The effect of performance-based financing on illness, care-seeking and treatment among children: an impact evaluation in Rwanda.

BACKGROUND: Performance-based financing (PBF) strategies are promoted as a supply-side, results-based financing mechanism to improve primary health care. This study estimated the effects of Rwanda's PBF program on less-incentivized child health services and examined the differential program impact by household poverty. METHODS: Districts were allocated to intervention and comparison for PBF implementation in Rwanda. Using Demographic Health Survey data from 2005 to 2007-08, a community-level panel dataset of 5781 children less than 5 years of age from intervention and comparison districts was created. The impacts of PBF on reported childhood illness, facility care-seeking, and treatment received were estimated using a difference-in-differences model with community fixed effects. An interaction term between poverty and the program was estimated to identify the differential effect of PBF among children from poorer families. RESULTS: There was no measurable difference in estimated probability of reporting illness with diarrhea, fever or acute respiratory infections between the intervention and comparison groups. Seeking care at a facility for these illnesses increased over time, however no differential effect by PBF was seen. The estimated effect of PBF on receipt of treatment for poor children is 45 percentage points higher (p = 0.047) compared to the non-poor children seeking care for diarrhea or fever. CONCLUSIONS: PBF, a supply-side incentive program, improved the quality of treatment received by poor children conditional on patients seeking care, but it did not impact the propensity to seek care. These findings provide additional evidence that PBF incentivizes the critical role staff play in assuring quality services, but does little to influence consumer demand for these services. Efforts to improve child health need to address both supply and demand, with additional attention to barriers due to poverty if equity in service use is a concern.

The effect of access to contraceptive services on injectable use and demand for family planning in Malawi.

CONTEXT: Previous studies have identified positive relationships between geographic proximity to family planning services and contraceptive use, but have not accounted for the effect of contraceptive supply reliability or the diminishing influence of facility access with increasing distance. METHODS: Kernel density estimation was used to geographically link Malawi women's use of injectable contraceptives and demand for birth spacing or limiting, as drawn from the 2010 Demographic and Health Survey, with contraceptive logistics data from family planning service delivery points. Linear probability models were run to identify associations between access to injectable services-measured by distance alone and by distance combined with supply reliability-and injectable use and family planning demand among rural and urban populations. RESULTS: Access to services was an important predictor of injectable use. The probability of injectable use among rural women with the most access by both measures was 7‒8 percentage points higher than among rural dwellers with the least access. The probability of wanting to space or limit births among urban women who had access to the most reliable supplies was 18 percentage points higher than among their counterparts with the least access. CONCLUSIONS: Product availability in the local service environment plays a critical role in women's demand for and use of contraceptive methods. Use of kernel density estimation in creating facility service environments provides a refined approach to linking women with services and accounts for both distance to facilities and supply reliability. Urban and rural differences should be considered when seeking to improve contraceptive access.

Geographically linking population and facility surveys: methodological considerations.

BACKGROUND: The relationship between health services and population outcomes is an important area of public health research that requires bringing together data on outcomes and the relevant service environment. Linking independent, existing datasets geographically is potentially an efficient approach; however, it raises a number of methodological issues which have not been extensively explored. This sensitivity analysis explores the potential misclassification error introduced when a sample rather than a census of health facilities is used and when household survey clusters are geographically displaced for confidentiality. METHODS: Using the 2007 Rwanda Service Provision Assessment (RSPA) of all public health facilities and the 2007-2008 Rwanda Interim Demographic and Health Survey (RIDHS), five health facility samples and five household cluster displacements were created to simulate typical SPA samples and household cluster datasets. Facility datasets were matched with cluster datasets to create 36 paired datasets. Four geographic techniques were employed to link clusters with facilities in each paired dataset. The links between clusters and facilities were operationalized by creating health service variables from the RSPA and attaching them to linked RIDHS clusters. Comparisons between the original facility census and undisplaced clusters dataset with the multiple samples and displaced clusters datasets enabled measurement of error due to sampling and displacement. RESULTS: Facility sampling produced larger misclassification errors than cluster displacement, underestimating access to services. Distance to the nearest facility was misclassified for over 50% of the clusters when directly linked, while linking to all facilities within an administrative boundary produced the lowest misclassification error. Measuring relative service environment produced equally poor results with over half of the clusters assigned to the incorrect quintile when linked with a sample of facilities and more than one-third misclassified due to displacement. CONCLUSIONS: At low levels of geographic disaggregation, linking independent facility samples and household clusters is not recommended. Linking facility census data with population data at the cluster level is possible, but misclassification errors associated with geographic displacement of clusters will bias estimates of relationships between service environment and health outcomes. The potential need to link facility and population-based data requires consideration when designing a facility survey.

When the cat is out of the bag: a case study in public health rationing in Oregon during the 2004-2005 influenza vaccine shortage.

Whereas the annual influenza season in the United States is fairly predictable, the influenza vaccine supply is variable, leaving providers vulnerable to supply and demand fluctuations each season. During the 2004-2005 influenza vaccine shortage, Oregon invoked Oregon Revised Statute 433-030 to target vaccine supplies to protect persons at highest risk for complications from influenza. This case study describes Oregon's efforts to ration vaccine at the point of administration by limiting the number of individuals eligible for vaccination. An evaluation of this process found that providers responded positively to the mandatory prioritization of vaccine recipients; however, limitations in assessing and affecting redistribution of privately held vaccine supplies and challenges in enforcement of the plan were revealed.