Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis.

BACKGROUND: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. METHODS: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. RESULTS: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. CONCLUSIONS: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

Impact of a maternal and newborn health results-based financing intervention (RBF4MNH) on stillbirth: a cross-sectional comparison in four districts in Malawi.

BACKGROUND: Malawi implemented a Results Based Financing (RBF) model for Maternal and Newborn Health, "RBF4MNH" at public hospitals in four Districts, with the aim of improving health outcomes. We used this context to seek evidence for the impact of this intervention on rates of antepartum and intrapartum stillbirth, taking women's risk factors into account. METHODS: We used maternity unit delivery registers at hospitals in four districts of Malawi to obtain information about stillbirths. We purposively selected two districts hosting the RBF4MNH intervention and two non-intervention districts for comparison. Data were extracted from the maternity registers and used to develop logistic regression models for variables associated with fresh and macerated stillbirth. RESULTS: We identified 67 stillbirths among 2772 deliveries representing 24.1 per 1000 live births of which 52% (n = 35) were fresh (intrapartum) stillbirths and 48% (n = 32) were macerated (antepartum) losses. Adjusted odds ratios (aOR) for fresh and macerated stillbirth at RBF versus non-RBF sites were 2.67 (95%CI 1.24 to 5.57, P = 0.01) and 7.27 (95%CI 2.74 to 19.25 P < 0.001) respectively. Among the risk factors examined, gestational age at delivery was significantly associated with increased odds of stillbirth. CONCLUSION: The study did not identify a positive impact of this RBF model on the risk of fresh or macerated stillbirth. Within the scientific limitations of this non-randomised study using routinely collected health service data, the findings point to a need for rigorously designed and tested interventions to strengthen service delivery with a focus on the elements needed to ensure quality of intrapartum care, in order to reduce the burden of stillbirths.

Estimating the cost of implementing a facility and community score card for maternal and newborn care service delivery in a rural district in Uganda.

INTRODUCTION: This paper aimed at estimating the resources required to implement a community Score Card by a typical rural district health team in Uganda, as a mechanism for fostering accountability, utilization and quality of maternal and child healthcare service. METHODS: This costing analysis was done from the payer's perspective using the ingredients approach over five quarterly rounds of scoring between 2017 and 2018. Expenditure data was obtained from project records, entered and analyzed in Microsoft excel. Two scale-up scenarios, scenario one (considered cost inputs by the MakSPH research teams) and scenario two (considering cost inputs based on contextual knowledge from district implementing teams), were simulated to better understand the cost implications of integrating the Community Score Card (CSC) into a district health system. RESULTS: The total and average cost of implementing CSC for five quarterly rounds over a period of 18 months were USD 59,962 and USD 11,992 per round of scoring, respectively. Considering the six sub-counties (including one Town Council) in Kibuku district that were included in this analysis, the average cost of implementating the CSC in each sub-county was USD 1998 per scoring round. Scaling-up of the intervention across the entire district (included 22 sub-counties) under the first scenario would cost a total of USD 19,003 per scoring round. Under the second scaleup scenario, the cost would be lower at USD 7116. The total annual cost of scaling CSC in the entire district would be USD 76,012 under scenario one compared to USD 28,465 under scenario two. The main cost drivers identified were transportation costs, coordination and supervision costs, and technical support to supplement local implementers. CONCLUSION: Our analysis suggests that it is financially feasible to implement and scale-up the CSC initiative, as an accountability tool for enhancing service delivery. However, the CSC design and approach needs to be embedded within local systems and implemented in collaboration with existing stakeholders so as to optimise costs. A comprehensive economic analysis of the costs associated with transportation, involvement of the district teams in coordination, supervision as well as provision of technical support is necessary to determine the cost-effectiveness of the CSC approach.

Factors influencing the performance of community health workers: A qualitative study of Anganwadi Workers from Bihar, India.

Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.

Examining the distribution of benefits of a free Maternal and Child Health programme in Enugu State, Nigeria: a benefit incidence analysis.

