routine activities: took a background,<sup>3</sup> asked about past issues,<sup>4</sup> asked about current issues,<sup>5</sup> provided iron supplementation, gave advice about warning signs,<sup>6</sup> helped to prepare for the birth,<sup>7</sup> checked HIV status, tested for syphilis, provided malaria prophylaxis, discussed appropriate nutrition, and checked the following vital signs: blood pressure, weight, conjunctiva, hemoglobin, rhesus, urine glucose, uterine size, fetal heartbeat and fetal presentation. As with the child health consultations, these data were used to calculate aggregate quality scores. National protocols provide guidelines for care that are specific to the number of prior visits and gestational age of the pregnant women. As not all activities are appropriate for all consultation, the quality indices were adjusted to reflect variations by gestational age (<32 weeks, 32 to 35 weeks, and >35 weeks) and whether or not the patient was experiencing her first pregnancy. Results are presented in Table 19 column 2.

We see a strong positive trend in the quality of ANC over time. On average, consultation scores improved by improved by 12.9 percentage points between baseline and endline (p<0.05). As shown in Table 19 column 2, there were no differences in any of the treatment groups in the change in ANC quality relative to the full control.

# **5. Discussion and Conclusions**

In order to distinguish the influence of the different components of the PBF reform, this evaluation compared four arms: (1) the standard PBF package, (2) the same level of financing but not linked to performance, and with the same levels of supervision, monitoring, and autonomy as PBF, (3) no additional resources or autonomy, but the same levels of supervision and monitoring as PBF, and (4) pure comparison.

Overall, the impact evaluation results reveal significant increases in the PBF arm for several indicators (child and mother vaccinations, use of modern family planning), but not for others, such as antenatal care visits and in-facility deliveries. Structural quality as measured by equipment availability, staff presence and staff satisfaction, improved in the PBF group. This finding is consistent with evidence from Malawi showing increases in functional equipment and essential drug stocks for maternal and newborn health services as a result of PBF (Brenner et al., 2017;

> 3 A composite score ranging from 0 to 1 indicating whether the worker asked about the patient’s age, medicines, and date of last menstruation.

> 4 A composite score ranging from 0 to 1 indicating whether the worker asked whether the patient had any prior deliveries, stillbirths, neonatal deaths, abortions, heavy bleeding during or after delivery, or assisted delivery.

5 A composite score ranging from 0 to 1 indicating whether the worker asked whether the patient had any bleeding, fever, headache or blurred vision, swollen face or hands, tiredness or breathlessness, felt the baby move, or if the client noticed any other symptoms or problems related to the pregnancy.

6 A composite score ranging from 0 to 1 indicating whether the worker warned the patient to watch for vaginal bleeding, fever, excessive tiredness or breathlessness, swollen hands and face, and severe headache or swollen vision.

7 A composite score ranging from 0 to 1 indicating whether the worker advised the client to prepare for the birth, including arranging money and transportation, advised to have skilled assistance at delivery, discussed what items to have on hand, emphasized the importance of immunization and the importance of exclusive breastfeeding.

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