Impact of Results-Based Financing on Key Health Indicators in a Devolved Health System: A Case Study from Northern Zambia

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DOI: 10.21522/TIJMG.2015.12.01.Art008

Authors : Mayeya Paul Mayeya

Abstract:

Results-Based Financing (RBF) has been promoted as an innovative health financing mechanism to improve service delivery and health outcomes in low-resource settings. However, evidence on its impact within devolved health systems remains limited. This study examines how RBF influences key performance indicators (KPIs) in Zambia's devolved district health services. An embedded multiple-case study was conducted across 12 districts in Northern Province, Zambia. Mixed methods were employed, combining qualitative interviews with 44 stakeholders and quantitative analysis of health facility data. The study focused on maternal and child health indicators, service utilization patterns, and health worker motivation following RBF implementation. RBF implementation was associated with improvements in several KPIs: maternal health outcomes (100% of facilities reported improvements), medicine availability (91%), and the quality of primary healthcare services (67%). Health worker motivation increased, with 42% agreeing and 24% strongly agreeing that RBF positively affected service delivery. Community-based volunteers responded positively to incentive structures. However, challenges included delayed fund disbursement (91.7% reported), inadequate funding (83.3%), and monitoring gaps (50%). RBF can enhance key health indicators in devolved systems when properly designed and implemented. Success depends on timely incentive disbursement, robust monitoring systems, and integration with existing community health structures. The study provides evidence for policymakers considering RBF scale-up in decentralized health systems.

References:

[1].   World Health Organization, 2010, Financing for universal health coverage. World Health Organization, Geneva.

[2].   Meessen, B., Soucat, A., Sekabaraga, C., 2011, Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform? Bulletin of the World Health Organization, 89, 153-156.

[3].   Ministry of Health Zambia, 2017, National Health Strategic Plan 2017-2021. Government of Zambia, Lusaka.

[4].   Witter, S., Toonen, J., Meessen, B., Kagubare, J., Fritsche, G., Vaughan, K., 2013, Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation. BMC Health Services Research, 13, 367.

[5].   Bossert, T. J., Mitchell, A. D., 2011, Health sector decentralization and local decision-making: decision space, institutional capacities and accountability in Pakistan. Social Science & Medicine, 72, 39-48.

[6].   Basinga, P., Gertler, P. J., Binagwaho, A., Soucat, A. L., Sturdy, J., Vermeersch, C. M., 2011, Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. The Lancet, 377, 1421-1428.

[7].   Kalk, A., Paul, F. A., Grabosch, E., 2010, Paying for performance in Rwanda: does it pay off? Tropical Medicine & International Health, 15, 182-190.

[8].   Lievens, T., Serneels, P., Buttiens, B., Garcia-Prado, A., Herbst, C. H., Soucat, A., 2011, Designing effective performance-based incentives for health workers: a review of the literature. Health Policy and Planning, 26, 191-204.

[9].   Musgrove, P., 2011, Financial and Other Rewards for Good Performance. In: Oxford Handbook of Health Economics. Oxford University Press.

[10].  Paul, E., et al., 2018, Performance-based financing in low-income and middle-income countries: a systematic review. Health Policy and Planning, 33(10), 1127-1140. Doi: 10.1093/heapol/czy078.

[11].  Das, A., Gopalan, S. S., Chandramohan, D., 2016, Effect of pay for performance to improve quality of maternal and child care in low- and middle-income countries: a systematic review. BMC Public Health, 16, 321.

[12].  Binyaruka, P., et al., 2017, Effects of performance-based financing on health system performance in Zambia. Health Systems & Reform, 3(3), 183-195. Doi: 10.1080/23288604.2017.1353778.

[13].  Fritsche, G. B., Soeters, R., Meessen, B., 2014, Performance-based financing toolkit. World Bank.

[14].  World Health Organization, 2015, Health financing for universal health coverage: a WHO framework. WHO.

[15].  Bossert, T. J., & Bechikh, D., 2016, Decentralization and governance in the Ghana health system. Health Systems & Reform, 2(2), 130-140. Doi: 10.1080/23288604.2016.1156158.

[16].  Mehta, A., & Hecht, R., 2016, Results-Based Financing (RBF) in the Health Sector of Low- and Middle-Income Countries: A Review of Programs and Lessons Learned. Results for Development Institute.

[17].  World Bank., 2019, Philippines Health Sector Support Program: Results-Based Financing for Health. World Bank, Washington, DC.

