How much does it cost to combine supply-side and demand-side RBF approaches in a single intervention? Full cost analysis of the Results Based Financing for Maternal and Newborn Health Initiative in Malawi

OBJECTIVE: To estimate the economic cost associated with implementing the Results Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi. No specific hypotheses were formulated ex-ante. SETTING: Primary and secondary delivery facilities in rural Malawi. PARTICIPANTS: Not applicable. The study relied almost exclusively on secondary financial data. INTERVENTION: The RBF4MNH Initiative was a results-based financing (RBF) intervention including both a demand and a supply-side component. PRIMARY AND SECONDARY OUTCOME MEASURES: Cost per potential and for actual beneficiaries. RESULTS: The overall economic cost of the Initiative during 2011–2016 amounted to €12 786 924, equivalent to €24.17 per pregnant woman residing in the intervention districts. The supply side activity cluster absorbed over 40% of all resources, half of which were spent on infrastructure upgrading and equipment supply, and 10% on incentives. Costs for the demand side activity cluster and for verification were equivalent to 14% and 6%, respectively of the Initiative overall cost. CONCLUSION: Carefully tracing resource consumption across all activities, our study suggests that the full economic cost of implementing RBF interventions may be higher than what was previously reported in published cost-effectiveness studies. More research is urgently needed to carefully trace the costs of implementing RBF and similar health financing innovations, in order to inform decision-making in low-income and middle-income countries around scaling up RBF approaches.