F. W. G. M. van de Looij | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 19, 2015

Performance-based Financing (PBF) is a promising approach to improve maternal, new-born and child health services in developing countries, but there are concerns that it may inadequately address inequalities in access to care. Incentives for reaching the poor may prove beneficial, but evidence remains limited.  We evaluated a system of targeting the poorest of society (“indigents”) in a PBF program in Cameroon, examining (under)coverage, leakage, and positive and negative (side) effects as experienced by the community. We conducted a documentation review, 59 key informant interviews, and 33 focus group discussions with community members (poor and vulnerable people – registered as indigents and those not registered as such).  We found that the criteria used to target indigents were consistent with local definitions of poverty and vulnerability. Leakage was not a concern. Nevertheless, the targeting system only reached a tiny proportion (≤1%) of the catchment population, and other poor and vulnerable people were missed. Low initial objectives and implementation problems –including a focus on easily identifiable groups (elderly, orphans), lack of clarity about the criteria, lack of transport for identification, and insufficient motivation of community health workers– are likely to explain the low coverage.  Registered indigents experienced improvements in access, quality and promptness of care. Improvements in economic status and less financial worries were also reported. However, problems including lack of transport and insufficient knowledge about the targeting benefits, remain barriers for health care use. The main negative effects of the system as experienced by indigents were negative reactions (e.g. jealousy) of community members.  In conclusion, a system of targeting the poorest of society in PBF programs may help reduce inequalities in health care use, but design and implementation problems can lead to substantial under-coverage. Furthermore, remaining barriers to health care use (e.g. transport) and negative reactions towards indigents due to their status deserve attention.