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Assessing quality of care in Malawi’s Support for Service Delivery and Integration Project’s Performance Based Incentives Intervention

A health worker cares for a newborn at Kochirira Health Centre in Mchinji District. Photo Credit: Uchembere Wangwiro Program

Research Overview

In Malawi, primary healthcare provision is largely based on an essential healthcare package (EHP), the set of health services that are meant to be provided free of charge in both public and private, not-for-profit facilities. Essential health services are not as widely available or as widely utilized as needed to achieve the Government of Malawi’s health objectives.
The Ministry of Health piloted a performance based incentives (PBI) program with support from USAID Malawi’s flagship health project, Support for Service Delivery Integration (SSDI), in order to improve the availability and uptake of services. The PBI pilot program was executed in three target districts. The SSDI-PBI program aimed to increase access, utilization, and quality indicators across a range of health areas including maternal and child health. The SSDI-PBI pilot project was unique from other PBI projects, both in Malawi and globally, in that financial incentives were awarded exclusively to facilities upon achievement of set targets, and not to individual health workers. 
The aim of the process and impact evaluation of the SSDI-PBI intervention in Malawi was to assess the effect that the SSDI-PBI intervention produced on the work environment, on provider behavior (including service outputs) and on providers’ sense of knowledge, motivation and self-efficacy. The study also examined effects in light of contextual factors that shaped program implementation and the costs of implementing the intervention in relation to outcomes produced.

Project Location

The study took place in three districts in Malawi: Chitipa, Nkhotakota, and Mangochi.

Research Objectives

Research questions included:
  • Focusing on service provision, to what extent did the SSDI-PBI intervention produce changes in the quantity and quality of services provided? Which work environment changes could be attributed to PBI (i.e. availability of equipment, drugs, staff, training, supervision in respect to clinical performance)? What heterogeneity in effects could be observed across districts and facilities? To what extent have changes affected incentivized vs. non-incentivized services?
  • Focusing on providers, how has the SSDI-PBI intervention changed motivation of health workers? Are changes in motivation reflected in changed attitudes or behavior at work?
  • Focusing on fidelity, to what extent was the SSDI-PBI intervention implemented according to its original implementation plan? Which contextual factors affected implementation, as defined in relation to acceptance and adoption of the intervention, at the various levels of service provision, including at health facility levels? Which contextual factors explained heterogeneity in implementation processes across districts and facilities? 
  • Focusing on efficiency, what were the costs of implementing the SSDI-PBI intervention in relation to the outcomes produced? Is the economic burden of designing, implementing and managing the SSDI-PBI system worthwhile considering results achieved? 

Study Approach

The study used a mixed methods approach. To assess fidelity to the implementation plan, quantitative data were collected through structured interviews with key intervention personnel as well as a structured document review. In-depth interviews (IDIs) and focus group discussions (FGDs) among implementers and providers were conducted to explain the implementation process and the acceptability and adoption of the intervention. 
Researchers extracted facility and service assessment data from existing sources of program data to examine changes in service quantity and quality at the facility level. In addition, IDIs with clients and FDGs with community members gathered data on client perceptions of the service quality.
To examine provider motivation and behavior, a structured survey and IDIs collected data on provider motivation and perceptions of the changes in their own behavior that took place during implementation as a result of the PBI intervention.
Finally, a cost-consequence analysis (CCA) was used for comparison of costs and benefits that were measured in different units. Cost data were collected through a financial document review and linked with quantity and quality outputs that were measured.


  • After an initial overhaul of the program design, results suggested that the program was executed in a manner that was faithful to its most critical elements and across respondents, the PBI program was described as well-designed.
  • Health care workers reported the delay of delivery of procured goods to facilities and stock outs as main issues throughout program implementation.
  • Among the most successful elements of the program- in terms of ability to facilitate implementation reported by respondents- was its emphasis on engagement, communication and participation across stakeholders.
  • The intervention had overall positive effects on services related to maternal and newborn health (antenatal care, including provision of IPT, prevention of mother-to-child transmission, and to some degree postnatal care), and the program positively affected service quality related to HIV counseling and testing and Vitamin A distribution, but it had no effect on counseling services related to family planning or skilled attendance at birth.
  • Women clients were not aware of the SSDI-PBI program and reported a lack of equipment and drugs, overworked providers, and reported experiencing delivering alone and feeling neglected.
  • Community leaders were well-sensitized on, engaged and pleased with the PBI program. They recommended more opportunities to the community, streamlining procurement and keeping the community informed regarding the flow of funds.
  • Overall, the health workers reported positive perceptions of the program and found it motivating and especially had positive feelings about the peer-to-peer model with peer reviewers from outside districts assessing quality indicators.
  • The intervention was found valued at over $3 million (USD) where personnel costs were the most costly and the design phase absorbed one third of the costs.

Policy Briefs

Social Media

  • Blog Post: Incentivizing Respectful Maternity Care - could PBF promote comprehensive change? 

Research into Action

Results from this study were used by the Malawi Ministry of Health and USAID in planning the future role of PBI within quality improvement efforts. This study provided valuable insights for policy makers and implementers beyond Malawi as it focuses on a non-typical PBI intervention design and is therefore a unique contribution in the field. 


University of Heidelberg Institute of Public Health (IPHHD)
University of Malawi College of Medicine (COM)
Bocconi University Center for Research on Health and Social Care Management (CERGAS)






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