Table 3 Summary of findings: impact of RBF on purchasing functions in Zimbabwe
Key strategic purchasing actions by government | Ensure adequate resources mobilised | •RBF provided modest but partially additional funds, still significant for primary care providers •Focused on MCH indicators •Donor dependent, though some Ministry of Finance copayments in later years |
Ensure accountability of purchaser(s) | •Parallel system with external purchasers •Accountability of purchasers to funders as well as to government •Bulk of purchasing continued through other channels, not affected | |
Fill service delivery infrastructure gaps | •RBF provided some upfront investment, but no major revision of infrastructure planning in relation to needs | |
Key strategic purchasing actions in relation to citizens/population served | Inform the population of entitlements Establish mechanisms for complaints and feedback Publicly report on use of resources and performance | •RBF requires price list to be made public on the facility wall •Community satisfaction survey carried out as part of RBF verification •RBF helped revive Health Centre Committees and shifted their focus from resource mobilization to resource allocation; variable results and capacity |
Assess needs, preferences, values of the population to specify benefits | •No consultations on needs, values and preferences linked to RBF package •Package defined nationally with no scope for variation at local level | |
Key strategic purchasing actions in relation to providers | Establish service agreements/select (accredit) providers | •RBF did not change accreditation system •RBF required facilities to meet minimum criteria, including developing an operational plan, having a bank account and a functioning HCC •RBF introduced contracts; contracts are limited to services and facilities covered by RBF |
Developing formularies and standard treatment guidelines | •RBF worked within existing guidelines; no change introduced here | |
Design, implement, modify provider payment methods to encourage efficiency and quality Establish provider payment rates Pay providers regularly | •RBF introduced payment rates for services (not the practice before in public purchasing) •Mixed picture in terms of outputs and quality improvements •Focus on MCH services, including some for which coverage is high, raising questions about efficiency; no local ability to adapt indicators •RBF functioning more as financing mechanism than incentive (partly because of wider budget cuts) •Payments driven mainly by catchment population size •Concerns over regularity and sustainability of payments (rates have been reduced over time); costs of RBF implementation high but reducing •Evidence of learning/iteration but RBF system is complex to adjust •Some quality improvements (e.g., drugs availability) and convergence on national tools for quality improvement (though still some duplication across programmes) | |
Allocate resources equitably and implement strategies to promote equitable access | •Remoteness bonus, but considered too small and failed to compensate facilities with small catchment areas •Equitable design in terms of service package covered •Poor urban areas excluded | |
Establishing and monitoring user payment policies | •RBF aimed to remove user fees for the MCH services it covered. However, no difference in incidence of out of pocket payments between control/intervention areas found in impact evaluation •Financial and non-financial barriers continue to be significant | |
Securing information on services provided, and developing, managing and using information systems | •RBF brought greater focus on data quality, though still many weaknesses •System for penalizing poor recording may be too strict (causing unfair loss of revenues by facilities) •RBF used HMIS data after having verified and corrected it •Providers have multiple data reporting requirements | |
Monitoring provider results and acting on poor results | •Pre-existing well developed and integrated supervision system to which RBF provided funding •Variation in robustness of supervision, linked to wider issues of leadership and resources •Considerable technical support required from implementers’ field officers (and challenges in institutionalizing that) | |
Auditing provider claims and protecting against fraud and corruption | •Complex verification/counter-verification procedures for RBF, and restrictions on procurement (from public finance rules) •Little evidence of false claims, able to move to risk based verification; challenge of shift to longer term (integrated) controls |