Household costs and time to seek care for pregnancy related complications: The role of results-based financing
Household costs and time to seek care for pregnancy related complications: The role of results-based financing
Jobiba Chinkhumba 1 2
Manuela De Allegri 0 2
Jacob Mazalale 0 1 2
Stephan Brenner 0 2
Don Mathanga 1 2
Adamson S. Muula 1 2
Bjarne Robberstad 2
0 Institute of Public Health, University of Heidelberg , Heidelberg , Germany
1 Department of Public Health, University of Malawi, College of Medicine, School of Public Health and Family Medicine, Blantyre, Malawi, 2 Center for international Health. University of Bergen , Bergen , Norway
2 Editor: Benjamin Bellows , Population Council , KENYA
Results-based financing (RBF) schemes±including performance based financing (PBF) and conditional cash transfers (CCT)-are increasingly being used to encourage use and improve quality of institutional health care for pregnant women in order to reduce maternal and neonatal mortality in low-income countries. While there is emerging evidence that RBF can increase service use and quality, little is known on the impact of RBF on costs and time to seek care for obstetric complications, although the two represent important dimensions of access. We conducted this study to fill the existing gap in knowledge by investigating the impact of RBF (PBF+CCT) on household costs and time to seek care for obstetric complications in four districts in Malawi. The analysis included data on 2,219 women with obstetric complications from three waves of a population-based survey conducted at baseline in 2013 and repeated in 2014(midline) and 2015(endline). Using a before and after approach with controls, we applied generalized linear models to study the association between RBF and household costs and time to seek care. Results indicated that receipt of RBF was associated with a significant reduction in the expected mean time to seek care for women experiencing an obstetric complication. Relative to non-RBF, time to seek care in RBF areas decreased by 27.3% (95%CI: 28.4±25.9) at midline and 34.2% (95%CI: 37.8±30.4) at endline. No substantial change in household costs was observed. We conclude that the reduced time to seek care is a manifestation of RBF induced quality improvements, prompting faster decisions on care seeking at household level. Our results suggest RBF may contribute to timely emergency care seeking and thus ultimately reduce maternal and neonatal mortality in beneficiary populations.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: This research project is funded through a
grant by the Norwegian Ministry of Foreign Affairs
to the Government of Malawi under Programme
Title MWI 12/0010 Effect Evaluation of
Performance Based Financing in Health Sector. The
Malawi College of Medicine as implementing
institution is recipient of this grant. This study was
Approximately 4% of pregnant women in sub-Saharan Africa suffer from severe obstetric
complications during the course of their pregnancy[
], while delayed effective management is
recognised as a major determinant of maternal mortality in low-income settings[
co-funded by the United States Agency for
International Development under Translating
Research into Action, Cooperative Agreement No.
GHS-A-00-09-00015-00. This study is made
possible by the support of the American People
through the United States Agency for International
Development (USAID). The findings of this study
are the sole responsibility of study team and do not
necessarily reflect the views of USAID or the United
and Maine have posited that delays in seeking obstetric emergency care occur at three levels.
The first delay involves making decisions to seek care and occurs at household level once an
emergency arises. Gender and power dynamics within households, perceptions of symptom
severity, quality of services available and the financial costs of care influence decision making
process at this level. The second delay relates to transport to a health facility once a decision to
seek emergency care is made and occurs at community level. Availability and affordability of
transport are important community level factors. The third delay relates to obtaining timely
emergency care after a woman with an obstetric emergency presents to health workers and
occurs at health facility level. At this level, facility readiness and provider skills are critical in
providing definitive care[
At facility level, a range of effective interventions to manage obstetric complications is
available in resource poor settings, including management of hemorrhage, eclampsia, sepsis and
obstructed labor [4±6]. Still, in resource poor countries, many pregnant women either
underutilize obstetric emergency services or present too late at health facilities in case of need[
Analysis of recent Demographic and Health Surveys (DHS) has identified lack of money as
an important obstacle to maternal services use[
]. To enhance utilization of maternal services,
some governments in low and middle income countries are experimenting with results-based
financing (RBF) strategies, including both demand-side(e.g. conditional cash transfers for
clients) and supply-side (e.g. performance based financing for workers) [10±14].
