29 results on '"ALLEGRI A"'
Search Results
2. A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India
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Ziegler, Susanne, Srivastava, Swati, Parmar, Divya, Basu, Sharmishtha, Jain, Nishant, and De Allegri, Manuela
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- 2024
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3. Costing curative outpatient care for the poorest in Burkina Faso: informing universal health coverage and leaving no one behind
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Yvonne Beaugé, Valéry Ridde, Sidibé Souleymane, Joël Arthur Kiendrébéogo, Hoa Thi Nguyen, Emmanuel Bonnet, and Manuela De Allegri
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Poorest ,Universal Health Coverage ,Cost Analysis ,Burkina Faso ,Curative Outpatient Care ,Budget Impact Analysis ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Introduction The poorest in Burkina Faso face numerous barriers to healthcare access, including financial and geographic obstacles, as well as a high burden of chronic conditions and multimorbidity. This study estimates the average cost of providing curative outpatient consultations at first-level healthcare facilities to the poorest in Burkina Faso. It also estimates the budgetary impact of scaling up free access to these services nationwide. The findings provide essential evidence on cost structures to inform decision-makers in developing policies aimed at achieving universal health coverage and ensuring that no one is left behind. Methods We conducted a micro-costing study to estimate the economic costs of providing curative outpatient healthcare services to the poorest at first-level healthcare facilities, considering a health system perspective. We measured the consumption of capital costs (building and equipment) using survey data from 32 primary health facilities and recurrent costs (drugs and consumables) from medical records of 1380 poor patients in Diébougou district. These individuals were targeted and exempted from user fees through a community-based targeting approach. We obtained unit costs from official price lists, pharmacy registries, and expert interviews. We calculated the national budget for providing curative care services to the exempted poorest based on the average cost per first-level consultation. Results The estimated capital and recurrent costs of providing curative care services ranged between USD 0.59 - USD 0.61 and USD 2.58 - USD 5.00, respectively. The total cost ranged between USD 3.17 - USD 5.61 per first-level consultation. Providing curative care to the bottom 20% of the population, assuming 0.25 healthcare contacts per person per year, would result in an annual expense ranging from USD 2.77 M to USD 5.38 M (0.74-1.43% of the healthcare budget in 2019). With 2 healthcare contacts per person per year, costs increase to USD 22.19 M to USD 43.05 M (5.91-11.45% of the healthcare budget). Conclusion The results can inform policies aimed at expanding access to curative care for the poorest in Burkina Faso, contributing to the goals of universal health coverage and leaving no one behind. Further research is needed to enhance cost estimation and budgeting for higher-level care in the country.
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- 2024
- Full Text
- View/download PDF
4. A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India
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Susanne Ziegler, Swati Srivastava, Divya Parmar, Sharmishtha Basu, Nishant Jain, and Manuela De Allegri
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Universal health coverage ,Health insurance ,Gender ,India ,RSBY ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India’s national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY). Methods We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics. Results At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled. Conclusion Findings are surprising in light of India’s well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women’s preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.
