Story by Jane Zhang, video by Peter Von Elling
CHIPARAWE, Zimbabwe – Teclar Gohori had heard plenty of horror stories about women dying of post-partum bleeding while giving birth at home. But when she became pregnant with her first child, she discovered that a hospital birth was simply out of reach.
In addition to a US$10 registration fee, the local clinic required that she bring her own sanitary pads, bed sheets, a bucket of water, a razor to cut the baby’s umbilical cord, gloves for the nurses, candles for lighting, and newborn clothes. All those would add up to $20. If she was transferred to a higher-level hospital in case of an emergency, she would have to pay at least $70 more. A blood transfusion, if needed, would cost her $120 per unit.
Most residents in this rural area – one hour’s drive on a dusty dirt road from Harare – don’t even have one dollar to spare, because most rely on subsistence farming. “I had no cash to go to the clinic,” recalled Gohori, now 30 years old. “It was emotionally very painful not to have what you were supposed to have for you to deliver at an institutional setup of a hospital.” That was six years ago. When her second child was born last February, however, Gohori didn’t worry about money at all. The Chiparawe Clinic no longer required patients to bring medical supplies, and she just showed up when she was in labor. When nurses found out that the baby was in the breech position – buttocks first – they transferred her to Marondera Provincial Hospital. All her care was free. “The eight days I stayed at the hospital, I just focused on my child to get well,” said Gohori, holding six-month-old Tinashe on her lap during an interview last August. “I know somebody was going to be there paying for me, RBF.”
RBF has become widely known among people living in rural areas across Zimbabwe. It’s remarkable how, in such a challenging setting, this approach has quickly contributed to better health services. The program, which is funded by a $15 million grant from the World Bank’s multi-donor Health Results Innovation Trust Fund at the request of the government, provides 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. As of March, the program covered 387 health facilities – mainly rural clinics – in 18 of the country’s 62 districts, with a population of 3.46 million.
Safer Births, Better Care
For patients like Gohori, RBF means safer births, healthier children – and no more user fees. For doctors, nurses and community health center committees, RBF means greater opportunity for local-level planning, as they are free to decide on how to use the subsidy. Most facilities have used the funding to renovate outdated buildings, such as repainting them, repairing water leaks and buying new windows, roofs, toilets, sewer water tanks, and even solar panels and generators. Even though bonuses mainly have been spent on improving their work environment, nurses say they are more motivated to provide better services.
The RBF program, which was introduced in two pilot districts – Marondera and Zvishavane – in July 2011, has brought about good results in a relatively short period of time. The number of women who had four or more prenatal visits rose to 560 in June 2012, up 65% from 339 a year before. That same month, the districts registered 212 deliveries at rural health centers, up 83% from a year before. They also recorded 238 postnatal visits, compared with 73 a year before. Even the 16 districts that enrolled in RBF this year have seen an average increase of 6% in institutional deliveries per month, to 2,482.
“We think it’s a good way to manage the health delivery system,” said Bernard Madzima, director of family and child health at the Ministry of Health. “We really wish it’s rolled out to all the districts in the country.”
The program came as the government sought to reduce maternal and infant deaths, which had stayed high in the aftermath of an economic collapse and rising poverty. The gap in health-care access between the haves and have-nots also grew, especially in rural areas, where nearly two-thirds of the country’s population lives.
Indeed, 60.6% of rural women in low-income households delivered babies at home, compared with 19.6% of those in higher-income families, according to a 2007 study. The cost – about $50 then for a normal delivery, including prenatal and postnatal care – was a major factor. Zimbabwe’s global domestic product per capita was about $468 in 2009, though it rose to $776 in 2011.
A World Bank team helped the government design the results-based financing program for rural Zimbabwe, focusing on the elimination of user fees. Cordaid, a Dutch development agency, serves as the implementation agency, working closely with the health ministry in contracting with health providers, verifying results, building in-country capacity, and providing oversight.
While the rest of the government operates on a central-planning structure, the health ministry agreed to set up separate deposit accounts for health facilities. The funding is disbursed every quarter, after the performance data are reported and verified.
Wenceslas Nyamayaro, the provincial medical director for Mashonaland West, said the RBF program is a positive addition to the health system. The government’s rigorous budgeting structure also has made it easier to account for RBF funding. “If you put money there, our system can follow it,” he said.
Streamlining Patient Care
As more patients and better care mean more money, doctors and nurses quickly realized that it pays to follow up with the patient as well. When a woman comes in for her first prenatal visit, they emphasize the importance of attending all four prenatalvisits. They test her urine to make sure there isn’t too much protein, and also test her for diseases such as HIV and syphilis. If necessary, they give her drugs to prevent HIV transmission to her child. Once the child is born, they want her to come back for family planning and child immunization services. That streamlined approach marked a shift in patient care. Before the RBF program began, even normal deliveries were routinely sent to district and provincial hospitals. Now, only high-risk pregnancies are referred to those upper-level facilities. In the Marondera Rural District, nurses meet every month to compare their performance scores, assess how much RBF funding their clinics receive, and then discuss ideas on how to do better. “The secret to our success is unity and dedication.” said Crispen Borerwe, the district medical officer for Mashonaland East. “Our health staff in the clinics, in the health centers are now more motivated.”
Community Leaders as RBF Facilitators
Another valuable asset for health facilities: community health-center committees. Committee members are often local community leaders, whose word carries a lot of weight in the area. In rural Zimbabwe, they have become key facilitators of the RBF program, mobilizing women to deliver at clinics. As part of what is called “social marketing” here, women such as Gohori receive incentives, such as a bar of soap and two cloth napkins. With better services and no user fees, it hasn’t been a hard sell. In addition to the delivery fees, the Chiparawe Clinic also eliminated other charges, such as $1 for transportation, $1 for consultation and $2 every time a drug was dispensed. Women can deliver here 24 hours a day, seven days a week. The clinic also has used the RBF funding to hire a guard, who wakes up the nurses when a woman in labor comes in at night. The building is freshly painted, with a new kitchen, a water tank and solar energy for electricity. “The RBF brought us money, which we didn’t have in our account, for the clinic,” said Musekiwa Mugarisanwa, chairman of the Ward 3 health committee. “I see this program as a big help to the people, and we want it to continue.”
Not surprisingly, the clinic’s patient volume has skyrocketed, to 883 in July 2012 from 152 a year before. The two nurses at the clinic delivered 30 babies in April 2012, compared with two in July 2011. In addition, 162 children received the measles vaccine in July 2012, up from 142 a year before. One day last August, nurse Sheila Gwarazimba started her day at 10 a.m., delivered a baby girl at 5 a.m. the next day, rested for a couple of hours in her room in the back of the clinic property, and opened the clinic’s door again at 7:30 a.m. Her only colleague was away in training, and she said she didn’t mind the hours – or the lack of personal bonus. “Since I’m part of the community, I think it’s O.K.,” Gwarazimba said. Her patients know her sacrifices. Under a tree outside the clinic building, a group of women sat in a circle with babies on their back, belly or lap. They dubbed their babies “RBF babies,” in honor of the free care they received, and talked about how nurses took care of them “whole-heartedly.” “Not many children are dying anymore,” Gohori said. “I would like to thank RBF.”
Kundhavi Kadiresan, the World Bank’s country director for Zimbabwe, said the Bank’s close collaboration with the government and Cordaid help make it a success. "Having seen the project on the ground, RBF helps people living in country areas because it provides more resources to health workers on the front line of making better health services work, while also creating more accountability for resources and results throughout the health system.” she said.