The political economy of results-based financing: The experience of the health system in Zimbabwe
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Date
2019-07-15Author
Witter, Sophie
Chirwa, Yotamu
Chandiwana, Pamela
Munyati, Shungu
Pepukai, Mildred
Bertone, Maria Paola
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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).
Abstract
Background: Since 2000, results based financing (RBF) has proliferated in health sectors in Africa in particular,
including in fragile and conflict affected settings (FCAS) and there is a growing but still contested literature about
its relevance and effectiveness. Less examined are the political economy factors behind the adoption of the RBF
policy, as well as the shifts in influence and resources which RBF may bring about. In this article, we examine these
two topics, focusing on Zimbabwe, which has rolled out RBF nationwide in the health system since 2011, with
external support. Methods: The study uses an adapted political economy framework, integrating data from 40 semi-structured
interviews with local, national and international experts in 2018 and thematic analysis of 60 policy documents
covering the decade between 2008 and 2018. Results: Our findings highlight the role of donors in initiating the RBF policy, but also how the Zimbabwe health
system was able to adapt the model to suit its particular circumstances – seeking to maintain a systemic approach,
and avoiding fragmentation. Although Zimbabwe was highly resource dependent after the political-economic crisis
of the 2000s, it retained managerial and professional capacity, which distinguishes it from many other FCAS
settings. This active adaptation has engendered national ownership over time, despite initial resistance to the RBF
model and despite the complexity of RBF, which creates dependence on external technical support. Adoption was
also aided by ideological retro-fitting into an earlier government performance management policy. The main
beneficiaries of RBF were frontline providers, who gained small but critical additional resources, but subject to high
degrees of control and sanctions. Conclusions: This study highlights resource-seeking motivations for adopting RBF in some low and middle income
settings, especially fragile ones, but also the potential for local health system actors to shape and adapt RBF to suit
their needs in some circumstances. This means less structural disruption in the health system and it increases the
likelihood of an integrated approach and sustainability. We highlight the mix of autonomy and control which RBF
can bring for frontline providers and argue for clearer understanding of the role that RBF commonly plays in these
settings.