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- 2024
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5. Healthcare system resilience in Bangladesh and Haiti in times of global changes (climate-related events, migration and Covid-19): an interdisciplinary mixed method research protocol
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Lucie Clech, Sofia Meister, Maeva Belloiseau, Tarik Benmarhnia, Emmanuel Bonnet, Alain Casseus, Patrick Cloos, Christian Dagenais, Manuela De Allegri, Annabel Desgrées du Loû, Lucas Franceschin, Jean-Marc Goudet, Daniel Henrys, Dominique Mathon, Mowtushi Matin, Ludovic Queuille, Malabika Sarker, Charlotte Paillard Turenne, and Valéry Ridde
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Healthcare systems resilience ,Global change ,Climate change ,Migration ,Covid-19 ,Mixed-methods ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Since climate change, pandemics and population mobility are challenging healthcare systems, an empirical and integrative research to studying and help improving the health systems resilience is needed. We present an interdisciplinary and mixed-methods research protocol, ClimHB, focusing on vulnerable localities in Bangladesh and Haiti, two countries highly sensitive to global changes. We develop a protocol studying the resilience of the healthcare system at multiple levels in the context of climate change and variability, population mobility and the Covid-19 pandemic, both from an institutional and community perspective. Methods The conceptual framework designed is based on a combination of Levesque’s Health Access Framework and the Foreign, Commonwealth and Development Office’s Resilience Framework to address both outputs and the processes of resilience of healthcare systems. It uses a mixed-method sequential exploratory research design combining multi-sites and longitudinal approaches. Forty clusters spread over four sites will be studied to understand the importance of context, involving more than 40 healthcare service providers and 2000 households to be surveyed. We will collect primary data through questionnaires, in-depth and semi-structured interviews, focus groups and participatory filming. We will also use secondary data on environmental events sensitive to climate change and potential health risks, healthcare providers’ functioning and organisation. Statistical analyses will include event-history analyses, development of composite indices, multilevel modelling and spatial analyses. Discussion This research will generate inter-disciplinary evidence and thus, through knowledge transfer activities, contribute to research on low and middle-income countries (LMIC) health systems and global changes and will better inform decision-makers and populations.
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- 2022
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6. Healthcare system resilience in Bangladesh and Haiti in times of global changes (climate-related events, migration and Covid-19): an interdisciplinary mixed method research protocol
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Clech, Lucie, Meister, Sofia, Belloiseau, Maeva, Benmarhnia, Tarik, Bonnet, Emmanuel, Casseus, Alain, Cloos, Patrick, Dagenais, Christian, De Allegri, Manuela, du Loû, Annabel Desgrées, Franceschin, Lucas, Goudet, Jean-Marc, Henrys, Daniel, Mathon, Dominique, Matin, Mowtushi, Queuille, Ludovic, Sarker, Malabika, Turenne, Charlotte Paillard, and Ridde, Valéry
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- 2022
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7. Responding to policy makers’ evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso
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Manuela De Allegri, Julia Lohmann, Aurélia Souares, Michael Hillebrecht, Saidou Hamadou, Hervé Hien, Ousmane Haidara, and Paul Jacob Robyn
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Burkina Faso ,Performance-based financing ,Randomized controlled trial ,Quasi-experiment ,Difference-in-differences ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. Methods This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. Discussion We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention’s impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. Trial registration Registered with RIDIE (RIDIE-STUDY-ID-54412a964bce8) on 10/17/2014.
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- 2019
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8. Impact of results-based financing on effective obstetric care coverage: evidence from a quasi-experimental study in Malawi
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Stephan Brenner, Jacob Mazalale, Danielle Wilhelm, Robin C Nesbitt, Terhi J Lohela, Jobiba Chinkhumba, Julia Lohmann, Adamson S Muula, and Manuela De Allegri
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Results-based financing ,Effective coverage ,Maternal and child health ,Quality of care ,Health care financing ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Results-based financing (RBF) describes health system approaches addressing both service quality and use. Effective coverage is a metric measuring progress towards universal health coverage (UHC). Although considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied. Methods Malawi introduced the Results-Based Financing For Maternal and Neonatal Health (RBF4MNH) Initiative in 2013 to improve quality of maternal and newborn health services at emergency obstetric care facilities. Using a quasi-experimental design, we examined the impact of the RBF4MNH on both crude and effective coverage of pregnant women across four districts during the two years following implementation. Results There was no effect on crude coverage. With a larger proportion of women in intervention areas receiving more effective care over time, the overall net increase in effective coverage was 7.1%-points (p = 0.07). The strongest impact on effective coverage (31.0%-point increase, p = 0.02) occurred only at lower cut-off level (60% of maximum score) of obstetric care effectiveness. Design-specific and wider health system factors likely limited the program’s potential to produce stronger effects. Conclusion The RBF4MNH improved effective coverage of pregnant women and seems to be a promising reform approach towards reaching UHC. Given the short study period, the full potential of the current RBF scheme has likely not yet been reached.
