Can Combining Performance-Based Financing With Equity Measures Result in Greater Equity in Utilization of Maternal Care Services? Evidence From Burkina Faso

Document Type : Original Article


1 Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany

2 Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK

3 The World Bank, Yaoundé, Cameroon

4 Centre MURAZ, Bobo-Dioulasso, Burkina Faso

5 UFR/ST, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso


As countries reform health financing systems towards universal health coverage, increasing concerns emerge on the need to ensure inclusion of the most vulnerable segments of society, working to counteract existing inequities in service coverage. To this end, selected countries in sub-Saharan Africa have decided to couple performance-based financing (PBF) with demand-side equity measures. Still, evidence on the equity impacts of these more complex PBF models is largely lacking. We aimed at filling this gap in knowledge by assessing the equity impact of PBF combined with equity measures on utilization of maternal health services in Burkina Faso.
Our study took place in 24 districts in rural Burkina Faso. We implemented an experimental design (cluster-randomized trial) nested within a quasi-experimental one (pre- and post-test design with independent controls). Our analysis relied on self-reported data on pregnancy history from 9999 (baseline) and 11 010 (endline) women of reproductive age (15-49 years) on use of maternal healthcare and reproductive health services, and estimated effects using a difference-in-differences (DID) approach, purposely focused on identifying program effects among the poorest wealth quintile.

PBF improved the utilization of few selected maternal health services compared to status quo service provision. These benefits, however, were not accrued by the poorest 20%, but rather by the other quintiles. PBF combined with equity measures did not produce better or more equitable results than standard PBF, with specific differences only on selected outcomes.
Our findings challenge the notion that implementing equity measures alongside PBF is sufficient to produce an equitable distribution in program benefits and point at the need to identify more innovative and context-sensitive measures to ensure adequate access to care for the poorest. Our findings also highlight the importance of considering changing policy environments and the need to assess interferences across policies.


