A Review of Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services in Low- and Middle-Income Countries

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A Review of Initiatives that Link Provider Payment
with Quality Measurement of Maternal Health
Services in Low- and Middle-Income Countries
Jenna Wright & Rena Eichler
To cite this article: Jenna Wright & Rena Eichler (2018) A Review of Initiatives that Link Provider
Payment with Quality Measurement of Maternal Health Services in Low- and Middle-Income
Countries, Health Systems & Reform, 4:2, 77-92, DOI: 10.1080/23288604.2018.1440344
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2. Research Article
A Review of Initiatives that Link Provider Payment
with Quality Measurement of Maternal Health
Services in Low- and Middle-Income Countries
Jenna Wright and Rena Eichler
Broad Branch Associates, Bethesda, MD, USA
CONTENTS
Introduction
Background
Methods
Results
Discussion
References
Abstract—To reduce maternal and newborn morbidity and
mortality, health care payers are experimenting with ways to better
align incentives to promote high-quality maternal health services.
This review examined 26 recent initiatives of health care payers in
16 low- and middle-income countries to pay for quality, and not
solely quantity, of maternal health services. Payers measured
quality by assessing availability of structural inputs (24 of 26
cases), adherence to processes (25 of 26 cases), and observation of
key outputs of health facilities (14 of 26 cases). Two payers sought
to also assess quality through observed patient outcomes. In 25 of
the initiatives, payers used the quality assessment to adjust facility
payments; in the remaining initiative, the payer used the quality
assessment to adjust payments to provincial governments, which in
turn pay facilities. The recent growth in such payment systems
suggests more health care payers have identified ways to link
quality measurement with provider payment mechanisms. Eleven
impact evaluations of systems documented changes in provider
behavior consistent with various elements of quality; however, only
three evaluations reported effects on maternal or newborn morbidity
and mortality and do not conclude whether the design or flaws in
how it was implemented led to the results. Implementation
fidelity—the degree to which the initiative was implemented as
designed—was not widely addressed and is an area for future
research. Furthermore, although payers in low- and middle-income
countries have identified ways to operationalize a payment system
that adjusts payments based on some measure of quality, the
complexity and level of resources required to operationalize them
raise concerns about sustainability.
INTRODUCTION
Although use of facility-based maternity services has
increased, maternal mortality in developing nations remains
unacceptably high at 232.8 per 100,000 live births in 2013.
The majority of these deaths occur during labor, delivery,
Keywords: maternal health, provider payment, quality, results-based
financing, strategic purchasing
Received 15 November 2017; revised 8 February 2018.; accepted 10
February 2018.
Correspondence to: Jenna Wright; Email: jennawright@broadbranch.org
Ó 2018 Jenna Wright and Rena Eichler.
This is an Open Access article distributed under the terms of the Creative Com-
mons Attribution License (http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction in any medium, pro-
vided the original work is properly cited.
77
Health Systems & Reform, 4(2):77–92, 2018
Published with license by Taylor & Francis on behalf of the USAID’s Health Finance and Governance Project
ISSN: 2328-8604 print / 2328-8620 online
DOI: 10.1080/23288604.2018.1440344

3. and the immediate postpartum period, with obstetric hemor-
rhage being the main medical cause of death.1
Maternal mor-
bidities such as anemia, fistula, uterine rupture and scarring,
and genital and uterine prolapse also represent significant
global burdens.2
To reduce maternal and newborn morbidity and mortality,
high coverage of maternal health interventions needs to be
matched with overall improvements in quality of maternal
health care. Health facilities and their staff play a key role in
this effort. Sustainable Development Goal 3 makes the link
between improved outcomes and an increase in the propor-
tion of births attended by skilled health personnel.3
A facil-
ity-based intrapartum care strategy has been identified by
experts in the field as critical to achieving reductions in
maternal mortality.4
However, high rates of facility-based
deliveries are not enough. A 2013 study using data from 29
countries compared the burden of complications related to
pregnancy with the coverage of key maternal health interven-
tions in facilities and concluded that high coverage alone of
essential maternal health interventions did not correlate with
reduced maternal mortality if the interventions provided
were of poor quality.5
Organizations or governments paying for health care serv-
ices—henceforth referred to as purchasers—can influence
the quality of services produced within the health system.
How providers are paid matters for encouraging availability
of key inputs for high-quality maternal health services.6
Dys-
functional incentives for health workers, or inadequate mech-
anisms to support, supervise, and hold workers accountable,
can also stymie provision of high-quality care.7
Provider pay-
ment initiatives can be designed to promote results-oriented
behaviors and better align incentives with desired outputs.8
This review identifies and describes recent initiatives in
low- and middle-income countries that aim to link provider
payment with quality measurement of maternal health serv-
ices. We discuss the implications of the findings, identify
gaps in the available literature, and propose areas for further
research.
BACKGROUND
Poor-quality services provided at health facilities are increas-
ingly of concern for maternal health as more women in
developing countries choose to deliver at health facilities.
Substandard care by a health worker accounted for two thirds
of avoidable factors contributing to maternal or perinatal
deaths in a systematic review of mortality audits (the other
one third included patient-oriented factors such as patient
delay, administrative/supply factors such as medication
shortage, and transport/referral factors).9
A 2013 review
found examples of suboptimal provider performance that
contribute to low quality of care, including absenteeism; the
“know–do gap” (failure to do in practice what a provider
knows to do in principle); providing unnecessary or incorrect
services; and failing to provide recommended preventive and
outreach services.10
Real or perceived poor quality of care at
facilities can lead to public mistrust of the system, resulting
in lower demand for services.11
Facility-based maternal
health services have been found to be cost-effective in stud-
ies that measured efficacious services delivered by skilled
professionals, but services provided in real-world settings by
less-skilled professionals may not be effective at all, let alone
cost-effective.12
Although providers in resource-poor settings face
immense challenges and barriers beyond their immediate
control, there is room for quality improvement at the point of
care within current resource constraints. Health worker
adherence to high-quality clinical practice guidelines, when
combined with simulation-based training, can improve
providers’ clinical skills, attitudes, and respectful care.13
Multiple conceptual models of quality of care identify health
workforce motivation and provider actions as key inputs to
quality at the point of care.14-17
Financial incentives have been used to improve provider
motivation and adherence to clinical guidelines in higher-
income countries for many years, including for maternal
health services. Yet until recently, few health care purchasers
in low- and middle-income countries linked provider pay-
ments to quality. A 2012 Cochrane Systematic Review of
performance-based financing studies that reported on perfor-
mance or patient outcomes identified nine payment interven-
tions, and only one linked payments to quality of care.6
The
United States Agency for International Development’s
(USAID) 2012 Maternal Health Evidence Summit reviewed
the literature on how financial incentives enhance the quality
and uptake of maternal health care; reviewers found that few
studies explicitly discussed whether quality was incentivized
in the programs they evaluated, and few reported effects on
quality measures.18
A 2013 systematic review of the effect of
health insurance on maternal and neonatal health found that
few studies focused on the relationship between health insur-
ance and the quality of maternal health services.19
Since the 2012 Cochrane Systematic Review, several ini-
tiatives have begun linking provider payment for maternal
health services with quality of those services. Some of these
initiatives fall under the heading of performance-based
financing or results-based financing because payment is
78 Health Systems & Reform, Vol. 4 (2018), No. 2