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- 2018
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9. Perceptions of quality across the maternal care continuum in the context of a health financing intervention: Evidence from a mixed methods study in rural Malawi
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Christabel Kambala, Julia Lohmann, Jacob Mazalale, Stephan Brenner, Malabika Sarker, Adamson S. Muula, and Manuela De Allegri
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Results-Based Financing ,Malawi ,Quality of care ,Demand-side financing ,Performance-based financing ,Maternal care ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women’s perspectives. Methods We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth. Results We did not observe a statistically significant effect of the intervention on women’s perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities. Conclusion Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers’ positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF.
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- 2017
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10. Responding to policy makers’ evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso
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De Allegri, Manuela, Lohmann, Julia, Souares, Aurélia, Hillebrecht, Michael, Hamadou, Saidou, Hien, Hervé, Haidara, Ousmane, and Robyn, Paul Jacob
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- 2019
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11. Correction to: Responding to policy makers’ evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso
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De Allegri, Manuela, Lohmann, Julia, Souares, Aurélia, Hillebrecht, Michael, Hamadou, Saidou, Hien, Hervé, Haidara, Ousmane, and Robyn, Paul Jacob
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- 2019
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12. Correction to: Responding to policy makers’ evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso
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Manuela De Allegri, Julia Lohmann, Aurélia Souares, Michael Hillebrecht, Saidou Hamadou, Hervé Hien, Ousmane Haidara, and Paul Jacob Robyn
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Public aspects of medicine ,RA1-1270 - Abstract
Due to an error introduced during copyediting of this article [1], there are two corrections about the Figs. 1. The caption of Fig. 1 should be changed to “Study design”. 2. The Fig. 2 is missing.
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- 2019
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13. Adverse selection in a community-based health insurance scheme in rural Africa: Implications for introducing targeted subsidies
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Parmar Divya, Souares Aurélia, de Allegri Manuela, Savadogo Germain, and Sauerborn Rainer
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Community-based health insurance ,Adverse selection ,Subsidy ,Burkina Faso ,Fixed effects ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.
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- 2012
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14. Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso
- Author
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De Allegri, Manuela, Lohmann, Julia, Souares, Aurélia, Hillebrecht, Michael, Hamadou, Saidou, Hien, Hervé, Haidara, Ousmane, and Robyn, Paul Jacob
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Difference-in-differences ,Quasi-experiment ,lcsh:Public aspects of medicine ,Correction ,lcsh:RA1-1270 ,Performance-based financing ,Study Protocol ,Randomized controlled trial ,Research Design ,Burkina Faso ,Humans ,Health Services Research ,Capitation Fee ,Needs Assessment - Abstract
Background The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. Methods This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. Discussion We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention’s impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. Trial registration Registered with RIDIE (RIDIE-STUDY-ID-54412a964bce8) on 10/17/2014.
- Published
- 2018
15. Perceptions of quality across the maternal care continuum in the context of a health financing intervention: Evidence from a mixed methods study in rural Malawi
- Author
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Malabika Sarker, Julia Lohmann, Adamson S Muula, Manuela De Allegri, Christabel Kambala, Jacob Mazalale, and Stephan Brenner
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Malawi ,medicine.medical_specialty ,Maternal Health ,media_common.quotation_subject ,Psychological intervention ,Health administration ,Neglect ,Interviews as Topic ,03 medical and health sciences ,610 Medical sciences Medicine ,0302 clinical medicine ,Nursing ,Health facility ,Pregnancy ,Health care ,medicine ,Healthcare Financing ,Humans ,Infant Health ,Maternal Health Services ,Prospective Studies ,030212 general & internal medicine ,Qualitative Research ,Quality of Health Care ,media_common ,Finance ,business.industry ,lcsh:Public aspects of medicine ,030503 health policy & services ,Health Policy ,Nursing research ,Public health ,Quality of care ,lcsh:RA1-1270 ,Performance-based financing ,Continuity of Patient Care ,Delivery, Obstetric ,Conditional Cash Transfers ,Focus group ,Results-Based Financing ,Maternal care ,Female ,0305 other medical science ,business ,Demand-side financing ,Research Article - Abstract
Background: In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women’s perspectives. Methods: We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth. Results: We did not observe a statistically significant effect of the intervention on women’s perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities. Conclusion: Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers’ positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF.
