Description of CPBF Pilot
Community Performance-Based Financing IE Ghana Maternal and Child Health and Nutrition Improvement Project (MCHNP) (P145792)
The CPBF pilot will be implemented in 8 districts in 4 regions: Northern: North Gonja, West Gonja; Upper East: Bawku West, Talensi; Upper West: Lawra, Nandom; Volta: Agortime Ziope, Kadjebi.
The CPBF impact evaluation (IE) accompanies the World Bank Ghana Maternal and Child Health and Nutrition Improvement Project (MCHNP) which has the Project Development Objective (PDO) “to improve the availability, accessibility, and utilization of community-based maternal, child health and nutrition (MCHN) services by women of reproductive age and children under-two years to i improve their health outcomes”.
The Community-based Health Planning Services (CHPS) zone is the main platform for CPBF ii implementation (GHS 2014) . CHPS zones are administrative units, encompassing roughly 3000 to iii 4500 people (GHS 2005) . Each CHPS zone has one Community Health Team (CHT) that provides health services to the catchment population (mainly through outreach house-to-house visits). CHTs are made up one of more Community Health Officers (CHOs) and several Community Health Volunteers (CHVs).
The IE focuses on the community performance based financing (CPBF) pilot, implemented as part of the MCHNP. CPBF is an innovative service delivery approach, which aims to improve both supply and demand of MCHN services to drive health outcomes. However, to-date there is little evidence on the magnitude of the effect and how CPBF works specifically. The IE is integral to the project as it is an explicit objective of the Health Results Innovation Trust Fund (HRITF) to contribute to strengthening the evidence base on PBF mechanisms both at the country and global levels.
Under the CPBF pilot, Community Health Teams (CHT) will be paid financial incentives based on the achievement of MCHN targets by the team. A performance-based contract will be in effect for each CHT which will be signed by a District Health Management Team (DHMT) representative and a CHO representative from the CHT. At the core of the project component that is subject to the IE lie the five CPBF indicators. These will constitute the basis for incentivized payments to CHTs. The performance on these indicators will be routinely recorded at the CHT/CHPS zone level.
Policy Relevance of the IE Firstly, the results of this pilot will inform the decision to expand the novel CPBF program. For this purpose, the IE will produce insights for 3 “evaluation dimensions”: Effectiveness, costeffectiveness, and equity.
These data will be collected as part of routine administrative data and will be verified on a quarterly basis. The Internal Verification Team is made up of representatives from the District Health Management Team (DHMT) and members of the Local Council (local administrative unit). Additionally, external verification will be conducted by an independent agency to verify the consistency of the data.
Secondly, the evidence generated through this IE will be beneficial for policy-makers in the region as well as for developing countries around the world that seek to improve access, quality of care and MCHN outcomes through PBF and community engagement. Identifying pathways and explaining the intermediate outcomes are essential in designing relevant future health policies and programs in Ghana and elsewhere. This IE will also add to evidence that is currently being generated in other contexts, such as programs in the Gambia and Rwanda.
CPBF Incentivized Indicators 1.
2.
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Number of pregnant women and children under 5 years in the intervention communities registered Number of pregnant women making the first antenatal visit in the first trimester in the intervention areas Number of pregnant women in the
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intervention areas receiving at least four quality antenatal visits and delivering in a health facility Number of mothers and neonates (who delivered in the intervention area) receiving at least two postnatal visits of which the first should be within 48 hours and the second by the end of the seventh day after delivery Number of children under 2 years monitored (weighed) continuously for the last 3 months
How is the introduction of CPBF perceived by the various stakeholders (DHMT, Facility, CHT, CHO, CHV, etc.) and how this perception change over time as the intervention matures? How is the introduction of enhanced monitoring and supervision perceived by various stakeholders?
Quantitative Surveys This IE will feature 5 dedicated survey modules:
IE Primary Research Questions:
Prior to Baseline/ Program Roll-out:
What is the additional effect of CPBF on MCHN access and utilization and, consequently, on health outcomes relative to the base regime (“MCHNP Base”)? What is the impact of community PBF on household financial protection and wealth? What is the distributional and health equity effect of CPBF? What is the impact of CPBF on provider behavior -- knowledge, attitude, practice (KAP) -- and performance, including volume (effort) and quality? What is the incremental cost-effectiveness of CPBF as compared to the “MCHNP Base?” What is the effect of CPBF on system costs, including on monitoring, supervision, and other administrative costs?
o
At Baseline and Endline: o o o o
Household survey Community survey Provider/health worker survey Facility survey: Health centers
Table 1: Approximate sample sizes for the IE
Survey Type Household Survey Community Survey Provider - Facility Provider – CHT Provider - CHT CHO Provider - CHT CHV
IE Secondary Research Questions:
CHT/CHPS listing exercise
Does CPBF improve beneficiaries’ physical access to services? How does the CPBF affect performance on nonincentivized indicators? Does CPBF, and particularly its Information Education Communication (IEC)/Behavioral Change Communication (BCC) component, improve how receptive beneficiaries are to MCHN services? How does the CPBF affect the relationship between the DHMT and CHTs? How does CPBF affect the relationship between the facility and CHTs? How does CPBF affect the dynamics within the CHT, between the CHOs and CHVs? How does the CPBF affect the relationship between the community and CHTs? How does the CPBF affect the relationship between beneficiaries/households and CHOs/CHVs?
Approximate Size 2,800 100 125 100 200 400
Timeline The CPBF baseline is planned for September-October 2015. The CPBF pilot phase will last 2 years, with the IE endline survey planned for September-October 2017. (The timing of the IE is subject to changes in the operational timeline). For further information, please contact: Edit Velenyi (PI):
[email protected] Felipe Dunsch (IE Coordinator):
[email protected] Aimée Miller (Field Coordinator):
[email protected] i
World Bank, AFTHW. (2014). Ghana Maternal and Child Health & Nutrition Project Appraisal Document. ii Ghana Health Service. (2014). Performance Based Financing Manual. (Draft, April 2014). iii Ghana Health Service. (2005). Community-Based Health Planning and Services (CHPS). The Operational Policy. Policy Document No20.
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