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Results-Based Financing for Maternal Neonatal Health (RBF4MNH)

Health provider cares for mother and newborn at a health center in Dedza District, Malawi. Photo Credit: Uchembere Wangwiro Program.

Research Overview

Scaling-up of results-based financing (RBF) schemes across sub-Saharan Africa has developed rapidly over the past few years. Although studies in several countries have suggested that RBF can play a role in improving service utilization, a substantial knowledge gap remains as to how various RBF interventions affect quality of care of essential obstetric and newborn care (EONC).
The Results-Based Financing for Maternal Neonatal Health (RBF4MNH), a pilot program, aimed to increase the number of facility-based births and enhance the quality of care provided to women during labor and delivery. The RBF4MNH consisted of a performance-based financing (PBF) component, which started in April 2013 in 18 emergency obstetric care (EmOC) facilities and was extended in October 2014 to a total of 28 EmOC facilities. In addition, the RBF4MNH also included a conditional cash transfer component (CCT) supporting pregnant women to use delivery services at EmOC facilities, which was fully in place and functional in late 2014.
The RBF4MNH impact evaluation aimed to bridge the evidence gap on questions of coverage and quality by assessing the expected and unexpected effects of performance-based incentives (PBI) on quality of maternal care services in Malawi.


Project Location

The study took place in 33 facilities and their catchment areas in four districts in Malawi: Balaka, Dedza, Mchinji, and Ntcheu.

Research Objectives

The purpose of this study was to assess the implementation and impact of the RBF4MNH Initiative on quality of care and access to maternal and neonatal health services in Malawi. Research study objectives included:
  • Establish anticipated and unanticipated effects of the RBF interventions on quality of obstetric care and service utilization.
  • Identify unanticipated effects of the RBF interventions on quality of a broader spectrum of maternal and neonatal services, including antenatal care (ANC), post-natal care (PNC), and newborn care.
  • Assess the pathways in which RBF incentives affect work-related satisfaction and motivation of health care workers.

Study Approach

This study examined the quality impact of the initiative on services directly targeted by the RBF program (i.e. obstetric services), as well as essential antenatal and newborn care to determine if intervention effects spillover into these other service areas. The study also examined the effect of the intervention on service utilization, provider motivation and job satisfaction, as well as the implementation of the intervention. Quantitative data were collected at three time points and qualitative data at two time points over a two-year period to compare changes in intervention and control facilities. 
The study produced quantitative data on quality of care (QoC) through: (1) structural quality indicators measured through facility assessments; (2) provider knowledge measured through vignettes, and (3) process indicators measured through systematic observation of clinical encounters as well as client exit interviews and facility record review. Furthermore utilization of care was measured through household surveys among women who had completed a pregnancy in the past twelve months.
Qualitative data were collected via in-depth interviews with maternal health care providers, RBF4MNH initiative implementers and stakeholders and collected via community-based focus group discussions with women living in catchment areas under study who had completed a pregnancy in the past twelve months.


  • Overall there were no changes in the rates of health service utilization attributable to the RBF4MNH intervention neither for directly targeted services (i.e. facility-based delivery) nor related services (i.e. antenatal and postnatal care services). A positive effect of the intervention on quality of care was measured in some areas, but not others. There were strong positive effects of the RBF4MNH intervention on the quality structural and process indicators, including availability of skilled staff and a positive effect on providers’ clinical performance related to HIV and pre-eclampsia risk factors assessments, infection prevention during labor (but not during birth), and routine oxytocin administration during third stage labor (but not for other aspects of AMTSL performance). However, there was no effect on the clinical performance of labor monitoring and partograph documentation and no statistically measurable overall effect of the RBF4MNH on the availability of equipment, supplies, medications, and commodities in RBF facilities.
  • In spite of reporting high satisfaction with their care experience, clients reported experiencing disrespect and/or abusive behavior by their maternal care providers across all facilities. Women in RBF4MNH facilities were more likely to report satisfaction with the level of confidentiality provided to them during labor and delivery than in comparison facilities. The evaluation also found that the RBF4MNH program may increase instances of consented care. Health providers from several facilities described feeling more accountable to women due to the creation of an exit interview process wherein women are asked to describe how they were treated by providers.
  • Only about half of all eligible women had enrolled in the conditional cash transfer program and about one quarter did not receive cash reimbursements despite fulfilling all conditions.
  • Low staffing levels and persisting challenges related to drugs and other supplies continued to be a source of frustration for many.
  • The RBF4MNH motivated health care providers to improve their performance due to additional rewards, improved supervision and feedback, and perceived improvements to their working environment.
  • Generally, the majority of stakeholders spoke highly of the RBF4MNH implementation process; however, reported challenges including overall understaffing of health facilities, delays in the facility upgrade component of the RBF, and the inefficient procurement processes for equipment.
  • All stakeholders perceived the RBF4MNH pilot as a successful approach and supported the idea of a RBF scale-up beyond the current facilities and districts.

Policy Briefs




Social Media

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


Research Into Action

Findings from this study were shared with the Ministry of Health throughout the duration of the project to enable implementation adjustments and to help inform policy decisions as the program scaled up. This study also assisted in filling the evidence gap related to the effects of RBF on quality of care. Research in this area is currently lacking, and the findings of this study contributed to RBF policy formation in Malawi and elsewhere.

Research Partner

University of Heidelberg Institute of Public Health
University of Malawi College of Medicine

Principal Investigator

Manuela De Allegri, University of Heidelberg 

Project Status

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