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- 2017
- Full Text
- View/download PDF
16. Impact of results-based financing on effective obstetric care coverage: evidence from a quasi-experimental study in Malawi
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Brenner, Stephan, primary, Mazalale, Jacob, additional, Wilhelm, Danielle, additional, Nesbitt, Robin C, additional, Lohela, Terhi J, additional, Chinkhumba, Jobiba, additional, Lohmann, Julia, additional, Muula, Adamson S, additional, and De Allegri, Manuela, additional
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- 2018
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17. The economic burden of chronic non-communicable diseases in rural Malawi: an observational study
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Wang, Qun, Brenner, Stephan, Kalmus, Olivier, Banda, Hastings Thomas, and De Allegri, Manuela
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Catastrophic health expenditure ,Adult ,Male ,Malawi ,Financing, Personal ,Adolescent ,300 Social sciences ,Economic burden ,Rural Health ,Young Adult ,610 Medical sciences Medicine ,Cost of Illness ,Humans ,Longitudinal Studies ,Child ,Poverty ,Family Characteristics ,Health Policy ,Middle Aged ,Health Surveys ,Chronic non-communicable diseases ,Chronic Disease ,Costs and Cost Analysis ,Female ,Health Expenditures ,Research Article - Abstract
Background Evidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi. Methods The study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households. Results A total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs. Conclusion Our study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1716-8) contains supplementary material, which is available to authorized users.
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- 2016
18. Evaluating complex health financing interventions: using mixed methods to inform further implementation of a novel PBI intervention in rural Malawi
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Shannon A, McMahon, Stephan, Brenner, Julia, Lohmann, Christopher, Makwero, Aleksandra, Torbica, Don P, Mathanga, Adamson S, Muula, and Manuela, De Allegri
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Malawi ,Motivation ,Research protocol ,Salaries and Fringe Benefits ,Cost-Benefit Analysis ,Health Personnel ,Performance-based financing ,Process evaluation ,Study Protocol ,Research Design ,Healthcare Financing ,Humans ,Prospective Studies ,Rural Health Services ,Results based financing ,Reimbursement, Incentive ,Performance-based incentives ,Quality of Health Care ,Health financing - Abstract
Background Gaps remain in understanding how performance-based incentive (PBI) programs affect quality of care and service quantity, whether programs are cost effective and how programs could be tailored to meet client and provider needs while remaining operationally viable. In 2014, Malawi’s Ministry of Health launched the Service Delivery Integration-PBI (SSDI-PBI) program. The program is unique in that no portion of performance bonuses are paid to individual health workers, and it shifts responsibility for infrastructure and equipment procurement from facility staff to implementing partners. This protocol outlines an approach that analyzes processes and outcomes, considers expected and unexpected consequences of the program and frames the program’s outputs relative to its costs. Findings from this evaluation will inform the intended future scale-up of PBI in Malawi. Methods/design This study employs a prospective controlled before-and-after triangulation design to assess effects of the PBI program by analyzing quantitative and qualitative data from intervention and control facilities. Guided by a theoretical framework, the evaluation consists of four main components: service provision, health worker motivation, implementation processes and costing. Quality and access outcomes are assessed along four dimensions: (1) structural elements (related to equipment, drugs, staff); (2) process elements (providers’ compliance with standards); (3) outputs (service utilization); (4) experiential elements (experiences of service delivery). The costing component includes costs related to start-up, ongoing management, and the cost of incentives themselves. The cost analysis considers costs incurred within the Ministry of Health, funders, and the implementing agency. The evaluation relies on primary data (including interviews and surveys) and secondary data (including costing and health management information system data). Discussion Through the lens of a PBI program, we illustrate how complex interventions can be evaluated via not only primary, mixed-methods data collection, but also through a wealth of secondary data from program implementers (including monitoring, evaluation and financial data), and the health system (including service utilization and service readiness data). We also highlight the importance of crafting a theory and using theory to inform the nature of data collected. Finally, we highlight the need to be responsive to stakeholders in order to enhance a study’s relevance.