OBJECTIVE: To determine the population groups that benefit from a Free Maternal and Child Health (FMCH) programme in Enugu State, South-east Nigeria, so as to understand the equity effects of the programme. METHOD: A community-based survey was conducted in rural and urban local government areas (LGAs) to aid the benefit incidence analysis (BIA) of the FMCH. Data were elicited from 584 randomly selected women of childbearing age. Data on their level of utilisation of FMCH services and their out-of-pocket expenditures on various FMCH services that they utilised were elicited. Benefits of the FMCH were valued using the unit cost of providing services while the net benefit was calculated by subtracting OOP expenditures made for services from the value of benefits. Costs were calculated in local currency (Naira (₦)) and converted to US Dollars. The net benefits were disaggregated by urban-rural locations and socio-economic status (SES). Concentration indices were computed to provide the level of SES inequity in BIA of FMCH. RESULTS: The total gross benefit incidence was ₦2.681 million ($7660). The gross benefit that was consumed by the urban dwellers was ₦1.581 million ($4517.1), while the rural dwellers consumed gross benefits worth ₦1.1 million ($3608.20). However, OOP expenditure for the supposedly FMCH was ₦6 527 580 (US$18 650.2) in the urban area, while it was ₦3, 194, 706 (US$ 9127.7) among rural dwellers. There was negative benefit incidence for the FMCH because the OOP exceeded the gross benefits at the point of use of services. There was no statistically significant difference in the benefit incidence and OOP expenditure between the urban and rural dwellers and across socio-economic groups. CONCLUSION: The distribution of the gross benefits of the FMCH programme indicates that it may not have achieved the desired aim of enhanced access particularly to the low-income population. Crucially, the high level of OOP erased whatever societal gain the FMCH was developed to provide. Hence, there is a need to review its implementation and re-strategise to reduce OOP and achieve greater access for improved effectiveness of the programme.

OBJECTIF: Déterminer les groupes de population qui bénéficient d'un programme de santé maternelle et infantile gratuite (F-MCH) dans l'Etat d'Enugu, dans le sud-est du Nigéria, afin de comprendre les effets du programme sur l'équité. MÉTHODE: Une enquête communautaire a été menée dans des zones locales gouvernementales (ZLG) rurales et urbaines pour faciliter l'analyse de l'incidence des bénéfices (AIB) du F-MCH. Des données ont été obtenues auprès de 584 femmes en âge de procréer sélectionnées aléatoirement. Les données sur leur niveau d'utilisation des services F-MCH et leurs dépenses directes de la poche (DDP) pour divers services F-MCH qu'elles ont utilisé ont été obtenues. Les bénéfices du F-MCH ont été évalués en utilisant le coût unitaire de la prestation des services, tandis que le bénéfice net a été calculé en soustrayant les dépenses directes de la poche pour les services de la valeur des bénéfices. Les coûts ont été calculés en monnaie locale (Naira ₦) et convertis en dollars américains USD. Les bénéfices nets ont été ventilés par endroits urbain-rural et par statut socioéconomique (SSE). Les indices de concentration ont été calculés pour fournir le niveau d'iniquité du SSE dans l'AIB du F-MCH. RÉSULTATS: L'incidence des prestations brutes totales était de ₦ 2.681.000 (7.660 USD). Le bénéfice brut qui a été consommé par les habitants des villes était de ₦ 1.581.000 (4.517,1 USD), tandis que les habitants ruraux ont consommé une valeur de bénéfices bruts de ₦ 1,1 million (3,608.20 USD). Cependant, les DDP pour le soi-disant F-MCH étaient de 6.527.580 ₦ (18.650,2 USD) dans la zone urbaine, alors qu'elles étaient de 3 194 706 ₦ (9.127,7 USD) parmi les habitants des zones rurales. Il y avait une incidence négative des bénéfices pour le F-MCH parce que les DDP dépassaient les bénéfices bruts au point d'utilisation des services. Il n'y avait pas de différence statistiquement significative dans l'incidence des bénéfices et les DDP entre les habitants des zones urbaines et rurales et entre les groupes socioéconomiques. CONCLUSION: La répartition des bénéfices bruts du programme F-MCH indique qu'il n'a peut-être pas atteint l'objectif souhaité d'un accès amélioré, en particulier pour la population à faible revenu. Fondamentalement, le niveau élevé de dépenses directes de la poche a effacé tout gain sociétal que le F-MCH avait été développé pour fournir. Par conséquent, il est nécessaire de revoir sa mise en œuvre et de revoir sa stratégie pour réduire les DDP et obtenir un meilleur accès pour une efficacité accrue du programme.

Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High-Value Model of Care.

Policy Points Birth center services must be covered under Medicaid per federal mandate, but reimbursement and other policy barriers prevent birth centers from serving more Medicaid patients. Midwifery care provided through birth centers improves maternal and infant outcomes and lowers costs for Medicaid beneficiaries. Birth centers offer an array of birth options and have resources to care for patients with medical and psychosocial risks. Addressing the barriers identified in this study would promote birth centers' participation in Medicaid, leading to better outcomes for Medicaid-covered mothers and newborns and significant savings for the Medicaid program. CONTEXT: Midwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. The national evaluation of Strong Start for Mothers and Newborns II, an initiative that tested enhanced prenatal care models for Medicaid beneficiaries, found that women receiving prenatal care at Strong Start birth centers experienced superior birth outcomes compared to matched and adjusted counterparts in typical Medicaid care. We use qualitative evaluation data to investigate birth centers' experiences participating in Medicaid, and identify policies that influence Medicaid beneficiaries' access to midwives and birth centers. METHODS: We analyzed data from more than 200 key informant interviews and 40 focus groups conducted during four case study rounds; a phone-based survey of Medicaid officials in Strong Start states; and an Internet-based survey of birth center sites. We identified themes related to access to midwives and birth centers, focusing on influential Medicaid policies. FINDINGS: Medicaid beneficiaries chose birth center care because they preferred midwife providers, wanted a more natural birth experience, or in some cases sought certain pain relief methods or birth procedures not available at hospitals. However, Medicaid enrollees currently have less access to birth centers than privately insured women. Many birth centers have difficulty contracting with managed care organizations and participating in Medicaid value-based delivery system reforms, and birth center reimbursement rates are sometimes too low to cover the actual cost of care. Some birth centers significantly limit Medicaid business because of low reimbursement rates and threats to facility sustainability. CONCLUSIONS: Medicaid beneficiaries do not have the same access to maternity care providers and birth settings as their privately insured counterparts. Medicaid policy barriers prevent some birth centers from serving more Medicaid patients, or threaten the financial sustainability of centers. By addressing these barriers, more Medicaid beneficiaries could access care that is associated with positive birth outcomes for mothers and newborns, and the Medicaid program could reap significant savings.

Participation in microfinance based Self Help Groups in India: Who becomes a member and for how long?

INTRODUCTION: Microfinance is a widely promoted developmental initiative to provide poor women with affordable financial services for poverty alleviation. One popular adaption in South Asia is the Self-Help Group (SHG) model that India adopted in 2011 as part of a federal poverty alleviation program and as a secondary approach of integrating health literacy services for rural women. However, the evidence is limited on who joins and continues in SHG programs. This paper examines the determinants of membership and staying members (outcomes) in an integrated microfinance and health literacy program from one of India's poorest and most populated states, Uttar Pradesh across a range of explanatory variables related to economic, socio-demographic and area-level characteristics. METHOD: Using secondary survey data from the Uttar Pradesh Community Mobilization project comprising of 15,300 women from SHGs and Non-SHG households in rural India, we performed multivariate logistic and hurdle negative binomial regression analyses to model SHG membership and duration. RESULTS: While in general poor women are more likely to be SHG members based on an income threshold limit (government-sponsored BPL cards), women from poorest households are more likely to become members, but less likely to stay members, when further classified using asset-based wealth quintiles. Additionally, poorer households compared to the marginally poor are less likely to become SHG members when borrowing for any reason, including health reasons. Only women from moderately poor households are more likely to continue as members if borrowing for health and non-income-generating reasons. The study found that an increasing number of previous pregnancies is associated with a higher membership likelihood in contrast to another study from India reporting a negative association. CONCLUSION: The study supports the view that microfinance programs need to examine their inclusion and retention strategies in favour of poorest household using multidimensional indicators that can capture poverty in its myriad forms.

Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region.

OBJECTIVE: To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. METHODS: We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. FINDINGS: We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. CONCLUSION: Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.

Conditional cash transfers, uptake of maternal and child health services, and health outcomes in western rural China.

