The magic of results-based financing

In 2018, the Zimbabwean government will fully take over the World Bank financed and Cordaid implemented health program in Zimbabwe. “We helped to revitalize the national health system”, says Arjanne Rietsema, Cordaid’s Country director in Zimbabwe. “Safely handing over the results-based financing program, will be one of our biggest achievements.”

This results-based financing (RBF) program mainly focuses on maternal and neonatal health care in 18 districts. Cordaid, acting as central purchasing agency, contracts 400 facilities (366 health centers and 34 hospitals) to provide a defined set of services. In total they serve a population of over 3 million people.

Sustained improvement of access to health care

“The government has allocated 10.2 million USD for the results-based financing program. This is great news. Our results will be consolidated”, says Arjanne Rietsema. The recent 2018 budget statement of the Zimbabwean government couldn’t have come at a better moment. As of January, Cordaid stops purchasing health services.

In the words of the new Zimbabwean government: “The recent turnaround in the improvement of key maternal, neonatal and child health indicators is largely on account of the implementation of innovative financing mechanisms such as results-based financing. This has led to a sustained improvement in the availability, accessibility, and utilisation of quality health care services. To sustain and consolidate these gains, the 2018 Budget proposes to allocate US$10.2 million.”

Infusing health facilities with an entrepreneurial spirit

“For years the Mugabe led government kept on reducing the health budget”, Rietsema explains. “It now seems that the new government is reversing the tide. They are serious in taking over the implementation of the RBF health program. This shows the success of Cordaid’s results-based financing approach. In five years’ time we managed to infuse hundreds of health facilities with an entrepreneurial spirit. This has drastically improved access to health care for the poorest, especially young mothers and children.”

Zimbabwe health program at a glance:

18 districts

400 health facilities (including 34 hospitals)

giving 3.2 million people access to health care

allowing 100.000 pregnant women to deliver safely

providing pregnancy check-ups to more than 125.000 women

Restarting after total collapse

To fully gauge the achievements of the RBF program, we need to go back to 2008. Mugabe’s economic adjustment program and his land reforms had devastated the economy. Public services, including the health system, collapsed. Salaries evaporated as a result of hyperinflation – at one point the state printed 100 trillion Zimbabwean dollar notes. Food production and life expectancy dropped and people fled the country by the millions.

Immediate results of results-based financing

Jos Dusseljee, Cordaid’s senior health expert who kickstarted the program back in 2011: “It’s on these vestiges we started the RBF program in 2011, after having won a World Bank tender. We knew the basic health infrastructure was intact, and the human capacity was basically there. But most health facilities were derelict. Salaries were very low, leading to absenteeism. Consequently the facilities were unable to provide a full package of primary health services, let alone adhere to quality standards. Our guess was that with little push – a relatively small financial investment of 2 USD per capita, and a strictly results-based financing method – we could achieve a steep increase in the quantity and quality of health services. This proved true. We saw the magic of RBF happening before our eyes.”

Cordaid purchased entire district maternal and child health services. Initially we did this in 2 front runner districts. Soon we expanded to 16 others. Dusseljee: “We pay – or do not pay – contracted facilities according to their verified scores on a pre-agreed set of indicators. There are quantity output indicators, such as the number of deliveries, child vaccinations, ante- and postnatal care. And quality indicators, such as the quality of the premises, of management and of service delivery, besides patient satisfaction.”

Monitoring 20 indicators in 400 facilities

Cordaid put in place a thorough monitoring and evaluation system to check monthly achievements. This involved district health officers as well as Community Based Organisations who traced patients and measured their satisfaction with the services they received. Dusseljee: “You can imagine that monitoring 20 indicators in 400 facilities spread all over the country was quite an operation. To manage, we set up small Cordaid outposts in different provinces.”

The impact was impressive. “I have been involved in health system strengthening for many years and many different countries”, says Dusseljee. “And I can say that the first results in Zimbabwe were astonishing. Utilisation of services increased significantly. So much so that the Ministry of Health wanted us to scale up fast after they saw the results in the front runner districts.”

