Maternal health services continue to favour the wealthiest in lower and middle income countries. Debate about the potential of performance-based financing (PBF) to address these disparities continues. As PBF is adopted by countries, it is critical to understand the equity effects for maternal services. The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population. In Rwanda, PBF was designed to increase health service use, which was universally low. Paired districts were randomly assigned to intervention and control for PBF implementation. Using Rwanda's Demographic Health Survey data from 2005 (pre-intervention) and 2007-8 (post-intervention), a cluster-level panel dataset of 7899 women 15-49 years of age from intervention (4477) and control districts (3422) was created. The impact of PBF on reported use of facility deliveries, antenatal care (ANC) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects. Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women. The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts (P = 0.014), while no significant effects were noted for ANC visits or modern contraceptive use. Service use increased for intervention and control populations and across all wealth quintiles from 2005 to 2007, with no evidence that PBF was a pro-poor or a pro-rich strategy. Insurance remained a positive predictor of service use. This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services, such as facility deliveries, may improve service use overall. However, if the equity gap is extreme, then a PBF programme without equity targets will do little to alleviate disparities.

译文

孕产妇保健服务继续有利于中低收入国家的最富有的人。关于基于绩效的融资 (PBF) 解决这些差距的潜力的辩论仍在继续。随着PBF被各国采用,了解孕产妇服务的公平效应至关重要。这项研究的目的是在没有针对最贫困人口的具体规定的情况下,研究PBF对孕产妇保健服务使用公平性的影响。在卢旺达,PBF旨在增加普遍较低的卫生服务使用。成对的地区被随机分配到PBF实施的干预和控制中。使用卢旺达的人口健康调查数据2005年 (干预前) 和2007-8 (干预后),创建了来自干预 (4477) 和控制区 (3422) 的7899名15-49岁妇女的集群级面板数据集。使用具有社区固定效应的差异差异模型估算了PBF对报告的设施分娩使用,产前护理 (ANC) 和现代避孕药具使用的影响。估计了财富五分位数与PBF之间的相互作用项,以确定PBF在较贫穷妇女中的不同作用。与对照地区相比,干预措施中提供设施的可能性增加了10个百分点 (P = 0.014),而对ANC就诊或使用现代避孕药具没有显着影响。干预和控制人群以及所有财富五分之一2005年2007年的服务使用有所增加,没有证据表明PBF是扶贫或致富战略。保险仍然是服务使用的积极预测因素。这项研究表明,如果服务使用率一直很低,那么激励特定服务 (例如设施交付) 的PBF计划可能会总体上改善服务使用率。但是,如果股权差距是极端的,那么没有股权目标的PBF计划将对缓解差距无济于事。

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