4. partially or fully contingent on delivering services that meet
a predetermined standard of quality; however, it is important
to note that not all initiatives using these terms link payment
with quality. A recent study described how quality of care
assessments factored into 32 performance-based financing
schemes20
; the broad scope of that study did not allow much
discussion on quality of maternal health services specifically.
This review summarizes literature produced since the 2012
Cochrane Systematic Review. We review and discuss recent
provider payment initiatives by health care payers in low-
and middle-income countries to incentivize high quality of
maternal health service delivery.
METHODS
Inclusion Criteria
We searched for provider payment initiatives in which one of
the design objectives was to improve quality of care, includ-
ing maternal health care. For a case to be eligible for inclu-
sion, one or more maternal health care quality indicators
must be regularly measured as part of the system, and at least
part of the provider payment must be based on the quality of
maternal health care indicators. Payment initiatives that do
not specifically measure and link payment to quality of
maternal health care indicators were excluded. Payment ini-
tiatives that pay providers solely on measures of volume of
services or access to services, regardless of the provider’s
quality at the point of care, were excluded.
Search Strategy
We conducted keyword and free text searches in the follow-
ing electronic reference libraries to identify potential cases:
PubMed, ProQuest, World Bank’s RBFhealth.org Database,
Google, and Google Scholar. Keywords included combina-
tions of “quality,” “maternal health,” “provider payment,”
“performance-based financing,” “results-based financing,”
and “strategic purchasing.” We considered French- and
English-language published articles from peer-reviewed
journals and published and unpublished program reports that
included details on how a specific provider payment system
linked maternal health quality measurement to provider pay-
ment and, if available, evaluation results of the system. We
also performed detailed examination of cross-references and
bibliographies of available publications to identify additional
sources of information and drew on author and other experts’
knowledge.
The search identified 74 peer-reviewed articles and pro-
gram reports covering information from 30 low- and middle-
income countries in PubMed, ProQuest, and Google Scholar.
In addition, 36 payment initiatives that link provider payment
with quality measurement in 31 countries were identified
through the RBFhealth.org database and cross-referenced
with the initiatives identified through peer-reviewed articles.
Additional initiatives were identified through cross-referen-
ces and bibliographies. We excluded initiatives that did not
meet the inclusion criteria specified above, which resulted in
26 cases from 16 countries.
We stratified initiatives by the following payment recipi-
ent types: provincial governments, referral facilities, and pri-
mary care facilities. Purchasers that paid both referral
facilities and primary care facilities were considered two sep-
arate cases. Purchasers that paid the same type of recipient
using two different methods were also considered two sepa-
rate cases.
Data Extraction
We extracted data from the peer-reviewed articles and
program reports identified through the search and from
two databases in the public domain. After the study team
reviewed all of the articles and program reports identified
during the search for relevance, 33 articles and program
reports were included for data extraction. We extracted
standardized information on the chosen payment mecha-
nisms, how they linked to quality, and the approaches
used to assess quality. We obtained each country’s
income category from the World Development Indicator
database for calendar year 2015.21
We accessed the
Multi-Country Performance Based Incentives Quality
Checklist Database to extract information about elements
of quality assessed and assessment methods used by any
provider payment initiative included in both this study
and in the database (15).22
The database lists and catego-
rizes quality of care indicators used in some perfor-
mance-based financing initiatives and was developed
under the USAID Translating Research into Action
(TRAction) Project and published in August 2016. For
the nine provider payment initiatives included in this
study but not included in the database, we extracted the
information from within the articles and program reports.
RESULTS
The literature search identified 26 provider payment initia-
tives that linked payment to quality of maternal health care
services in 16 low- and middle-income countries. Initiatives
were launched between 2004 and 2015. Two countries were
designated upper-middle income, six countries were
Wright and Eichler: Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services 79