The mechanisms through which demand-side and supply-side incentives are expected to
operate have been outlined in the literature. By making cash transfers conditional on health
care seeking, the financial rewards can be used to shape household behaviour leading to
increased use of maternal health services. Conditioning acts through the price effect
mechanism: a ªpriceº is incurred (loss of a financial reward) if a particular behaviour is not
]. Alternatively, cash transfers, if large or frequent enough, can increase household
incomes. Increased income is believed to improve the ability of poor households to overcome
economic barriers, leading to increased expenditures on normal goods e.g. healthcare. In this
aspect, the cash transfers are anticipated to change consumption behavior through income
effect as predicted by microeconomic theory[
Through the provision of performance incentives, health facilities and health workers
receive payments based on the achievement of a set of pre-defined quantity and quality targets
]. Building on the constructs of principal-agent theory, financial incentives are expected to
redirect health workers' behavior towards provision of better quality care and to attract more
patients to health facilities[
While there is emerging evidence on the impact of RBF on service use and quality of service
delivery[12±14], little is known on the RBF impact on household costs or time to seek care,
especially for women experiencing obstetric complications. Cost studies on obstetric
complications commonly focus on describing the high economic burden of individual maternal
], or the differences in costs between women surviving or dying from complications[
or the cost differentials in women with and without complications[
]. Similarly, although
perceived and actual costs of care are linked to delays in seeking emergency care, little is known
about the association between RBF and timeliness for emergency obstetric care[
]. Filling this
knowledge gap is important as it may offer an understanding if and how the provision of
financial incentives has potential to affect household costs and reduce time to seek care for women
experiencing obstetric complications.
Our study aimed to fill this gap in knowledge through an analysis directed specifically at
identifying the impact of RBF on i) household costs and ii) time to seek care for women with
pregnancy related complications. We focused on delays encountered at household and
community levels: it was outside the scope of our study to consider delays at the facility. Our study
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was conducted within the framework of a larger impact evaluation related to the
implementation of the RBF for Maternal and Neonatal Health (RBF4MNH) initiative in Malawi [
Malawi is a low income country with a population of 17 million. Its gross domestic product
(GDP) is 4.3 billion US$, of which 4.2% is spent on healthcare[
]. Total expenditure on
reproductive health (RH) rose from US$50.1 million in 2009/10 to US$74.3 million in 2010/2011,
and then declined to US$63.6 million in 2011/12 [
]. On average, US$9.9 per annum was
spent on RH over the same period on each woman of reproductive age (15±49 years). Routine
and emergency obstetric care are provided free at all public health facilities and at selected
private not for profit facilities contracted by the government through Service Levels Agreements.
Although Malawi imposes no formal fees for emergency obstetric care (EmOC), evidence
shows that some medical costs are still shifted towards patients due to stock outs of drugs and
other items needed for surgery[
]. In each district, health centers provide basic emergency
obstetric care (BEmOC) and refer complicated cases to respective district hospitals, which
provide comprehensive emergency obstetric care (CEmOC). Despite the government's financial
commitment towards reproductive health, maternal mortality ratio in the country is still high
at 574/100,000 live births[
The results-based financing strategy
Details of the RBF4MNH initiative are provided elsewhere [
]. Briefly, the aim of RBF4MNH
initiative is to reduce maternal and neonatal mortality through increased access and improved
quality of service delivery. The RBF4MNH initiative includes both supply-side and
demandside conditional financial incentives. Supply-side incentives are paid on a quarterly basis to
health facilities upon attainment of pre-agreed performance targets: 70% to be divided as
topup among health workers providing maternal and child health (MCH) services and 30% to be
invested in improving facility infrastructure and supplies. Hospitals receive 60% for top-up
and 40% for investments. The demand-side incentives are paid to pregnant
women,irrespective of income or socio-economic status, residing in the designated health facility catchment
areas upon delivering in the designated health facility or if referred at the district hospital. The
cash transfers, averaging US$10.50 per woman[
], consist of a flat lump sum (US$ 4.0) and of
a variable portion, depending on whether a woman remains at a facility 48 hours postpartum
and on the distance travelled to access facility care. Although the transfer is only disbursed at
delivery, women must register already while pregnant during antenatal visit. Health
surveillance agents are responsible to verify women's village of residence to confirm their eligibility
and determine the amount to be received. To ensure sufficient capacity for obstetric care
service provision, the RBF4MNH initiative was preceded by a one-time infrastructural and supply
upgrade. Additional facility investments were considered to occur based on the earmarked
performance rewards. The Ministry of Health (MoH), through district health management
teams (DHMTs), is the lead agent in the RBF4MNH implementation. Technical assistance is
provided by Options Consulting Services Limited.
