(How)does RBF strengthen strategic purchasing of health care?Comparing the experience of Uganda,Zimbabwe and the Democratic Republic of the Congo

Background:Results-Based Financing(RBF)has proliferated in health sectors of low and middle income countries,especially fragile and conflict-affected ones,and has been presented as a way of reforming and strengthening strategic purchasing.However,few studies have empirically examined how RBF impacts on health care purchasing in these settings.This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings:Uganda,Zimbabwe and the Democratic Republic of Congo(DRC)over the past decade.Methods:The article is based on a documentary review,including 110 documents from 2004 to 2018,and 98 key informant(KI)interviews conducted with international,national and district level stakeholders in early 2018 in the selected districts of the three countries.Interviews and analysis followed an adapted framework for strategic purchasing,which was also used to compare across the case studies.Results:Across the cases,at the government level,we find little change to the accountability of purchasers,but RBF does mobilise additional resources to support entitlements.In relation to the population,RBF appears to bring in improvements in specifying and informing about entitlements for some services.However,the engagement and consultation with the population on their needs was found to be limited.In relation to providers,RBF did not impact in any major way on provider accreditation and selection,or on treatment guidelines.However,it did introduce a more contractual relationship for some providers and bring about(at least partial)improvements in provider payment systems,data quality,increased financial autonomy for primary providers and enforcing equitable strategies.More generally,RBF has been a source of much-needed revenue at primary care level in under-funded health systems.The context-particularly the degree of stability and authority of government-,the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed.Conclusions:Our evidence suggests that expectations of RBF as an instrument of systemic reform should be nuanced,while focusing instead on expanding the key areas of potential gain and ensuring better integration and institutionalisation,towards which two of the three case study countries are working.

The political economy of results-based financing:the experience of the health system in Zimbabwe

Background:Since 2000,results based financing(RBF)has proliferated in health sectors in Africa in particular,including in fragile and conflict affected settings(FCAS)and there is a growing but still contested literature about its relevance and effectiveness.Less examined are the political economy factors behind the adoption of the RBF policy,as well as the shifts in influence and resources which RBF may bring about.In this article,we examine these two topics,focusing on Zimbabwe,which has rolled out RBF nationwide in the health system since 2011,with external support.Methods:The study uses an adapted political economy framework,integrating data from 40 semi-structured interviews with local,national and international experts in 2018 and thematic analysis of 60 policy documents covering the decade between 2008 and 2018.Results:Our findings highlight the role of donors in initiating the RBF policy,but also how the Zimbabwe health system was able to adapt the model to suit its particular circumstances-seeking to maintain a systemic approach,and avoiding fragmentation.Although Zimbabwe was highly resource dependent after the political-economic crisis of the 2000s,it retained managerial and professional capacity,which distinguishes it from many other FCAS settings.This active adaptation has engendered national ownership over time,despite initial resistance to the RBF model and despite the complexity of RBF,which creates dependence on external technical support.Adoption was also aided by ideological retro-fitting into an earlier government performance management policy.The main beneficiaries of RBF were frontline providers,who gained small but critical additional resources,but subject to high degrees of control and sanctions.Conclusions:This study highlights resource-seeking motivations for adopting RBF in some low and middle income settings,especially fragile ones,but also the potential for local health system actors to shape and adapt RBF to suit their needs in some circumstances.This means less structural disruption in the health system and it increases the likelihood of an integrated approach and sustainability.We highlight the mix of autonomy and control which RBF can bring for frontline providers and argue for clearer understanding of the role that RBF commonly plays in these settings.