The document presents an overview of the Results-Based Financing (RBF) program in Zimbabwe, which aims to enhance the efficiency of health service delivery and improve maternal and child health indicators. Preliminary evaluations indicate significant improvements in key services, such as a 13% increase in facility deliveries and a 12% increase in post-natal care coverage, while highlighting challenges in some areas like antenatal care coverage and contraceptive use. The program is supported by funding from international donors and aligns with the national health strategy to ensure equitable access to essential health services.

1. 1

2. • Key messages, strategic context and overview of
RBF program
• Brigadier General Dr. Gwinji, MOHCC
• Preliminary results from impact evaluation and
process evaluation
• Dr. Sibanda, MOHCC

3. • RBF is a health systems management tool intended to improve the
efficiency of utilization of system inputs
• RBF in Zimbabwe piloted in 2 front runner districts in July 2011,
then scaled up to 16 additional districts in March 2012
• Contextual background: Dramatic improvements in MCH indicators
witnessed throughout the country (MICS 2014)
• Yet faster rates of improvement in RBF districts for key indicators
• 13 percentage point improvement in the in-facility delivery rate
• 12 percentage point improvement in post-natal care coverage
• Significant improvement in the quality of ANC services
• Not all indicators show relative improvement under RBF
• No differential gain in coverage of ANC services
• Small gain in use of modern contraceptives

4. • Improvements in part due to
• Team based incentives facilitating teamwork
• Regular and structured supervision visits yielding feedback to improve
performance
• Enhanced community participation
• Challenges to be addressed include
• Facilities in remote areas or with small catchment populations
• Capacity to fully operationalize the quality of care components
• Demand side barriers related to religious and socio-economic factors

5. Country & Project Context During Design
Phase [2010-2011]
• Population: 13 million (2002 Census estimates)
• Decline in public sector financing
• Effect on management
• supportive supervision
• Increase in household out-of-pocket expenditures due to
various forms of user-fees
• Decline in outcomes & slow progress on some key health
MDGs [MDGs 4 & 5]

6.  RBF aligned with and supports National Health Strategy and policy–
equity in access to health services;
◦ User fee removal (package of high impact services)
◦ Rebuild the quality of care standards
◦ Increase access to priority maternal, family planning and child
health services
◦ Strengthen the referral system (promotes appropriate care
seeking at appropriate levels)
◦ Decentralized service delivery and revitalized primary health care
 Prioritized package of services directly linked to burden of disease
for mothers, newborns and children under 5
 RBF used to operationalize GoZ Results-Based Management
Strategy and Results-Based Budgeting Pilot

7. • Fee-for-services : for both quality and quantity –
partial replacement of user fees
• Functions separated: purchaser, provider,
regulator & external verifier
• Key role for community –Health Center
Committees
1. Results-Based
Contracting
• Strengthening planning and RBF management
capacity: RBF national management team
• Purchasing, verification, strategic management
2. Management and
Capacity Building
• Capture effect on health outcomes and various
aspects of the health system
• Accountability through community tracer surveys
(CBOs)
3. Monitoring and
Documentation

8. Package of RBF Services
Rural Health Centers
District Hospital
9. Tetanus TT2+
10. ARVs to HIV+ preg. Women (PMTCT)
11. Family planning short and long term
methods
12. High risk perinatal referrals
13. Vitamin A supplementation
14. Children fully immunized
15. Growth monitoring, children < 5yrs
16. Cure discharged acute malnutrition
children < 5yrs (October 2012)
1. OPD new consultations
2. First ANC visit during the first 16 weeks
of pregnancy (October 2012)
3. Ante natal care 4 visits completed
4. Post natal care 2 or more
5. Normal deliveries
6. HIV VCT in ANC
7. Syphilis RPR test
8. IPT (x2 doses)
1. Normal deliveries in district hospital
2. Deliveries with complications (caesareans excluded) and post partum
complications
3. Caesareans performed
4. Family planning: Tuba Ligations
5. Counter referral note arrives at RHC (October 2012)

9.  Verified data from health facility registers collected by
Local Purchasing Units (LPUs) and entered in the RBF
database is utilized for payments
 Data flow integrated within national HMIS, no parallel
system used
 Quantity verification by the LPU undertaken every month
 Quality verification by the DHE (for RHCs) and by PHE
(for DH) undertaken every quarter
 Client satisfaction performed by the CBOs every month
and by the counter-verifier every quarter
10/1/2014 9

10. HMIS - DHIS 2
Entry and Submission into DHIS2 Routine Reporting - T-Series
District Facility
Programme Database
HFO
s
Data
Accessible in
Programme
System:
Same Platform
RBF Indicators
Downloaded
Verified Data Entered Into
System
Updating HMIS
with Verified
Data Verificati
on