Study sites and RBF implementation design
In 2013, the Malawi MoH selected four districts, Balaka, Dedza,Ntcheu and Mchinji with a
combined population of 1.9 million to pilot the RBF4MNH initiative[
]. The districts were
purposefully selected so that they were relatively representative of the rest of the 28 districts in
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Fig 1. Provides information on incentives and data collection periods for evaluation of the Malawi RBF4MNH
initiative. The vertical arrow indicates when supply-side incentives to health workers were applied to Intervention
facilities. The intervention facilities in addition received demand-side incentives for women which were fully functional
from 2014. Blue horizontal arrow represents interventin facilities. White horozontal arrow represents control facilities.
Horizontal axis shows the before and after periods and timing of data collection. Back pointing arrows indicate the 12
months recall period data was collected during each survey round.
the country in terms of maternal/childhood illness patterns and administrative arrangements.
Across the four districts, the MoH identified a total of 33 public health facilities (28 BEmOC
and 5 CEmOC) eligible to provide EmOC services and selected 17 of those (4 district
hospitals/CEmOCs and 13 BEmOCs) to be recipients of the RBF4MNH initiative. One year later,
the intervention was expanded with one private not for profit mission hospital/CEmOC and
10 BEmOCs (including 5 private not for profit facilities). The supply-side component was
rolled out at the selected CEmOC and BEmOC facilities soon after the official launch of the
program in April 2013. Due to implementation challenges, the demand-side component
became fully effective across facilities only one year later. Fig 1 illustrates how in terms of
intervention exposure, this arrangement entailed that women needing complication care
residing in the catchment areas of RBF4MNH facilities (hereafter defined as RBF group) were likely
affected by the supply-side incentives provided at both BEmOC and CEmOC level as well as
by the conditional cash transfers, while women residing in the catchment areas of
nonRBF4MNH facilities (hereafter defined as non-RBF group) were likely affected by the
supplyside incentives only if referred to seek complication care in a CEmOC facility.
Data for this study were obtained through three repeated cross-sectional household surveys,
conducted at baseline, midterm, and endpoint: April to May 2013, June to July 2014 and June
to July 2015 respectively (S1 Data). The data were collected as part of a larger study evaluating
the impact of the RBF4MNH strategy, the detailed data collection design and procedures have
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already been published [
]. Before the first survey, enumeration areas were randomly selected
for each health facility. Within each enumeration area, eligible women were interviewed. The
surveys targeted all women having completed a pregnancy in the 12 months prior to the survey
date. The analysis presented here is limited to the truncated sample of women who reported
having experienced a pregnancy-related complication at any point in the course of their
pregnancy. Fig 1 provides details on timing of data collection and appropriate recall periods.
Trained interviewers collected data from the women using a structured questionnaire,
programmed digitally and administered using tablet computers. The questionnaire was
administered in Chichewa, the common local language. Information was collected on the women's
social demographic features, self-reported complications and hospital admissions due to
complications related to the pregnancy completed within the prior 12 months. The information on
selfreported complications was collected in the form of lay person descriptions of a combination of
symptoms and signs suggestive of common obstetric complications[
]. This information was
validated by interviewers using formal diagnosis recorded in the women's health passports,
where possible. For each self-reported complication, information about relevant out-of-pocket
expenditures on medical costs (consultations, drugs, surgical procedures, radiological and
laboratory fees) transport costs, food and accommodation were recorded. Time use for seeking and
obtaining care for both patients and their informal caregivers was also recorded. All women
reporting a complication were asked if they sought care. If the response was yes, the women
were then asked to report how quickly after symptoms onset they had decided to seek care, and
how many days elapsed before they presented to a facility once decision to seek care was made.
