Facility and Community Results-Based Financing to Improve Maternal and Child Nutrition and Health in The Gambia

ABSTRACT

In 2013, the Government of The Gambia implemented a novel results-based financing (RBF) intervention designed to improve maternal and child nutrition and health through a combination of community, facility and individual incentives. In a mixed-methods study, we used a randomized 2 × 2 study design to measure these interventions’ impact on the uptake of priority maternal health services, hygiene and sanitation. Conditional cash transfers to individuals were bundled with facility results-based payments. Community groups received incentive payments conditional on completion of locally-designed health projects. Randomization occurred separately at health facility and community levels. Our model pools baseline, midline and endline exposure data to identify evidence of the interventions’ impact in isolation or combination. Multivariable linear regression models were estimated. A qualitative study was embedded, with data thematically analyzed. We analyzed 5,927 household surveys: 1,939 baseline, 1,951 midline, and 2,037 endline. On average, community group interventions increased skilled deliveries by 11 percentage points, while the facility interventions package increased them by seven percentage points. No impact was found, either in the community group or facility intervention package arms on early ANC. The community group intervention led to 49, 43 and 48 percentage point increases in handwashing stations, soaps at station and water at station, respectively. No impact was found on improved sanitation facilities. The qualitative data help understand factors underlying these changes. No interaction was found between the community and facility interventions. Where demand-side barriers predominate and community governance structures exist, community group RBF interventions may be more effective than facility designs.

KEYWORDS:

• Child health
• health policy
• health systems
• hygiene
• maternal health

Contributorship Statement

We would like to acknowledge the time and expertise of the many experts who contributed to the development of this article.

Overall Development, Coordination And Oversight

Laura Ferguson, Principal Investigator

Rifat Hasan, co-Principal Investigator of the impact evaluation

Quantitative Data Team

Yaya Jallow – University of The Gambia

Günther Fink – Swiss TPH and University of Basel

Chantelle Boudreaux – Harvard University

Gambia Bureau of Statistics:

Project Manager: Nyakassi M B Sanyang

Field Manager: Lamin L Dibba

Coordinators: Catherine Gibba Omo, Famara Fatty, Lamin Kanteh, Samba Barrow

Supervisors: Abdou Sanyang, Abie Jabang, Amie Bojang, David Mendy, Ebrima Jammeh, Ebrima Tunkara, Fatou S Jabang, Ndye Binta Bojang, Saikou Jawara, Sainey Sanneh, Sandiki Colley

Household interviewers: Abou Fofana, Aja T.M.Kinteh, Alimameh Badjie, Amie Gigo, Amie Sallah, Aminata Badjie, Babucarr Danso, Babucarr Jasseh, Bai Matarr Jaiteh, Bintou Badjie, Charles Demba, Dembo Fofana, Dobally Jobe, Ebrima Jallow, Edrisa Njie, Fabakary Jawneh, Famara Nyabally, Fatou Manneh, Fatoumatta Ceesay, Fatou Suwareh, Indira Henry Jammeh, Isatou A Badjie, Isatou Bah, Isatou Jallow, Ismaila Dibba, Josephine Sylva, Madi Mangan, Mam Fatou Gaye, Mamanding Colley, Mansour Dibba, Mansour B Joof, Mariama Dibba, Modou S Nyassi, Momodou Sarr, Muhammed Bah, Muhammed Sanneh, Mustapha Saho, Mustapha Sanyang, Nafisatou Jatta, Olimatou Sissoho, Omar Njie, Ousman Cham, Pa Ousman Ceesay, Tabara Gibba, Tida Gassama

Health facility interviewers: Adama Humma, Alieu Faal, Hassan Njie, Lamin B. Fatty, Lamin Saidykhan, Mass Joof, Mustapha Sanneh, Omar Mbackeh

Anthropometrists: Balla Cham, Basiru Sanyang, Fatou Cham, Imran Jabang, Lamin Darboe, Muhammed Joof, Ousman L. Kanyi

Real-Time Analytics: Le Dang Trung and his team

Qualitative Data Team

Mariama Dibba, Sira Bah, Momodou Conteh, Sering Fye, Kristin Dessie Zaccharias, Bita Minaravesh

Peer Review

Project Implementation Committee: Modou Cheyassin Phall, Abdou Aziz Ceesay, Ousman Ceesay, Dr. Momodou L. Waggeh, Mamady Cham, Famata Colley, Modou Lamin Darboe, Malang N. Fofana, Catherine Gibba, Bakary Jallow, Musa Loum, Elizabeth Mago, Lamin Njie, Matty Njie, Alhagie Sankareh. World Bank Task Team: Rifat Hasan, Menno Mulder-Sibanda and Ronald Mutasa, The World Bank GroupImpact Evaluation Advisory Panel: Christopher Belford UTG, Alfusaney Jabbi MOF, Bakary Jallow NaNA, Dr Momodou Jasseh MRC, Sainey Sanneh MOHSW, Sheriffo Sonko NMCP

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Data Availability

The data used for this evaluation are publicly available through the World Bank Microdata Repository (Reference: GMB_2014_HRBFIE-BL_v01_M).

Supplementary Material

Supplemental material for this article can be accessed online at https://doi.org/10.1080/23288604.2022.2117320

Notes

[a]. Minor health facilities provide only primary health care while major health facilities have a larger, better trained workforce as well as a functional blood bank, operating theater and electricity.

Additional information

Funding

Funding for this study was provided by the World Bank Health Results Innovation Trust Fund.