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How rewards improve health practice in Malawi: Learnings from a Maternal and Newborn Health Initiative


Health provider attending mother and baby in Dedza District Hospital, Malawi.

Writer: Dr Mary White-Kaba

Peer reviewer: Dr Valéry Ridde, Professor of Public Health, Université de Montréal, Canada
Dr Maria Paola Bertone, Research Fellow, Institute for Global Health and Development, Queen Margaret University, Scotland

Published by Federal Ministry for Economic Cooperation and Development (BMZ), July 2017

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Key learnings

Implementing the intervention as a shared learning experience enables adaptation and ownership. Adopting an action-research approach, together with the partners, in which strategies are tested and adapted in the course of implementation, ensures continued relevance of the project despite a changing context.

Results-Based Financing (RBF) can empower health worker teams to improve their own working conditions and the quality of care they provide. Rewarding the performance of the health facility as a whole fosters teamwork, and reserving part of the cash reward as a ‘facility portion’ to be spent at the team’s discretion improves quality of care and fosters staff’s self-efficacy.

Compared to investments in infrastructure and equipment, investments in staff motivation make a greater difference. Incentivising quality of care led to rapid and sustained improvement, well before reception of the Initiative’s equipment and infrastructure component.

Regular review and adaptation of payment indicators are important and should be participatory. Incentivising quality of care indicators allows a direct link with health-care provision. Indicators can be targeted at specific areas of weakness and must be verifiable by an external team. To be motivating, rewards must relate closely to performance, reward cycles must be short and feedback of results prompt.

It remains a challenge to ensure careful monitoring of performance indicators while keeping a lid on staff workload. Keeping up with reward indicator monitoring in addition to routine administration and reporting is time-consuming and often perceived by staff members as reducing their availability to provide quality care. RBF interventions need to carefully assess the time ratio between performance and accounting for the performance in order to find a realistic balance.

Associating supply-side and demand-side interventions can lead to improved maternal-newborn outcomes. Health-promoting behaviours such as pregnant mothers’ early arrival and prolonged stay after delivery can be supported by a Conditional Cash Transfer (CCT) that defrays their costs for transport, delivery items and food while away from home, while health personnel are rewarded for regularly checking newborns’ vital signs during the crucial 48 hours after birth.

At district level RBF can facilitate effective health service decentralisation. Anchoring the intervention at district level and rewarding the District Health Management Teams’ supportive supervision has improved these teams’ management capacities, their resource allocation and their responsiveness to feedback – not just for the intervention facilities but for their districts as a whole. Evidence-based results on district level can in turn feed into national health policy and strategy.

The challenge: Persistent high maternal and neonatal mortality

Despite a greatly improved Institutional Delivery Rate (IDR) of nearly 90%, Malawi’s rates of maternal and newborn mortality remain high at 439/100,000 and 27/1000 live births respectively. Factors include on the one hand sub-optimal quality of care in maternity services, reflecting insufficient human, financial and material resources in the health sector, and on the other hand late arrival and early departure after delivery by mothers, many of whom cannot afford to be away from home for long.

The response: Incentivising improved health practice and supporting mothers’ stay in the health facility

RBF4MNH aims to improve the quality and accessibility of selected Emergency Obstetric and Newborn Care (EmONC) facilities in four rural districts since 2012 via three main components:

  • Supply-side incentives – health facilities and District Health Management Teams earn monetary rewards by fulfilling indicators related to quality of care and health system improvements, of which 40% – the ‘facility portion’ – is to be reinvested by the team to improve their working conditions.
  • Demand-side payments – to make it more affordable for mothers to come early and stay longer after delivery, Conditional Cash Transfers (CCT) assist pregnant women to defray costs for transport between home and the health facility, for delivery-related items and for expenses during their stay in the health facility.
  • Investment in equipment and infrastructure was designed as a preliminary measure to bring the intervention EmONCs up to a minimum standard for ensuring emergency obstetric care.

Taking a highly participatory action-research approach, with a major accent on communication and collaboration with traditional chiefs, the Initiative team and its partners on district, community and central level have fine-tuned their strategies in the course of implementation, accompanied by an external impact evaluation conducted by Heidelberg University’s Institute of Public Health and Malawi’s College of Medicine. Adaptations of the Initiative design have included definition and monitoring of reward indicators, management of incentives, enabling health facility staff to manage the cash for the CCTs and the ‘facility portion’, and adjusting targeting of CCT beneficiary mothers from an inefficient administrative approach to one which involves the communities in determining women’s eligibility.

What has been achieved

RBF4MNH has largely succeeded in achieving its goal ‘Women deliver increasingly in targeted health facilities, where maternal and neonatal services of good quality are offered.’ All 33 of the currently supported EmONCs fulfil 100% of the MoH’s quality criteria, and the majority of women delivering in these facilities benefit from the CCT. With the new community-based approach, all poor women residing in the district are eligible for CCT. RBFsupported EmONCs attract an estimated 10% more women than before the intervention. Eighty-seven per cent of women stay 48 hours after delivery, and the proportion of maternal and neonatal deaths appears to be decreasing.

Incentivising District Health Management Teams’ management and supportive supervision of all health facilities – not just the RBF EmONCs – has led to overall improvement in quality of care in each district.

Further readings on RBF4MNH

Policy brief

BMZ glossary

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