and (ii) to assess their satisfaction with the services the additional improvements in indicators observed in treated areas, δ provided. are facility fixed effects and Month are calendar month indicators to control for seasonal fluctuations in service utilization. We assumed 2.6. Indicators dependence of residuals from facility observations over time, and have therefore clustered standard errors at the facility level in all regression A wide range of health services were incentivized during the pilot models. study (Appendix 1). For analytical purposes, we focus on four key To address the concern that more complete data from intervention maternal health service indicators: the number of antenatal care visits, facilities drives our results, we test whether removing health facilities the proportion of antenatal care visits that occurred during the first that report missing data in any month for any of the three health trimester of pregnancy, the number of complicated and uncomplicated services affects our results. The results from this model are presented deliveries at the health facility, and the number of postnatal consulta- in Appendix 3. tions occurring 42 days after pregnancy provided. Complicated deliv- eries were defined as pregnancies with abnormal fetal size or position 3. Results resulting in difficult delivery. Uncomplicated deliveries were defined as spontaneous vaginal deliveries occurring when a pregnant female goes Table 1 below presents baseline characteristics for intervention and into labor without the use of drugs or techniques to induce labor, and matched control districts in 2010, the year before PBF began. While delivers her baby in the normal manner, without forceps, vacuum there are some differences in population size and the number of extraction, or a cesarean section. For antenatal care, we focus on primary health facilities in matched districts, the number of facilities women completing at least 4 visits to capture the proportion of women per 100,000 people was similar in the matched pairs in the pre- meeting the WHO ANC standards. We chose to focus on maternal intervention period. The matched pairs also have similar literacy rates, health services in this analysis as they have been identified as priority and proportions of the population living close to a health facility; services for many performance-based financing evaluations, including however, the poverty rate differs in the matched districts in Centre- a large randomized controlled trial planned in Burkina Faso. Nord and Nord. Table 2 shows the average number of the four health services 2.7. Statistical analysis examined here – 4th and 5th antenatal care visits, the proportion of first antenatal care visits that occurred during the first trimester of The data set extracted covers the period from January 2009 to pregnancy, deliveries, and postnatal care visits – for health facilities by December 2012; PBF was formally started in April 2011; we therefore district during the pre-intervention period from January 2009 through 181 M. Steenland et al. SSM – Population Health 3 (2017) 179–184 Table 1 Health district characteristics, 2010a. Region District Treatment Population Number of health Number of health facilities Percent of the population less than 5 Literacy rate Poverty rate facilities per 100,000 people km from a health facility Centre- Boulsa Intervention 365,473 28 7.66 0.30 87.0 0.439 Nord Centre- Barsalogho Comparison 163,320 11 6.74 0.30 90.8 0.606 Nord Centre- Leo Intervention 233,315 31 13.29 0.42 83.2 0.504 Ouest Centre- Sapouy Comparison 199,934 17 8.50 0.34 87.8 0.578 Ouest Nord Titao Intervention 158,356 20 12.63 0.46 84.7 0.600 Nord Yako Comparison 353,315 42 11.89 0.50 88.1 0.375 a Data from the Annuaire Statistique 2010, Ministère de la Santé, Burkina Faso March 2011. The mean facility level number of monthly deliveries Table 3 ranged from 17 in Titao to 33 in Barsalogho. The monthly mean during Post intervention and interaction term coefficients from difference-in-differences the pre-intervention period among all three PBF districts was the same models, Burkina Faso January 2009 – December 2012. as the monthly mean in the intervention district (22). The mean Dependent variable β 95% CI Relative number of monthly 4th and 5th facility prenatal visits was lowest in increase** Yako, Leo and Titao (6) and highest in Barsalogho (15). Similar to deliveries, the monthly mean during the pre-period was the same for Four or five prenatal care visits intervention and comparison districts (8). The mean proportion of first PBF*post 2.336* [0.446, 4.225] =2.336/ ANC visits provided to women in the first trimester of pregnancy 8.432=0.277 ranged from 15% in Yako to 27% Sapouy. The proportion in interven- N 8074 tion districts before the start of PBF was 23% compared to 19% in Percent of ANC visits comparison districts. The number of postnatal care visits was lowest in occurring in the first Titao (3) and highest in Barsalogho (19). The monthly mean in the trimester three intervention districts was 8 and the mean in comparison districts PBF*post 0.085* [0.043, 0.126] =0.085/ was 9 during the pre-period. 