Health Results-Based Financing Impact Evaluation 2014, Baseline Survey
Results-based financing (RBF) in the health sector has been defined as a financing mechanism where cash or non-monetary transfers are made to a national or sub-national government, manager, provider, payer or consumer of health services after predefined service delivery or health outcomes results have been attained and verified.
An increasing number of countries are implementing RBF approaches as an alternative to input-based financing, and many of these countries have been employing a performance-based financing approach, a particular type of RBF in which health facilities are rewarded monetarily for producing predefined results in terms of quantity and quality of agreed services, subject to verification of those outputs by an independent party.
The Health Results Innovation Trust Fund (HRITF) was created in 2007 to support results-based financing approaches in the health sector. Through RBF, the HRITF aims to improve maternal and child health around the world. HRITF is supported by the Governments of Norway through Norad and the United Kingdom through the Department for International Development (DFID). It is administered by the World Bank.
To date, HRITF has committed $396 million for 36 RBF programs in 30 countries, linked to $2.2 billion in financing from IDA—the World Bank’s fund for the poorest.
The objective of this impact evaluation is to assess in a rigorous way the impact of the health and nutrition result-based financing (RBF) approach on service utilization and health and nutrition outcomes in the Gambia, introduced as part of the Maternal and Child Nutrition and Health Results Project.
The Maternal and Child Nutrition and Health Results Project is composed of four components. Components 1 and 2 apply RBF mechanisms to address demand- and supply-side challenges as well as social and behavioral issues for improving maternal and child health and nutrition outcomes, respectively. Component 2 also encompasses interventions to improve food and nutrition security. Component 3 strengthens overall management capacity (including monitoring and evaluation) of communities, local government and the health system to effectively engage in results-based management. Component 4 focuses on Ebola preparedness and control. Innovative aspects of this project are the combined use of RBF approaches on the demand- and supply-sides and at the community and PHC levels to improve health and nutrition outcomes.
In collaboration with the Gambia National Nutrition Agency and the Ministry of Health and Social Welfare, a research team from the World Bank, University of Southern California and Harvard University has developed an evaluation and roll-out design which allows rigorous assessment of the impact of the results-based financing interventions on health related outcomes.
The key objective of the impact evaluation is to assess the effectiveness and cost-effectiveness of the package of supply and demand side interventions developed for, and implemented at health facilities and communities as part of the Gambia Maternal and Child Nutrition and Health Results Project. This project is implemented in three regions with some of the poorest performing indicators - Upper River, Central River and North Bank West Regions. Over the five-year period of implementation, the project is expected to reach approximately 183,000 children under five and 180,000 women aged 15-49 years, yielding a total of 363,000 direct beneficiaries of the project. The interventions will provide support through RBF arrangements with women, Village Development Committees (VDC) and Village Support Groups (VSG), and primary health facilities.
The primary research questions are grouped according to three broad categories: effect on nutrition and health outcomes, effect on service utilization and adoption of behaviors, and effect on intermediate outcomes along pathways of impact. The evaluation uses a mixed-methods explanatory design with an embedded process evaluation based on a conceptual framework that details out the pathways of impact for both interventions.
The overall approach for the impact evaluation is a randomized phased-in 2 x 2 design. The plan for the supply-side is that facilities in the three target regions are enrolled in the project in two phases, each lasting 18 months which should provide a sufficiently long time window to allow behavioral changes. In addition to the supply-side interventions, some communities in the target regions will be enrolled in a community-based demand-side component, for which each phase will last 12 months.
To measure the community-level impact of the project, three main surveys are to be conducted. A baseline survey was administered at the beginning of the project in October 2014 - February 2015. A midline survey is planned to be conducted approximately 18 months after the project launch, and an endline survey - after approximately 36 months of the project start.
The quantitative and qualitative data from the baseline survey is documented here. This assessment prepared a baseline against which the impact of the project can subsequently be measured. The quantitative baseline data was collected through household, health facility and village questionnaires. Qualitative baseline data was collected using focus group discussions and in-depth interviews.