Ethical approval for the study was obtained from University of Malawi, College of Medicine
Research and Ethics Committee (COMREC) protocol P.02/13/1353 and Ethics Committee of
Faculty of Medicine of the University of Heidelberg, Germany, protocol number S-256/2012.
Permission to conduct the study was sought from district and village authorities. Written
informed consent was obtained from all women prior to the interview.
Variables definitions and measurements
Dependent variables. In line with the two objectives, we defined two dependent variables
a) Total costs and b) Time to seek care. Total costs were defined as the sum of both direct costs
(e.g. medical and transport fees) and indirect costs incurred for each reported complication.
We estimated costs of time taken to seek care and actually spent at health facilities using a
simplified human capital approach[
]. For each reported complication, we quantified and added
up lost patient and informal caregiver's time in days. Given the high level of self or informal
employment in our sample (>80%) and the lack of job specific mean wage information for
those in formal employment, we used minimum wages to value lost productivity for both the
formally and informally employed. While using minimum wage for those formally employed
would bias their wages downwards, this would be offset by using minimum wage for the
majority of self or informally employed who probably earn less than the minimum wage.
Productivity loss (opportunity cost) was estimated as the product of the time lost and daily
minimum wage pertaining to the survey year. Reported minimum wages per day in US$ were 0.87,
1.30, 1.25 for years 2013,2014 and 2015 respectively [
].To compare the costs reported over
the years, we used annual Consumer Price Index (CPI) increases from 2013 to 2014, 2014 to
2015 and 2014 to 2015 respectively to adjust the 2013(baseline) and 2014 (midline) costs to
2015(endline) values (1US$ = 550MK). Hereafter, we refer to total costs simply as costs, unless
stated otherwise. Time to seek care was defined as duration in days a woman with a reported
complication took to present for care at a health facility after symptoms onset. Hereafter, we
refer to time to seek care simply as time.
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Independent variables. The main exposure was receipt of RBF (PBF + CCT) for women
in designated health facility areas. To control for confounding in the estimation of the effect,
we included independent variables identified as important determinants of care seeking[
and that have local context and cultural relevance within the framework of understanding
obstetric complications care seeking[
]. The variables include age, parity, education,
socio-economic status(SES), area of residence, facility type and distance to facility. We
additionally included variables indicating if women were registered to receive financial incentives
and for those who sought care, whether they were treated as in-patients (a proxy for disease
severity) and days spent in facility. We assumed these variables would have bearing on costs.
Following standard approaches, we generated a wealth index based on household assets
ownership using principal component analysis. We used the wealth index to rank the women
into three SES terciles. Table 1 provides details of the independent variables.
In settings where direct and indirect costs for obstetric complications care are substantial, the
apriori effects of cash transfers contingent on facility delivery on household costs is not clear.
It would depend on the size of the transfer, the share of women with complications (during
labor/delivery) who receive cash and whether receipt of cash actually substitutes for other
material support for upkeep or reduce the need for informal caregiver time. For example, if
the size of the transfer is large, one would expect an increase in direct costs. If the transfers are
used for upkeep while a woman is admitted for care and lessen the need for informal caregivers
time/support, one might expect a decrease in indirect costs. Given this lack of clear a
prediction, we attempted to answer this question empirically.
Although the 3-delay model outlined by Thaddeus and Maine originally applies to delivery
care, we expanded its use by applying the same set of concepts to all care pertinent to maternal
care, since we assumed that the same set of barriers to access persist along the maternal care
continuum. We further extended the model by linking it with performance incentives offered
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Fig 2. Conceptual framework depicting the association between Supply-Side Incentives, Demand-Side Incentives
and prompt presentation for obstetric complications care.
to health providers/facilities, cash transfers offered to women and time to seek care in Fig 2.
The framework provides a foundation for studying the relationship between supply-side and
demand-side financial incentives and time to seek care, while accounting for numerous factors
that interact and may contribute to attainment of prompt emergency care.
