Healthy competition drives success in results-based aid: Lessons from the Salud Mesoamérica Initiative

<div><p>Objectives</p><p>The Salud Mesoamérica Initiative (SMI) is a three-operation strategy, and is a pioneer in the world of results-based aid (RBA) in terms of the success it has achieved in improving health system inputs following its initial operation. This success in meeting pre-defined targets is rare in the world of financial assistance for health. We investigated the influential aspects of SMI that could have contributed to its effectiveness in improving health systems, with the aim of providing international donors, bilateral organizations, philanthropies, and recipient countries with new perspectives that can help increase the effectiveness of future assistance for health, specifically in the arena of RBA.</p><p>Methods</p><p>Qualitative methods based on the criteria of relevance and effectiveness proposed by the Development Assistance Committee of the Organization for Economic Co-operation and Development. Our methods included document review, key informant interviews, a focus group discussion, and a partnership analysis.</p><p>Participants</p><p>A purposive sample of 113 key informants, comprising donors, representatives from the Inter-American Development Bank, ministries of health, technical assistance organizations, evaluation organizations, and health care providers.</p><p>Results</p><p>During May–October 2016, we interviewed regarding the relevance and effectiveness of SMI. Themes emerged relative to the topics we investigated, and covered the design and the drivers of success of the initiative. The success is due to 1) the initiative’s regional approach, which pressured recipient countries to compete toward meeting targets, 2) a robust and flexible design that incorporated the richness of input from stakeholders at all levels, 3) the design-embedded evaluation component that created a culture of accountability among recipient countries, and 4) the reflective knowledge environment that created a culture of evidence-based decision-making.</p><p>Conclusions</p><p>A regional approach involving all appropriate stakeholders, and based on knowledge sharing and embedded evaluation can help ensure the effectiveness of future results-based aid programs for health in global settings.</p></div

Timeline of Salud Mesoamerica Initiative’s operations and respective indicators’ measurements.

<p>^a: baseline measurements were conducted in 2011 only in El Salvador. ^b: on average operations are 24 months but do not start at the same time in all countries and hence might appear longer. ^c: dates for the 3rd operation and its respective indicators’ measurements are not final at this time.</p

Key informants of the Salud Mesoamerica Initiative process evaluation.

<p>Key informants of the Salud Mesoamerica Initiative process evaluation.</p

Institutional Delivery and Satisfaction among Indigenous and Poor Women in Guatemala, Mexico, and Panama

<div><p>Indigenous women in Mesoamerica experience disproportionately high maternal mortality rates and are less likely to have institutional deliveries. Identifying correlates of institutional delivery, and satisfaction with institutional deliveries, may help improve facility utilization and health outcomes in this population. We used baseline surveys from the Salud Mesoamérica Initiative to analyze data from 10,895 indigenous and non-indigenous women in Guatemala and Mexico (Chiapas State) and indigenous women in Panama. We created multivariable Poisson regression models for indigenous (Guatemala, Mexico, Panama) and non-indigenous (Guatemala, Mexico) women to identify correlates of institutional delivery and satisfaction. Compared to their non-indigenous peers, indigenous women were substantially less likely to have an institutional delivery (15.2% vs. 41.5% in Guatemala (P<0.001), 29.1% vs. 73.9% in Mexico (P<0.001), and 70.3% among indigenous Panamanian women). Indigenous women who had at least one antenatal care visit were more than 90% more likely to have an institutional delivery (adjusted risk ratio (aRR) = 1.94, 95% confidence interval (CI): 1.44–2.61), compared to those who had no visits. Indigenous women who were advised to give birth in a health facility (aRR = 1.46, 95% CI: 1.18–1.81), primiparous (aRR = 1.44, 95% CI: 1.24–1.68), informed that she should have a Caesarean section (aRR = 1.41, 95% CI: 1.21–1.63), and had a secondary or higher level of education (aRR = 1.36, 95% CI: 1.04–1.79) also had substantially higher likelihoods of institutional delivery. Satisfaction among indigenous women was associated with being able to be accompanied by a community health worker (aRR = 1.15, 95% CI: 1.05–1.26) and facility staff speaking an indigenous language (aRR = 1.10, 95% CI: 1.02–1.19). Additional effort should be exerted to increase utilization of birthing facilities by indigenous and poor women in the region. Improving access to antenatal care and opportunities for higher-level education may increase institutional delivery rates, and providing culturally adapted services may improve satisfaction.</p></div

Mexican women’s utilization of services along the continuum of care.

<p>**Abbreviations: ANC, skilled antenatal care; PNC, post-natal care.</p

Correlates of satisfaction among women who gave birth in a health facility in Guatemala and Mexico in the Salud Mesoamérica Initiative, 2011–2013.

<p>Correlates of satisfaction among women who gave birth in a health facility in Guatemala and Mexico in the Salud Mesoamérica Initiative, 2011–2013.</p

Correlates of institutional delivery across Guatemalan and Mexican women in the Salud Mesoamérica Initiative, 2011–2013.

<p>Correlates of institutional delivery across Guatemalan and Mexican women in the Salud Mesoamérica Initiative, 2011–2013.</p

Panamanian women’s utilization of services along the continuum of care.

<p>**Abbreviations: ANC, skilled antenatal care; PNC, post-natal care.</p

Reasons why Panamanian women would not give birth in the same health facility again (n = 51).

<p>Reasons why Panamanian women would not give birth in the same health facility again (n = 51).</p

Guatemalan women’s utilization of services along the continuum of care.

<p>**Abbreviations: ANC, skilled antenatal care; PNC, post-natal care.</p