The RBF program in Zimbabwe was launched in July 2011, to provide performance-based subsidies to rural health clinics and hospitals based on their performance in delivering a package of free health services to pregnant women and children under five. Positive initial results have spurred the Government of Zimbabwe to commit $5 million per year of its own funds in addition to $35 million in funding from HRITF to help scale-up existing RBF programs around the country and to pilot the approach in select urban areas. Cordaid, a Dutch NGO, is the implementing agency working under the guidance of the Ministry of Health and Child Care (MHCC). Phaoroah Mlambo, a member of the Cordaid team in Gwanda District, works with health facilities to build their capacity to introduce and implement a performance-based financing (PBF) approach.
1: Tell us about your work with health facilities.
As a Health Field Officer, I help facilities develop and implement operational plans and comply with PBF contracting and verification processes. Part of that involves coaching staff on how to use PBF incentives effectively, as well as how to manage and accurately compile their documentation and reports. I also make verification visits to facilities to identify any gaps, issues, or training needs, and make recommendations to address these.
2: What do you find most fulfilling about your work with facilities?
The most fulfilling part about my work is seeing health facilities achieve their objectives and implement the strategies. It is also fulfilling to see the community benefit from facilities that are nearby, instead of having to travel long distances. In Gwanda, RBF has meant seeing more mothers successfully delivering babies at the clinic, children getting immunizations and check-ups, all at no cost. Clinics have also been able to renovate their facilities and improve sanitation and waste disposal units.
3: What are some of the challenges of your work with facilities?
There are many challenges we have had to address head on, such as bringing District Authorities together to set goals for RBF Health; selling the program to key stakeholders; and convincing facilities that despite some delays, the incentive payments would eventually come —and how to use the funds when they did arrive. Another challenge has been separating the program from politics, and thus maintaining a truly apolitical reputation.
And as the rainy season approaches in Zimbabwe, I am also reminded of our challenge with transportation. Traveling through adverse weather on a motorbike is often inconvenient with the material, equipment and the rider often being soaked.
4: What are some of the changes you have noticed in the facilities since they started implementing RBF?
Prior to implementing RBF, facilities lacked adequate resources to provide basic services. Medicine was in short supply, lighting was poor, delivery equipment was limited or non-existent, and the water supply was pathetic. Some facilities resorted to drawing water from riverbeds, streams and wells.
Since the implementation of RBF, there have been many positive changes, including:
- Clinics are now able to replenish their medicine stock using the RBF fund.
- Running water has been restored in facilities that once lacked a proper supply.
- Many facilities bought solar lanterns, generators and solar panels to ensure proper lighting at night.
- Also, many have bought equipment, which has motivated staff to conduct deliveries at the primary facilities.
There have also been improvements to administrative practices in the facilities. Facilities are doing an overall better job of maintaining accurate records. Inter-clinic communication was once a significant challenge. During emergencies, it was impossible for clinics to be in contact. Since RBF, telecommunications access has improved and clinic radios have been revived.
In addition, staff morale and participation has improved. Today, every clinic now has an engaged Health Centre Committee (HCC), which is very active in decision-making, including how to use the money raised through the RBF fund.
5: Can you share a particular story or incident that really demonstrates the impact of RBF in Gwanda district?
A pastor representing local churches was present during our meeting with the HCC for ZIMCAN clinic to plan for 2013. His sect does not believe in going to the clinic for healthcare, and they do not allow their children to be vaccinated. As a result, there are incidences of children from this sect dying from preventable diseases.
During the meeting, the church leader confessed that previously he strongly believed children should not be vaccinated. However, he noted that RBF has made him aware of the importance of proper healthcare for children and pledged that he would no longer decry members who sent their children to be immunized. He also promised to have all his members be immunized, and invited me to gatherings to educate his congregation about the program.
True to his words, by March 2013, his family and church members were all immunized and the children are now weighed every month. Also, the Nurse in Charge at the clinic has confirmed that mothers from the church are coming in for antenatal, delivery, and postnatal care.