A Review of Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services in Low- and Middle-Income Countries

Abstract Abstract—To reduce maternal and newborn morbidity and mortality, health care payers are experimenting with ways to better align incentives to promote high-quality maternal health services. This review examined 26 recent initiatives of health care payers in 16 low- and middle-income countries to pay for quality, and not solely quantity, of maternal health services. Payers measured quality by assessing availability of structural inputs (24 of 26 cases), adherence to processes (25 of 26 cases), and observation of key outputs of health facilities (14 of 26 cases). Two payers sought to also assess quality through observed patient outcomes. In 25 of the initiatives, payers used the quality assessment to adjust facility payments; in the remaining initiative, the payer used the quality assessment to adjust payments to provincial governments, which in turn pay facilities. The recent growth in such payment systems suggests more health care payers have identified ways to link quality measurement with provider payment mechanisms. Eleven impact evaluations of systems documented changes in provider behavior consistent with various elements of quality; however, only three evaluations reported effects on maternal or newborn morbidity and mortality and do not conclude whether the design or flaws in how it was implemented led to the results. Implementation fidelity—the degree to which the initiative was implemented as designed—was not widely addressed and is an area for future research. Furthermore, although payers in low- and middle-income countries have identified ways to operationalize a payment system that adjusts payments based on some measure of quality, the complexity and level of resources required to operationalize them raise concerns about sustainability.