5. designated lower-middle income, and eight countries were
designated low income in calendar year 2015.
The 26 provider payment initiatives shared basic design
features by virtue of the search strategy and scope of the
review. In each initiative, an entity (a government agency, a
donor, or another risk-pooling entity such as an insurance
agency) acted as a purchaser of health services. This pur-
chaser’s role was to finance health care delivery by paying
providers to deliver health services to a population. This pur-
chaser–provider arrangement is quite common; it exists any-
where that health care is not solely financed by user fees paid
by patients at the point of care. What makes these 26 initia-
tives unique from the common purchaser–provider arrange-
ment is that under each initiative, the purchaser opted to
implement a quality assessment process and use the results
of the assessment to adjust payments to the providers.
Although sharing those basic design features, the 26 pro-
vider payment initiatives varied in several ways. These
design variations include the type of entity that acted as the
purchaser; the type of health care provider that was the
payee; the elements of health care quality assessed; the qual-
ity assessment method; the quality assessment frequency; the
way in which the payee’s payment was modified; and the
payment frequency. These variations are explored below.
Types of Purchasers and Payees
In most cases, the purchaser included a donor partner and the
country’s Ministry of Health. The Health Results Innovation
Trust Fund (HRITF), a multidonor trust fund administered
by the World Bank, was the primary funding source for 16 of
the 26 cases. Five cases were funded through other World
Bank funding mechanisms, two by USAID, one by the Chi-
nese Ministry of Health, one by the Department for Interna-
tional Development, and one jointly funded by the
governments of Norway and Germany. National ministries
of health were reported as the sole implementing organiza-
tion for most schemes. Co-implementation by another sub-
national or external organization with the national Ministry
of Health was reported for six of the 26 cases. Only one case
did not list any government agency as an implementing orga-
nization. Appendix A summarizes the purchaser (including
the primary funding source and the implementing organiza-
tion) and the payee (payment recipient) of the 26 initiatives.
The payee in each of the 26 cases fell into one of three cat-
egories: sub-national governments, referral facilities, and
primary care facilities. One initiative linked payment to
sub-national governments with quality of maternal health
services. This initiative was included because the quality-
adjusted payment to the sub-national government directly
affected provider payment. Nine initiatives linked payments
to hospitals with quality of maternal health services, and the
remaining 16 initiatives linked payments to primary care
facilities to quality of maternal health services.
Purchasers’ Strategies to Purchase Quality Maternal
Health Services
Purchasers employed a variety of strategies to purchase good
quality in general, including good quality maternal health serv-
ices. Appendix B shows the five design elements of the pur-
chaser’s strategy in each of the 26 cases to purchase quality:
elements of quality assessed, assessment method, assessment
frequency, payment modification, and payment frequency.
Purchasers assessed maternal health service quality using
indicators of outcomes, outputs, processes, or structural
inputs. Table 1 shows an example to illustrate each type of
quality indicator. Outcomes were measured in only two of the
26 cases. In slightly over half the cases, purchasers assessed
outputs as a way of measuring quality. In most cases, purchas-
ers assessed processes and structural inputs of providers.
Purchasers employed multiple methods to assess quality. In
23 cases, purchasers used on-site checklists combined with one
or more other methods (direct observation, patient record
review, patient/household survey, register review, and staff
interview). In the remaining three cases, purchasers did not use
on-site checklists but analyzed provider-reported electronic
data without on-site verification of those data (Argentina’s Plan
Nacer) or assessed quality through household surveys (India’s
Karnataka Health System Development Project). Quality
assessments occurred quarterly in 22 of the 26 cases.
Purchasers also employed a variety of methods to modify
payments based on the quality assessment. In most of the
cases, the purchaser paid providers on a fee-for-service basis
for the quantity of services provided during the assessment
period and then adjusted the total facility payment propor-
tional to the composite quality score. These facility payments
were often, but not always, referred to as bonus payments. In
some cases, no bonus payment was made unless the facility
met or exceeded a predetermined target for each of the indi-
cators individually or for the composite quality score.
Two cases allocated payments based on the expected vol-
ume of care in a catchment area. In one scheme in China,
part of the facility’s global budget (determined by the num-
ber of patients in the catchment area) was initially withheld
and later paid based on the quality assessment. A global bud-
get-derived bonus was the payment mechanism employed in
Rwanda’s hospital scheme. Appendix C identifies the meth-
ods used by purchasers or their surrogates in each of the 26
cases to measure quality of care.
80 Health Systems & Reform, Vol. 4 (2018), No. 2

