In general, the results indicate that PBF in Cameroon is an efficient mechanism to bring payments and funding at the provider level, leading to significant increases in utilization (child and maternal immunization, family planning, HIV testing) and improvements in structural quality of care. However, for many of those outcomes, the differences between the PBF group (T1) and the additional financing group (C1) are not significant. It should be noted that the C1 group offered all the elements of PBF except the direct link between individual facility performance and additional financing. There was, however, a clear effect of additional financing, irrespective of incentives, plus reinforced supervision through PBF instruments (comparing groups T1 and C1 with the C2 group and then C3, the control group), suggesting that enhanced supervision and monitoring are not sufficient to improve maternal and child health (MCH) outcomes.

We note, however, that we did not identify an impact for some MCH indicators such as skilled deliveries and ANC visits. It is possible that the supply-side incentives for providers were not sufficient given existing user fees which might act as a barrier on the demand-side. In addition, given that these types of services are primarily provided at the health center, outreach and community-based service delivery was not an option for providers to implement to increase coverage. In terms of quality of care, most of the positive impacts were observed on structural quality, presence of qualified staff, and provider and patient satisfaction. However, despite an increase in providers and supplies available at health facilities, PBF did not increase the completeness of service provision (content of care) during antenatal care and child health consultations. But PBF led to a decrease in out-of-pocket payments, in particular unofficial payments.

Section 2 of this paper presents the context and program design of PBF in Cameroon, sections 3 and 4 respectively describe the methods and results while section 5 discusses study limitations and the policy implications of the findings.

# **2. Context and Design**

# HEALTH BACKGROUND

Despite being one of the more wealthy countries in the Central Africa region, and the country’s relatively high health spending of $59 per capita in 2014 (World Health Organization Global Health Expenditure database, 2016), Cameroon’s health indicators resemble countries that spend much less on health care (The World Bank, 2016). Cameroon did not achieve Millennium Development Goals 4 & 5 which called for large reductions in maternal and child mortality. Moreover, Cameroon is one of the few countries with high maternal mortality where maternal mortality did not decrease at all between 1990 and 2015 (Alkema et al., 2015). One in every 25 women of reproductive age in Cameroon continues to die from pregnancy-related causes (Institut National de la Statistique (INS) et ICF International, 2012). Though many factors affect maternal mortality, one potential explanation for the country’s slow progress in achieving declines in maternal mortality is that the proportion of women delivering in health facilities has remained unchanged over much of the last decade. During the last ten years (between 2004 and 2014), the percentage of deliveries that were assisted by a skilled health professional increased from 61.7 percent to only 64.7 percent (ICF International, 2012; Institut National de la Statistique, 2015).

3