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A Mixed-Methods Evaluation Of A USAID Performance Based Incentives Program To Improve The Uptake And Quality Of Essential Health Care Services In Malawi

Principal investigator: PD Dr. Manuela De Allegri, IPH Heidelberg

Project Scientific Coordinator:  Dr Shannon McMahon, IPH Heidelberg

Funding: TRAction (USAID)

Prof. Adamson Muula and Prof. Don Mathanga, College of Medicine, Malawi
Dr. Aleksandra Torbica, Bocconi University

Project description:
In Malawi, persistently high rates of morbidity and mortality have been linked to factors including shortages in terms of human resources for health, and inadequacies within facilities related to basic and essential infrastructure, management, support and services. To address these shortages, the Ministry of Health (MoH) continues to explore innovative approaches that can secure sustainable health financing sources, improve the health sector’s efficiency, and ensure equitable resource allocation within the health system. The MoH views Performance-Based Incentive (PBI) programs as a promising mechanism to address health system shortcomings. The MoH included a novel PBI component within its broader essential health intervention program (the Support for Service Delivery Initiative (SSDI)). To date, a substantial knowledge gap remains as to how various PBI interventions affect quality of care for basic or essential health services and whether or how interventions should be tailored to address local needs. To fill this gap, this study will engage in a process evaluation with the stated objective of relating the analysis of processes to that of outcomes, assessing both expected and unexpected consequences of the intervention and offering information on how the intervention could be modified to better align with the local context.

The planned evaluation will take place for one year and consist of four complementary branches of research: implementation processes, service provision, provider motivation and costing. These veins of research will rely on quantitative and qualitative methods alternately or in conjunction. Data collection activities will include: structured and in-depth interviews with key personnel involved in the intervention; structured reviews of implementation documents; and structured and in-depth interviews with health care providers. In addition, secondary data from the Malawi's Health Management (and Logistics Management) Information Systems (HMIS and LMIS, respectively), the country's Service Provision Assessment, patient registries, SSDI baseline, and SSDI monitoring and evaluation data will be used. Qualitative data will be analyzed using an approach based in Grounded Theory, supported by NVivo 10 during the coding and analytical process. Quantitative data will be analyzed with the appropriate statistical techniques using Stata 13. The research team will undertake data triangulation as a mean to compare information across data sources, checking for consistency in the interpretation of information emerging across research themes.

A prospective controlled before-and-after triangulation design will be used to assess single and combined impact of each PBF intervention by analyzing quantitative and qualitative data from intervention facilities (i.e. facilities enrolled in QPC) and control facilities (i.e. facilities not enrolled in QPC) before and after each PBF intervention is set in place. Quality and access outcomes will be assessed along three dimensions: (1) structural elements (i.e. availability of equipment, drugs, staff); (2) process elements (i.e. providers’ compliance with national and international standards); (3) experiential elements (i.e. providers’ and clients’ expectations and experience related to service delivery). Causal effects of the single and combined PBF interventions will be determined by a rigorously defined counterfactual using trends over time in the measured quality indicators.

The study team will work closely with stakeholders throughout the study period (particularly at the outset of the study). For stakeholders and implementers, the team will devise a series of webinars as the research progresses and will conclude with the dissemination of material that is done within the context of an existing meeting organized by the Ministry of Health and SSDI at the close of the intervention's pilot phase.

Status: Ongoing

Manuela De Allegri manuela.de.allegri@urz.uni-heidelberg.de
Shannon McMahon mcmahon@uni-heidelberg.de