Results-based financing as a strategic purchasing intervention: Some progress but much further to go in Zimbabwe?

Background: Results-Based Financing (RBF) has proliferated in the health sectors of low and middle income countries, especially those which are fragile or conflict-affected, and has been presented by some as a way of reforming and strengthening strategic purchasing. However, few if any studies have empirically and systematically examined how RBF impacts on health care purchasing. This article examines this question in the context of Zimbabwe’s national RBF programme. Methods: The article is based on a documentary review, including 60 documents from 2008 to 2018, and 40 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in Zimbabwe. Interviews and analysis of both datasets followed an existing framework for strategic purchasing, adapted to reflect changes over. Results: We find that some functions, such as assessing service infrastructure gaps, are unaffected by RBF, while others, such as mobilising resources, are partially affected, as RBF has focused on one package of care (maternal and child health services) within the wider essential health care, and has contributed important but marginal costs. Overall purchasing arrangements remain fragmented. Limited improvements have been made to community engagement. The clearest changes to purchasing arrangements relate to providers, at least in relation to the RBF services. Its achievements included enabling flexible resources to reach primary providers, funding supervision and emphasising the importance of reporting. Conclusions: Our analysis suggests that RBF in Zimbabwe, at least at this early stage, is mainly functioning as an additional source of funding and as a provider payment mechanism, focussed on the primary care level for MCH services. RBF in this case brought focus to specific outputs but remained one provider payment mechanism amongst many, with limited traction over the main service delivery inputs and programmes. Zimbabwe’s economic and political crisis provided an important entry point for RBF, but Zimbabwe did not present a ‘blank slate’ for RBF to reform: it was a functional health system pre-crisis, which enabled relatively swift scale-up of RBF but also meant that the potential for restructuring of institutional purchasing relationships was limited. This highlights the need for realistic and contextually tailored expectations of RBF. The case study is largely retrospective, focusing on the period since 2011, although drawing on insights into the health system in Zimbabwe pre-crisis from earlier studies [15, 16]. It is based on KI interviews at national, provincial and district levels, integrated with analysis of documentation (policies and strategies, project documents and manuals, project evaluations and academic articles). Data collection was done at national level and in two provinces (Midlands and Mashonaland East), including four districts (Murewa, Marondera, Gokwe North and Gokwe South). These provinces were selected as they were the sites for the pilot districts in 2011. The districts were chosen as representing one each from the two schemes (Cordaid and Crown Agents) per province and including the two pilot districts. We searched for documents on RBF in Zimbabwe from sources such as reliable websites (both for peer-reviewed and grey literature, including the World-Bank RBF website, the PBF Community of Practice and government websites), suggestions from KIs from government departments, donors and NGOs (including the implementers, Cordaid and Crown Agents), as well as documents already available because of the long term engagement in-country of the researchers. The documents included the following: A snowball technique was adopted by checking the references provided in the documents analysed and retrieving further relevant documents. The documents date from the decade after 2008 – i.e. after the most acute period of crisis and prior to the introduction of RBF in 2011 – up till 2018. Some 60 documents were reviewed, the vast majority of which were operational and grey literature. Purposive sampling was used to identify KIs at national, provincial and district levels, based on their knowledge and involvement on RBF from its inception. The selection of interviewees was as comprehensive as possible, including individuals currently holding RBF-related posts or who were previously in such positions. A number of relevant organizations, groups and individuals involved in RBF were preliminarily identified. New individuals were added based on the results of the documentary review or as suggested by KIs. Individuals to be interviewed included representatives of: The breakdown of KIs interviewed (40 in total) is provided in Table ​Table1.1. 18 MoHCC staff were interviewed at national, provincial and district levels. The development partner group was the next-largest constituency, with 10 KIs. Overall, men predominated, reflecting gender discrepancies in public service, particularly at higher levels. For RBF implementers, by contrast, staff at central and field offices were more commonly female. KIs summary KIs were approached by email or telephone, providing them with a brief explanation of the research project. A time and date for an interview was agreed upon. Before the interview, the researcher explained the study objectives and scope, and informed consent was obtained in writing. Confidentiality was assured. Consent was requested for recording, with manual note-taking as a fall-back option where the respondent was not comfortable with the conversation being recorded or where security arrangements or technology did not permit recording. 26 out of 40 interviews were recorded. KIs were interviewed in English, using a semi-structured interview guide, based on the strategic purchasing framework [9], using a topic guide which was developed by the research team (supplementary file 1). Most interviews took place in the informant’s place of work, but in a location where privacy was assured. Some interviews were conducted by phone or Skype, where physical distance or access necessitated it. Interviews focused on the period from 2008 (prior to RBF introduction) to present and were tailored to the time available and the knowledge of the KI. Interviews lasted from 30 min to 2 hours, with an average of 1 hour. The questioning was led by a senior researcher, with a colleague assisting in taking notes. Interviews took place from early February to late March 2018. We analyse our findings using a strategic purchasing framework which has been adapted from the literature [9]. The framework reflects the conceptualisation of strategic purchasing as the interaction between the purchaser and three levels of stakeholders: governments, citizens (or the population) and providers. The framework provides a descriptive and comprehensive list of actions and decisions that need to be made with reference to these three sets of stakeholders to ensure (strategic) purchasing (Table ​(Table2).2). The framework was chosen to provide a clear, pre-existing conceptualisation of a broad concept. We later reflect on the advantages and disadvantages of the framework chosen. The choice of an existing framework was done explicitly to avoid creating something ‘ad hoc’ for our analysis but rather rely on a previous, theoretical exploration of the concept. However, given the novelty of the concept of ‘strategic purchasing’ and its operationalisation, we recognise that there is a discussion to be had around the framework itself, beyond our specific findings. While this is not the purpose of the paper, we briefly do so in the first part of the discussion section. Data analysis was done iteratively. A first analysis of the documents collected was conducted before the interviews in the field, and guided the discussion during interviews. Later on, new documents were added to the review, and a final thematic analysis [17] was conducted of documents and interview transcriptions or notes, using mostly pre-defined themes based on the strategic purchasing framework [9] which was adapted to the specific context and to reflect on the role of fragility in the case study (Table ​(Table2).2). Results of the analysis of documents and interviews were written-up together to allow for triangulation and complementarity between data sources. Ethical clearance was obtained from the Research Ethics Panel of Queen Margaret University, Edinburgh, and from the Medical Research Council of Zimbabwe. The study also received authorisation from the MoHCC.