Photo credit: World Bank/ Arne Hoel
Since the 1990s, Zambia has made progress in some health outcomes, notably reducing the under-five mortality rate threefold, and substantially reducing the incidence and deaths rates linked to HIV/AIDS and malaria (UN Inter-Agency Group for Child Mortality Estimation, 2015; WHO, 2016). Despite this progress, under-five and maternal mortality rates remain high with 64 child deaths per 1,000 live births in 2015 (UN Inter-Agency Group for Child Mortality Estimation, 2015), and 224 maternal deaths per 100,000 live births in 2015 (WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, 2015). Further, Zambia has one of the highest total fertility rates in the world with 5.3 births per woman in 2013/14 (Zambia Central Statistics Office, 2014), which contributes to under-five and maternal mortality, and to increased malnutrition. An estimated one-third of under-five mortality and almost a quarter of maternal mortality are associated with malnutrition, which affects immune status, physical and cognitive development, learning performance and productivity in adult life.
Low coverage and utilization of Maternal, neonatal and child health (MNCH) and nutrition services are attributed to demand as well as supply side constraints. On the demand side, communities often lack information on preventive practices, including early detection of health and nutrition complications. In addition, long distances to health facilities and lack of transportation often limit access to services and delay in seeking care. On the supply side, despite the increase in the number of health facilities, including primary care, service utilization remains low due to a variety of bottlenecks, including (i) stock-outs of essential health and nutrition supplies and consumables due largely to supply chain issues; (ii) insufficient and inequitable distribution of skilled health workers to carry out facility-based and outreach activities especially in the management of childhood illnesses and severe malnutrition, midwifery, and obstetric complications; and (iii) compromised efficiency of health workers due to tardiness, low morale, and absenteeism.
RBF AT A GLANCE
The ZHSIP is a results-oriented project and uses Disbursement Linked Indicators (aimed at rewarding policy and institutional level achievements) under Component 1, and results-based financing (RBF) at service delivery level under Component 2. In particular, the project uses RBF to improve the supply and demand for MNCH and nutrition at district, primary healthcare (PHC) facilities, and community levels. At district level, Provincial Medical Offices (PMOs) contract District Medical Offices (DMOs) to improve the performance of the health system, and assessment is done using a graded district performance management framework. This framework measures performance based on the availability of protocols and guidelines, compliance with supervision standards, provision of technical support, maintenance of equipment, human resource management, medicines and supplies management, budget execution, and other measures. In addition, PMOs also contract district hospitals to strengthen the referral system and quality of care. The RBF at district hospitals focuses on quality improvement by incentivizing payments for the delivery of a package of MNCH and nutrition services using a comprehensive quality assessment tool covering 12 key domains. In addition to performance on quality, district hospitals are also rewarded if they provide a referral feedback note on MNCH and nutrition services to a Health Centre. This indicator is designed to strengthen the referral system.
Health centers are contracted by DMOs to deliver a package of MNCH and nutrition services. Performance towards delivery of this package is assessed using 7 key MNCH and nutrition quantity indicators, and quality. At community level, the project uses RBF to boost service delivery, increase the accountability of community health workers (CHWs), and strengthen the linkages between communities and health facilities. Under this community-based scheme, health centers contract community-based organizations to (i) provide timely antenatal care and skilled delivery assistance; (ii) conduct outreach activities to improve the management of childhood illnesses at household level; (iii) mobilize community members for growth monitoring, child immunization and nutrition education; and (iv) for holding regular meetings to plan and review progress on the implementation community level activities.
At all levels, RBF payments are made quarterly by the Ministry of Health (MOH) based on the quantity and/or quality of services provided.
Internal verifications are conducted on a quarterly basis at all levels aimed at validating the quantity and quality of services provided, and to trigger payments. In particular, higher level institutions are used to collect and validate performance at the lower levels. For instance, health centers validate performance at community level, while DMOs validate the performance on quantity indicators at health centers. On the other hand, the district hospitals conduct quality assessment at the health centers. For the district hospitals, assessments are conducted by General Hospitals, while the DMOs are assessed by the PMOs. The data collected from the field is initially discussed at the District RBF Steering Committees, and eventually at the Provincial RBF Steering Committees. The District RBF Steering Committees are responsible for counter-verifying data at district level, and are chaired by the District Council Secretary or District Commissioner. These committees have representatives from all other key line ministries in the district as well as NGOs, Civil Society, and community. On the other hand, Provincial RBF Steering Committees are responsible for counter-verifying data at provincial level, and are chaired by Provincial Medical Officers. Provincial RBF Steering Committees are also responsible for approving payments for disbursement by the fund holder. These committees have representatives from all key line ministries in the province including NGOs, Civil Society, and Churches.
In addition to this internal RBF verification process, an independent external verification agent is contracted to conduct annual external verification at all levels (community, health center, district hospital, and DMO); and to evaluate the performance of the overall program. The main role of the external verification agent is to independently verify the accuracy of data reported through the internal verification process, trace patients in the community, and ascertain the quality of care through client satisfaction surveys. The external verification agent will calculate the margins of error and recommend corrective measures to remedy the situation. Accepted thresholds of error (i.e. +/- 10%). Penalties are applied if the results are beyond these margins of error.
Status and achievements
The ZHSIP builds on the Zambia RBF project that was implemented in 11 districts between 2008 and 2014. The RBF component under the ZHSIP was officially launched on 1st October 2016, and seeks to expand the RBF horizontally and vertically by the end of the project in June 2019 as follows:
- Increased population coverage from 1.7 million to 4.4 million
- Increase the number of districts from 11 to 39; and the number of health centers from 203 to 702
- Introduce RBF at 20 district hospitals
- Introduce RBF at 1,755 community-based organizations
Implementation of the RBF under the ZHSIP has been phased to allow for adequate capacities to be built in the districts that have never implemented RBF before. This is important because the RBF will be significantly expanded to include the community level and district hospitals. As at April 2017, the RBF was being implemented in 20 districts, 214 health centers, and 5 district hospitals. In addition, community RBF is being implemented at 73 health centers representing 365 community-based organizations. By October 2017, the RBF will be expanded to the remaining districts, district hospitals, health centers, and community-based organizations in line with the project aspirations. RBF trainings to accommodate this expansion will commence in June 2017.