(How) does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo

Abstract

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.

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

“…Based on our case study of Zimbabwe, it suggests that expectations of institutional reform and in particular the potential for RBF to drive a more strategic approach to purchasing [5] [4] should be moderated, particularly at early stages of RBF implementation [43] . Considering our strategic purchasing framework, we find (see summary in Table 3) that rather than systematically reforming strategic purchasing functions, in contexts like Zimbabwe's RBF adds a new provider payment mechanism into the mix, which can produce benefits, but also adds to a complex landscape and does not resolve many underlying challenges [44] [45] iv . Some functions, such as assessing service infrastructure gaps, are unaffected by RBF, while others, such as mobilising resources are partially improved, as RBF in Africa has focused on one package of care (MCH services) within the wider essential health care, and even here has contributed only marginal costs.…”

The political economy of results-based financing: the experience of the health system in Zimbabwe

“…In relation to our second question on implementation, the MoHCC retained authority over decision-making, however, the complexity of RBF programmes poses a challenge, with our study and a related study of the effects of RBF on strategic purchasing highlighting the risk of important technical decisions being decided in smaller groups and merely being ratified by governing bodies [44]. The discussion about ‘purity’ of the model also raises the issue of trade-marking of concepts: while some groups have historically had a very strong influence over the development of RBF in low and middle income countries, it is clear that there are differing understandings and applications across settings and indeed that some degree of local adaptation may be essential for the schemes’ success [8, 39] and to ensure that RBF is not seen as a standalone programme.…”

“…In terms of the resources which RBF brought to the under-financed health system in Zimbabwe, this represented a small but significant (and partially additional) increment in public resources for health, around 3% of the estimated need per capita for an essential health care package or 5% of available funding. Rather than providing an incentive, due to shortfall in the public budget it was used as the main source of funding for non-salary recurrent costs at PHU level, thus functioning as a core financing mechanism [44] and supporting the improved performance of the sector as a whole [30, 32]. Its future role within the wider health financing landscape remains unclear.…”

Misunderstandings and ambiguities in strategic purchasing in low‐ and middle‐income countries

“…Furthermore, the intermarriage of PBF and strategic purchasing is also fuelled within the PBF literature, which has increasingly presented PBF as a preferred tool to implement strategic purchasing. For example, World Bank consultants state that PBF programmes “use strategic purchasing of services to expand coverage and promote quality ….” 22 Witter et al examined how (and whether) PBF strengthens strategic purchasing of health in three countries 23 . Gautier et al explain that “[w]hen the concept of ‘strategic purchasing’ came into the debate in late 2016, PBF offered to operationalise that concept… PBF thus got linked to strategic purchasing, reportedly thanks to internal framing activities done by individual [diffusion entrepreneurs] within the World Health Organization.” 24 …”