6. How the Provider Payment Initiative Improved Quality
of Maternal Health Services and Maternal and Newborn
Health Outcomes
External evaluations were completed on 11 of the 26 initia-
tives. These evaluations reported findings related to one or
more of the following: the effects of the initiative on the
quality of maternal health services, the effect of the initiative
on maternal and newborn health outcomes, and the effect of
the initiative on provider (individual or facility) behavior.
Appendix D summarizes evaluation findings on the effect of
the initiative on quality of maternal health services and the
effect of the initiative on maternal and newborn health out-
comes. The external evaluations were of mixed quality:
some were conducted as randomized control trials and relied
on data sources independent of the initiative, whereas others
relied on data collected through the initiative itself. Several
evaluations reported qualitative findings collected on a small,
nonrepresentative sample.
Three external evaluations identified changes in facility
management that were associated with improvements in
quality of maternal health services. Three evaluations
reported that basing provider payment on quality promoted
better management. The evaluation of Burundi’s initiative
reported improved monitoring systems at all facility and dis-
trict levels, improved governance structures to analyze and
hold service providers accountable for results, development
of verification activities and evaluations to measure the
effects at household level, and introduction of guidance to
institutionalize changes at facilities.23
In Rwandan hospitals,
the payment initiative helped to clarify the responsibilities
and roles of all parties involved in the production, monitor-
ing, and evaluation of health services, although it was unclear
whether this clarification led to an improvement in quality.24
The evaluation of the payment initiative in Senegal reported
strengthened leadership of health post directors, increased
involvement of community health workers, more transparent
financial management of the facility, and improved
recording and monitoring of services provided.25
These eval-
uations did not seek to measure the direct correlation
between improvements in patient outcomes with such
observed management results, so results should be inter-
preted with caution.
Two evaluations reported that the payment initiative pro-
moted better care processes that are typically associated
with higher quality at the point of care. In Zimbabwe, quali-
tative research conducted in five districts found that
improved teamwork, facilitated by the team-based incentives
and more regularly received structured supervision and feed-
back, improved health worker performance and enhanced
community participation.26
The initiative in Senegal was
found to improve communication and promote better divi-
sion of labor among facility staff, improve working condi-
tions (including hygiene, infrastructure, and availability of
equipment), and improve monitoring of drugs stocks and
procurement.25
One evaluation in Uganda found that the outcomes
observed after basing provider payment on quality were not
Element of Quality
Measured
Indicator Related to Quality of Maternal
Health Services
Outcome Five-minute Apgar scores of over six
Output The following have been noted for all visits:
(five points) (1) hemoglobin, (2) venereal
disease research laboratory (VDRL) /
rapid plasma reagin (RPR), (3) blood
pressure checks, (4) intermittent
preventive treatment (IPT) for malaria (if
pregnancy over 20 weeks), (5) tetanus
vaccine administered accordingly, (6)
fetal heart rate/lie/presentation, (7)
ferrous sulfate/folic acid
Output Antenatal care with defined quality
parameters—starting before 16 weeks,
four visits or more, including provision
of tetanus vaccination and malaria
prevention, with appropriate measures
for the prevention of mother-to-child
transmission of HIV
Process Correct prescription of (1) iron and folic
acid, (2) mebendazole, (3) insecticide-
treated net, (4) compliance with
sulfadoxine pyrimethamine protocol
(refer to ten ANC records)
Process Analysis of 10 randomly selected partograms:
(1) partogram filled out according to the
rules, (2) decision made/documented if
alert line is passed within one hour, (3)
delivery by qualified staff (at least a nurse,
midwife, clinical officer, doctor)
Structural input Available and functional equipment and
supplies: (1) consultation table, (2) blood
pressure cuff, (3) stethoscope, (4) tape
measure, (5) scale with height gauge, (6)
fetoscope, (7) unused and nontorn
surgical gloves
Structural input Privacy: Curtains or painted windows, room
divider (if shared room), doors that close,
running water (tap or bucket with tap), three
buckets for infection prevention, labeled
TABLE 1. Illustrative Indicators of Maternal Health Service Qual-
ity, by Element of Quality Measured. VDRL D Venereal Disease
Research Laboratory, RPR D rapid plasma reagin, IPT D intermit-
tent preventive treatment, ANC D antenatal care, RBF D results-
based financing, P4P D performance-based financing
Wright and Eichler: Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services 81

