Bonfrer Igna, Van de Poel Ellen, Van Doorslaer Eddy
Institute of Health Policy & Management, Erasmus University Rotterdam, The Netherlands.
Institute of Health Policy & Management, Erasmus University Rotterdam, The Netherlands.
Soc Sci Med. 2014 Dec;123:96-104. doi: 10.1016/j.socscimed.2014.11.004. Epub 2014 Nov 6.
Africa's progress towards the health related Millennium Development Goals remains limited. This can be partly explained by inadequate performance of health care providers. It is therefore critical to incentivize this performance. Payment methods that reward performance related to quantity and quality, called performance based financing (PBF), have recently been introduced in over 30 African countries. While PBF meets considerable enthusiasm from governments and donors, the evidence on its effects is still limited. In this study we aim to estimate the effects of PBF on the utilization and quality of maternal and child care in Burundi. We use the 2010 Burundi Demographic and Health Survey (August 2010-January 2011, n = 4916 women) and exploit the staggered rollout of PBF between 2006 and 2010, to implement a difference-in-differences approach. The quality of care provided during antenatal care (ANC) visits improved significantly, especially among the better off, although timeliness and number of ANC visits did not change. The probability of an institutional delivery increased significantly with 4 percentage points among the better off but no effects were found among the poor. PBF does significantly increase this probability (with 5 percentage points) for women where PBF was in place from the start of their pregnancy, suggesting that women are encouraged during ANC visits to deliver in the facility. PBF also led to a significant increase of 4 percentage points in the probability of a child being fully vaccinated, with effects more pronounced among the poor. PBF improved the utilization and quality of most maternal and child care, mainly among the better off, but did not improve targeting of unmet needs for ANC. Especially types of care which require a behavioral change of health care workers when the patient is already in the clinic show improvements. Improvements are smaller for services which require effort from the provider to change patients' utilization choices.
非洲在实现与健康相关的千年发展目标方面进展依然有限。这部分可归因于医疗服务提供者的表现欠佳。因此，激励这种表现至关重要。奖励与数量和质量相关表现的支付方式，即基于绩效的融资（PBF），最近已在30多个非洲国家推行。虽然PBF受到政府和捐助者的极大热情，但关于其效果的证据仍然有限。在本研究中，我们旨在评估PBF对布隆迪孕产妇和儿童保健利用情况及质量的影响。我们使用2010年布隆迪人口与健康调查（2010年8月至2011年1月，n = 4916名妇女），并利用2006年至2010年期间PBF的逐步推广，采用双重差分法。产前检查（ANC）期间提供的护理质量显著提高，尤其是在较富裕人群中，尽管ANC检查的及时性和次数没有变化。较富裕人群中机构分娩的概率显著增加了4个百分点，但贫困人群中未发现影响。对于从怀孕开始就实施PBF的妇女，PBF确实显著提高了这一概率（增加了5个百分点），这表明在ANC检查期间鼓励妇女在医疗机构分娩。PBF还使儿童完全接种疫苗的概率显著提高了4个百分点，在贫困人群中的效果更为明显。PBF改善了大多数孕产妇和儿童保健的利用情况及质量，主要是在较富裕人群中，但没有改善对未满足的ANC需求的针对性。特别是当患者已经在诊所时，需要医护人员行为改变的护理类型有改善。对于需要提供者努力改变患者利用选择的服务，改善较小。
