Examining the Implementation of the Performance-Based Financing Equity Strategy in Improving Access and Utilization of Maternal Health Services in Cameroon: A Qualitative Study

Performance-based financing (PBF)-a supply-side strategy that incentivizes health providers based on predefined quality and quantity criteria-introduced an innovative approach to reaching the poor by means of using PBF equity instruments. These PBF equity instruments include paying providers more to reach out to poor women, selecting services used by the poor, subsidizing user fees to reduce out-of-pocket expenses, and adding complementary demand-side intervention. Before the implementation of the PBF equity instrument in Cameroon, there were few initiatives/schemes to enable the poor to access maternal health services. Moreover, there is a significant research gap on how the equity elements are defined and implemented across contexts. This study aims to understand (i) how health facilities define and classify the poor and vulnerable in the context of PBF, (ii) how the equity elements are implemented at the community and facility levels, and (iii) the potential impact on access to and the use of maternal health services at the facility level and challenges in the implementation process. We used key informant interviews and focus group discussions (FGDs) based on a grounded theory approach to gain an understanding of the social processes and experiences. Data were collected from three districts in the Southwest region of Cameroon from April 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. The thematic analysis approach/technique was used to analyze data. Key informant interviews and focus groups were conducted with 79 participants, including 28 health professionals and service administrators, 27 pregnant women, and 24 community health workers in three districts. Health facilities employed various subjective approaches to assess and define poor and vulnerable (PAV) persons. Home visits were reported to have an impact in reaching the poor and vulnerable to improve access to maternal services. Meanwhile, a delay in the payment of PBF incentives was reported to be the main challenge that had a negative relationship with the consistent provision of care to the poor and vulnerable, especially in private health facilities. The theory generated from our findings suggests that the impact of the PBF equity elements specific to maternal health depends on (i) a shared understanding of the definition of PAV among different stakeholders, including providers and users, as well as how the PAV is operationalized (structure), and (ii) the appropriate and timely payment of incentives to health facilities and health providers.