7. uniform across facilities. The evaluation found that the finan-
cial incentives introduced through the provider payment ini-
tiative increased quantity and quality of health services
provided in facilities that had more transparent communica-
tion between management and clinical staff more than in
facilities without this observed characteristic. However,
when a staff incentive was anticipated but not provided, staff
demotivation and, in some cases, boycotts were observed.27
One of the evaluations of the Rwanda hospital initiative
discussed the operational difficulties in and considerations
for institutionalizing quality measurement. First, hospitals
and evaluators had difficulty understanding some indicators
and their composite criteria. An operations manual was not
available, and peer evaluators had to rely heavily on techni-
cal assistance from central government staff. Second, gather-
ing of information and uniform interpretation of data were
difficult due to the lack of standardization of medical files
and forms in the hospitals, and the evaluation tool was ini-
tially very complex. Aside from these difficulties, the evalua-
tion found that hospitals were able to achieve high-quality
scores quickly, which prompted two revisions of the evalua-
tion grid over three years in order to make the evaluation cri-
teria more specific, precise, and measurable and to adapt to
changing needs observed at hospitals.24
This finding may be
helpful for designers and managers of future quality mea-
surement initiatives to consider when rolling out a new sys-
tem that can promote continuous quality improvement.
Other evaluations noted additional implementation chal-
lenges. The program in China brought additional patients
into the participating hospitals, but hospitals’ efforts to reor-
ganize staff lagged behind the increased workload.28
The
program in Uganda encouraged private facilities to better
retain staff given the effort required to train staff in providing
higher-quality care. However, the evaluation found that turn-
over was a repeated challenge as staff in the participating pri-
vate facilities continued to transition to public-sector
positions. There was a perception that the workload in partic-
ipating private clinics was considerably higher than at public
facilities in the area, though salaries were lower. As a result,
gains in quality of care that had been achieved were often
lost when a health worker left the facility.27
Authors of three evaluations concluded that the size of the
provider payment—in both absolute terms and relative to
payments for other services—is an important factor in
improving quality at the point of care. In all of the cases, the
payment that is tied to quality is considered a subsidy, or a
payment above and beyond the cost of inputs required to pro-
vide care. This subsidy is intended to promote the provider
behaviors that lead to high quality at the point of care and
ultimately to improvements in utilization. The authors of the
Burundi evaluation compared the experience in Burundi to
Rwanda and found that the probability of institutional deliv-
ery improved in Rwanda but not in Burundi. They posit that
this finding could be explained by the relatively low subsidy
for institutional deliveries in Burundi compared with other
services, unlike in Rwanda, where the subsidy for institu-
tional deliveries was higher.29
The authors of the China eval-
uation suggested that the incentive payments in the
program—although not tied to maternal health—might not
have been large enough to induce behavioral change among
providers managing chronic illnesses.28
Authors of the evalu-
ation in Rwandan hospitals found that subsidies were consid-
ered inadequate for the requisite efforts made.24
DISCUSSION
This review identified at least 26 cases where purchasers in
low- and middle-income countries are experimenting with
paying providers based on quality of maternal health services
in an effort to improve the quality of maternal health serv-
ices. This apparent increase in cases in recent years suggests
that more health care purchasers recognize the potential to
design payment systems to incentivize quality improvement
and have identified ways to operationalize the approach.
Details of the payment models and evaluation results indicate
that conditioning provider payment on quality can improve
facility management and enhance care processes that are
associated with higher levels of care. Challenges that impede
the potential of linking payment to quality include staff turn-
over and unreliable payment.
These cases indicate that payment mechanisms that
reward quality have potential to stimulate improvements in
management processes at facility level. By specifying quality
measures and holding facility teams accountable for achiev-
ing them, facility managers and staff monitor and report on
achievements and are stimulated to improve the quality that
is rewarded through the payment system. Cases report that
information, drug and financial management systems, and
the use of those systems are improved. In addition, cases doc-
ument increased supervisory visits that may contribute to
improved quality.
These cases also provide evidence of better care processes
that are associated with higher levels of quality. For example,
incentives that reward facilities stimulate teamwork. Regular
and structured supervision with feedback strengthens care
delivery. Cases document improved working conditions that
lead to improved care processes such as better monitoring of
drug stocks, timely procurement, improved hygiene, and
enhanced availability of equipment.
82 Health Systems & Reform, Vol. 4 (2018), No. 2

8. In settings with frequent staff rotation, turnover is a chal-
lenge to realizing quality improvements associated with pay-
ment systems that reward quality because new staff need to
be retrained and team work may weaken. Cases that docu-
mented irregular or unreliable payment found that staff
became unmotivated. In addition, getting the payment levels
at a high enough level to stimulate change was a challenge in
some cases.
In most cases, quality is assessed through on-site monitor-
ing by purchasers or their surrogates (e.g., district health offi-
cials) using on-site checklists combined with one or more
other methods (direct observation, patient record review,
patient/household survey, register review, and staff inter-
view). This approach appears popular particularly in lower-
income countries. A minority of cases do not use on-site
evaluations. One example is Argentina’s Plan Nacer, which
measures quality by analyzing facility-reported electronic
data and does not regularly conduct on-site verification of
those data. This may be because self-reported health facility
data in Argentina are generally complete and accurate. Incor-
porating quality measurement into a payment system in a
country with widespread data incompleteness and inaccuracy
appears to require on-site verification. This raises questions
about the long-term sustainability of such initiatives, given
that an in-person verification process can be quite resource
intensive.
This review has several limitations. We only included
provider payment initiatives in low- and middle-income
countries that had documentation available in the web-
based public domain. There are likely other initiatives
being tried by purchasers in low- and middle-income
countries that were not included due to lack of available
documentation. It is likely that strategies employed by
private health care payers in particular would not have
been identified through this review. Second, a large pro-
portion (20 of the 26 cases) received financing through
the World Bank, through either the Health Results Inno-
vation Trust Fund (15 cases) or another financial vehicle
(5 cases). The authors note that the Trust Fund cases
have similar designs, which limits our ability to compare
and contrast a wide variety of approaches. A strategy
applied in a majority of study cases does not necessarily
mean that different payers have converged on that strat-
egy, and majority findings should be interpreted with cau-
tion. Finally, less than half of the cases had external
evaluations, so this study is not able to conclude which
purchasing strategies are most effective in improving
quality maternal health services or improving maternal
and newborn health outcomes.
Available impact evaluations reported the provider
response to the payment system intervention and effects on
health outcomes (findings presented in Appendix D). Most
evaluations discuss contextual details surrounding the results,
which we are not able to do so in this article. Of note, our
review found that implementation fidelity—the degree to
which the initiative was implemented as designed30
—is not
widely addressed in impact evaluations. This finding is con-
sistent with a 2013 literature review of evaluations of perfor-
mance-based financing initiatives in low- and middle-income
countries.31
Implementation fidelity is important to consider
when interpreting evaluation results, because the initiative’s
impact on quality of maternal health services and maternal
and newborn health outcomes will be affected not only by
the appropriateness of the design but also by the degree to
which the initiative was implemented as designed. For exam-
ple, the available literature includes very little discussion of
how well purchasers or their surrogates were able to measure
quality of care and communicate results to health workers.
Future implementation research could shed light on whether
the impact of an initiative was likely muted by poor imple-
mentation and provide lessons learned for health care payers
seeking to implement similar programs.
Overall, findings from this review can help other payers in
low- and middle-income countries seeking to improve qual-
ity of maternal health services identify models for potential
replication or adjustment, as well as identify available docu-
mentation and evaluations of different models to assist with
that process.
DISCLOSURE OF POTENTIAL CONFLICTS
OF INTEREST
No potential conflicts of interest were disclosed.
ACKNOWLEDGMENTS
The authors are grateful to the maternal health quality and
health financing experts who reviewed the study findings and
provided valuable technical comments.
FUNDING
This manuscript was funded by the U.S. Agency for Interna-
tional Development (USAID) as part of the Health Finance
and Governance project (2012-2018), a global project work-
ing to address some of the greatest challenges facing health
systems today. The project is led by Abt Associates in
Wright and Eichler: Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services 83