BACKGROUND: Empirical evidence suggests that the uptake of maternal and child health (MCH) services is still low in poor rural areas of China. There is concern that this low uptake may detrimentally affect child health outcomes. Previous studies have not yet identified the exact nature of the impact that a conditional cash transfer (CCT) has on the uptake of MCH services and, ultimately, on child health outcomes. The objective of this study is to examine the relationship between CCT, uptake of MCH services, and health outcomes among children in poor rural areas of western China. METHODS: We designated two different sets of villages and households that were used as comparisons against which outcomes of the treated households could be assessed. In 2014, we conducted a large-scale survey of 1522 households in 75 villages (including 25 treatment and 50 comparison) from nine nationally designated poverty counties in two provinces of China. In each village, 21 households were selected based on their eligibility status for the CCT program. Difference-in-difference analyses were used to assess the impact of CCT on outcomes in terms of both intention-to-treat (ITT) and average-treatment-effects-on-the-treated (ATT). RESULTS: Overall, the uptake of MCH services in the sample households were low, especially in terms of postpartum care visits, early breastfeeding, exclusive breastfeeding, and physical examination of the baby. The uptake of the seven types of MCH services in the CCT treatment villages were significantly higher than that in the comparison villages. The results from both the ITT and ATT analyses showed that the CCT program had a positive, although small, impact on the uptake of MCH services and the knowledge of mothers of MCH health issues. Nonetheless, the CCT program had no noticeable effect on child health outcomes. CONCLUSIONS: The CCT program generated modest improvements in the uptake of MCH services and mothers' knowledge of MCH services in poor rural areas of Western China. These improvements, however, did not translate into substantial improvements in child health outcomes for two potential reasons: poor CCT implementation and the low quality of rural health facilities.

Maternal and Neonatal Hospitalization Costs Associated With Elective Induction of Labor at Term in California, 2007-2011.

OBJECTIVE: To compare hospitalization costs of pregnancies managed by elective induction of labor to those with spontaneous labor in a large cohort of pregnant women. METHODS: We conducted a retrospective cohort study of women with singleton, nonanomalous births in California from 2007 to 2011. We excluded women with placenta previa, breech presentation, prior cesarean delivery, planned cesarean delivery, medically indicated induction of labor, gestational age less than 37 weeks or at or greater than 41 weeks, and stillbirths. We adjusted hospital charges using a cost-to-charge ratio and costs included hospitalization costs for admission for delivery only. We estimated the difference in costs between elective induction of labor (resulting in a vaginal or cesarean delivery) and spontaneous labor for both women and neonates, stratified by mode of delivery, parity, gestational age at delivery and geographic location. We conducted analyses using Kruskal-Wallis equality-of-populations rank tests with a significance level of 0.05. RESULTS: In a California cohort of 1,278,151 women, 190,409 (15%) had an elective induction of labor. Median maternal hospitalization costs were $10,175 (interquartile range: $7,284-$14,144) with induction of labor and $9,462 (interquartile range: $6,667-$13,251) with spontaneous labor (P<.01) for women who had a vaginal delivery, and $20,294 (interquartile range: $15,367-$26,920) with induction of labor and $18,812 (interquartile range: $13,580-$25,197) with spontaneous labor (P<.01) for women who had a cesarean delivery. Maternal median hospitalization costs were significantly higher in the setting of elective induction of labor regardless of parity, mode of delivery, and gestational age at delivery. Alternatively, median hospitalization costs for neonates of women who had an elective induction of labor were significantly lower. CONCLUSION: Further research regarding approaches to induction of labor is necessary to determine whether strategies to reduce health care costs without affecting or even improving outcomes could help curb costs associated with induction of labor.

Measuring universal health coverage in reproductive, maternal, newborn and child health: An update of the composite coverage index.

