The effects of performance incentives on the utilization and quality of maternal and child care in Burundi

Africa's progress towards the health related Millennium Development Goals remains limited. This can be partly explained by inadequate performance of health care providers. It is therefore critical to incentivize this performance. Payment methods that reward performance related to quantity and quality, called performance based financing (PBF), have recently been introduced in over 30 African countries. While PBF meets considerable enthusiasm from governments and donors, the evidence on its effects is still limited. In this study we aim to estimate the effects of PBF on the utilization and quality of maternal and child care in Burundi. We use the 2010 Burundi Demographic and Health Survey (August 2010–January 2011, n = 4916 women) and exploit the staggered rollout of PBF between 2006 and 2010, to implement a difference-in-differences approach. The quality of care provided during antenatal care (ANC) visits improved significantly, especially among the better off, although timeliness and number of ANC visits did not change. The probability of an institutional delivery increased significantly with 4 percentage points among the better off but no effects were found among the poor. PBF does significantly increase this probability (with 5 percentage points) for women where PBF was in place from the start of their pregnancy, suggesting that women are encouraged during ANC visits to deliver in the facility. PBF also led to a significant increase of 4 percentage points in the probability of a child being fully vaccinated, with effects more pronounced among the poor. PBF improved the utilization and quality of most maternal and child care, mainly among the better off, but did not improve targeting of unmet needs for ANC. Especially types of care which require a behavioral change of health care workers when the patient is already in the clinic show improvements. Improvements are smaller for services which require effort from the provider to change patients' utilization choices.