We hypothesise that, faced with an obstetric complication, perceptions of improved quality
of care at health facility resulting from supply-side incentives and guarantees of cash
reimbursements would positively influence decision making at household level, leading to reduced
likelihood of encountering first delay; and that promises of cash reimbursements would enable
households make better transport choices(e.g. more use of motorized transport) leading to
reductions in the second delay. Combined, these actions may lead to discernible reductions in
average times women with obstetric complications take before presenting themselves for
emergency care at health facilities.
We provide descriptive summary statistics (means, proportions and corresponding 95%
confidence intervals) for social-demographic characteristics of the women with a reported
complication in the control and intervention groups. We use t-tests and chi-square tests to assess
differences in means and proportions, respectively, between the two groups.
Health care data are typically positively skewed, heteroskedastic and may have nontrivial
fraction of zeros making it problematic to use parametric analytic approaches[
]. To estimate
populations means, E(y|x), while taking into account the non-normal distribution of health
care data, generalized linear models (GLMs) are recommended as they allow for making direct
inference about expected population means without recourse to complex transformations or
]. Given skewness of the study dependent variables (costs and time), we
opted to use GLM to model the dependent variables. As total costs had trivial amounts of zeros
(< 3%), a two part model, an approach often used in modeling cost data, is likely to have little
effect on the overall predicted mean costs[
]. We thus limited the cost analysis into a single
part prediction model.
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GLMs require explicit specification of the distribution (F) of the dependent variable and the
link function (g) describing how independent variables are functionally related to the
]. We used modified Parks test to select appropriate distribution and link
functions for the study outcomes[
]. Through this test, we found that a log link with Gamma and
Poisson families respectively provide best fits for the costs and time data.
The empirical GLMs took the form:
mi b0 b1Year ib2RBFi b3RBFi
Year i b4XI;
Where μi denotes the dependent variable of interest (costs/time) for every unit (pregnant
woman seeking care for a reported complication),Year i is a categorical variable indicating the
time point taking value 0 at baseline, 1 at midline and 2 at endline, RBFi, is an indicator
variable coded 1 if the unit is in the intervention group, 0 if in the control group, Xi is a vector of
independent factors known to influence the dependent variables as outlined above. The
estimable quantities of interest are thus: β0, a common constant for all observations,β1, effect of
time on each unit, β3 the effect of treatment (and the main target of inference) and β4
representing a vector of coefficients for X(Table 1). Given that the decision to admit women with
reported complications for in-patient care was based on clinical assessments, we considered
women admitted for care a distinct subgroup. We thus ran two separate models for each of the
primary study outcomes: the first model included all women with a reported complication
who sought care (full model), while the second was restricted to the women who were
admitted (restricted model). As the models have a log link, the exponential of coefficients should be
interpreted as the ratio of arithmetic means [
]. We generated robust standard errors and
corrected for clustering using the cluster command to allow for clustering of women at health
facility levels. StataIC/14 (Stata-corp LP, Texas, USA) was used for the analysis.
Out of 5,622 women surveyed across the three time points: 2,219 (39.4%) reported a
complication. Of these, 1,716 (30.5%) sought care and out of those, 691(12.2%) were admitted as
inpatients. The women's mean age ranged from 24.8 to 26.0 years, most (66.7±75.0%) had given
birth at least twice or more and the majority (55.8±66.4%) had completed primary school
education. At endline, there were significantly fewer married women (82.3 vs 89.1%), but more
women heading households (13.6 vs 6.2%) in the non-RBF than the RBF group. Nearly all
women in the non-RBF groups were in rural areas, a result of assigning district hospitals/
CEmOCs areas into RBF. There was suggestive evidence that care seeking for reported
complications was low among women in non-RBF groups at baseline and midline, but this did not
reach significant levels. Care-seeking decreased substantially in both RBF and non-RBF
facilities between baseline and endline. More descriptive details are shown in Table 2.