9. collaboration with Avenir Health, Broad Branch Associates,
Development Alternatives Inc., the Johns Hopkins Bloom-
berg School of Public Health, Results for Development Insti-
tute, RTI International, and Training Resources Group, Inc.
This material is based upon work supported by the United
States Agency for International Development under coopera-
tive agreement AID-OAA-A-12-00080. The contents are the
responsibility of the authors and do not necessarily reflect the
views of USAID or the United States Government.
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Wright and Eichler: Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services 85

11. APPENDIXA:CASESMEETINGINCLUSIONCRITERIA,ALPHABETIZEDBYCOUNTRYFOREACHTYPEOFPAYEE
PurchaserPayee
CaseNo.CountryCountryIncomeLevelProgram/SchemeNameYearLaunchedPrimaryFundingSourceImplementingOrganizationPaymentRecipient
Payee:Sub-nationalgovernment
G-1ArgentinaUpper-middlePlanNacer2004WorldBankMinistryofHealth,
Argentina
Provincialgovernments
Payee:Referralfacilities
R-1BurundiLowPerformance-based
financing
2006GovernmentofBurundi;
HRITF
GovernmentofBurundiHospitals
R-2CameroonLower-middlePerformance-based
financinginitiativein
Cameroon
2012HRITFPerformancePurchasing
Agencycontractedby
theMinistryofHealth,
Cameroon
Hospitals
R-3KyrgyzRepublicLower-middleHealthandSocial
ProtectionProject:
Results-basedfinancing
(RBF)pilotforhospitals
2012HRITFKyrgyzMinistryofHealthRayon(district)hospitals
R-4NigeriaLower-middleNigeriaStatesHealth
ProgramInvestment
Project(Nasarawaand
Ondostatesaswellasin
allnortheasternstates)
2014HRITFFederalMinistryofHealth,
nationalandstate
primaryhealthcare
developmentagencies
Secondarycareproviders
R-5RwandaLowRwandanationalPBF
schemefordistrict
hospitals
2006WorldBankMinistryofHealth,
Rwanda
Districthospitals
R-6SierraLeoneLowReproductiveandChild
HealthProject
2011HRITFMinistryofHealthand
Sanitation
Hospitals
R-7TanzaniaLowTanzaniaresults-based
financingsystem
2015WorldBankMinistryofCommunity
Development,Gender
andChildren
Districthospitals
R-8ZambiaLower-middleZambiaresults-based
financingscheme
2012HRITFMinistryofHealthDistricthospitals
R-9ZimbabweLowHealthSectorDevelopment
SupportProject
2011HRITFMinistryofHealthand
ChildCare;Cordaid
Districthospitals
Payee:Primarycarefacilities
P-1BeninLowBeninresults-based
financing,Health
SystemPerformance
Project
2011HRITFMinistryofHealth,Benin;
independentverification
agency
Healthcenters
P-2BurundiLowPerformance-based
financing
2006GovernmentofBurundi;
HRITF
GovernmentofBurundiHealthcenters
P-3CameroonLower-middlePerformance-based
financinginitiativein
Cameroon
2012HRITFPerformancePurchasing
Agencycontractedby
theMinistryofHealth,
Cameroon
Healthcenters
(Continuedonnextpage)
86 Health Systems & Reform, Vol. 4 (2018), No. 2

