Results Based Financing (RBF) rewards the doers. When mothers have their children immunised or when healthcare providers reach a set target of immunised children, an RBF system provides the money. The long-used method of input based funding is assumed to improve health through providing money for salaries, construction, training, equipment – but that’s not always the case.
Billions of dollars have gone into health programmes in African countries over the last decade through input based funding, and despite some significant successes, statistics for measures like maternal and child deaths and malnutrition, remain tragically high in many countries.
At Crown Agents, we believe that RBF can achieve results – and so does Zimbabwe’s ministry of health and child care (MOHCC), which has fully bought in to the concept. Since 2014, we’ve been working with health and development firm, Hera, and the MOHCC to roll out the funding structure under Zimbabwe’s health transition fund, which is managed by Unicef. Our approach has drawn heavily on the pioneering work done by Cordaid, with World Bank funding, on a separate RBF scheme run in 18 districts. Our programme purchases for 16 core maternal, newborn and child health (MNCH) indicators, with the aim of strengthening health systems and scaling up the implementation of high impact MNCH interventions through support to the health sector. RBF is being rolled out in all of Zimbabwe’s eight provinces, supporting 923 rural health centres and hospitals.
It’s a big task. It requires substantial institutional transformation and proving the merits of RBF to everyone involved. We’re getting there, though, and here are some of the things we’re keeping at the front of our minds along the way:
1. Make it fit
An RBF system needs to build upon existing systems where it can and take into account priorities that are already in place. We’re making sure that the RBF system in Zimbabwe is consistent with MOHCC policies, processes and systems as much as possible. This will strengthen what’s there already and also help grow the sustainability of it.
2. Build capacity
For lasting institutional transformation in Zimbabwe’s healthcare, ‘sustainability’ and ‘country ownership’ are absolutely unavoidable terms. And to achieve them, the MOHCC must have enough capacity to take ownership of the work. How are we helping to achieve this? One example is we trained the existing network of community health sisters (CHSs) to undertake first level data verification and the network of health information officers (HIOs), who capture data within the government’s district health executives (DHEs).
3. Support people and their skills
Starting in May 2014, Crown Agents and Cordaid trained 50 provincial trainers in all of the eight provinces, in a project led by the MOHCC with World Bank funding. These trainers, with support from Crown Agents and Cordaid staff, then worked to cascade the training to cover 235 CHSs and HIOs from all of the 42 districts, who have since started practical data verification at their designated health facilities.
4. Keep a close eye
The RBF model prioritises the monitoring and assessment of the quality of services provided by facilities. A quality of care checklist has been developed and adopted for use by MOHCC, and will be checked at all facilities on a regular basis. Given the critical role of monitoring and evaluation in the RBF model, a health M&E advisor has also been appointed.
5. Make it local
The presence of local purchasing units and health field officers close to facilities at provincial and district levels helps with continuous monitoring, data verification and troubleshooting, capturing risks that need the attention of the MOHCC or central RBF team. These teams cover vast distances around the countryside on a fleet of motorbikes provided by Unicef.
6. Keep learning
We’re taking a learning approach to the whole RBF implementation, continually refining and developing a sustainable model. We’re pushing to raise service quality, increase the coverage and impact and make sustainability an inherent priority consideration.