Paying for Maternal Health, Punishing Providers: Why Provider Payment Drives, and Performance Monitoring Suppresses, Maternal Health Service Delivery under Cameroon's Health Voucher Programme

Cameroon's national health voucher programme, launched in 2015 with the support of the French Development Agency and German Financial Cooperation, was extended to the Northwest Region in October 2024 as a demand-side financing mechanism intended to remove financial barriers to maternal healthcare. Although the programme is now operational across 51 accredited facilities, empirical evidence on which of its four core strategic purchasing functions actually move maternal health service delivery remains scarce. This study examines the effect of the core purchasing functions of the health voucher (benefits specification, contracting arrangements, provider payment, and performance monitoring) on maternal health service delivery in selected health facilities in the Northwest Region of Cameroon. A structured questionnaire was administered to 100 healthcare workers (80% female; 69% nurses; 40% with six or more years of experience). Multiple Correspondence Analysis was used to construct continuous indices for each function, and an Ordinary Least Squares regression was estimated, controlling for worker experience. The model is statistically significant overall, F(7, 92) = 4.32, p < 0.001, and the four purchasing functions jointly explain a meaningful share of the variation in service delivery quality (adjusted R² = 0.190). Three findings are striking. First, provider payment exerts the strongest positive effect on maternal health service delivery (β = 0.442, p < 0.001), and yet its implementation strength is the lowest of all four functions (MCA index = 0.065). Second, performance monitoring has a statistically significant negative effect on service delivery (β = -0.217, p = 0.006), an unexpected finding that suggests current monitoring practices generate administrative burden faster than they generate accountability. Third, contract management is well-implemented (MCA index = 0.920) but produces only a weakly significant positive effect (β = 0.219, p = 0.074), and benefits specification has no significant effect at all (β = 0.043, p = 0.401). Together, these findings show that the purchasing function on which the programme depends most for impact is also the one in which it invests least. Three policy implications follow: protect and accelerate provider payment, redesign monitoring as a learning instrument rather than a paperwork instrument, and prioritise reform sequencing over symmetric investment across all four functions. The results contribute one of the first quantitative empirical assessments of strategic purchasing function effects on maternal service delivery in a conflict-affected sub-Saharan setting.

Strategic Purchasing, Provider Payment, Performance Monitoring, Maternal Health, Health Voucher, Universal Health Coverage, Fragile Settings, Cameroon

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