Endris Mohammed Seid 1,2, Arjanne Rietsema 1 1: CORDAID-Zimbabwe 2: Ministry of Health and Child Care- Zimbabwe Improving Maternal, Neonatal and Child Health (MNCH) through the Results Based Financing Programme for Health in Zimbabwe

Presentation Outline Background Methods Quantity verification and Results Quality of care assessment and results Lesson learnt and Recommendations Acknowledgement

Background World Bank between mid-2011 and 2015, awarded grants to the Government of Zimbabwe, to pilot and roll out Results Based Financing for Health (RBF) RBF-a strategy of financing health care delivery based on results (output, performance) Measured through predefined indicators at 394 rural health centres and district hospitals in 18 rural districts Covers approximately a total of 3.7 million people Implemented by CORDAID, a Dutch based NGO Aim: Supporting MoHCC effort to increase the availability, accessibility and utilisation of quality health care to improve maternal and child health Context: MMR: 570/100,000 live births in 1990 to 960/100,000 live births in 2010 <5 mortality rate: 76 to 84/1000 live births from 1990 to 2010 Non-RBF districts: input based financing through HTF ( until Q3 2014)

Methods Separation of functions: Fund holder/Purchaser, Regulator,, and Provider Linking Payment to results: Quantity Verification: CORDAID field officers Quality assessment: Provincial and District health executive members Community empowerment: CBOs conducting client satisfaction surveys Health Center Committees: play a critical role in supporting the implementation of RBF at health center level Autonomy: RBF subsidies transferred to Health facilities accounts Health facilities develop operational plan and utilize the subsidies accordingly Capacity Building: On RBF, survey tool, quality checklist, operational plan development, M&E, etc Counter verification: Quantity and quality of care

Quantity verification Conducted by CORDAID field officers: Frequency: as per the category of the facility: Red: once a month Amber: once in two months Green: once a quarter Compare the reported data in HIMS with the actual data in the registers Difference >5%, facility will not get the subsidy for the indicator Collect data on pre-defined set of quantity indicators e.g. First ANC visit before 16 weeks, HIV test for pregnant women, ARV for HIV positive pregnant women Calculate the amount of money per indicator Uses the existing system: Source of data: routine HIMS report and registers Mechanism for calculating the amount of the RBF subsidy for the facility 25% of the subsidy: incentives to health care providers

Results: Quantity verification

Quality of care assessment Both provider and perceived quality of care assessed: Provider: Quality checklist input and process indicators (Structural, administrative and clinical indicators) Clinical indicators: e.g. management of labor, and delivery, common childhood illnesses, HIV PMTCT ( Option B+) Administered quarterly by Provincial Health and District Health Executive members ( PHEs and DHEs) for Hospitals and Clinics, respectively Perceived: Client satisfaction survey tool Administered by CBOs: Quarterly on 19 sampled clients per facility Waiting time, friendliness of service, availability of essential medicines assessed Feedback to HCC at clinic: action plan for improvement by the facility Impact evaluation by World Bank ( Mid term and end of project) Dif. In Dif. Method Comparison between intervention and control districts Different tools: Checklist ( quality and quantity), Observation and interview

Result-Quality of care assessment Client satisfaction survey tool: Reduction of waiting time: Hiring additional staff in busy clinics and re-organizing services Improved reception of clients at facilities Construction of maternity waiting home, bore holes, toilets Quality checklist: increased from 55% in 2012 to 80% in 1 st quarter of 2015 Proportion of children correctly assessed and treated for diarrhea at clinic level : ↑20% ( Q2 214 to Q4 2014) Proportion of correctly filled partographs: ↑12% (Q2 214 to Q4 2014) Mid-term evaluation by World Bank: Structural quality: Family and child health: statistically significant increment as compared to non-RBF districts Clinical process: performing urine analysis on pregnant women: statistically significant difference between RBF and non-RBF facilities

Lessons learnt and Recommendation An increasing trend in coverage of MNCH services Some of the results consistent with the Mid term evaluation results of World Bank ( in comparison with non-RBF districts): 13 percentage point improvement in the in-facility delivery rate 12 percentage point improvement in post-natal care coverage Significant improvement in the quality of select ANC services Results need to be carefully interpreted: need to take into account impact of other interventions e.g. HTF Scaled up to 42 more districts Co-financing by the Government of Zimbabwe ( Sustainability and Ownership) Improved responsiveness of facilities to clients Steady improvement in clinical care process indicators As a country a decline in MMR and <5 Mortality: 2014: MMR ( 614/100,000live births) and <5 mortality (74/1000 live births) There is a contribution of RBF: needs to be measured Need for Incentivizing TB and Paediatric HIV indicators Need for initiating QI in RBF context: aligned with HIV QI program End of project evaluation: critical

Acknowledgement MoHCC World bank Cordaid PHEs and DHEs in 18 districts CBOs Health care providers in the 18 Districts