Institutionalizing Results-Based Financing in Devolved Health Systems: Lessons from Zambia's Northern Province
Abstract:
Zambia has
implemented significant health-sector decentralization since 1992,
culminating in the devolution of district health services to local authorities
under the 2016 Constitutional Amendment. Results-Based Financing
(RBF) has been piloted as a performance incentive mechanism, but
its institutionalization within devolved structures remains largely unexplored.
This study explores the opportunities and challenges of embedding
RBF within Zambia's devolved health system, with a focus on Northern
Province. A qualitative case study design was used, involving forty-four
participants from twelve districts. Purposive sampling selected
health workers from provincial and district health offices, local
authority representatives, and national stakeholders. Data collection included
semi-structured interviews, document reviews, and observations, with thematic
analysis conducted using NVivo 9. Most respondents (82%) reported involvement
in RBF implementation, and fifty-three% believed that increased Constituency
Development Fund (CDF) allocations improved district health services. Key
benefits cited were increased accountability (81.8%) and greater community participation
(77.3%). Challenges included insufficient funding (83.3%), delays in disbursing
funds (91.7%), and limited understanding among local authority implementers.
Infrastructure development and procurement of medical equipment were identified
as primary areas for CDF improvements (56%). Respondents also agreed (53%) that
the Ministry of Health and the Ministry of Local Government would support the
institutionalization of RBF. Effective integration of RBF into devolved systems
requires harmonizing policies between health and local government ministries, building
capacity within local authorities, and aligning RBF with other domestic
financing mechanisms, such as CDFs. A phased approach to integration, with
clearly defined governance structures, is recommended to ensure sustainable
scaling.
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