0.229=0.371 Table 3 presents our main impact estimates. On average, PBF N 8047 facilities provided approximately two more 4th and 5th antenatal visits Facility births per month (2.336, 95% CI 0.446–4.225) compared to comparison PBF*post 2.052* [0.034, 4.069] =2.052/ facilities after the start of PBF. The proportion of first ANC visits 22.243=0.092 provided to women in the first trimester of pregnancy increased by 8.5 N 8074 percentage points more in PBF districts than comparison districts Postnatal visits (0.085, 95% CI 0.043–0.126), institutional deliveries increased by two PBF*post 9.501* [6.099, 12.903] =9.501/ births per month (2.052, 95% CI 0.034–4.069) and PBF facilities on 8.005=1.187 average completed 9.5 more postnatal care visits (9.501, 95% 6.099, N 8074 12.903) per month. * p < 0.05 Figs. 2–5 illustrate these results graphically. For all four indicators, ** Relative increase was calculated by dividing each indicator's interaction term by the the pre-intervention trends in PBF and comparison districts appear pre-intervention mean in the PBF districts similar from January 2009 through March 2011, and then diverge significantly in the post-period. of maternal health services. Relative to comparable health facilities, the average number of advanced ANC visits, deliveries and postnatal care 4. Discussion visits increased by 27.7%, 9.2%, and 119% percent, respectively. These changes are substantial, and were achieved within a relatively short The results presented in this paper suggest that the PBF program period, suggesting that the program was highly effective in the setting implemented in Burkina Faso led to sizeable increases in the provision Table 2 Average monthly health facility number of 4th and 5th prenatal visits, deliveries, and postnatal visits by health district during the pre-intervention period, January 2009 – March 2011. Region District Treatment Na Deliveries ANC Visits (4 or 5) First ANC in the first trimester Postnatal visits mean sd mean sd mean sd mean sd Centre-Nord Boulsa Intervention 31 28 16 12 13 0.24 0.21 12 18 Centre-Nord Barsalogho Comparison 14 33 13 15 10 0.21 0.18 19 12 Centre-Ouest Leo Intervention 35 19 15 6 6 0.20 0.20 7 9 Centre-Ouest Sapouy Comparison 18 24 18 11 9 0.27 0.18 9 9 Nord Titao Intervention 24 17 9 6 5 0.26 0.22 3 5 Nord Yako Comparison 51 18 17 6 6 0.15 0.18 6 8 Intervention 90 22 15 8 10 0.23 0.22 8 13 Comparison 83 22 17 8 8 0.19 0.19 9 10 a The number of functioning health facilities varied over the study period; numbers in the figure represent the total number of health facilities that were open at any point during the study period in each district 182 M. Steenland et al. SSM – Population Health 3 (2017) 179–184 Fig. 2. Number of 4th or 5th antenatal care visits performed by month in PBF and Fig. 5. Number of postnatal care visits performed by month in PBF and comparison comparison districts, January 2009 – December 2012. districts, January 2009 – December 2012. facilities. To investigate this we repeated the same difference-in- differences regression analysis used in the results after dropping all the health facilities that reported missing data for any of our outcomes for any month included in the dataset. As shown in Appendix 3, the results remain similar after dropping facilities missing monthly data on one or more of the outcomes. We can therefore rule out the possibility that improved reporting on the extensive margin can explain our results; however, we cannot rule out the possibility of that the PBF facilities that reported data at baseline increased the completeness of their reporting after the start of the intervention. In addition to data reliability, our use of aggregated administrative data limited our ability to determine who benefited from the program. Without individual-level data, we were not able to examine whether PBF resulted in disproportionally greater coverage increases among groups with higher socioeconomic status, a concern that has been Fig. 3. Proportion of monthly first ANC visits that occurred in the first trimester of raised in previous research (Lannes, Meessen, Soucat, & Basinga, pregnancy in PBF and comparison districts, January 2009 – December 2012. 