Costs of obstetric complications care
Women reporting a complication incurred similar mean costs at baseline and midline. The
mean costs appeared high for the women in RBF group at endline. However, Mann-Whitney
test showed that the median costs were not significantly different between the women in
nonRBF and RBF groups across the surveys Table 3.The pooled costs incurred by women who
received in-patient care for complications across the surveys are shown in Table 4. As resource
use may differ by level of health facility, the costs are also shown separately by facility type
within each group. Women admitted for in-patient care had slightly higher mean costs at
BEmOC than at CEmOC health facilities; this result was fairly consistent for each cost category
and between women in RBF and non-RBF groups. Although women admitted for care had
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cFigures may not add up 100 due to rounding
high mean costs in the RBF group, there were no significant differences in the median costs
incurred by women between the two groups. As a percentage of total costs, non medical costs
(e.g. transport, food and accommodation) and productivity losses separately accounted for
nearly one half of all costs while medical costs accounted for a much smaller percentage, which
is expected since health care services are free in public health facilities in Malawi.
N = 372
N = 300
N = 445
aExchange rate mid-year 2015, 1 US$ = 550 Malawi Kwacha (MK)
bP values estimated using Mann-Whitney test.
cSD Standard deviation
N = 638
aExchange rate mid-year 2015,1 US$ = 550 MK
bSD Standard deviation
cOther costs include food and accommodation
dNo statistical differences in medians for total costs between RBFand non-RBFgroups,P = 0.729. Mann-Whitney test.
The expected mean costs for obstetric complications were not significantly different between
women in non-RBF and RBF groups. This was the case both for all women seeking care with
reported complications (the full model) and when only women who ended up admitted for
inpatient care were included (restricted model) Table 5. The full model showed significant
negative associations between costs and parity, women heading households, registration for
incentives and the middle poor, meaning that women with these attributes had lower expected mean
costs of care. The full model also showed significant evidence of positive association between
cost and increasing number of in facility days and, as might be expected, between costs and
inpatient care, the proxy for complication severity. The expected mean costs increased by 7.8%
(95% CI:6.1±9.6) for each additional day in a facility and was 945.4% (95%CI: 843.7±1,058.8)
greater for women who received in-patient care. In the restricted model associations were
similar, except that heading household and being middle poor status were no longer significantly
negatively associated with costs, while residence in urban areas was.
Time taken to present for obstetric complications care
At both baseline and endline, women with reported complications in the RBF group on
average took more days before presenting for care than they did at endline. At baseline and
midline, the median duration to seek care was similar for women with reported complications
between the two groups but women in RBF group took significantly less median duration
(p = 0.025) before presenting for care at endline Table 6.
The expected mean time taken to present for obstetric complications were significantly
lower for women in RBF compared to women in the non-RBF group. This was the case both
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N = 227
N = 372
*P values estimated using Mann-Whitney test.
aSD Standard Deviation
for all women seeking care for reported complications (the full model) and when only women
who ended up as in-patients were included (restricted model). In both models, the estimated
effects were much stronger in the second year of RBF implementation Table 7. In the full
model, women in RBF group in year 1 took 27.3% (95% CI:28.4±25.9) less while in Year 2 they
took 34.2% (95%CI: 37.8±30.4) less time to care compared to women in non-RBF group. As
for attributes influencing time to seek care, there were subtle differences in significance
patterns across the two models. The full time model showed significant positive association
between increasing age, being married and registration for incentives and time whereas parity,
education and in-patient care(disease severity) were significantly negatively associated with
time. Women who ended up admitted for in-patient care took 63.7%(95%CI: 73.9±49.5)less
time to present for care than women with reported complications but who were not admitted
for care, and the effect was statistically significant. As the decision to admit women who
presented for care was made at facilities and clinical assessments for inpatient care are largely
based on complication severity, this finding means that women who experienced severe
complications in the RBF group on average took much less time to present for care.
In the restricted time model, being married was the only attribute significantly positively
associated with time while age, education, distance and middle poor were significantly
negatively associated with time. The important negative association between distance and time
may seem surprising and unexpected. However, if distance is sufficiently long, women may be
forced to pay for motorized transport in any case which could be quicker than un-motorized
This study makes a unique contribution to the literature since it is the first to describe costs
and time to seek care for obstetric complications within the context of RBF. Results indicate
that RBF substantially reduced time to seek care for women experiencing an obstetric
complication, while RBF did not produce any substantial effect on related overall household costs.