Happy with the money, not with the conditions

By this time, the Ministry of Health’s initial hesitance to collaborate with Cordaid had vanished. From the start the World Bank had insisted to work with a private implementing and purchasing agency, rather than with the government. Rietsema: “When Cordaid started, the government was happy with the money invested in Zimbabwean public health. But they weren’t happy with the conditions and the fact that not themselves, but Cordaid was the main implementer and purchasing agency.”

Once Cordaid started to roll out the program, health centers got back on track after years of gradual collapse. And government’s attitude changed overnight. “Soon government delegations came over to visit us”, Rietsema recalls. “And in their wake came delegations of other countries who wanted to learn from us.”

After 2,5 years the RBF approach implemented by Cordaid, was integrated in national health policies.

Long awaited make-over

On average and on a quarterly basis, Cordaid buys services worth 1000 USD per health center and 30.000 USD per hospital. Rietsema: “Theoretically our RBF payments are meant for innovation and as an incentive to perform better. They don’t cover the regular bills. State subsidies should do that. But these were lacking. That’s why RBF World Bank money – the main source of income for most facilities – was invested in the make-over they had been waiting for for years: building waiting rooms for pregnant mothers, installing solar panels, connecting facilities to the grid, giving walls a fresh coat of paint and other basic infrastructural improvements. Making the premises much more attractive and welcoming. The next step was the improvement of services, procurement of medicines, of diagnostic equipment.”

Early booking for antenatal services

The RBF change – or ‘the magic’ as Dusseljee calls it – is more than just the improvement of infrastructural and services. Rietsema: “Health staff had been used to things being supplied – and more often not supplied – either by donor agencies or the state. They weren’t used to the freedom and the responsibility to manage their own budget. RBF gave them just this. It pushed them to manage their own health centers and hospitals. Staff felt the need to develop strategies to attract patients. Patients who had lost their faith in public health services a long time ago. RBF pushed health staff to become more entrepreneurial. For example, some nurses have become very creative in promoting ‘early booking’ for antenatal services. Which is great as pregnant women often seek medical assistance far too late in their pregnancy. Women who book their antenatal care services early, receive soap and groceries. These are very welcome items for most households! They might cost something, but the financial benefits coming with the increase in patients far outweigh the costs.”

One thing that astonished Dusseljee – apart from the quick results – is how fast the Zimbabwean government embraced the RBF policy and nationalized it. “This and the fact that other countries took over our method as well. It confirmed our capacity to design and successfully implement innovative health financing approaches. And it strengthened our relationship with the World Bank.”

Future of the program

There’s one wish Rietsema still has for the next phase of the program. “I hope there will still be a technical unit that focuses on innovation and system improvement in RBF. We have started working with tablets and smartphones. But we need to do more to promote electronic invoicing and the use of tablets and applications in monitoring, to name just a few technical innovations. In addition to that: quality improvement is something we have only just started emphasising strongly. This needs to be continued.”

Dusseljee, from his side, comes with another piece of advice: “The program is built on supply-side incentives. This worked well, but statistics show that after the spectacular initial results, service use is now levelling. In order to make sure we reach everyone and come one step closer to Universal Health Coverage, there should be provisions for demand-side incentives too. For example, the government could contract and reward communities for their efforts to help the most needy in accessing health care services.”

Handing over to the government

Cordaid’s technical role in the RBF program will continue until mid-2018, but as of January the Zimbabwean Ministry of Health and Child Care will replace Cordaid as the purchasing agency. Rietsema: “This is why it’s so important they have allocated more than 10 million USD. The next step is that the government implements the budget and continues the program. Which would be a great relief. Cordaid is already in the process of handing over. The Ministry of Health already accommodates our technical staff.”

“At the start, we worked against the odds. Now, we can hand over a well-functioning program to a government that shows real health care commitment and is ready to further expand the RBF scheme”, Rietsema concludes. “That, to me, is very satisfying.”