2015). Finally, our reliance on administrative data made it difficult to examine service-specific changes in quality of care. A second limitation of our study is that did not contain measures that could be used to more closely examine the mechanisms of change. Two important potential mechanisms include the effect of increased overall facility resources, which might affect service use through infrastructure improvement if electricity, more space, or more hospital beds allowed the facilities to serve more patients for longer hours. Other studies have provided comparison facilities with an equivalent amount of financial resources in an effort to isolate the effect of incentives (Basinga et al., 2010). No extra financial resources were provided to comparison facilities in this study; however, funding from the Programme d’Appui au Développement Sanitaire (Program for Health Development) which had previously supported PBF facilities was not provided during the intervention period. A second mechanism is the additional financial resources provided to health facilities and health workers, which can offer motivation and increased flexibility Fig. 4. Number of number of institutional deliveries performed by month in PBF and (Basinga et al., 2010). The average monthly amount of the quarterly comparison districts, January 2009 – December 2012. PBF payment for nurses from April 2011 – March 2012 was 25,787 CFA ($43), which is equivalent to approximately 16% of average studied. This paper adds to several other quasi-experimental designs government salaries for this category of health worker. In the absence that found mixed and positive results of PBF using measures of health of more data, qualitative research and formal meetings including local service provision, health service quality, and health provider efficiency. stakeholders could be used to shed light on the causal mechanisms Overall, when considered alongside other evidence that is evolving explaining the effects observed in this study. from the multitude of PBF evaluations that have recently been The third limitation is that neither the pilot districts, nor the conducted, this study makes a strong case that PBF can be used to comparison districts were randomly selected. While we show in our increase the provision of at least some targeted health services. analysis that facilities in treatment and comparison areas look very similar The use of administrative data for this analysis results in several with respect to their pre-intervention trends, it is possible that differential limitations. The first is that administrative data may be more subject to trends would have emerged even in the absence of the intervention. The misreporting than survey data. It is possible that some facilities in both results in this paper may apply to other regions in Burkina Faso, as the groups were not reporting services before the start of PBF and that the intervention and comparison districts share similar health and economic increases shown here are the result of improved reporting in PBF characteristics as other rural districts in the country. 183 M. Steenland et al. SSM – Population Health 3 (2017) 179–184 There are several policy implications for these results. Since 2006 in allocation and district performance. Health Policy and Planning, 18(4), 357–369. De Allegri, M., Tiendrebéogo, J., Müller, O., Yé, M., Jahn, A., & Ridde, V. (2015). an attempt to reduce financial barriers, delivery care has been exempt Understanding home delivery in a context of user fee reduction: A cross-sectional from user fees in Burkina Faso (Ridde, Richard, Bicaba, Queuille, & mixed methods study in rural Burkina Faso. BMC pregnancy and childbirth, 15(1), Conombo, 2011). While user fee reductions have been shown to 1. Direction Generale Ministere de la Sante Burkina Faso (2014). Annuaire Statistique N. increase service coverage, many women continued to deliver at home 001 2013. Ouagadougou, Burkina Faso demonstrating that cost was not the only barrier to care seeking (De Falisse, J.