Scaling-up of performance-based financing (PBF) schemes across sub-saharan Africa has developed rapidly over the past few years. Many studies have shown a positive association between PBF and health service coverage, and some with improvements in quality. However, a lack of controls and confounders in most studies that have been published on PBF initiatives means that the impact of PBF initiatives on service coverage, quality and health outcomes remains open to question. Moreover, few studies have examined the factors that influence the impact of PBF- an area of considerable operational significance since PBF often involves a package of constituent interventions: linking payment and results, independent verification of results, managerial autonomy to facilities and enhanced systematic supervision of facilities. As a result, the policy objectives of the following Impact Evaluation are to: (a) identify the impact of PBF on Maternal and Child Health (MCH) service coverage and quality; (b) identify key factors responsible for this impact; and (c) assess cost-effectiveness of PBF as a strategy to improve coverage and quality. The results from the impact evaluation will be useful to designing national PBF policy in Cameroon and will also contribute to the larger body of knowledge on Performance-based Financing (PBF).
The impact evaluation is a blocked-by-region cluster-randomized trial (CRT), having a pre-post with comparison design. The evaluation relies primarily on experimental control to answer the main research questions for this study. Individual health facilities in each region have been randomized to one of the 4 study groups. Individual public and private primary care health facilities in 14 districts from the 3 pilot regions have been randomly assigned to each study group to create a factorial study design.
The evaluation relied on two main sources of data:
- Household surveys: A household survey was implemented at baseline (i.e., before implementation of PBF begins), and at endline (i.e., after PBF has been implemented for two years).
- Facility-based surveys: A facility-based survey was implemented at baseline and at endline.