BACKGROUND: Monitoring universal health coverage in reproductive, maternal and child health requires appropriate indicators for assessing coverage and equity. In 2008, the composite coverage index (CCI)-a weighted average of eight indicators reflecting family planning, antenatal and delivery care, immunizations and management of childhood illnesses-was proposed. In 2017, the CCI formula was revised to update the family planning and diarrhea management indicators. We explored the implications of adding new indicators to the CCI. METHODS: We analysed nationally representative surveys to investigate how addition of early breastfeeding initiation (EIBF), tetanus toxoid during pregnancy and post-natal care for babies affected CCI levels and the magnitude of wealth-related inequalities. We used Pearson's correlation coefficient to compare different formulations, and the slope index of inequalities [SII] and concentration index [CIX] to assess absolute and relative inequalities, respectively. RESULTS: 47 national surveys since 2010 had data on the eight variables needed for the original and revised formulations, and on EIBF, tetanus vaccine and postnatal care, related to newborn care. The original CCI showed the highest average value (65.5%), which fell to 56.9% when all 11 indicators were included. Correlation coefficients between pairs of all formulations ranged from 0.93 to 0.99. When analysed separately, 10 indicators showed higher coverage with increasing wealth; the exception was EIBF (SII = -2.1; CIX = -0.5). Inequalities decreased when other indicators were added, especially EIBF-the SII fell from 24.8 pp. to 19.2 pp.; CIX from 7.6 to 6.1. The number of countries with data from two or more surveys since 2010 was 30 for the original and revised formulations and 15 when all the 11 indicators were included. CONCLUSIONS: Given the growing importance of newborn mortality, it would be desirable to include relevant coverage indicators in the CCI, but this would lead a reduction in data availability, and an underestimation of coverage inequalities. We propose that the 2017 version of the revised CCI should continue to be used.

How Should Home-Based Maternal and Child Health Records Be Implemented? A Global Framework Analysis.

BACKGROUND: A home-based record (HBR) is a health document kept by the patient or their caregivers, rather than by the health care facility. HBRs are used in 163 countries, but they have not been implemented universally or consistently. Effective implementation maximizes both health impacts and cost-effectiveness. We sought to examine this research-to-practice gap and delineate the facilitators and barriers to the effective implementation and use of maternal and child health HBRs especially in low- and middle-income countries (LMICs). METHODS: Using a framework analysis approach, we created a framework of implementation categories in advance using subject expert inputs. We collected information through 2 streams. First, we screened 69 gray literature documents, of which 18 were included for analysis. Second, we conducted semi-structured interviews with 12 key informants, each of whom had extensive experience with HBR implementation. We abstracted the relevant data from the documents and interviews into an analytic matrix. The matrix was based on the initial framework and adjusted according to emergent categories from the data. RESULTS: We identified 8 contributors to successful HBR implementation. These include establishing high-level support from the government and ensuring clear communication between all ministries and nongovernmental organizations involved. Choice of appropriate contents within the record was noted as important for alignment with the health system and for end user acceptance, as were the design, its physical durability, and timely redesigns. Logistical considerations, such as covering costs sustainably and arranging printing and distribution, could be potential bottlenecks. Finally, end users' engagement with HBRs depended on how the record was initially introduced to them and how its importance was reinforced over time by those in leadership positions. CONCLUSIONS: This framework analysis is the first study to take a more comprehensive and broad approach to the HBR implementation process in LMICs. The findings provide guidance for policy makers, donors, and health care practitioners regarding best implementation practice and effective HBR use, as well as where further research is required.

Results-based financing as a strategic purchasing intervention: some progress but much further to go in Zimbabwe?

BACKGROUND: Results-Based Financing (RBF) has proliferated in the health sectors of low and middle income countries, especially those which are fragile or conflict-affected, and has been presented by some as a way of reforming and strengthening strategic purchasing. However, few if any studies have empirically and systematically examined how RBF impacts on health care purchasing. This article examines this question in the context of Zimbabwe's national RBF programme. METHODS: The article is based on a documentary review, including 60 documents from 2008 to 2018, and 40 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in Zimbabwe. Interviews and analysis of both datasets followed an existing framework for strategic purchasing, adapted to reflect changes over. RESULTS: We find that some functions, such as assessing service infrastructure gaps, are unaffected by RBF, while others, such as mobilising resources, are partially affected, as RBF has focused on one package of care (maternal and child health services) within the wider essential health care, and has contributed important but marginal costs. Overall purchasing arrangements remain fragmented. Limited improvements have been made to community engagement. The clearest changes to purchasing arrangements relate to providers, at least in relation to the RBF services. Its achievements included enabling flexible resources to reach primary providers, funding supervision and emphasising the importance of reporting. CONCLUSIONS: Our analysis suggests that RBF in Zimbabwe, at least at this early stage, is mainly functioning as an additional source of funding and as a provider payment mechanism, focussed on the primary care level for MCH services. RBF in this case brought focus to specific outputs but remained one provider payment mechanism amongst many, with limited traction over the main service delivery inputs and programmes. Zimbabwe's economic and political crisis provided an important entry point for RBF, but Zimbabwe did not present a 'blank slate' for RBF to reform: it was a functional health system pre-crisis, which enabled relatively swift scale-up of RBF but also meant that the potential for restructuring of institutional purchasing relationships was limited. This highlights the need for realistic and contextually tailored expectations of RBF.