-B., Ndayishimiye, J., Kamenyero, V., & Bossuyt, M. (2015). Performance- Allegri, Tiendrebéogo, Müller, Yé, Jahn & Ridde, 2015; Ganaba et al., based financing in the context of selective free health-care: An evaluation of its effects on the use of primary health-care services in Burundi using routine data. 2016). This study shows that in the context of user fee reductions, Health Policy and Planning, 30(10), 1251–1260. additional strategies that focus on reinforcing the delivery of essential Fritsche, G. B., Soeters, R., & Meessen, B. (2014). Performance-based financing toolkit health services, such as performance-based financing, might be a Washington D.C, USA: World Bank Publications. Ganaba, R., Ilboudo, P. G., Cresswell, J. A., Yaogo, M., Diallo, C. O., Richard, F., & Witter, successful policy tool to further increase coverage by increasing health S. (2016). The obstetric care subsidy policy in Burkina Faso: What are the effects worker motivation while ensuring quality of care. PBF in Burkina Faso after five years of implementation? Findings of a complex evaluation. BMC has a relatively low cost for implementation, with an average cost of US Pregnancy Childbirth, 16, 84. http://dx.doi.org/10.1186/s12884-016-0875-2. $3.00 per capita per year to target the entire package of services at the Gertler, P. J., & Giovagnoli, P. I. and Martinez S. (2014). Rewarding provider performance to enable a healthy start to life: Evidence from Argentina’s Plan Nacer. primary and secondary levels of care. Given the positive results World Bank Policy Research Working Paper(6884). observed during the pre-pilot period and the limited resources avail- Hatt, L. E., Makinen, M., Madhavan, S., & Conlon, C. M. (2013). Effects of user fee able in the health sector, the PBF program in Burkina Faso may be a exemptions on the provision and use of maternal health services: A review of literature. Journal of Health, Population and Nutrition, 31, 67–80. low-cost, high impact intervention to improve maternal and child Huillery, E., & Seban, J. (2014). Performance-Based Financing, Motivation and Final health. In-depth cost-benefit analyses of different policies should be Output in the Health Sector: experimental evidence from the Democratic Republic of conducted to compare the impact of these interventions relative to their Congo. Retrieved from 〈http://econ.sciences-po.fr/sites/default/files/file/elise/ paper_DRC_July2014_AER.pdf〉 cost. Additionally, research investigating how to better target the poor, ICF International (2012). The DHS Program STATcompiler. Retrieved June 10, 2015, and how to solve demand side challenges within PBF program from 〈http://www.statcompiler.com〉 approach would be valuable. Ir, P., Korachais, C., Chheng, K., Horemans, D., Van Damme, W., & Meessen, B. (2015). Boosting facility deliveries with results-based financing: A mixed-methods evaluation of the government midwifery incentive scheme in Cambodia. BMC 5. Conclusion Pregnancy Childbirth, 15(1), 1. Jones, G., Steketee, R. W., Black, R. E., Bhutta, Z. A., Morris, S. S., & Group, B. C. S. S. (2003). How many child deaths can we prevent this year? The Lancet, 362(9377), The PBF pilot program in three districts of Burkina Faso that ran 65–71. from 2011–2013 resulted in a significant increase in key maternal Kuruvilla, S., Bustreo, F., Kuo, N., Mishra, C., Taylor, K., Fogstad, H., & Thomas, J. health indicators for PBF. As the country has embarked since 2014 on a (2016). The Global strategy for women's, children's and adolescents' health (2016– progressive scale-up of PBF that currently covers one-third of the 2030): A roadmap based on evidence and country experience. Bulletin of the World Health Organization, 94(5), 398–400. country and includes an embedded experimental impact evaluation, Lannes, L., Meessen, B., Soucat, A., & Basinga, P. (2015). Can performance‐based more knowledge and evidence is expected to be produced by the financing help reaching the poor with maternal and child health services? The Burkina Faso PBF program in the coming years. experience of rural Rwanda. The International Journal of Health Planning and Management, 31(3), 309–348. Meessen, B. (2012). An online debate on "Performance-based financing in low- and Funding middle-income countries: still more questions than answers". Ministere de la Sante Burkina Faso (2013). Guide de Mise en Oeuvre du Financement Base sur les Resultats dans le secteur de la Sante: Ministere de la Sante Burkina Faso This work was supported by the World Bank through the Health Nair, M., Yoshida, S., Lambrechts, T., Boschi-Pinto, C., Bose, K., Mason, E. M., & Mathai, Results Innovation Trust Fund (HRITF). M. (2014). Facilitators and barriers to quality of care in maternal, newborn and child health: A global situational analysis through metareview. BMJ Open, 4(5), e004749. http://dx.doi.org/10.1136/bmjopen-2013-004749. Conflict of interest statement Peabody, J. W., Shimkhada, R., Quimbo, S., Solon, O., Javier, X., & McCulloch, C. 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