The RBF project in Zimbabwe is anchored on three components: 1) results-based contracts, 2) management and capacity building, and 3) monitoring and documentation. It is anticipated that through this project, both supply and demand for health services— particularly maternal and child health—will be significantly improved, contributing to a reduction in maternal and child mortality and morbidity.
This report presents the second cycle of the process monitoring and evaluation (PME) for the Results Based Financing (RBF) project in Zimbabwe, formally the Health Sector Development Support (HSDS) Project. The overarching goal of the PME study is to help the Ministries of Health and Child Care (MOHCC) and Finance and Economic Development (MOFED), Cordaid, the World Bank Task Team and interested local and international stakeholders learn from the RBF project; make mid-course adjustment to the technical design and operational processes; and enhance evidence-based project management decision making.
The study seeks to understand qualitative factors at district, health facility, health worker and community levels that explain performance under the RBF project. The specific objectives were to:
- Assess the extent to which the RBF project is implemented as intended and planned, as well as examine unintended implementation changes and effects.
- Identify changes facilitated by the project, including facility performance and perceptions on equity.
- Examine factors influencing quality of care, including linkages with supportive supervision and health worker motivation.
- Explore factors influencing changes from different perspectives including supply (provider) and demand (community).
DHE teams, health facilities, health center committees (HCCs) and health facility catchment communities within World Bank-funded RBF districts constituted the sampling frame. Health workers and HCC members for these health facilities as well as community members in the facility catchment areas constituted the population of individuals from which primary qualitative data was collected.
The study’s findings demonstrate the linkages between the first and second PME evaluations. The study prioritizes performance of incentivized indicators, quality of care (QoC) and expenditure/payment data aspects of the health system and program components.
The RBF program is being generally implemented as intended and planned – with many of the intended consequences being achieved, and expectedly, some unintended changes and effects occurring. RBF improved communication and cooperation between the RDC and the DHE and facilitated the adoption of a shared goal of improving facility performance. This has helped to foster a localized level of stewardship for service delivery. Many RBF program design and implementation factors played a significant role in influencing the performance of health facilities and the motivation and satisfaction of staff at these facilities, both good performance and poor performance. Similarly, contextual factors played a significant role in the performance of health facilities. Performance in most facilities, particularly the low performing facilities, was also greatly affected by the HCCs, which were often not properly functioning.
The RBF program design and implementation processes triggered and facilitated changes in the facility staff’s performance. Staff at all the facilities used their earnings to invest and improve the quality of care through the purchase of essential equipment and drugs. The RBF program created conditions for facility staff to take the initiative in improving the quality of services.
While community participation in the RBF program was generally marginal, a beginning has definitely been made; this is thus both a gap and an opportunity for the RBF program. As a result of the RBF program, previously defunct HCCs have been revived; this is one area on which the RBF program needs to put greater emphasis. Efforts need to be made to gain insight into citizens’ understanding and ideas of the purpose, fairness and benefits of the RBF program.
There were inconsistencies in respondents’ perceptions of the role the communities play and the ways and means for them to participate and exercise ownership. The RBF program can contribute to defining the roles, lines of accountability, and processes for triggering inclusiveness, representation, and genuine community participation. Doing so would help better achieve the RBF program objective of equitable access to care. The RBF program should examine the stresses in the relationships between different actors and identify opportunities to improve community participation from beyond the current mere consultation-based participation to a more developmental orientation directed at achieving genuine partnership and citizen control over local services.
· Continuously examine roles and skills capacity building on RBF issues for both the health facility staff and the HCC. The HCC should be given comprehensive training using the HCC training guidelines produced by the MOHCC and the CWGH.
· Financially and technically strengthen the capacities of the DSC in order for them to effectively support HCCs. There is also need for close collaboration between the DHE and DSC and to strictly utilize the feedback mechanism proposed in the PIM to resolve conflicts between the two parties.
· PHEs should ensure that DHE teams are fully constituted when supervising health facilities so they are able to adequately monitor all clinic sections and functions. Processes should be established to ensure that supervisory visits by DHEs achieve their supportive potential.
· Integrate key non-incentivized services into the quality supervision checklist; the current supervision checklist emphasizes incentivized indicators.
· Revise the RBF facility performance assessment framework to be more participatory, consultative and flexible. Such a framework should have room to better account for local contextual factors when making performance judgments.
· Systematically support poor performing facilities with capital investments so that clinics can focus on items that directly support improved clinical care, QoC and performance. This could be done through the development of a redistribution based, equity and need oriented resource allocation process, among other things.
· Develop a clear strategy to improve community participation from beyond the current consultation-based participation, to a more developmental orientation directed at achieving genuine partnership and shared control over local services.
· To address staff shortages and avoid handing over tasks to unqualified staff it is important for the GoZ to further investigate current workloads to better understand the actual versus perceived problem and to ensure that all facilities have adequate skilled staff.