- Published
- 2016
19. Perceptions of quality across the maternal care continuum in the context of a health financing intervention: Evidence from a mixed methods study in rural Malawi
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Kambala, Christabel, primary, Lohmann, Julia, additional, Mazalale, Jacob, additional, Brenner, Stephan, additional, Sarker, Malabika, additional, Muula, Adamson S., additional, and De Allegri, Manuela, additional
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- 2017
- Full Text
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20. Developing attributes and attribute-levels for a discrete choice experiment on micro health insurance in rural Malawi
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Grace Bongololo Mbera, Paul Jacob Robyn, Manuela De Allegri, Gilbert Abotisem Abiiro, and Gerald Leppert
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Male ,Rural Population ,Malawi ,Knowledge management ,Population ,qualitative study ,rural communities ,Pilot Projects ,Qualitative property ,Context (language use) ,Micro health insurance ,Choice Behavior ,Insurance Coverage ,Nursing ,Health care ,Credibility ,Humans ,Medicine ,Policy Making ,education ,Qualitative Research ,education.field_of_study ,Insurance, Health ,microinsurance ,business.industry ,Health Policy ,discrete choice experiment ,attribute-levels development ,Focus Groups ,Rural communities ,Focus group ,micro health insurance ,Discrete choice experiment ,Conceptual framework ,Female ,Systematic process ,Qualitative study ,business ,Attribute and attribute-levels development ,Research Article - Abstract
Background Discrete choice experiments (DCEs) are attribute-driven experimental techniques used to elicit stakeholders’ preferences to support the design and implementation of policy interventions. The validity of a DCE, therefore, depends on the appropriate specification of the attributes and their levels. There have been recent calls for greater rigor in implementing and reporting on the processes of developing attributes and attribute-levels for discrete choice experiments (DCEs). This paper responds to such calls by carefully reporting a systematic process of developing micro health insurance attributes and attribute-levels for the design of a DCE in rural Malawi. Methods Conceptual attributes and attribute-levels were initially derived from a literature review which informed the design of qualitative data collection tools to identify context specific attributes and attribute-levels. Qualitative data was collected in August-September 2012 from 12 focus group discussions with community residents and 8 in-depth interviews with health workers. All participants were selected according to stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three researchers to identify context-specific attributes and attribute-levels. Expert opinion was used to scale down the attributes and levels. A pilot study confirmed the appropriateness of the selected attributes and levels for a DCE. Results First, a consensus, emerging from an individual level analysis of the qualitative transcripts, identified 10 candidate attributes. Levels were assigned to all attributes based on data from transcripts and knowledge of the Malawian context, derived from literature. Second, through further discussions with experts, four attributes were discarded based on multiple criteria. The 6 remaining attributes were: premium level, unit of enrollment, management structure, health service benefit package, transportation coverage and copayment levels. A final step of revision and piloting confirmed that the retained attributes satisfied the credibility criteria of DCE attributes. Conclusion This detailed description makes our attribute development process transparent, and provides the reader with a basis to assess the rigor of this stage of constructing the DCE. This paper contributes empirical evidence to the limited methodological literature on attributes and levels development for DCE, thereby providing further empirical guidance on the matter, specifically within rural communities of low- and middle-income countries.