11. 10/1/2014 11
 RBF Funding
 DFID and Government of Norway (US$35m)
 Ministry of Finance: US$5 million per year from 2014
 US$ 28 million disbursed (including $5 million Government
counterpart funding)
 Population Coverage : 4,1 million
 Geographic coverage : 18 rural and 2 low-income
urban and peri-urban districts (Harare and
Bulawayo)
 July, 2011 to October, 2015

12. Governance & Institutional Arrangements
Contract
Contract
District Health Executive
Tracing clients and
client satisfaction
Policy and
Supervision
Policy and
Supervision
Policy and
Supervision
MoHCW
Provincial Health Executive
Health Facilities and HCC
(415)
National Steering Committee
District Steering Committee
CORDAID Private Purchasing Agency (NPA)
Contract + Payment
Payment
Community Based
Clients Organisations
CORDAID Local Purchasing Unit
Payment
Contract + Verification
External verification
10/1/2014 12

13. 13
Baseline
(2011)
Midline Impact Evaluation
(Mar-Sept 2014)
Program Inception
Endline IE
(TBD)
Process Monitoring
and Evaluation
(PME)
(November 2013)
Technical Review
(June 2012)
Routine
Performance
Review (Quarterly) –
Operational Data
Mid-Term Review
(January 2013)
Technical Adjustments: Prices and
Services
Technical Modifications –clinical quality,
streamlining verification, equity
monitoring
2nd PME Round
Planned for
October 2014

14. The IE seeks to determine the causal impact of RBF on priority
service utilization and related health indicators
◦ Treatment: Facilities and patients residing in districts that
introduce the RBF program
◦ Comparison: Facilities and households in matched
“business as usual” districts
◦ Districts matched on various characteristics including:
 Average catchment size of facility
 Proportion of staff positions filled
 Population rates over 2008 – 2010 of ANC coverage, in-facility
delivery rates, immunization coverage
14

15. Participating Districts

16. Given the purposive selection of study districts, the evaluation
must be quasi-experimental. Specifically,
◦ A difference-in-difference (“diff-n-diff”) estimator between
matched districts in treatment and control (16 in each arm)
estimates program impact
◦ To estimate actual impact: two years of program exposure
(2012-2014) is contrasted with a two year period
immediately (2008-2010) before the program
16

17. Household information –
 Population representative surveys of health behavior,
• including utilization, recall of procedures
 health outcomes,
• including anthropometry, satisfaction with care, knowledge
 and mediating variables
• socio-demographics
 Baseline data for community and household utilized the 2011 DHS
 Follow up data at community, household structured to replicate
and supplement the earlier DHS
 Yields a sample of ~2800 recent pregnancies/births
17

18. Facility survey – a comprehensive review of the structure,
provision, and quality of care at clinic level
 Instruments
◦ Facility checklist
◦ Health worker tool
◦ Exit interview tool (ANC, child illness)
◦ Direct observation (ANC, labor and delivery and child illness)
◦ Chart audit* of routine and complicated delivery
• Only in the follow up
180 facilities in 2011 baseline (the NIHFA) and 231 in follow up
Technical support from USAID and UNICEF was critical in this
undertaking
18

19. • Data has just been collected and still being
processed
• However the preliminary results from both population
and facility data are now available…
• Overall it is a story of strong gains in select health
indicators for the entire nation (consistent with
the MICS results), with yet more rapid
improvement in RBF districts
• RBF gains in both the quantity and quality of
care, but not for all prioritized indicators
19

20. • RBF led to gains in both the quantity and quality
of care
• A 13 percentage point increase in the in-facility
delivery rate
• A 12 percentage point increase in post-natal care
coverage
• More women receiving full package of ANC services
including urine tests, blood tests, tetanus shots
• But not for all prioritized indicators
• Little change in ANC coverage and contraceptive use–
baseline rates already high
20

21. RBF pre-trend
RBF trend
comparison pre-trend
comparison trend
Start of RBF
0.65
0.6
0.55
0.5
0.45
0.4
2008 2009 2010 2011 2012 2013 2014

22. Outcome Impact
Level of
significance
Any modern contraception 0.05 0.21
Receipt of any antenatal care (ANC) 0.02 0.43
Time of first ANC -0.19 0.22
Number of ANC visits 0.40 0.15
Blood pressure checked during ANC 0.03 0.55
Urine sample collected during ANC 0.16 0.02
Blood sample collected during ANC 0.08 0.14
Receipt of tetanus vaccine during pregnancy 0.08 0.05
Number of tetanus vaccine 0.33 0.05
Any iron supplements received during pregnancy 0.00 0.99
Receipt of any postpartum care (PPC) 0.12 0.05
A PPC within 2 months of delivery 0.12 0.06
PPC by a skilled provider 0.14 0.02
Facility delivery 0.13 0.00
Skilled delivery 0.14 0.00
22
Most impacts measured in proportional terms. Statistically significant
results with in red.

