Background: While maternal mortality has declined globally, it remains highest in low-income countries. High-quality antenatal care (ANC) can control or decrease pregnancy-related complications for mothers and newborns. The implementation of performance-based financing (PBF) schemes in Sub-Saharan Africa to improve primary healthcare provision commonly includes mechanisms targeting ANC service quality. In this study, we examine changes in ANC provision produced by the introduction of a PBF scheme in rural Burkina Faso. Methods: This study followed a quasi-experimental design with two data collection points comparing effects on ANC service quality between primary health facilities across intervention and control districts based on difference-in-differences estimates. Outcome variables were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision (i.e. screening, prevention) for two different client groups (i.e. first ANC visits, follow-up visits). Results: We found a statistically significant increase of 10 percent-points in facilities’ readiness to provide ANC services. Although clinical care provided to different ANC client groups was generally low, especially with respect to preventive care measures, we failed to observe any substantial changes in the clinical provision of ANC care attributable to the PBF. Conclusion: The observed effect pattern seems largely to reflect the incentive structure implemented by the scheme, with a stronger focus on structural elements compared with clinical aspects of care. This might have limited the scheme’s overall potential to improve ANC provision at the client level after the observed three-year implementation period. To improve both facility readiness and health worker performance, stronger incentives might be needed to increase adherence to technical standards and technical patient care outcomes.
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Appel et al. (2022) studied this question.