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- 2014
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21. Evaluating complex health financing interventions: using mixed methods to inform further implementation of a novel PBI intervention in rural Malawi
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McMahon, Shannon A., primary, Brenner, Stephan, additional, Lohmann, Julia, additional, Makwero, Christopher, additional, Torbica, Aleksandra, additional, Mathanga, Don P., additional, Muula, Adamson S., additional, and De Allegri, Manuela, additional
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- 2016
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22. A qualitative study assessing the acceptability and adoption of implementing a results based financing intervention to improve maternal and neonatal health in Malawi
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Wilhelm, Danielle J., primary, Brenner, Stephan, additional, Muula, Adamson S., additional, and De Allegri, Manuela, additional
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- 2016
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23. Gaps in universal health coverage in Malawi: A qualitative study in rural communities
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Abiiro, Gilbert Abotisem, primary, Mbera, Grace Bongololo, additional, and De Allegri, Manuela, additional
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- 2014
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24. Developing attributes and attribute-levels for a discrete choice experiment on micro health insurance in rural Malawi
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Abiiro, Gilbert Abotisem, primary, Leppert, Gerald, additional, Mbera, Grace Bongololo, additional, Robyn, Paul J, additional, and De Allegri, Manuela, additional
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- 2014
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25. Design of an impact evaluation using a mixed methods model – an explanatory assessment of the effects of results-based financing mechanisms on maternal healthcare services in Malawi
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Brenner, Stephan, primary, Muula, Adamson S, additional, Robyn, Paul Jacob, additional, Bärnighausen, Till, additional, Sarker, Malabika, additional, Mathanga, Don P, additional, Bossert, Thomas, additional, and De Allegri, Manuela, additional
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- 2014
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26. The economic burden of chronic non-communicable diseases in rural Malawi: an observational study.
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Qun Wang, Brenner, Stephan, Kalmus, Olivier, Banda, Hastings Thomas, De Allegri, Manuela, and Wang, Qun
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NON-communicable diseases ,HOUSEHOLD surveys ,MEDICAL care costs ,NEUROPSYCHIATRY ,ECONOMIC statistics ,CHRONIC diseases ,MEDICAL care cost statistics ,COMPARATIVE studies ,ECONOMIC aspects of diseases ,ECONOMICS ,FAMILIES ,LONGITUDINAL method ,RESEARCH methodology ,MEDICAL cooperation ,POVERTY ,RESEARCH ,RURAL health ,SURVEYS ,COST analysis ,EVALUATION research - Abstract
Background: Evidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi.Methods: The study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households.Results: A total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs.Conclusion: Our study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs. [ABSTRACT FROM AUTHOR]- Published
- 2016
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27. Gaps in universal health coverage in Malawi: A qualitative study in rural communities
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Grace Bongololo Mbera, Manuela De Allegri, and Gilbert Abotisem Abiiro
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Rural Population ,Financing, Personal ,Malawi ,Economic growth ,medicine.medical_specialty ,Population ,Poison control ,Health informatics ,Health Services Accessibility ,Health administration ,Gaps in coverage ,Nursing ,Universal Health Insurance ,Universal health coverage ,Health care ,Humans ,Medicine ,Geographical inequities ,education ,Qualitative Research ,education.field_of_study ,Community perspective ,business.industry ,Public health ,Health Policy ,Public sector ,Focus Groups ,Private sector ,Cross-Sectional Studies ,Financial protection ,Access to health care ,Qualitative study ,business ,Delivery of Health Care ,Research Article - Abstract
Background In sub-Saharan Africa, universal health coverage (UHC) reforms have often adopted a technocratic top-down approach, with little attention being paid to the rural communities’ perspective in identifying context specific gaps to inform the design of such reforms. This approach might shape reforms that are not sufficiently responsive to local needs. Our study explored how rural communities experience and define gaps in universal health coverage in Malawi, a country which endorses free access to an Essential Health Package (EHP) as a means towards universal health coverage. Methods We conducted a qualitative cross-sectional study in six rural communities in Malawi. Data was collected from 12 Focus Group Discussions with community residents and triangulated with 8 key informant interviews with health care providers. All respondents were selected through stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three independent researchers. Results The results showed that the EHP has created a universal sense of entitlements to free health care at the point of use. However, respondents reported uneven distribution of health facilities and poor implementation of public-private service level agreements, which have led to geographical inequities in population coverage and financial protection. Most respondents reported affordability of medical costs at private facilities and transport costs as the main barriers to universal financial protection. From the perspective of rural Malawians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as: shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers’ attitudes, distance and transportation difficulties, and perceived poor quality of health services. Conclusions Moving towards UHC in Malawi, therefore, implies the introduction of appropriate interventions to fill the financial protection gaps in the private sector and the access-related gaps in the public sector and/or an effective public-private partnership that completely integrates both sectors. Current universal health coverage reforms need to address context specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks.
