Results-Based Financing for Health: A Case Study of Knowledge and Perceptions Among Stakeholders in a Donor-Funded Program in Zambia

The lack of a fully developed results-based financing model before implementation of a program in the health sector begins can lead to difficulty in communicating about the program to different actors involved and delay components of implementation. Key Messages The intended incentive structure of results-based financing (RBF) makes it particularly important that program implementers communicate to beneficiaries of a program before implementation begins about the nature of the program and that RBF will be used. Improved decision making and communication about the requirements and expectations of an RBF program can enhance stakeholders' knowledge and perceptions of the program, and ultimately make implementation easier. Key Findings The lack of a fully developed RBF model meant the program was more difficult to communicate to the different actors involved. The lack of knowledge of the RBF program and the existence of incentives raises doubts about whether the program incentivized actors for the intended targets. Key Implications Program managers should recruit stakeholders from all governments and organizations involved in program financing and implementation to participate in the design of RBF schemes so that they can effectively communicate the structure and indicators to different levels of their respective organizations. Program implementers using RBF should have a flexible plan in place for the RBF model before implementation begins, even if the plan might change. ABSTRACT In 2015, the Zambian government and the Swedish International Development Cooperation Agency (Sida) signed an agreement in which Sida committed to funding a program for Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH). The program includes a results-based financing (RBF) model that aims to reward Zambian districts for improved district-wide results on relevant indicators with additional funding. We aimed to describe stakeholders' knowledge of the RBF model and perceptions of the incentive structure during the first 18 months of the program's implementation. This study illuminates the possible pitfalls of implementing an RBF scheme without giving attention to all necessary steps of the process. A qualitative case study was used and included a review of documents, in-depth interviews, and observations. From February–April 2017, we conducted 37 in-depth interviews, representing the views of 12 development partner agencies, government departments, and health facility staff throughout Zambia. We used a qualitative framework analysis. Findings show that the Zambian government and Sida had different perceptions on what levels of the health system RBF will incentivize and that most districts and hospital administrators interviewed were unaware of the indicators that the RBF was part of the RMNCAH program at all. The lack of knowledge about the RBF scheme among respondents suggests the possibility that the model did not ultimately have the necessary preconditions to create an effective incentive structure. These results demonstrate the need for improved communication between stakeholders and the importance of sufficiently planning an RBF model before implementation.