Background
Methods
Study setting
Beneficiary | Indicators |
---|---|
Health Facility | 1. Number of facility-based deliveries 2. Number of maternal and newborn deaths audits 3. Number of women tested for HIV if unknown status and treatment if indicated 4. Number and quality of Health Information Management Systems (HMIS) reports completed 5. Quality of stock cards for medications filled and submitted 6. Quality of RBF4MNH Initiative specific reports submitted 7. Number of completely filled partographs 8. Routine use of uterotonic in 3rd stage of labor 9. Routine use of magnesium sulfate for pre-eclampsia 10. Number of patient satisfaction surveys filled out for each quarter by women who delivered in facility 11. Routine administration of vitamin A to all newborns 12. Complete report on broken maternity equipment to District Health Officer 13. Routine use of infection prevention and quality checklist each month |
District Health Management Team | 1. Number of facility-based deliveries across districts 2. One-month supply of essential drugs and commodities available at all facilities in district 3. All essential equipment available in operating condition in participating facilities 4. Quality of Health Management Information Systems (HMIS) reports submitted to central office |
Beneficiary | Indicators |
---|---|
Pregnant Women | Utilization of facility-based services at time of delivery |
Women who delivered | Extension of facility stay to at least 48 h after delivery |
Conceptual framework and research design
Sampling
Data collection
Data analysis
Results
RBF4MNH initiative introduction and design
“It’s the Norwegians and the Germans who approached us with the money, then people really worked together to say what initiative we could do.” – MoH central-level member“I was involved from the design stage up to the implementation. So whatever decision was made along the way I think I was an important part of it.” – MoH central-level member
“This orientation was done by the Ministry of Health government of Malawi, Reproductive Health Unit, in liaison with the results based financing personnel.” – DHMT member“There were lots of meetings introducing the program where we were oriented as management. And where we had an input of what is supposed to happen and the choice of health centers.” – DHMT member
“They just used the indicators that the Ministry of Health is using. So it did not give a problem or any suspicion. We welcome the indicators.” – DHMT member“The indicator will say you need to have this but you don’t have full control. So that’s another challenge (…) one faulty system will affect all the other indicators.” – DHMT member
“I would say let’s emphasize more on family planning and take out the indicator of more deliveries every time (…) and let’s make sure we reward women who are compliant on family planning issues as well. I know the program is not aimed at increasing the number of pregnancies, but the interpretation in the community might be different if we don’t attach the family planning element.” – DHMT member“But if we say that this facility has done well, then everybody is talking about it. Then they will get a t-shirt or a certificate. Then they will say, this district has done well. They have received that. And that would be more sustainable than money.” –DHMT member
Acceptability
“After the first rewards cycle (…) there was this change [in MoH members] from observing to participation. And I think now within 2014, there’s a strong move towards ownership.” –external consultant
“The program at this point in time means a great improvement in the maternal-neonatal health indicators. And also it means boosting of staff morale (…). So it is a success to me.” –DHMT member
“I like the fact that it’s flexible. It’s not like they say this is what we have put in place and you have to follow it whether you like it or not. When we make an input they consider it. That’s what I like about it.” – DHMT member
Adoption
“We always invited the District Commissioner and one other member from the local government so that we work together (…) we also involved the health education unit in the district, so that they could assist us in the sensitization of the districts about our program in the community.” – Reproductive Health Directorate
“We felt that the people that are at the health centers are not trained to keep monies. Were we not going to misappropriate funds that the donors have faithfully given to us to improve the lives of the Malawians?” – central-level MoH member“It already was a problem to have the specific [bank] account at the district level and it took a very long time. So there are some steps in this procedure where the money gets stuck. And then you run the risk that the facilities run out of money.” – external consultant
“With the program we knew we would have this workload. Now knowing that we are already short staffed and then with that workload, we are struggling to meet the indicators.” – DHMT member
“[District review meetings] are really good, because we discuss issues on the ground affecting implementation of the Initiative. As we share information and suggestions are made, actions plans are made, and we implement and see a change.” – DHMT member
“They [MoH] are talking about RBF in their plans. When they are going out for supervision…they can also see the positive affect of it already. So yes, there is ownership now.” –Funding agency
Sustainability
“If it doesn’t continue, it will demoralize people. The commitment will go back to continue delivering in the community. So that is our biggest fear.” – DHMT member“The issue was at the end of the day is how would we integrate the finances into the budget, into the general budget. How would we do it using the regular budget?” – MoH member