12. PurchaserPayee
CaseNo.CountryCountryIncomeLevelProgram/SchemeNameYearLaunchedPrimaryFundingSourceImplementingOrganizationPaymentRecipient
P-4ChinaUpper-middleSeparationofrevenueand
chargesscheme
2005MinistryofHealth,ChinaMinistryofHealth,ChinaCommunityhealthcenters
andruralmutualhealth
carevillageclinics
P-5IndiaLower-middleKarnatakaHealthSystem
DevelopmentProject
2013HRITFMinistryofHealthand
FamilyWelfare,
governmentof
Karnataka
Rural,privateobstetriccare
providers
P-6IndiaLower-middleKarnatakaHealthSystem
DevelopmentProject
2013HRITFMinistryofHealthand
FamilyWelfare,
governmentof
Karnataka
Rural,privateobstetriccare
providers
P-7MalawiLowRBF4MNHInitiative2012GovernmentofNorway,
governmentofGermany
MalawiMinistryofHealthHealthcenters
P-8MalawiLowSupportforservice
delivery—integration
2014USAIDMalawiMinistryofHealthHealthcenters
P-9NigeriaLower-middleNigeriaStatesHealth
ProgramInvestment
Project(Nasarawaand
Ondostatesaswellasin
allnortheasternstates)
2014HRITFFederalMinistryofHealth
(viatheNational
PrimaryHealthCare
DevelopmentAgency);
StatePrimaryHealth
CareDevelopment
Agency
Primarycareproviders
P-10RwandaLowRwandanational
performance-based
financing(P4P)scheme
forprimaryhealth
centers
2005WorldBankMinistryofHealth,
Rwanda
Primaryhealthcenters
P-11SenegalLower-middlePerformance-based
financing
2012USAIDMinistryofHealthand
SocialAction
Healthcentersandhealth
posts
P-12SierraLeoneLowReproductiveandChild
HealthProject
2011HRITFMinistryofHealthand
Sanitation
Peripheralhealthunits
P-13TanzaniaLowTanzaniaresults-based
financingsystem
2015WorldBankMinistryofCommunity
Development,Gender
andChildren
Healthcenters
P-14UgandaLowNorthernUgandaHealth
Programme
2011UKAidHealthPartners
International
Privatenot-for-profit
facilities
P-15ZambiaLower-middleZambiaresults-based
financingscheme
2012HRITFMinistryofHealthRuralhealthcenters
P-16ZimbabweLowHealthSectorDevelopment
SupportProject
2011HRITFMinistryofHealthand
ChildCare;Cordaid
Healthcenters
Wright and Eichler: Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services 87

13. APPENDIXB:COMPARISONOFQUALITYMEASUREMENTMECHANISMS
ElementsofQualityMeasured(related
toMaternalHealthServicesand
Others)AssessmentMethod
Case
No.CountryOutcomesOutputsProcess
Structural
Inputs
AnalysisofElectronic
DatawithoutOn-site
Verification
On-site
Checklist
Direct
Observation
Patient
Record
Review
Patient/
Household
Survey
Register
Review
Staff
Interview
Assessment
Frequency
G-1ArgentinaXXXXXEveryfour
months
R-1BurundiXXXXXXXQuarterly
R-2CameroonXXXXXXXQuarterly
R-3Kyrgyz
Republic
XXXXXXXXQuarterly
R-4NigeriaXXXXXXXXQuarterly
R-5RwandaXXXXXXXQuarterly
R-6Sierra
Leone
XXXQuarterly
R-7TanzaniaXXXXXXQuarterly
R-8ZambiaXXXXXXQuarterly
R-9ZimbabweXXXQuarterly
P-1BeninXXXXXXXQuarterly
P-2BurundiXXXXXQuarterly
P-3CameroonXXXXXXQuarterly
P-4ChinaXXXXAnnually
P-5IndiaXXOne-time
measurement
P-6IndiaXXOne-time
measurement
P-7MalawiXXXXXXQuarterly
P-8MalawiXXXXXXXQuarterly
P-9NigeriaXXXXXXXXQuarterly
P-10RwandaXXXXXXXQuarterly
P-11SenegalXXXQuarterly
P-12Sierra
Leone
XXXXQuarterly
P-13TanzaniaXXXXXXXQuarterly
P-14UgandaXXXXQuarterly
P-15ZambiaXXXXXXQuarterly
P-16ZimbabweXXXQuarterly
Total21425241238167147—
88 Health Systems & Reform, Vol. 4 (2018), No. 2

14. APPENDIX C: COMPARISON OF PURCHASING STRATEGIES TO PURCHASE QUALITY—PAY-
MENT MODIFICATIONS
Case No. Country Payment Modification Payment Frequency
G-1 Argentina Budget transfer from national to provincial governments based on
enrollment and quality measurement
Monthly and quarterlya
R-1 Burundi Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
R-2 Cameroon Payment for quantity of services provided in the quarter, adjusted
for quality if minimum threshold reached (if minimum
threshold reached for each indicator)
Quarterly
R-3 Kyrgyz Republic Bonus payments totaling up to 10% of a hospital’s maternal and
newborn health budget for demonstrated quality improvements
Quarterly
R-4 Nigeria Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
R-5 Rwanda Global prospective budget-derived bonus Quarterly
R-6 Sierra Leone Payment for quantity of services provided in the quarter, adjusted
for quality if 50% quality score achieved
Quarterly
R-7 Tanzania Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
R-8 Zambia Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
R-9 Zimbabwe Payment for quantity of services provided in the quarter, adjusted
for quality if predefined performance threshold surpassed
Quarterly
P-1 Benin Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-2 Burundi Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-3 Cameroon Payment for quantity of services provided in the quarter, adjusted
for quality (if minimum threshold reached for each indicator)
Quarterly
P-4 China Payout of withheld funds of the facility’s global budget Annually
P-5 India Bonus payment based on decreasing linear function of incidence
of four adverse maternal and neonatal health outcomes
One-time payment
P-6 India Bonus payment based on increasing linear function of quality One-time payment
P-7 Malawi Payment for number of services provided or quality assurance
actions completed in the quarter
Quarterly
P-8 Malawi Payment for quantity target achieved, adjusted for quality Quarterly
P-9 Nigeria Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-10 Rwanda Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-11 Senegal Payment for quantity of services provided in the quarter, adjusted
for quality if targets for output indicators are met
Quarterly
P-12 Sierra Leone Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-13 Tanzania Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-14 Uganda Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-15 Zambia Payment for quantity of services provided in the quarter, adjusted
for quality
Quarterly
P-16 Zimbabwe Payment for quantity of services provided in the quarter, adjusted
for quality if predefined performance threshold surpassed
Quarterly
a
60% of the per capita value monthly based on enrollment; 40% of the per capita value every four months based on tracer indicators.
Wright and Eichler: Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services 89

