RBF Zambia Dr. Cosmas Musumali, Dr. Reuben K. Mbewe, Collins Chansa, - - PowerPoint PPT Presentation

Measur suring ing Result lts s and nd Evalu luating ating Impa pact: t:

Turn rnin ing g Promise ises s in into Evid idence ence

Cape Town, South Africa December 2009

RBF Zambia

Human Development Network Development Impact Evaluation Initiative Spanish Impact Evaluation Fund Africa Region

• Dr. Cosmas Musumali, Dr. Reuben K. Mbewe, Collins Chansa,

Caeser Cheelo, Harrison Mkandawire, John Makumba,

• Dr. Caroline N. Phiri

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Background …



Population: 12.2 million (2007 proj.)



Under-5 mortality rate: 119 per 1,000 live births



Infant mortality rate 70 per 1,000 live births



Maternal Mortality: 591 per 100,000



Poverty incidence: 64 percent



Gini-coefficient: 0.57

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• 1. Background ….

 HRBF Pilot to assess if incentives and

related investments improve service delivery outcome

 To inform policy on mode of funding of

Health sector

 6 MCH indicators paid on fee for service

quality adjusted basis

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• 2. Results Chain

Inputs Activities Outputs Outcomes Longterm Outcomes

• Trust Fund

financing

• MoH and

consultant technical support

• Quarterly

assessment of quality adjusted services and payout

• Investments in

facility infrastructure and staff capacity

• 3rd party

audit/verification

• f self-reported

indicators

• Reduced Neonatal

mortality, U5MR, MMR

• Improved

nutritional status

• f women and

children - higher productivity, better cognitive development, etc.

• Woman able to

attain ideal family size

• Increased rates
• f: in-facility

deliveries, PNC, immunization coverage, ANC, contraceptive uptake, ITN usage

• Increased

quality of MCH services

• Increased

capacity of DHMT

• Increased

financing through incentive payments

• Facilities

upgraded: MCH equipment and supplies, water reticulation

• Capacity

building: HW trained, systems strengthened

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• 3. Primary Research Questions

 What is the causal effect of the Zambian

HRBF on the health services outcomes of the interest?

 Do higher incentive payments in

rural/remote areas result in increased health outcomes and greater retention of staff

 How does the likelihood of audit/external

verification of results affect the accuracy

• f reported data?

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• 4. Outcome Indicators

 Institutional deliveries by skilled birth

attendant

 Postnatal visits within 6 days of delivery

by health centre staff (delivery at home or in facility

 Full immunization coverage of children

under 1

 Pregnant women receiving at least 2

doses of IPT

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• 4. Outcome Indicators

 Women (ages 15 -49) or partners using

any type of contraception (new acceptors)

 Women receiving iron supplements at

antenatal care

 Community outcome indicators to be

finalized

 Non-incentivized outcome indicators also

tracked

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• 5. Identification Strategy/Method

Question 1: Three districts per province matched and randomized across:

 Equipment, commodities, financing and incentives  Equipment, commodities and financing  “Business as usual”

Facilities then matched across treatments arms and dif-in-dif strategy

Question 2: Incentive levels randomized across remote/rural facilities within selected districts Question 3: Audit frequency and method randomized across facilities within selected districts

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• 6. Sample and data

 Administrative data (HMIS, etc.) – on-

going and continuos

 Household survey data – baseline and

follow-up (24 months follow-up) of 3000 households mínimum

 Facility survey data – baseline and follow-

up of 200 facilites mínimum

 Qualitative interviews with health staff,

community

 External audit data – at minimum twice

yearly

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• 7. Time Frame/Work Plan

 On-going pre-pilot in 1 district (1 year)  Pilot-project

for 9 districts extends to three years begining in June 2010

 Draft design and PIM already in place  Currently

fine-tuning and designing community component, quality tools

 Evaluation design drafted and currently

revising cost analysis and cost data collection, qualitative evaluation design

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• 8. Sources of Financing

 Norwagian Trust Fund: USD$ 11 million  MoH support: Staff time and logistics,

infrastructure

 World Bank preparatory grant and Impact

Evaluation Trust Fund