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

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 ec...

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Autores principales: Witter, Sophie, Chirwa, Yotamu, Chandiwana, Pamela, Munyati, Shungu, Pepukai, Mildred, Bertone, Maria Paola
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628468/
https://www.ncbi.nlm.nih.gov/pubmed/31338425
http://dx.doi.org/10.1186/s41256-019-0111-5
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author Witter, Sophie
Chirwa, Yotamu
Chandiwana, Pamela
Munyati, Shungu
Pepukai, Mildred
Bertone, Maria Paola
author_facet Witter, Sophie
Chirwa, Yotamu
Chandiwana, Pamela
Munyati, Shungu
Pepukai, Mildred
Bertone, Maria Paola
author_sort Witter, Sophie
collection PubMed
description 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.
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spelling pubmed-66284682019-07-23 The political economy of results-based financing: the experience of the health system in Zimbabwe Witter, Sophie Chirwa, Yotamu Chandiwana, Pamela Munyati, Shungu Pepukai, Mildred Bertone, Maria Paola Glob Health Res Policy Research 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. BioMed Central 2019-07-15 /pmc/articles/PMC6628468/ /pubmed/31338425 http://dx.doi.org/10.1186/s41256-019-0111-5 Text en © The Author(s) 2019 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
spellingShingle Research
Witter, Sophie
Chirwa, Yotamu
Chandiwana, Pamela
Munyati, Shungu
Pepukai, Mildred
Bertone, Maria Paola
The political economy of results-based financing: the experience of the health system in Zimbabwe
title The political economy of results-based financing: the experience of the health system in Zimbabwe
title_full The political economy of results-based financing: the experience of the health system in Zimbabwe
title_fullStr The political economy of results-based financing: the experience of the health system in Zimbabwe
title_full_unstemmed The political economy of results-based financing: the experience of the health system in Zimbabwe
title_short The political economy of results-based financing: the experience of the health system in Zimbabwe
title_sort political economy of results-based financing: the experience of the health system in zimbabwe
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628468/
https://www.ncbi.nlm.nih.gov/pubmed/31338425
http://dx.doi.org/10.1186/s41256-019-0111-5
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