1. The impact of performance-based financing on the delivery of HIV testing, prevention of mother to child transmission and antiretroviral delivery in the Cameroon health system International AIDS Conference, Amsterdam, July 24, 2018 Damien de Walque, Paul Jacob Robyn, Hamadou Saidou, Gaston Sorgho, Maria Steenland

2. RBF Definition
Results-Based Financing (RBF) is a cash payment or nonmonetary transfer made to a national or sub-national government, manager, provider, payer or consumer of health services after predefined results have been attained and verified.
RBF is an umbrella term that encompasses various types of interventions that target beneficiaries (for example, conditional cash transfers), providers (for example, performance-based financing), and country governments (for example, cash on delivery).

3. Impact Evaluation Methods

4. Treatment groups (looking into the PBF black box)
PBF group with performance-based bonuses provided to health workers C1
Same amount of financial resources as the PBF group, but not linked to performance; same level of supervision and management autonomy as T1 C2
No additional resources but the same level of supervision as the PBF group; however, these facilities did not have management autonomy C3
Status quo

5. Intervention group comparisonT1
Complete PBF with performance bonuses for medical personnel C1
PBF with subsidies that are not linked to performance C2
Only supervision without bonuses or autonomy C3
Status quo
Contract
 Classic PBF contract
Contract stipulating the conditions of PBF for verification and supervision
Contract stipulating technical support in the form of supervision
 No contract
Business plan 
 Yes
Simple business plan focused on intensified supervision
No business plan
Quality evaluation
Quality evaluation and feedback with quality taken into account in bonus payment
Quality evaluation with feedback as in T1, but no effect on payment
Quality evaluation with feedback as in T1
Quality evaluation with written feedback twice a year
Review/verification of service amounts
Review and verification of service quantities
Single quarterly statement without verification of the quantity of services produced
Payment
Payments tied to performance
Payments not tied to performance
No payment
Management autonomy
 Management autonomy, including control of the facility’s income.
No management autonomy, continuation the status quo system
Monthly activity report submitted to district
Yes

6. HIV specific indicators and payments (500 FCFA ~= 1 US $)12
HIV positive Pregnant Women put on ARV prophylactic treatment
Number of HIV positive Pregnant Women put on ARV prophylactic treatment according to the national PMTCT protocol in the month
PMTCT Register
7000 FCFA 13
Newborn management of a baby born of an HIV positive mother.
Number of babies born of HIV positive mothers who are placed on PMTCT protocol in the month according to National directive 14
Voluntary Counseling and Testing for HIV/AIDS
Number of people who came to the health facility for HIV/AIDS voluntary counseling and testing and who collected their results
VCT Register
1000 FCFA

7. Public randomization ceremony to assign each facility to one of 4 groups
A ceremony took place in each region
North West: February 2012
South West: April 2012
East: July 2012
All heads of the health facilities in the evaluation districts participated

8. Impact evaluation methods
Regions
North West (Districts: Fundong, Kumbo East, Ndop, Nkambe)
South East (Districts: Buea, Kumba, Limbe, Mamfe)
East (Districts: Kette, Doume, Abong-mbang, Lomie, Messamena, Nguelemendouga)
200 primary health facilities (+ district hospitals and private health facilities)
All public health facilities
A sample of private health facilities
All of the primary care health facilities were randomized into 4 treatment groups; all hospitals were assigned to PBF
Mention that 245 was the eligible number of FOSA but some FOSA were not included at baseline and others were not included at endline

9. Impact evaluation surveys
Health facility survey at baseline (2012)/and at endline (2015)
Facility evaluation (number and type of staff, equipment, availability of medicine, supervision)
Health worker survey
Direct observation of consultations (Antenatal care, <5 consultations, outpatient adult consultations)
Exit interviews (Antenatal care, <5 consultations, outpatient adult consultations)
Household survey at baseline (2012)/and at endline (2015)
A random sample of 16/20 households in each health facility catchment area
Households with at least one woman who had been pregnant in the previous 24 months were eligible for inclusion
Health service use
Good balance across 4 study groups at baseline

10. Health facility survey results

11. Facility results summary
Effect of PBF
(T1 & C3)
Effect of bonus + supervision
(C1 & C3)
Effect of supervision
(C2 & C3)
Antenatal consultations
Deliveries
Postnatal consultations ✓✓
Modern family planning
✓✓✓
Polio 3/Pentavalent 3 ✓
Measles
Tetanus vaccine among pregnancy women
Negative result : ✓ = *, ✓✓ = ** ✓✓✓ = ***; Postive result : ✓ = *, ✓✓ = **, ✓✓✓ = ***

12. HIV Testing 4.239 Post indicator [3.031] 61.115***
Post*Interaction PBF
61.115***
[17.817]
Post*Interaction Control 1
51.466***
[13.668]
Post*Interaction Control 2
6.596
[5.757]
* p < 0.1, ** p < 0.05, *** p< 0.01

13. Prevention of Mother to Child Transmission
Post indicator
-3.552
[3.323]
Post*Interaction PBF
2.084
[4.011]
Post*Interaction Control 1
2.372
[3.189]
Post*Interaction Control 2
1.648
[3.156]

14. Antiretroviral treatment
Post indicator
1.021*
[0.609]
Post*Interaction PBF
-1.455
[0.888]
Post*Interaction Control 1
-0.671
[0.573]
Post*Interaction Control 2
-0.681
[0.595]
* p < 0.1, ** p < 0.05, *** p< 0.01

15. Questions?