Impact Evaluation Note Country Dr Tayyab Massod !Dr Akhtar Rashid

H E A LT H R E S U LT S I N N O VAT I O N T R U S T F U N D

1. Background

•  Punjab’s health outcomes have improved but the pace of change remains slow.

•  Punjab’s under-five and infant mortality (MDG 5) at 104 and 82 deaths per 1000 live births in 2011.

•  Immunization coverage is suboptimal - only 35% of children aged 12-23 months in Punjab are fully immunized (measles 2)

•  Maternal mortality ratio (MDG 4) at 227 per 100,000 live births is lower than national average.

•  Inequities persist in health outcomes and service use between the poor and non-poor and between rural and urban households

•  The efficiency of resource use is low due to pervasive problems of governance and weak and centralized management.

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1. Background

•  GoP has approved a health sector strategy •  The Bank and DFID are supporting this with a $285m

investment •  HRITF grant will be used to test a few pertinent innovations

outlined in the strategy

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2. Description of Intervention

•  Facility Based Performance Incentives: o  To enhance performance and improvements in quality of services at facility level o  Facilities will be contracted with specific outputs/ indicators related to primary health care

and incentive will be utilized for individuals as well as recurrent costs

•  Demand side voucher for safe delivery : o  Improve institutional delivery and maternal survival targeted on income level o  Voucher will cover ANC, PNC and institutional delivery o  Cash incentive to the beneficiary and pre-determined cost for institutional delivery to be

paid to the health facility (includes public and private). •  Performance based district management contracts :

o  To strengthen performance based management at the district level o  Provide performance rewards to good performing districts o  Improving quality of care through better planning, monitoring and supervision

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3. Results Chain

o  Cash Transfers to facilities…

INPUTS ACTIVITIES OUTPUTS OUTCOMES LONGER-TERM

OUTCOMES HIGHER ORDER

GOALS

o  Signing of Contracts:

o  Supervision & Monitoring

o  Provision of identified Services.

o  Improvement in Preventive Health Indicators…

o  Decreased mother and child mortality

o  Signing of Contracts:

o  Quarterly evaluations/ meetings

o  Improvement in Preventive Health Indicators…

o  Decreased mother and child mortality

1. Facility based performance contracts

2. Performance Based District Management Contracts

Verification of Results

o Improvement in delivery of Essential Package of Health Services, including integrated MNCH/FP, nutrition, and control of communicable disease

o  Improved Supervision and M&R budgets

o  Performance incentives to managers

Verification of Results

3. Results Chain

o  Awareness of services,

o  Incentive to provider and consumer

INPUTS ACTIVITIES OUTPUTS OUTCOMES LONGER-TERM

OUTCOMES HIGHER ORDER

GOALS

o Identification of Beneficiaries o Voucher

Distribution

o  2+ ANC, Institutional Delivery, PNC

o  Decrease maternal morbidity

o  Decreased mother and child mortality

3. Demand Side Incentives for Safe Delivery (Voucher Scheme)

Verification of Results

4. Primary Research Questions

•  Can RBF approaches increase the level of health service utilization leading to better health outcomes in Punjab o  Which approach will have more effect? o  What is the cost?

•  Comparison between Five Approaches o  Outsourcing Primary Care Services (PRSP) o  Performance based district management contracts o  Facility based performance contracts o  Demand side Incentives for safe delivery (vouchers o  Health Protection/ Insurance for the Poor

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5. Outcome Indicators

•  District Management Contracts o  performance indicators related to delivery of essential package of

health care, integrated Maternal Neonatal and Child Health program and communicable disease control

•  Facility contracts o  Maternal Neonatal and Child Health program, nutrition,

immunization, family planning and general management.

•  Safe Delivery Voucher o  At least 2 Antenatal Care Visits, Delivery by SBA at Health Facility,

Post Natal Care

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6. Identification Strategy/ Method

•  Multiple Research methods include o  Data collection will be on a prospective basis, from Community,

Facilities and management

•  Statistical Techniques to be used will be: o  Difference in Difference to assess quantitative effect o  Discontinuity Regression to statistically control and validate the Diff

in Diff results o  Ongoing qualitative work: including a political economy study o  Process evaluations will inform implementation

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7. Sample and Data

•  The Universe is the worse off 18 out of 36 Districts in Punjab

•  The data collection will be done in six districts o  Two for vouchers o  Two for facility contracts o  Two for health protection/ insurance

•  Qualitative : In depth Interviews with managers, community beneficiaries, health facility staff

•  Quantitative: Health Diaries at Household level, Community surveys, exit interviews, health facility assessment, management reviews

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8. Time Frame / Work Plan •  Ac#vity   TimeLine •  Project  team  on  board   June 2014 •  I.E  team     June 2014 •  Comple4on  of  contrac4ng  process  for  :  

•  (IE  data  collec4on  firm,  University,  VMA,  Health  Facili4es,  District  Management  contracts,  External  Verifica4on  Firm)  

December 2014

•  Iden4fica4on  of  beneficiaries  for  vouchers   December 2014 •  Vouchers  distribu4on     March 2015 •           Midline  Evalua4on   March 2016 •  Expansion  of  facility  contracts   June 2016 •  End  line  evalua4on   March 2018

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