[18].  Shen, G. C., Nguyen, H. T., Das, A., Sachingongu, N., Chansa, C., Qamruddin, J., et al., 2017, Incentives to change: effects of performance-based financing on health workers in Zambia. Human Resources for Health, 15, 20.

[19].  Chansa, C., Das, A., Qamruddin, J., Friedman, J., Ranganathan, M., Vermeersch, C., 2018, Understanding the effect of a performance-based financing project on health worker motivation in Zambia. Health Policy and Planning, 33, 931-938.

[20].  Ssengooba, F., McPake, B., Palmer, N., 2012, Why performance-based contracting failed in Uganda: an open-box evaluation of a complex health system intervention. Social Science & Medicine, 75, 377-383.

[21].  Bhattacharyya, K., et al., 2011, Community health worker incentives: a review of the evidence. International Journal of Health Planning and Management, 26(2), 141-155. Doi: 10.1002/hpm.1077.

[22].  Nkonki, M. K., et al., 2017, Community-based volunteers: a review of their role in health interventions. Journal of Public Health in Africa, 8(2), 684. Doi: 10.4081/jphia.2017.684.

[23].  Eijkenaar, F., et al., 2013, Effects of pay for performance in health care: a systematic review of systematic reviews. Health Policy, 110(2-3), 115-127. Doi: 10.1016/j.healthpol.2013.01.008.

[24].  Dusseljee, D., Schutjens, M., Kamwanga, J., Kuipers, P., van der Wilt, G. J., 2014, Performance-based financing in Zambia: the need for adaptation to the context. Health Policy and Planning, 29, 1090-1101.

[25].  Mayeya, P. M., 2021, Results-based financing and maternal health outcomes in Lunte District, Zambia.

[26].  Renard, J. P., et al., 2018, Performance-based financing in fragile states: opportunities and challenges. Health Policy and Planning, 33(10), 1113-1126. Doi: 10.1093/heapol/czy079.

[27].  Pritchett, L., & Woolcock, M., 2004, Solutions when the solution is the problem: arraying the disarray. World Development, 32(2), 191-212. Doi: 10.1016/j.worlddev.2003.08.009.

[28].  World Health Organization., 2019, Results-based financing: a framework for health systems strengthening. WHO, Geneva.

[29].  Meier, B. M., & Brugh, K., 2014, Results-based financing in health: achieving results through results. Global Health Governance, 7(2), 1-17.

[30].  Oluwole, E. O., & Mash, R., 2018, Results-based financing in low- and middle-income countries: a systematic review of its effectiveness. Health Policy and Planning, 33(10), 1111-1122. Doi: 10.1093/heapol/czy078.

[31].  Masiye, F., Kaonga, O., Kirigia, J. M., 2021, Does performance-based financing improve health system efficiency? Evidence from Zambia. International Journal of Health Planning and Management, 36, 126-140.

[32].  Pawson, R., & Tilley, N., 1997, Realistic Evaluation. Sage Publications.

[33].  Greenhalgh, T., & Papoutsi, C., 2018, Studying complexity in health services research: desperately seeking an overdue paradigm shift. BMC Medicine, 16(1), 95. Doi: 10.1186/s12916-018-1089-4.

[34].  Ministry of Local Government Zambia, 2019, Decentralization implementation plan 2019-2023. Government of Zambia, Lusaka.

[35].  JSI Research & Training Institute, Inc., 2020, Evaluation of the results-based financing pilot in Zambia. JSI, Boston.

[36].  World Bank, 2019, Zambia health sector public expenditure review. World Bank, Washington, DC.

[37].  Witter, S., Chirwa, Y., Chandiwana, P., Munyati, S., Pepukai, M., Bertone, M. P., 2019, The political economy of results-based financing: the experience of the health system in Zimbabwe. Global Health Research and Policy, 4, 20.

[38].  Falisse, J. B., Ndayishimiye, J., Kamenyero, V., Bossuyt, M., 2015, Performance-based financing in the context of selective free health-care: an evaluation of its effects on the use of primary health-care services in Burundi using routine data. Health Policy and Planning, 30, 1251-1260.

[39].  Bertone, M. P., Lagarde, M., Witter, S., 2018, Performance-based financing in the health sector in low- and middle-income countries: is there anything whereof it may be said, see, this is new? International Journal of Health Policy and Management, 7, 1-10.

[40].  Chimhutu, V., Lindkvist, I., Lange, S., 2014, When incentives work too well: locally implemented pay for performance (P4P) and adverse sanctions towards home birth in Tanzania - a qualitative study. BMC Health Services Research, 14, 23.