External Verification of Results Based Financing in Zambia

By Maria Paalman (consultant and team leader)

Results Based Financing (RBF) is increasingly being applied in a variety of different ways and contexts to strengthen the demand, supply and quality of health services in low and middle income countries. It is based on the assumption that financial incentives can motivate and improve the performance of health care professionals (supply-side RBF) and increase service utilisation among targeted population groups (demand-side RBF).

The Government of the Republic of Zambia received a $17 million grant from the Health Results Innovation Trust Fund (financed by Norway and DFID), administered by the World Bank, to pilot a RBF scheme in 10 districts, in a bid to increase utilisation and quality of health services. The approach of the RBF project, which began in April 2012, is “fee-for-service conditional on quality of care” targeting nine key services for improving maternal and child health outcomes. The success of the RBF project hinges on accurate reporting at all levels of the health system and built-in checks and balances to assure the quality of services.  

During 2014 Euro Health Group finalised a one-year contract with the Ministry of Health to carry out the first ever external verification in Zambia, internal verification is carried out by the project,  through the implementation of two components: an external facility audit of services invoiced by the health facilities and internally verified by the District Community Medical Officer; and a client tracer survey tracking clients in their communities to confirm receipt of services and assess client satisfaction with the services.

The EHG team consisted of Maria Paalman (team leader) and Jason Pickering (data management expert), while Rosemary Kabwe headed the facility audit team and Christopher Zimba the client tracer team. The client tracer survey was overseen by  AKROS Global Health , a Zambian company.  

The external verification included a sample of 72 rural health centres and surrounding communities covering all provinces in Zambia and all 9 RBF indicators. The client tracing survey attempted to trace and interview 30 clients per health centre, 15 women who had delivered in the facility and 15 infants who had been fully vaccinated. All data were uploaded in open source software, adapted to the requirements of the study. An overall report aggregated the data from the 10 districts and provided more general conclusions and recommendations.

Given this was the first external verification of the RBF programme in Zambia, the objective to learn from the exercise was as important as the actual result.

The consultant team formulated several lessons learnt keeping in mind that initially large discrepancies between different types of verification are often seen, narrowing over time, when more experience is gained. Most importantly, in order for any verification to be useful and reliable it is necessary to ensure that facilities have sufficient capacity to do the self-assessments and that internal and external verifiers all use exactly the same methods of counting the services. To this end detailed instructions have to be developed for each indicator, because the definitions alone are not sufficient to guarantee this.

The final report provided a number of recommendations for the next phase of the RBF programme scheduled for  January 2015.