Witter Sophie, Chirwa Yotamu, Chandiwana Pamela, Munyati Shungu, Pepukai Mildred, Bertone Maria Paola
1ReBUILD programme, Queen Margaret University, Edinburgh, EH21 6UU UK.
2ReBUILD and Biomedical Research and Training Institute, P O Box CY 1753, Harare, Zimbabwe.
Glob Health Res Policy. 2019 Jul 15;4:20. doi: 10.1186/s41256-019-0111-5. eCollection 2019.
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.
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.
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.
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.
自2000年以来，基于结果的融资（RBF）在非洲卫生部门尤其盛行，包括在脆弱和受冲突影响的地区（FCAS），关于其相关性和有效性的文献日益增多，但仍存在争议。RBF政策采用背后的政治经济因素，以及RBF可能带来的影响力和资源转移，较少受到审视。在本文中，我们聚焦于自2011年起在外部支持下已在全国卫生系统推行RBF的津巴布韦，探讨这两个主题。
本研究采用了一个经过调整的政治经济框架，整合了2018年对当地、国家和国际专家进行的40次半结构化访谈的数据，以及对2008年至2018年这十年间60份政策文件的主题分析。
我们的研究结果凸显了捐助者在启动RBF政策方面的作用，同时也展现了津巴布韦卫生系统如何能够调整该模式以适应其特殊情况——力求保持系统方法，避免碎片化。尽管津巴布韦在21世纪经历政治经济危机后高度依赖资源，但它保留了管理和专业能力，这使其有别于许多其他FCAS地区。随着时间的推移，这种积极的调整产生了国家自主权，尽管最初对RBF模式存在抵制，且RBF本身复杂，导致对外部技术支持的依赖。意识形态上向早期政府绩效管理政策的改造也有助于其采用。RBF的主要受益者是一线提供者，他们获得了虽少但关键的额外资源，但受到高度控制和制裁。
本研究强调了在一些低收入和中等收入环境，尤其是脆弱环境中采用RBF的资源寻求动机，同时也表明在某些情况下，地方卫生系统行为者有能力塑造和调整RBF以满足自身需求。这意味着卫生系统的结构破坏较小，增加了采用综合方法和实现可持续性的可能性。我们强调了RBF可为一线提供者带来的自主权与控制权的结合，并主张更清晰地理解RBF在这些环境中通常所起的作用。
