Effects of Results-Based Financing on Patient Satisfaction in Afghanistan

A Results-Based Financing (RBF) program has been implemented in Afghanistan since September 2010 to improve the quality of health care and increase the utilization of maternal and child health services. This PhD study examines the impact of RBF on patient satisfaction and on determinants of patient satisfaction at health facility level in Afghanistan. Determinants of patient satisfaction in the study refer to health provider performance, availability of medicines, vaccines, equipment, and physical appearance of health facilities.  I used data collected from a panel of health facilities over a three-year period. The data consist of nearly 3000 patient observations and exit interviews. I included 112 health facilities in my study. These health facilities were part of the 428 health facilities which had been randomly assigned to treatment and control groups prior to the start of RBF in 2010. Financial incentives were distributed among health providers in the treatment facilities through four administration mechanisms: salary-based, task-based, equal-amount, and mixed-method. Follow-up surveys were conducted in 2011 and 2012 in the same 112 facilities, but for new cross-sections of patients and health providers. I analysed a range of patient satisfaction and patient satisfaction determinants measures using a regression-adjusted difference-in-differences estimation model.  The results from this study show that after a period of two years, there was an increase of only 8 percentage points in the proportion of patients who were very satisfied with services as a whole. However, the effect was not statistically significant. Similarly, specific aspects of patient satisfaction were not significantly affected by the intervention. Likewise, RBF did not have any significant effect on health provider performance, on availability of medicines, vaccines, and equipment, and on physical appearance of health facilities over a two-year period. I also found no difference in RBF treatment effects by the different incentive administration mechanisms.  My study provides evidence which suggests that paying monetary incentives alone may not have the impetus to improve health provider performance to the satisfaction of patients in a post conflict country. In such settings, RBF initiatives need to include both financial and non-financial incentives for health providers in order to achieve the intended objectives of quality of care and patient satisfaction. My study provides pragmatic recommendations aimed at holistic approaches to improving quality and delivery of healthcare in a post conflict setting.