Kind of Data
Sample survey data [ssd]
Unit of Analysis
- health facilities,
1) v01, edited, anonymous quantitative data files
Anonymous data files were created by removing the following information:
- Health facility names
- Global Positioning System (GPS) coordinates
- Community names
- Names of individuals
2) Anonymous qualitative transcripts (available in Related Materials)
Qualitative transcripts have been anonymized by removing the following information:
- Health facility names
- Community names
- Names of individuals
The scope of the study includes:
- Demographic characteristics
- Housing, assets
- Sources of income, consumption
- Mortality, health status and utilization
- Pregnancy history, maternal care, reproductive health
- Anthropometrics of a child
- Community health worker service usage and satisfaction
- Staff training, supervision
- Hours and duties
- Compensation, supplemental income
- Satisfaction, personal drive, innovation
- Administration, management, leadership
- Human resources, staff roster
- Laboratory, equipment, drugs, vaccine
- Services and user fees
- Health management information systems
- Basic services, community programs
- Social capital and community empowerment
- Economic activities
- External shocks
- Costs of RBF projects
Upper River, Central River and North Bank West Regions
Producers and sponsors
University of Southern California
Health Results Innovation Trust Fund
A household survey targeted a random sample of women 15 and older in communities in 2259 households, and a facility survey directly targeted all 24 health facilities in the area.
For the household survey, two-stage cluster sampling was used to identify a random sample of approximately 100 households with at least one woman of age 15 or older and at least one child under the age of five from the catchment areas of each facility. To identify these women, researchers first randomly selected five enumeration areas from the catchment areas of each of the 24 facilities using probability proportional to population size (based on the latest census estimates); in all selected enumeration areas, a household listing was conducted. From all eligible households listed, 20 households were selected for the survey.
The resulting sample is not representative at the national or regional level for three main reasons: first, geographically, the project covered only 3 regions in the country, which are on average less developed than the regions not included. Second, within regions, surveys were only conducted in communities with existing health platforms. These communities are on average slightly larger and likely also more developed than communities without such platforms. Last, within communities, the survey targeted only women with recent births, which are not representative of the larger adult female population.
Overall, surveys were administered to the officer in charge of each of the 24 health facilities and a total of 94 health workers working in maternal and child health services. Exit interviews were administered to 150 women attending ANC services and 160 caregivers of children aged under 5 attending out-patient services.
The community-based survey was administered to 109 VDC (Village Development Committee) members and 108 VSG (Village Support Group) members.
Dates of Data Collection
Data Collection Mode
Data Collection Notes
All quantitative data collection was carried out using tablet computers, with data uploaded to a cloud system for verification as soon as network allowed.
The qualitative assessments were conducted to help provide an explanation of the quantitative results, and to allow for more in-depth exploration of topics of particular interest. A combination of focus group discussions and in-depth interviews was used.
During the interviews and focus group discussions, the following themes were explored, varying slightly by target group:
- Uptake of MNCH services
- MNCH-related knowledge and beliefs
- Family planning knowledge, attitudes and practices
- Availability, accessibility, acceptability and quality of health services
- Barriers to accessing services
- Work-related behaviors (Motivation & Morale, Teamwork & Collaboration, Communication, Awareness, Perceived Control, Demand for Knowledge)
- Awareness and understanding of the The Maternal and Child Nutrition and Health Results Project (MCNHRP)
- Key behavioral attributes (understanding, expectancy, valence, buy-in, perceived fairness)
A sample interview guide and focus group discussions are available in Relatated Materials, Questionnaires.
A mix of quantitative and qualitative methods were employed for the baseline survey. The quantitative part of the evaluation relied on three main sources of data, while the qualitative part of the study used both focus group discussions and key informant interviews with a wide range of stakeholders to elicit their perspectives on different issues relevant to maternal and child nutrition and health.
1) Household surveys: 2,257 households, within which questionnaires were administered to two people
2) Facility-based surveys: 24 health facilities in the study area, within which questionnaires were administered to the head of the health facility, health workers and women attending Maternal and Child Health (MCH) services.
3) Community-based surveys (Village Development Committees and Village Support Groups): 109 communities (approximately five for each facility), within which questionnaires were administered to members of the committees.
1) Focus group discussions: 27 focus group discussions of approximately 5-8 participants each.
2) Key informant interviews: 20 interviews.
University of Southern California
Use of the dataset must be acknowledged using a citation which would include:
- the Identification of the Primary Investigator
- the title of the survey (including country, acronym and year of implementation)
- the survey reference number
- the source and date of download
Rifat Hasan, World Bank, Laura Ferguson, University of Southern California, Guenther Fink, Harvard University. The Gambia Health Results-Based Financing Impact Evaluation 2014, Baseline Survey. Ref. GMB_2014_HRBFIE-BL_v01_M. Dataset downloaded from [URL] on [date].
Disclaimer and copyrights
The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or for interpretations or inferences based upon such uses.