15. APPENDIX D: LIST AND SUMMARY OF QUALITY-BASED PROVIDER PAYMENT INITIATIVE
EFFECTS ON MATERNAL HEALTH SERVICES FROM IMPACT EVALUATIONS
Case No. Country
Reported Effect on Provision
of Maternal Health Services
Reported Effect on Maternal and
Newborn Health Outcomes Citation
G-1 Argentina At facilities enrolled in the program: Overall impact of clinic adopting the
program is 22% reduction in neonatal
mortality (regardless of individual
beneficiary status)
Gertler et al.32
Increase in the number of prenatal care
visits
The impact on Plan Nacer beneficiaries
specifically is a 74% reduction in
neonatal mortality
Increase in the share of mothers who
receive the tetanus toxoid vaccine
Reduction in the number of births
delivered by caesarian
R-1; P-2 Burundi Significant rise in the likelihood of
blood pressure measurement and anti-
tetanus vaccination during antenatal
care visit
Did not improve population coverage
of ANC
Bonfrer et al.29
Improvements found in types of care
that require a behavioral change of
health care workers when the patient is
already in the clinic
Greater effects on institutional
deliveriesamong higher income people
Little effect on services that require
effort from the provider to change
patients’ utilization choices
P-10 Rwanda Reduction in the gap between provider
knowledge and actual practice of the
appropriate clinical procedures by
approximately 20%
Increase of 0.53 standard deviations in
the weight-for-age of children zero to
11 months and 0.25 standard deviations
in the height-for-age of children 24–49
months
Gertler and Vermeersch33
No increase in prenatal care usage
P-10 Rwanda Increase of 0.157 standard deviations
(95% confidence interval, 0.026–0.289)
in prenatal quality (i.e., compliance
with Rwandan prenatal care clinical
practice guidelines; measured through
patient exit interviews and household
surveys performed for the impact
evaluation)
Basinga et al.34
P-10 Rwanda Significant increase in the proportion of
women delivering in facilities
Sherry et al.35
No impact on antenatal care utilization
P-10 Rwanda Program achieved efficiency gains by
inciting health care providers to focus
on the easier to reach (the less poor).
Equity remains an issue
Lannes et al.36
(Continued on next page)
90 Health Systems Reform, Vol. 4 (2018), No. 2

16. Case No. Country
Reported Effect on Provision
of Maternal Health Services
Reported Effect on Maternal and
Newborn Health Outcomes Citation
R-5 Rwanda Behavioral change observed in the
studied sites: (1) introduction of
mechanisms to take initiatives resulting
in better performance (appropriate
archiving, additional staff recruitment,
improved welcoming conditions for
patients) and/or (2) or development of
new services (e.g., installation of a
dental surgery, physiotherapy services)
Janssen et al.24
P-11 Senegal 42% of facilities met target for
postnatal care attendance
El-Khoury et al.25
7% met target for skilled birth
attendance
P-14 Uganda Monitoring progress in labor using a
partograph was uncommon at baseline
but improved substantially over time in
both intervention and control group and
more so in the intervention group
Health Partners International27
R-8; P-15 Zambia Health workers in facilities with the
new payment mechanism spent
significantly more time during
consultations with their patients as
compared to control health facilities
Women residing in districts with the
new payment mechanism were
significantly more likely to list several
out of the 12 danger signs during
pregnancy
Chansa et al.37
Timing of the first Antenatal care
(ANC) visit was earlier by two weeks
under the new payment mechanism as
compared to control groups
The new payment mechanism contributed
to some important health gains over
business as usual, but several of the gains
were also achieved in the districts that
received additional financing without
direct incentives for quality
Number of deliveries by skilled
providers improved in facilities that
received additional funding and
facilities that used the new payment
mechanism, relative to the control
group that received no additional
funding
Quality of the delivery room was higher
in districts with the new payment
mechanism
(Continued on next page)
Wright and Eichler: Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services 91

17. Case No. Country
Reported Effect on Provision
of Maternal Health Services
Reported Effect on Maternal and
Newborn Health Outcomes Citation
R-9; P-16 Zimbabwe 12 percentage point increase in
postnatal care coverage
Friedman et al.26
13 percentage point increase in the in-
facility delivery rate due to the
Zimbabwe results-based financing
(RBF)
A significant increase in the rate of
pregnant women receiving a full
package of ANC services
includingurine and blood tests and
tetanus shots
Not all indicators show relative
improvement in RBF districts during
the pilot (both indicators where
baseline coverage levels were already
quite high):
No increase in ANC service coverage
Small gain in use of modern
contraceptives
92 Health Systems Reform, Vol. 4 (2018), No. 2