This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied-Uganda, Sierra Leone, Zimbabwe and Cambodia-which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts-particularly in relation to physical threats and psychosocial threats-while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.

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.

BackgroundResults-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade.MethodsThe article is based on a documentary review, including 110 documents from 2004 to 2018, and 98 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in the selected districts of the three countries. Interviews and analysis followed an adapted framework for strategic purchasing, which was also used to compare across the case studies.ResultsAcross the cases, at the government level, we find little change to the accountability of purchasers, but RBF does mobilise additional resources to support entitlements. In relation to the population, RBF appears to bring in improvements in specifying and informing about entitlements for some services. However, the engagement and consultation with the population on their needs was found to be limited. In relation to providers, RBF did not impact in any major way on provider accreditation and selection, or on treatment guidelines. However, it did introduce a more contractual relationship for some providers and bring about (at least partial) improvements in provider payment systems, data quality, increased financial autonomy for primary providers and enforcing equitable strategies. More generally, RBF has been a source of much-needed revenue at primary care level in under-funded health systems. The context – particularly the degree of stability and authority of government–, the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed.ConclusionsOur evidence suggests that expectations of RBF as an instrument of systemic reform should be nuanced, while focusing instead on expanding the key areas of potential gain and ensuring better integration and institutionalisation, towards which two of the three case study countries are working.

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.(Continued on next page)

Background Zimbabwe experienced a socio-economic crisis from 1997 to 2008 which heavily impacted all sectors. In this context, human resource managers were confronted with the challenge of health worker shortage in rural areas and, at the same time, had to operate under a highly centralised, government-centred system which defined health worker deployment policies. This study examines the implementation of deployment policies in Zimbabwe before, during and after the crisis in order to analyse how the official policy environment evolved over time, present the actual practices used by managers to cope with the crisis and draw lessons. ‘Deployment’ here was considered to include all the human resource management functions for getting staff into posts and managing subsequent movements: recruitment, bonding, transfer and secondment. The study contributes to address the existing paucity of evidence on flexibility on implementation of policies in crisis/conflict settings. Methods This retrospective study investigates deployment policies in government and faith-based organisation health facilities in Zimbabwe before, during and after the crisis. A document review was done to understand the policy environment. In-depth interviews with key informant including policy makers, managers and health workers in selected facilities in three mainly rural districts in the Midlands province were conducted. Data generated was analysed using a framework approach. Results Before the crisis, health workers were allowed to look for jobs on their own, while during the crisis, they were given three choices and after the crisis the preference choice was withdrawn. The government froze recruitment in all sectors during the crisis which severely affected health workers’ deployment. In practice, the implementation of the deployment policies was relatively flexible. In some cases, health workers were transferred to retain them, the recruitment freeze was temporarily lifted to fill priority vacancies, the length of the bonding period was reduced including relaxation of withholding certificates, and managers used secondment to relocate workers to priority areas. Conclusion Flexibility in the implementation of deployment policies during crises may increase the resilience of the system and contribute to the retention of health workers. This, in turn, may assist in ensuring coverage of health services in hard-to-reach areas.