Costs of obstetric complications care
Our findings indicate that in settings like Malawi which do not impose formal user fees, it may
be difficult for RBF to produce a significant effect on household costs associated with seeking
care, when both direct and indirect costs are considered at once. Nevertheless, the observation
that indirect costs were substantially lower for households that benefited from CCT suggests
that RBF has the potential to reduce overall burden on the households. Unfortunately, the data
at our disposal makes it impossible to assess the overall social health protection effect of this
observed reduction in indirect costs. Our findings are consistent with findings by McIntyre D
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], indicating that other direct costs(e.g. transports, food, accommodation) and indirect
costs represent a substantially higher burden for households than medical costs alone. In turn,
this suggests the importance of intervention that can lower these costs, even when these
interventions are unable to affect direct medical costs. Our findings on reduced expected mean
costs and reduced informal caregiver engagement among women receiving CCT suggest that
cash receipts can substitute for informal caregivers' time or support. Therefore, among
beneficiaries, fewer informal caregivers per case allows households to minimise productivity loses
sufficiently to lower overall household costs. Qualitative inquiries can further aid
understanding on how this plays out in practice.
Time to seek obstetric complication care
The mean time to care for obstetric complications was significantly lower for women subjected
to RBF intervention. This effect was stronger in the longer rather than shorter term. The
finding that financial reimbursements are associated with reduced delays in seeking emergency
care is similar to that published by Nahar S et al [
] even though their work is not within a
formal RBF context. There are a number of possible explanations for the observed reduction
in time to seek care in our setting. Supply side improvements in quality of care may have
occurred in intervention facilities, inclining household decision making towards early care
seeking. The promise of transport refunds may have emboldened beneficiaries to increase
fiscal expenditure thresholds, allowing them to use relatively expensive, but quick modes of
transport to get to facilities. Alternatively, the prompt care seeking noted in intervention areas
could have been part of a response to broader health education/promotion efforts in the areas
informing women about obstetric dangers signs and encouraging them to seek formal care
early, or a more functional referral system may have existed in intervention areas. We examine
each of these plausible explanations in turn.
First, there is consensus that quality health services attract women to formal care[39±41].
Project documents provided evidence of attendant improvements in structural quality for
intervention facilities as a result of equipment and other supplies provided as part of RBF4MNC to
strengthen facility capacities. Because the majority of women in the study areas at least attend
one antenatal care visit[
], it is probable that engagement with better antenatal care services
during preceding visit(s) may have ªprimedº the women's perceptions regarding improved
quality of care at intervention facilities, leading to subsequent prompt care seeking in times of
potential obstetric emergencies. Second, guarantees of transport refunds could have empowered
potential beneficiaries to use their fiscal resources to pay for motorized modes of transport.
Alternatively, guarantees of cash refunds could have reduced perceived financial constraints
allowing household to take immediate decisions to seek emergency obstetric care. Regarding
the former, our data do not support this assertion as the percentage of households that used any
motorized form of transport (e.g. cars) did not significantly differ between intervention and
control areas. Women registered for incentives had significantly higher expected mean time to
care, which does not support our premise that perceptions of fiscal empowerment may have
promoted prompt decision making. Third, health education is an integral part of RH services
provided to antenatal women. Centrally planned and coordinated, standardized reproductive
health education is evenly provided across all facilities in a district. Although local
non-governmental organizations are increasingly taking part and supporting DHMT in health promotion
activities in the study districts, we have no evidence that intervention areas received any special
intensive health promotion activities. In fact, our data shows that care seeking patterns were not
different between intervention and control groups (Table 1). Fourth, even though referral
systems were not explicitly incentivised, there is a possibility that (presumably) motivated health
13 / 18
providers in intervention BEmOC facilities could have coordinated better with CEmOC
facilities to arrange transport for the women with complications, for those referred from BEmOC to
CEmOC facilities. There is evidence that differential transport arrangements existed between
intervention and control facilities, but this was in favour of referrals from control BEmOCs.
