Results-based financing (RBF) has been implemented in low- and middle-income countries with the aim of transforming health systems and achieving Millennium Development Goals 4 and 5. However, there is a dearth of empirical research on the impact of RBF-facility financing and provider incentives on performance related factors such as health workers satisfaction, motivation, productivity, and retention. This paper attempts to fill this gap by examining the relationship between RBF and health care practitioner outcomes through the case of Zambia. It uses a randomized intervention/control design to evaluate before–after changes for three groups: one that received pay for performance, a counterfactual group that received additional financing not conditioned on performance, and another counterfactual group that received no enhanced financing.
Mixed methods are employed. The quantitative portion comprises a baseline and a three-year follow-up survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of RBF and enhanced financing on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences.
Econometric analysis shows that RBF led to increased satisfaction and decreased attrition, but had rather limited effects on motivation and no effects on productivity. The enhanced financing group also experienced some positive effects on motivation. These results are rather different from the qualitative assessment, which reveals very strong motivation and increased workload among the intervention group. The qualitative evidence, however, also provides possible explanations for the lack of RBF significant impact on motivation and productivity, such as workers’ burnout, rigid supervision from the District Medical Office, and at times lack of true autonomy (which was intended to be part of the RBF intervention).
Keywords: Human resources for health, HRH