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28. Adverse selection in a community-based health insurance scheme in rural Africa: Implications for introducing targeted subsidies
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Rainer Sauerborn, Manuela De Allegri, Aurélia Souares, Germain Savadogo, and Divya Parmar
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Male ,Rural Population ,medicine.medical_specialty ,Financing, Government ,Adverse selection ,R Medicine (General) ,HM ,Health informatics ,Health administration ,jel:G22 ,610 Medical sciences Medicine ,RA0421 ,Burkina Faso ,G1 ,medicine ,Humans ,Community Health Services ,Subsidy ,HB Economic Theory ,Fixed effects ,Government ,Insurance, Health ,Public economics ,business.industry ,lcsh:Public aspects of medicine ,Nursing research ,Public health ,Health Policy ,community-based health insurance ,ddverse selection ,subsidy ,fixed effects ,lcsh:RA1-1270 ,Fixed effects model ,jel:I10 ,Female ,Community-based health insurance ,business ,Research Article - Abstract
Background Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.
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29. Evaluating complex health financing interventions: using mixed methods to inform further implementation of a novel PBI intervention in rural Malawi
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McMahon, Shannon A., Brenner, Stephan, Lohmann, Julia, Makwero, Christopher, Torbica, Aleksandra, Mathanga, Don P., Muula, Adamson S., and De Allegri, Manuela
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PERFORMANCE-BASED FINANCING ,610 Medical sciences Medicine ,HEALTH FINANCING ,PROCESS EVALUATION ,RESEARCH PROTOCOL ,Health Policy ,MALAWI ,PERFORMANCE-BASED INCENTIVES ,HEALTH FINANCING, MALAWI, PERFORMANCE-BASED FINANCING, PERFORMANCE-BASED INCENTIVES, PROCESS EVALUATION, RESEARCH PROTOCOL, RESULTS BASED FINANCING, HEALTH POLICY ,RESULTS BASED FINANCING - Abstract
Background: Gaps remain in understanding how performance-based incentive (PBI) programs affect quality of care and service quantity, whether programs are cost effective and how programs could be tailored to meet client and provider needs while remaining operationally viable. In 2014, Malawi’s Ministry of Health launched the Service Delivery Integration-PBI (SSDI-PBI) program. The program is unique in that no portion of performance bonuses are paid to individual health workers, and it shifts responsibility for infrastructure and equipment procurement from facility staff to implementing partners. This protocol outlines an approach that analyzes processes and outcomes, considers expected and unexpected consequences of the program and frames the program’s outputs relative to its costs. Findings from this evaluation will inform the intended future scale-up of PBI in Malawi. Methods/design: This study employs a prospective controlled before-and-after triangulation design to assess effects of the PBI program by analyzing quantitative and qualitative data from intervention and control facilities. Guided by a theoretical framework, the evaluation consists of four main components: service provision, health worker motivation, implementation processes and costing. Quality and access outcomes are assessed along four dimensions: (1) structural elements (related to equipment, drugs, staff); (2) process elements (providers’ compliance with standards); (3) outputs (service utilization); (4) experiential elements (experiences of service delivery). The costing component includes costs related to start-up, ongoing management, and the cost of incentives themselves. The cost analysis considers costs incurred within the Ministry of Health, funders, and the implementing agency. The evaluation relies on primary data (including interviews and surveys) and secondary data (including costing and health management information system data). Discussion: Through the lens of a PBI program, we illustrate how complex interventions can be evaluated via not only primary, mixed-methods data collection, but also through a wealth of secondary data from program implementers (including monitoring, evaluation and financial data), and the health system (including service utilization and service readiness data). We also highlight the importance of crafting a theory and using theory to inform the nature of data collected. Finally, we highlight the need to be responsive to stakeholders in order to enhance a study’s relevance.
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