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in most of households, particularly for
households in cluster B and C.
Most households in cluster A were
found to have been engaged in agricultural
activities on their own land during
the last rainy season where they cultivated
mainly millet. Households in clusters B
and C did not cultivate land which made
these households dependent on food aid
and on purchase of food from the local
market.
Cluster A households ate a wider variety
of food items in the two weeks prior to
conducting the interviews when
compared to households in cluster B and
C during the same period. In cluster A,
food types consumed included cereals,
sugar, cooking oil, dry and fresh meat,
milk, biscuits, dry okra, fresh vegetables,
and sometimes fruits. In comparison,
households in clusters B and C were
found to have rarely consumed fresh
meat, vegetables and fruits.
Children in cluster A were between the
ages of 7-22 months and were found to
have been fed more frequently i.e.
between 3-4 times, when compared to
children in clusters B and C who were fed
between 2-3 times a day. Children in cluster
B and C were mainly fed asida and
poor quality molah made of dry meat, dry
okra and kawal.
Heads of households in cluster A were
found to have more access to regular
sources of income and were either receiving
monthly salaries from regular
employment or owned small business
which provided regular sources of income
all year as well as access to cultivation.
The household heads of cluster B and C
depended on seasonal employment
opportunities. These household reported
experiencing money shortage and subsequently
food shortage frequently during
the year.
Water consumption/uses in all households
seemed to be adequate. Differences
between the three clusters were mainly in
water uses/quality/hygiene. Observation
of water containers, especially water
jerkins, from all households in cluster A
looked clean unlike most jerkins from
cluster B and C.
Interview results suggest that left-over
food was not consumed by the targeted
children in most of the cluster A households.
The few households in cluster A
which fed targeted children left-over,
reported feeding children the leftover
food only after reheating. They also
reported food was consumed shortly after
it was prepared/reheated. These ‘good’
food handling practices were not prevalent
in the other two clusters, where left
over food was often fed to the targeted
children.
Mothers from all households in cluster
A reported washing their hands with soap
and water more frequently during the day,
7-10 times, compared to mothers in clusters
B and C who used to wash their hands
only between 5-6 times. Soap consump-
tion was reported to be more prevalent in
households in cluster A than in households
in clusters B and C.
All children in cluster A where found
not to have not experienced any illness
such as diarrhea, vomiting, fever or
common cold within the last 30 days prior
to conducting of the interviews for this
study. On the other hand, all children
included in Clusters B and C were sick
with diarrhoea, vomiting and fever within
the last 14 days prior to conducting of the
interviews. Food consumption of children
in these clusters during the illness period
was described as very poor. Mother
reported that these were children mainly
dependent on breastfeeding during the
bouts of illness. These findings were more
evident in cluster C (severely malnourished
children).
Discussion and Recommendations
Although the sample size of households
included in this study was small and
therefore, findings cannot be generalized
to the larger population in Al-Salaam area
or Kabkabyia town these findings are still
useful for planning purposes.
Findings suggest that agencies should
consider job creation interventions, e.g.
income generating activities, that would lift
vulnerable populations out of poverty.
Training on proper finance management at
the household level should also be considered
in an effort to change the noted culture
of “I only need to look for work when there
is no money or food in the house”.
It is also important to look at the
adequacy of food aid rations received by
displaced people. The study finds a significant
discrepancy between number of
people living in a household with the
number registered on the ration card, so
that the ration does not last as long as
planned. The ongoing re-verification exercise
of the IDPs in Darfur should help in
addressing such discrepancies and should
also assist WFP in determining which
household are more vulnerable than
others and therefore allow for provision of
food aid required accordingly.
There is also a need for more education
and awareness raising programmes
around issues of hygiene and sanitation,
as well as more provision of soaps/detergents
or water purifiers as necessary to the
households.
The issue of soap shortage in most of
the households with malnourished children
should also be addressed. This can be
done through increasing the soap ration
received, which should be linked to the
results of the proposed verification exercise
in order to properly match the
number of people actually living in the
household with the number of soap bars
to be received.
There also needs to be awareness raising
activities for mothers and child
caregivers regarding symptoms and
management of child malnutrition with an
emphasis on child feeding practices.
Effects of performance
payments to health
workers in Rwanda
Summary of published research 1
Research
Astudy just published in the Lancet set out to assess
the effect of performance-based payment of
healthcare providers on the use and quality of
child and maternal care services in healthcare facilities in
Rwanda. Payment for performance (P4P) schemes
provide financial incentives to healthcare providers for
improvements in utilisation and quality of specific care
indicators. They can affect the provision of heath care in
two ways: by giving incentives for providers to put more
effort into specific activities and by increasing the
amount of resources available to finance the delivery of
services. However, P4P schemes can have a detrimental
effect. For example, when P4P payments depend on
completion of reports, providers might spend more time
on administrative duties and less time ensuring that
patients receive the best quality care. In this study, the
researchers assessed the potential of a P4P scheme to
increase use and quality of key maternal and child health
services. The impact evaluation was done prospectively
in parallel with the rollout of a national P4P programme
in Rwanda.
One hundred and sixty-six facilities were randomly
assigned at the district level either to begin P4P funding
between June 2006 and October 2006 (intervention
group, n=80) or to continue with the traditional inputbased
funding until 23 months after study baseline
(control group, n=86). Randomisation was done by toss
of a coin. The researchers surveyed facilities and 2,158
households at baseline and after 23 months. The main
outcome measures were prenatal care visits, institutional
deliveries (births), quality of prenatal care, child preventive
care visits and immunisation. The study team
isolated the incentive effect from the resource effect by
increasing comparison facilities’ input-based budgets by
the average P4P payments made to the treatment facilities.
The team estimated a multivariate regression
specification of the difference-in-difference model, in
which an individual’s outcome is regressed against a
dummy variable, indicating whether the facility received
P4P that year, a facility-fixed effect, a year indicator, and a
series of individual and household characteristics.
The model estimated that facilities in the intervention
group had a 23% increase in the number of institutional
deliveries and increases in the number of preventive care
visits by children aged 23 months or younger (56%) and
children aged between 24 months and 59 months
(132%). No improvements were seen in the number of
women completing four prenatal care visits or of children
receiving full immunisation schedules. The team
also estimated an increase of 0.157 standard deviations
(95% CI 0.026-0.289) in prenatal quality as measured by
compliance with Rwandan prenatal care clinical practice
guidelines. The P4P scheme in Rwanda had the greatest
effect on those services that had the highest payment
rates and needed the least effort from the service
provider.
Researchers concluded that P4P financial performance
incentives can improve both the use and quality of
maternal and child health services and could be a useful
intervention to accelerate progress towards Millennium
Development Goals for maternal and child health.
1
Basinga. P et al (2011). Effect on maternal and child health services
in Rwanda of payment to primary health-care providers for
performance: an impact evaluation. Lancet 2011, 377: 1421-28
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