No effects of pilot performance-based intervention implementation and withdrawal on the coverage of maternal and child health services in the Koulikoro region, Mali: an interrupted time series analysis.

Performance-based financing (PBF) has been promoted and increasingly implemented across low- and middle-income countries to increase the utilization and quality of primary health care. However, the evidence of the impact of PBF is mixed and varies substantially across settings. Thus, further rigorous investigation is needed to be able to draw broader conclusions about the effects of this health financing reform. We examined the effects of the implementation and subsequent withdrawal of the PBF pilot programme in the Koulikoro region of Mali on a range of relevant maternal and child health indicators targeted by the programme. We relied on a control interrupted time series design to examine the trend in maternal and child health service utilization rates prior to the PBF intervention, during its implementation and after its withdrawal in 26 intervention health centres. The results for these 26 intervention centres were compared with those for 95 control health centres, with an observation window that covered 27 quarters. Using a mixed-effects negative binomial model combined with a linear spline regression model and covariates adjustment, we found that neither the introduction nor the withdrawal of the pilot PBF programme bore a significant impact in the trend of maternal and child health service use indicators in the Koulikoro region of Mali. The absence of significant effects in the health facilities could be explained by the context, by the weaknesses in the intervention design and by the causal hypothesis and implementation. Further inquiry is required in order to provide policymakers and practitioners with vital information about the lack of effects detected by our quantitative analysis.

Health-care investments for the urban populations, Bangladesh and India.

OBJECTIVE: To estimate the costs and mortality reductions of a package of essential health interventions for urban populations in Bangladesh and India. METHODS: We used population data from the countries' censuses and United Nations Population Division. For causes of mortality in India, we used the Indian Million Death Study. We obtained cost estimates of each intervention from the third edition of Disease control priorities. For estimating the mortality reductions expected with the package, we used the Disease control priorities model. We calculated the benefit-cost ratio for investing in the package, using an analysis based on the Copenhagen Consensus method. FINDINGS: Per urban inhabitant, total costs for the package would be 75.1 United States dollars (US$) in Bangladesh and US$ 105.0 in India. Of this, prevention and treatment of noncommunicable diseases account for US$ 36.5 in Bangladesh and U$ 51.7 in India. The incremental cost per urban inhabitant for all interventions would be US$ 50 in Bangladesh and US$ 75 in India. In 2030, the averted deaths among people younger than 70 years would constitute 30.5% (1027/3362) and 21.2% (828/3913) of the estimated baseline deaths in Bangladesh and India, respectively. The health benefits of investing in the package would return US$ 1.2 per dollar spent in Bangladesh and US$ 1.8 per dollar spent in India. CONCLUSION: Investing in the package of essential health interventions, which address health-care needs of the growing urban population in Bangladesh and India, seems beneficial and could help the countries to achieve their 2030 sustainable development goals.

The cost of improving nutritional outcomes through food-assisted maternal and child health and nutrition programmes in Burundi and Guatemala.

Evidence on the cost-effectiveness of multisectoral maternal and child health and nutrition programmes is scarce. We conducted a prospective costing study of two food-assisted maternal and child health and nutrition programmes targeted to pregnant women and children during the first 1,000 days (pregnancy to 2 years). Each was paired with a cluster-randomized controlled trial to evaluate impact and compare the optimal quantity and composition of food rations (Guatemala, five treatment arms) and their optimal timing and duration (Burundi, three treatment arms). We calculated the total and per beneficiary cost, conducted cost consequence analyses, and estimated the cost savings from extending the programme for 2 years. In Guatemala, the programme model with the lowest cost per percentage point reduction in stunting provided the full-size family ration with an individual ration of corn-soy blend or micronutrient powder. Reducing family ration size lowered costs but failed to reduce stunting. In Burundi, providing food assistance for the full 1,000 days led to the lowest cost per percentage point reduction in stunting. Reducing the duration of ration eligibility reduced per beneficiary costs but was less effective. A 2-year extension could have saved 11% per beneficiary in Guatemala and 18% in Burundi. We found that investments in multisectoral nutrition programmes do not scale linearly. Programmes providing smaller rations or rations for shorter durations, although less expensive per beneficiary, may not provide the necessary dose to improve (biological) outcomes. Lastly, delivering effective programmes for longer periods can generate cost savings by dispersing start-up costs and lengthening peak operating capacity.