23. 23
Patient exit interviews
◦ ANC interviews (n=1105) indicate significant improvements in care
processes such as measured abdomen and urine sample
◦ Child health interviews (n=1612) indicate significant improvement in
measurement and growth monitoring
◦ Client satisfaction is also higher (although at marginal significance,
p=.128)
Facility measures
◦ Improvements in select facility conditions after RBF:
 8 percentage point increase in availability of bio-med waste disposal
◦ Increases in supervision and community involvement after RBF:
 Increase in number of HCC meetings (2.7 more per year)
 Increase in external assessments of staff (2.4 more per year)
 34 percentage point increase in presence of facility work plan

24. RBF Investments Program
Outcomes

25.  Need to go beyond numbers
◦ Capture rich experiences and lessons from frontlines of PBF
implementation & context
 Community engagement and support (HCC)
 Geographic influences (supervision aspect, cross-catchment area
patient movement)
 Health facility management skills and dynamism
 Extent of mentorship and clinical supervision by district/province
 Explain contextual factors that matter the most & account for variation in
provider performance
 Supporting impact evaluation and not substituting it –better
understanding of the our intervention
25

26. Providers at high performing health facilities (HPF)
were reported to be highly motivated.
 Regular and well structured supportive supervision improved
the capacity to earn more subsidies e.g one (HPF) had an
increase in subsidies of 53% to 94% between the first and
second quarters.
 Team work improved communication
...we are now working as a team to ensure that the T5 (data
compilation form) is correct and accurate and we are able to send it
to the district in time. We are motivated to work as we get paid for
our effort. --( HF Staff Member)
 Higher client satisfaction attracted more patients (patient
choice)

27. When low performance is found, facilities attribute
reasons to:
 Smaller catchment populations & at times
geographic remoteness
 Irregular supportive supervision
Socio-economic and religious factors in the
population

28.  Revisit the remoteness criteria & facility catchment issue
 RBF performance payment calculation formula being reviewed
(higher remoteness bonus)
 Content & structure of quality supervision checklists
 Written feedback by district managers mandatory
 Modified supervision checklist – more process measures
of clinical care introduced
 District Health Executive supervision contract revisited –
ensure incentive to regularly supervise remote facilities
 Integrate RBF into HR management
28

29. Thank You!
29

30. Extra slides
30

31.  What is the impact of RBF on maternal and child health
services utilization and outcomes?
 What is the impact of RBF (counter verification) on
health management information system (HMIS) and on
supportive supervision?
 What is the effect of RBF on community participation
and social determinants of health?
 What is the effect of RBF on health workers’ attitude,
job satisfaction, retention and attrition, etc?
 What is the effect of RBF on patient/client satisfaction
and in health seeking behavior?
31

32. Given the purposive selection of study districts, the evaluation
must be quasi-experimental. Specifically,
◦ A difference-in-difference (“diff-n-diff”) estimator between
matched districts in treatment and control (16 in each arm)
estimates program impact
 In a diff-n-diff estimator, the observed trends in outcomes for
the comparison districts stand for what would have happened
in the RBF districts if not for the RBF program
 The validity of this approach can be assessed by comparing
pre-RBF trends of same outcomes in RBF and comparison
districts before RBF program
 To estimate actual impact: two years of program exposure
(2012-2014) will be contrasted with a two year period
immediately (2008-2010) before the program
32

33. Start of RBF
0.95
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
RBF pre-trend
RBF trend
comparison pre-trend
comparison trend
2008 2009 2010 2011 2012 2013 2014

34. After introduction of
RBF
1
0.98
0.96
0.94
0.92
0.9
0.88
RBF pre-trend
RBF post-trend
comparison pre-trend
comparison post-trend
2007 2008 2009 2010 2011 2012 2013

35.  Key areas PME assessed
• Factors affecting health provider performance
• Factors influencing changes on the demand
(community) side
• Compliance of the RBF stakeholders to the
project’s implementation guidelines.
35

36. Binga, Chipinge, Kariba, Mazowe and Zvishavane.

37.  Selected three facilities in each of five districts
 Sequential mixed method deployed
 Participants selected included mothers of reproductive age,
male community members, influential leaders, health center
committee members, district management team, as well as
clinic health staff

38.  RBF:
◦ Strengthens relationships between health care providers &
communities and improves access to services at community level (e.g.
community ambulance)
◦ Fosters innovations and entrepreneurship among health workers
◦ Improves district managers supportive supervision
◦ Improves health facility infrastructure (service delivery environment)
◦ Improves staff morale and promotes team work
38

39.  Staff shortage
“When one of us attends a workshop only one person is left to deal with registers and
the workload is huge and most of the mistakes we make are due to fatigue. We are
now losing patients to other institutions…”HF staff
“There are a number of clinics surrounding therefore there is competition for example
X clinic is GVT owned and well equipped, has drugs and well-staffed so
patients prefer going there than spending more time in long queues here where there
is staff shortage”. -- HF Staff Member
 Shortage of drugs e.g. vaccines
 Inadequate infrastructure