Start: In 2010 with Cordaid. Later, with WB funding in 10 districts until 2019.
Phase: Results-based financing stopped in 2019 and was replaced by the National Health Insurance Scheme, which did not develop into a mature health system.
Coverage Estimate in 2018: 10%
Feasibility Score in 2018 based on 23 PBF criteria: 32%
Supported by: Ministry of Health, the World Bank, USAID, DFID, and SIDA

Description: WB-financed results-based financing pilot started in 10 districts after a pre-pilot phase in Katete District. The pilot was linked to an impact evaluation that showed encouraging results. The Ministry of Health of Zambia has been engaged in RBF for several years, but it has not yet established a national PBF unit. Four RBF projects are financed by the World Bank, USAID, DFID, and SIDA and are managed under 4 different departments. This creates challenges for coordination and resource optimization.

This changed, however, when the Government announced a shift from INPUT-based planning to OUTPUT-based planning at the beginning of 2018. On this basis, the Zambia team proposed lobbying for the integration and establishment of a professional PBF Unit directly under the Permanent Secretary to better coordinate the different vertical RBF programs.

Main challenges (Zambia group attending the 70th PBF course in Mombasa, June 2018)

PBF principles stress the need to establish a PBF Unit, preferably at the decision-making level. PBF also emphasizes efficient and effective use of funds. However, this contrasts with the current situation in the Ministry of Health, where no unit is established, and efforts are duplicated due to vertical, fragmented project implementation.

In the situation in 2018;

• There is fragmentation of PBF interventions depending on the source of funds (no resource pooling);
• There is no standard approach to PBF.

The Zambian group attending the 70th PBF course in Mombasa estimated that the feasibility score of the Zambia PBF program in 2018 was 32%. For details, see the report.

They said a major challenge will be convincing the PS and other stakeholders to set up a coordinated funding basket run by a central PBF Unit, rather than having project implementation units run in parallel. We also anticipate resistance from various donors in establishing a common funding basket. This could create conflict at different levels, including senior management at the Ministry of Health.

In 2019, Zambia moved towards the National Health Insurance Scheme (NHIS). Yet it combined this with generalized free health care in government health facilities.

The WHO Health Financing Progress Matrix assessment for Zambia 2024 stated the following.

The government health budget is the primary mechanism for pooling and redistribution of resources, supporting free primary care for all citizens. More generally, multiple fragmented pools include the Central Treasury, the National Health Insurance Scheme (NHIS), the health basket fund, vertical programs, and private health insurance companies. The NHIS, established to reduce fragmentation and improve the health system’s capacity to redistribute risks, still has limited capacity. Health service purchasing is largely passive, and provider payment mechanisms do not adequately incentivize improvements in care quality. 

In short, results-based financing was stopped despite calls from evaluation studies to continue it (Mayeye, P; Mulenga, F, 2021).