Ruling out these alternatives, we conclude that the significantly reduced time to care observed
in intervention areas most likely resulted from prompt decision making at household level due
to perceptions of facility quality improvement, while community level delays appear to be less
From a policy perspective, it is important that women with higher risk profiles for obstetric
complications (e.g. high parity or the poor) present for curative care early. It is therefore worth
exploring how responsive women with different risk attributes were to RBF. We found that
high parity, education, increasing distance and medium poor status were associated with
significantly lesser expected mean time to care. The experience that comes with more births (high
parity) and information associated with high education allows women to make better decisions
as might be expected. That the medium poor respond faster than the poor reiterates the usual
disadvantage faced by the poor.
It is a fair question to ask what influence different components of RBF4MNH had on
primary study outcomes. The observed short term effects give an estimate of what to expect if
only supply-side incentives were in place; a significantly reduced mean time to care but no
substantial change in overall household costs. Unfortunately, estimating with certainty any
additional effects accruing from a combination of supply and demand-side incentives is not
possible in our study given the low coverage (25%) for demand-side incentives. Because this
would be valuable information for policy makers, studies based on optimally designed and
implemented RBF programs that allow for such detailed evaluations are needed. Information
on relative effectiveness of RBF components will provide more policy options: enabling better
configuration of financial incentive structures to align with local health priorities and health
Our study can not explain how RBF influence power dynamics in the home in view of the
fact that in many societies, it's the men who make key decision related to health choices[
Neither can it shed light on how actually the women/ households mobilized resources to
finance transport during emergencies. These are potential qualitative research question for
future studies. Finally, for countries like Malawi where donors provide a large share of
], it is important to consider sustainability and cost-effectiveness of RBF in
This study has some limitations. First, women with complications self-select for obstetric care.
The women who did not seek care for reported complications could thus bias the results. Since
the intervention did not produce significant effects on overall service use between the two
groups across the survey years, we do not anticipate a large selection bias. Second, as the
information was collected retrospectively, recall bias resulting in time-varying deferential reporting
of study outcomes may have affected the results. As four week recall is often used in cost
studies, we compared mean costs/ time estimates reported within 4 weeks of termination of
pregnancy with those reported after 4 weeks as validation checks and to assess size of bias, if any.
We made these comparisons between groups, before and after the implementation of
intervention. The results (available upon request) demonstrate no influence of recall bias on time
estimates but suggest recall bias may have affected cost estimates in the post intervention period.
We thus argue that our results should be read with these limitations in mind.
14 / 18
The most important finding of this study is the significant reduction in the expected mean
time taken before presenting for obstetric complication care by recipients of RBF. This
occurred despite the lack of a substantial change in overall household costs. This result is
probably a manifestation of the RBF induced quality improvements which encourage immediately
care seeking when women are faced with potential obstetric complications. Our results suggest
RBF may contribute to prompt emergency care seeking and thus ultimately reduce maternal
morbidity and mortality in beneficiary populations.
This research project is funded through a grant by the Norwegian Ministry of Foreign Affairs
to the Government of Malawi under Programme Title MWI 12/0010 Effect Evaluation of
Performance Based Financing in Health Sector. The Malawi College of Medicine as implementing
institution is recipient of this grant.
This study was co-funded by the United States Agency for International Development
under Translating Research into Action, Cooperative Agreement No. GHS-A-00-09-00015-00.
This study is made possible by the support of the American People through the United States
Agency for International Development (USAID). The findings of this study are the sole
responsibility of study team and do not necessarily reflect the views of USAID or the United
The authors are indebted to Julia Lohmann, Christabel Kambala, Judith Daire, Alinafe
Mwanza, District health officers, enumerators and all surveyed women whose whole hearted
support were invaluable throughout the data collection.
Conceptualization: JC BR MDA.
Data curation: JC JM.
Formal analysis: JC BR MDA JM.
Funding acquisition: MDA AM.
Investigation: JC JM SB DM AM.
Methodology: JC BR MDA.
Project administration: JC JM SB.
Resources: MDA AM DM.
Supervision: BR MDA AM DM.
Validation: BR JM.
Visualization: JC BR MDA SB DM AM JM.
15 / 18
Writing ± original draft: JC.
Writing ± review & editing: BR MDA SB AM JM SB DM.
16 / 18
17 / 18
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