  1. Rasanathan K. 10 years after the Commission on Social Determinants of Health: social injustice is still killing on a grand scale. Lancet. 2018;392(10154):1176-1177. doi:10.1016/s0140-6736(18)32069-5
  2. Hosseinpoor AR, Bergen N, Magar V. Monitoring inequality: an emerging priority for health post-2015. Bull World Health Organ. 2015;93(9):591-591A. doi:10.2471/blt.15.162081
  3. UNICEF. UNICEF data: Monitoring the Situation of Children and Women-Maternal Mortality.  Accessed July 14, 2020. Published 2019.
  4. Moucheraud C, Owen H, Singh NS, et al. Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5? BMC Public Health. 2016;16 Suppl 2(Suppl 2):794. doi:10.1186/s12889-016-3401-6
  5. Renmans D, Holvoet N, Criel B, Meessen B. Performance-based financing: the same is different. Health Policy Plan. 2017;32(6):860-868. doi:10.1093/heapol/czx030
  6. Ireland M, Paul E, Dujardin B. Can performance-based financing be used to reform health systems in developing countries? Bull World Health Organ. 2011;89(9):695-698. doi:10.2471/blt.11.087379
  7. Friedman J, Scheffler RM. Pay for performance in health systems: theory, evidence and case studies. In: Scheffler RM, ed. World Scientific Handbook of Global Health Economics and Public Policy. Singapore: World Scientific; 2016:295-332. World Scientific Series in Global Health Economics and Public Policy. doi:10.1142/9789813140530_007
  8. Lannes L, Meessen B, Soucat A, Basinga P. Can performance-based financing help reaching the poor with maternal and child health services? the experience of rural Rwanda. Int J Health Plann Manage. 2016;31(3):309-348. doi:10.1002/hpm.2297
  9. Bonfrer I, Van de Poel E, Van Doorslaer E. The effects of performance incentives on the utilization and quality of maternal and child care in Burundi. Soc Sci Med. 2014;123:96-104. doi:10.1016/j.socscimed.2014.11.004
  10. Binyaruka P, Robberstad B, Torsvik G, Borghi J. Who benefits from increased service utilisation? examining the distributional effects of payment for performance in Tanzania. Int J Equity Health. 2018;17(1):14. doi:10.1186/s12939-018-0728-x
  11. Engineer CY, Dale E, Agarwal A, et al. Effectiveness of a pay-for-performance intervention to improve maternal and child health services in Afghanistan: a cluster-randomized trial. Int J Epidemiol. 2016;45(2):451-459. doi:10.1093/ije/dyv362
  12. Priedeman Skiles M, Curtis SL, Basinga P, Angeles G. An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Health Policy Plan. 2013;28(8):825-837. doi:10.1093/heapol/czs122
  13. Ridde V, Gautier L, Turcotte-Tremblay AM, Sieleunou I, Paul E. Performance-based financing in Africa: time to test measures for equity. Int J Health Serv. 2018;48(3):549-561. doi:10.1177/0020731418779508
  14. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254-258. doi:10.1136/jech.57.4.254
  15. Atchessi N, Ridde V, Zunzunegui MV. User fees exemptions alone are not enough to increase indigent use of healthcare services. Health Policy Plan. 2016;31(5):674-681. doi:10.1093/heapol/czv135
  16. Belaid L, Ridde V. An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso. BMC Pregnancy Childbirth. 2012;12:143. doi:10.1186/1471-2393-12-143
  17. Ministère de la Santé du Burkina Faso. Les mesures de gratuité des enfants de moins cinq ans et des femmes enceintes lancées. http://wwwsantegovbf/indexphp?option==com_content&view=article&id=285:lancement-mesuresde-gratuites&catid=87&Itemid=1075.206.
  18. De Allegri M, Lohmann J, Souares A, et al. Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso. BMC Health Serv Res. 2019;19(1):733. doi:10.1186/s12913-019-4558-3
  19. Beaugé Y, Koulidiati JL, Ridde V, Robyn PJ, De Allegri M. How much does community-based targeting of the ultra-poor in the health sector cost? Novel evidence from Burkina Faso. Health Econ Rev. 2018;8(1):19. doi:10.1186/s13561-018-0205-7
  20. Ridde V, Yaogo M, Kafando Y, et al. A community-based targeting approach to exempt the worst-off from user fees in Burkina Faso. J Epidemiol Community Health. 2010;64(1):10-15. doi:10.1136/jech.2008.086793
  21. Mwase T, Brenner S, Mazalale J, et al. Inequities and their determinants in coverage of maternal health services in Burkina Faso. Int J Equity Health. 2018;17(1):58. doi:10.1186/s12939-018-0770-8
  22. Blasius J, Greenacre M. Multiple Correspondence Analysis and Related Methods in Practice. In: Greenacre M, Blasius J, eds. Multiple Correspondence Analysis and Related Methods. Florida: CRC Press-Taylor & Francis Group; 2006:3-40.
  23. Ridde V, Turcotte-Tremblay AM, Souares A, et al. Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso. Implement Sci. 2014;9:149. doi:10.1186/s13012-014-0149-1
  24. Angrist JD, Pischke JS. Mostly Harmless Econometrics: An Empiricist's Companion. New Jersey: Princeton University Press; 2009.
  25. Cameron AC, Gelbach JB, Miller DL. Bootstrap-based improvements for inference with clustered errors. Rev Econ Stat. 2008;90(3):414-427. doi:10.1162/rest.90.3.414
  26. Imbens GW, Kolesar M. Robust standard errors in small samples: some practical advice. Rev Econ Stat. 2016;98(4):701-712.
  27. Van de Poel E, Flores G, Ir P, O'Donnell O. Impact of performance-based financing in a low-resource setting: a decade of experience in Cambodia. Health Econ. 2016;25(6):688-705. doi:10.1002/hec.3219
  28. Lawn JE, Blencowe H, Oza S, et al. Every Newborn: progress, priorities, and potential beyond survival. Lancet. 2014;384(9938):189-205. doi:10.1016/s0140-6736(14)60496-7
  29. Wing C, Simon K, Bello-Gomez RA. Designing difference in difference studies: best practices for public health policy research. Annu Rev Public Health. 2018;39:453-469. doi:10.1146/annurev-publhealth-040617-013507
  30. Turcotte-Tremblay AM, De Allegri M, Gali-Gali IA, Ridde V. The unintended consequences of combining equity measures with performance-based financing in Burkina Faso. Int J Equity Health. 2018;17(1):109. doi:10.1186/s12939-018-0780-6
  31. Bodson O, Barro A, Turcotte-Tremblay AM, Zanté N, Somé PA, Ridde V. A study on the implementation fidelity of the performance-based financing policy in Burkina Faso after 12 months. Arch Public Health. 2018;76:4. doi:10.1186/s13690-017-0250-4
  32. Ridde V, Yaogo M, Zongo S, Somé PA, Turcotte-Tremblay AM. Twelve months of implementation of health care performance-based financing in Burkina Faso: a qualitative multiple case study. Int J Health Plann Manage. 2018;33(1):e153-e167. doi:10.1002/hpm.2439
  33. De Allegri M, Tiendrebéogo J, Müller O, Yé M, Jahn A, Ridde V. Understanding home delivery in a context of user fee reduction: a cross-sectional mixed methods study in rural Burkina Faso. BMC Pregnancy Childbirth. 2015;15:330. doi:10.1186/s12884-015-0764-0
  34. Ridde V, Leppert G, Hien H, Robyn PJ, De Allegri M. Street-level workers' inadequate knowledge and application of exemption policies in Burkina Faso jeopardize the achievement of universal health coverage: evidence from a cross-sectional survey. Int J Equity Health. 2018;17(1):5. doi:10.1186/s12939-017-0717-5
  35. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9:34. doi:10.1186/1471-2393-9-34
  36. Renmans D, Holvoet N, Orach CG, Criel B. Opening the 'black box' of performance-based financing in low- and lower middle-income countries: a review of the literature. Health Policy Plan. 2016;31(9):1297-1309. doi:10.1093/heapol/czw045
  37. Meyer BD. Natural and quasi-experiments in economics. J Bus Econ Stat. 1995;13(2):151-161. doi:10.1080/07350015.1995.10524589
Volume 11, Issue 3
March 2022
Pages 308-322
  • Receive Date: 12 September 2019
  • Revise Date: 29 June 2020
  • Accept Date: 29 June 2020
  • First Publish Date: 01 March 2022