Health Economics and Data Analytics, School of Population Health, Curtin University, GPO Box U1987, Perth, WA 6845, Australia.
School of Economics and Finance, University of the Witwatersrand, P Bag 3, Johannesburg 2050, South Africa.
Health Policy Plan. 2024 Nov 14;39(10):1022-1031. doi: 10.1093/heapol/czae080.
The results-based financing (RBF) programme, first implemented in Zimbabwe in 2011 and gradually expanded to other districts, aimed to address disparities in maternal health outcomes by improving the utilization of health services. This study leverages the staggered rollout of the programme as a quasi-experimental design to assess its impact on asset wealth-related inequalities in selected maternal health outcomes. The objective is to determine whether RBF can effectively reduce these disparities and promote equitable healthcare access. We employ an extended two-way fixed effects (ETWFE) model to exploit temporal variation in RBF implementation as well as individual-level variation in birth timing for identification. Utilizing pooled cross-sectional and nationally representative data from the Zimbabwe demographic and health surveys collected between 1999 and 2015, our analysis reveals significant reductions in relative and absolute maternal health inequalities, especially in the frequency and timing of prenatal care, delivery by caesarean section and family planning. Specifically, the RBF programme is associated with reductions in disparities for completing at least four or more prenatal care visits (-0.026, P < 0.01), first-trimester prenatal care (-0.033, P < 0.01), delivery by caesarean section (-0.028, P < 0.005) and family planning (-0.033, P < 0.005). Additionally, the programme is associated with improved prenatal care quality, as evidenced by progress on the prenatal care quality index (-0.040, P < 0.01). These effects are more pronounced among lower socio-economic groups in RBF districts, highlighting RBF's potential to promote equitable healthcare access. Our findings advocate for targeted policy interventions prioritizing expanding access to critical maternal health services in underserved areas and incorporating equity-focused measures within RBF frameworks to ensure inclusive and effective healthcare delivery in Zimbabwe and other low-income countries.
基于成果的融资（RBF）计划于 2011 年首次在津巴布韦实施，并逐步扩展到其他地区，旨在通过改善卫生服务的利用来解决孕产妇健康结果的差异。本研究利用该计划的交错推出作为准实验设计，评估其对选定孕产妇健康结果与资产财富相关不平等的影响。目的是确定 RBF 是否可以有效地减少这些差距并促进公平的医疗保健获取。我们采用扩展的双向固定效应（ETWFE）模型来利用 RBF 实施的时间变化以及出生时间的个体差异进行识别。利用津巴布韦人口与健康调查在 1999 年至 2015 年期间收集的 pooled 横截面和全国代表性数据进行分析，我们的分析表明，相对和绝对孕产妇健康不平等有了显著减少，特别是在产前护理的频率和时间、剖腹产分娩和计划生育方面。具体而言，RBF 计划与减少至少进行四次或更多次产前护理访问的差距相关（-0.026，P < 0.01）、第一孕期产前护理（-0.033，P < 0.01）、剖腹产分娩（-0.028，P < 0.005）和计划生育（-0.033，P < 0.005）。此外，该计划与产前护理质量的提高有关，这表现在产前护理质量指数上的进展（-0.040，P < 0.01）。在 RBF 地区的社会经济地位较低的群体中，这些影响更为明显，突显了 RBF 促进公平医疗保健获取的潜力。我们的研究结果提倡采取有针对性的政策干预措施，优先扩大在服务不足地区获得关键孕产妇健康服务的机会，并在 RBF 框架内纳入注重公平的措施，以确保津巴布韦和其他低收入国家提供包容性和有效的医疗保健。