The crowded space of local accountability for maternal, newborn and child health: a case study of the South African health system.

Global and national accountability for maternal, newborn and child health (MNCH) is increasingly invoked as central to addressing preventable mortality and morbidity. Strategies of accountability for MNCH include policy and budget tracking, maternal and perinatal death surveillance, performance targets and various forms of social accountability. However, little is known about how the growing number of accountability strategies for MNCH is received by frontline actors, and how they are integrated into the overall functioning of local health systems. We conducted a case study of mechanisms of local accountability for MNCH in South Africa, involving a document review of national policies, programme reports, and other literature directly or indirectly related to MNCH, and in-depth research in one district. The latter included observations of accountability practices (e.g. through routine meetings) and in-depth interviews with 37 purposely selected health managers and frontline health workers involved in MNCH. Data collection and analysis were guided by a framework that defined accountability as answerability and action (both individual and collective), addressing performance, financial and public accountability, and involving both formal and informal processes. Nineteen individual accountability mechanisms were identified, 10 directly and 9 indirectly related to MNCH, most of which addressed performance accountability. Frontline managers and providers at local level are targeted by a web of multiple, formal accountability mechanisms, which are sometimes synergistic but often duplicative, together giving rise to local contexts of 'accountability overloads'. These result in a tendency towards bureaucratic compliance, demotivation, reduced efficiency and effectiveness, and limited space for innovation. The functioning of formal accountability mechanisms is shaped by local cultures and relationships, creating an accountability ecosystem involving multiple actors and roles. There is a need to streamline formal accountability mechanisms and consider the kinds of actions that build positive cultures of local accountability.

Assessment of a free maternal and child health program and the prospects for program re-activation and scale-up using a new health fund in Nigeria.

BACKGROUND: A Free Maternal and Child Health program (FMCHP) was implemented in 12 states in Nigeria by the National Health Insurance Scheme (NHIS), between 2009 and 2015, using funds from the debt relief gains. It was called the Millennium Development Goals (MDGs) NHIS-MDG FMCHP. The program ended with the termination of the MDG in 2015. With the creation of the Basic Health Care Provision Fund (BHCPF) in Nigeria, this study sought to examine the past implementation experiences of the NHIS-MCH project with a view to identifying the enabling and constraining factors to program implementation, and the opportunities for adaptation and program scale-up in Nigeria using the BHCPF. METHODS: The study was undertaken in the Federal Capital Territory, Abuja, and involved review of relevant documents and in-depth interviews with 21 key informants. The program was assessed in themes from the conceptual framework. Interviews were transcribed and analyzed using thematic analysis. RESULTS: The program enrolled about 1.5 million pregnant women and children during the period of implementation in the country. The respondents perceived the program as pro-poor, efficient, and effective, and led to marked improvement in the functionality of the facilities, availability of services and reduced out-of-pocket expenditure, which led to increased demand and utilization of MCH services. There was inadequate stakeholder consultation, alleged corrupt practices, challenges with registration, issues with counterpart funding and public financing management issues identified. Most respondents supported the idea of using the new fund (BHCPF) to revitalize/scale-up the Free MCH program. CONCLUSION: This study highlights the key lessons and implementation challenges identified by the respondents. The NHIS-MDG FMCHP had positive impact on the target population though it was not sustained following the conclusion of the MDG program. The findings will inform policy decisions about the appropriateness of sustaining the program and the feasibility of extending healthcare coverage using the proposed BHCPF. The new fund (BHCPF) can be used to reactivate and scale-up the Free MCH program, but the current level of funding will not assure universal health coverage for the target beneficiaries as realized from the costing aspect of this study.