Changes in Inequality in Use of Maternal Health Care Services: Evidence from Skilled Birth Attendance in Mauritania for the Period 2007-2015.

Skilled birth attendance is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the use of skilled birth attendance services in Mauritania. The study identifies the inequality determinants and explores its changes over the period 2007−2015. The concentration curve, concentration index, decomposition of the concentration index, and Oaxaca-type decomposition technique were performed to measure socioeconomically-based inequalities in skilled birth attendance services utilization, and to identify the contribution of different determinants to such inequality as well as the changes in inequality overtime using data from Mauritania Multiple Indicator Cluster Surveys (MICS) 2007 and 2015. The concentration index for skilled birth attendance services use dropped from 0.6324 (p < 0.001) in 2007 to 0.5852 (p < 0.001) in 2015. Prenatal care, household wealth level, and rural−urban residence contributed most to socioeconomic inequality. The concentration index decomposition and the Oaxaca-type decomposition revealed that changes in prenatal care and rural−urban residence contributed positively to lower inequality, but household economic status had an opposite contribution. Clearly, the pro-rich inequality in skilled birth attendance is high in Mauritania, despite a slight decrease during the study period. Policy actions on eliminating geographical and socioeconomic inequalities should target increased access to skilled birth attendance. Multisectoral policy action is needed to improve social determinants of health and to remove health system bottlenecks. This will include the socioeconomic empowerment of women and girls, while enhancing the availability and affordability of reproductive and maternal health commodities. This policy action can be achieved through improving the availability of obstetric service providers in rural areas; ensuring better distribution and quality of health infrastructure, particularly health posts and health centers; and, ensuring user fees removal for equitable, efficient, and sustainable financial protection in line with the universal health coverage objectives.

Measuring and understanding the effects of a performance based financing scheme applied to nutrition services in Burundi-a mixed method impact evaluation design.

BACKGROUND: Malnutrition is a huge problem in Burundi. In order to improve the provision of services at hospital, health centre and community levels, the Ministry of Health is piloting the introduction of malnutrition prevention and care indicators within its performance based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services, as PBF has done, in Burundi and elsewhere, for several other services. METHODS: This paper presents the protocol for the impact evaluation of the PBF scheme applied to malnutrition. The research design consists in a mixed methods model adopting a sequential explanatory design. The quantitative component is a cluster-randomized controlled evaluation design: among the 90 health centres selected for the study, half receive payment related to their results in malnutrition activities, while the other half get a budget allocation. Qualitative research will be carried out both during the intervention period and at the end of the quantitative evaluation. Data are collected from 1) baseline and follow-up surveys of 90 health centres and 6,480 households with children aged 6 to 23 months, 2) logbooks filled in weekly in health centres, and 3) in-depth interviews and focus group discussions. The evaluation aims to provide the best estimate of the impact of the project on malnutrition outcomes in the community as well as outputs at the health centre level (malnutrition care outputs) and to describe quantitatively and qualitatively the changes that took place (or did not take place) within health centres as a result of the program. DISCUSSION: Although PBF schemes are blooming in low in-come countries, there is still a need for evidence, especially on the impact of revising the list of remunerated indicators. It is expected that this impact evaluation will be helpful for the national policy dialogue in Burundi, but it will also provide key evidence for countries with an existing PBF scheme and confronted with malnutrition problems on the appropriateness to extend the strategy to nutrition services. TRIAL REGISTRATION: ClinicalTrials.gov PRS Identifier: NCT02721160; registered March 2016.