{"id":95,"date":"2013-01-25T23:22:17","date_gmt":"2013-01-25T22:22:17","guid":{"rendered":"http:\/\/www.sina-health.com\/?page_id=95"},"modified":"2026-10-19T16:38:47","modified_gmt":"2026-10-19T14:38:47","slug":"zimbabwe","status":"publish","type":"page","link":"https:\/\/www.sina-health.com\/?page_id=95","title":{"rendered":"Zimbabwe"},"content":{"rendered":"<p><strong>Start: \u00a0 \u00a0<\/strong>2011 &#8211; ended December 2024<br \/>\n<strong>Phase: <\/strong>Pilot started in 2 districts; upscaled in 2014<br \/>\n<strong>Coverage Estimate:\u00a0<\/strong>100% of the rural districts. Urban districts covered by voucher program<br \/>\n<strong>PBF Feasibility Score: <\/strong>64% (Cordaid); 32% (Crown Agents)<br \/>\n<strong>Supported by:<\/strong>\u00a0MOH\/MOF<strong>,\u00a0<\/strong>World Bank; Health Development Fund, Trust Fund, other donors.<\/p>\n<p><strong>Implemented by:<\/strong> Cordaid, Crown Agents<\/p>\n<p style=\"font-weight: 400;\">The RBF program in Zimbabwe was implemented in three phases (Fichera, E., et all., 2021).<\/p>\n<ul>\n<li style=\"font-weight: 400;\"><em>Phase One,<\/em> RBF began in the Marondera and Zvishavane districts from July 2011 to March 2012. <i>In Phase Two, from March 2012 to June 2014, RBF <\/i>rolled out to 16 additional rural districts.<\/li>\n<li style=\"font-weight: 400;\"><em>Phase Three<\/em>, RBF rolled out to the remaining 42 districts in July 2014, and the program introduced an urban voucher system in two cities (Harare and Bulawayo) in April 2014.<\/li>\n<li style=\"font-weight: 400;\">The World Bank largely financed Phases One and Two ($50 million), with co-funding from the Government of Zimbabwe ($13.5 million). Cordaid was the program implementer.<\/li>\n<li style=\"font-weight: 400;\">The RBF rollover to Phase Three in the 42 districts was financed from a pooled multi-donor Health Transition Fund and Health Development Fund ($350 million), with Crown Agents implementing in the new districts while Cordaid remained in the existing districts. A multi-stakeholder National Steering Committee, chaired by the Ministry of Health, maintains national oversight.<\/li>\n<\/ul>\n<p>The impact evaluation results were encouraging, showing a cost-effective program (Shepard, S; et all. JHMHP, 2021)<\/p>\n<div class=\"\" data-bfc=\"\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-ved=\"2ahUKEwif97-8tbyXAxWx1wIHHddqHLEQi4wTegoIAggACAAIFhAA\" data-hveid=\"CAIIAAgACBYQAA\">\n<ul class=\"XSq4R KI3fJ\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQAQ\">\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQAg\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\">Reduced Under-Five Mortality:<\/strong> The RBF program lowered overall under-five mortality rates by about 2 percentage points nationwide, with the greatest impact among populations with above-median wealth and education.<\/span><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQBw\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\">Increased Facility Deliveries:<\/strong> Institutional deliveries rose by roughly 7 to 8.6 percentage points, with particularly strong uptake among the poorest, least-educated rural mothers.<\/span><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQDA\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\">Better Prenatal Care:<\/strong> Prenatal visits increased by an average of 0.185 units per mother, and first-trimester care attendance jumped by 7.7 percentage points.<\/span><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQEQ\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\">Optimized C-Section Rates:<\/strong> Unnecessary or emergency C-section rates decreased by 1.3 to 3 percentage points, reflecting better primary risk management and triage at rural facilities.<\/span><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQEQ\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\">Removal of User Fees:<\/strong> By subsidizing and linking facility payouts to verified service outputs, RBF removed direct financial barriers (user fees) that previously forced poor households to forgo care or rely on substandard options.<\/span><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQEQ\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\">Closing Socioeconomic Gaps:<\/strong> The program significantly narrowed relative and absolute inequalities in access to prenatal care, professional birth assistance, and family planning services, directly benefiting marginalized rural communities.<\/span><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\" data-hveid=\"CAIIAAgACBYQEQ\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-epip=\"\">Shift to Quality and Strategic Purchasing:<\/strong> The health sector shifted from passive, input-based funding to output- and quality-driven performance incentives for rural health centers and referral hospitals.<\/span><\/li>\n<\/ul>\n<\/div>\n<p style=\"font-weight: 400;\">The Zimbabwe team, attending the 64th PBF course in Mombasa in December 2017, included three high-level officials from the Ministry of Health and two Provincial Medical Officers. They conducted a thorough analysis of Zimbabwe&#8217;s RBF program. Zimbabwe&#8217;s Ministry of Health and Child Care began piloting performance-based financing in 2011.<\/p>\n<p style=\"font-weight: 400;\">They found serious design problems, and their PBF feasibility score rated the intervention&#8217;s purity at 66% in the 16 World Bank-financed and Cordaid-supported districts. Yet, in the 42 Health Development Fund-financed districts supported by Crown Agents, the score was only 32%. For details on the feasibility scores, see page 68 of the 64th PBF <span style=\"color: #993300;\"><strong><a style=\"color: #993300;\" href=\"https:\/\/www.sina-health.com\/wp-content\/uploads\/Rep64PBFCourseMombasaV181217.pdf\">course report<\/a>.\u00a0<\/strong><\/span><\/p>\n<p style=\"font-weight: 400;\">This shows that the PBF program in Zimbabwe, like other donor-driven programs, was fragmented in 2017. The government contributed 20% of the PBF budget for the 16 World Bank districts supported by Cordaid, but it contributed nothing to the 42 Health Development Fund districts supported by Crown Agent.<\/p>\n<p style=\"font-weight: 400;\"><strong>Other problems identified by the team were the following:<\/strong><\/p>\n<ul>\n<li>The government and the local councils had not clearly chosen between providing generalized &#8220;free health care&#8221; (also supported by DFID, the EU, and the HDP partners) and the World Bank-supported PBF equity approach, which targets the very poor while maintaining user fees for households that can pay.<\/li>\n<li>The government spends far less than the 15% Abuja standard on health.<\/li>\n<li>The government&#8217;s central medical stores system controls drug and equipment distribution, creating a monopoly.<\/li>\n<li>PBF contracts exclude private health facilities.<\/li>\n<\/ul>\n<p style=\"font-weight: 400;\"><strong>Recommendations of the PBF course team from Zimbabwe:<\/strong><\/p>\n<ul>\n<li>Advocate for a purer form of PBF together with previous PBF course participants.<\/li>\n<li>Advocate that the Ministry of Health change input budget lines from GOZ funding, levies, taxes, and partners towards PBF performance funding.<\/li>\n<li>Provide all health facilities, public, religious, or private, urban or rural, equal opportunity to obtain PBF contracts.<\/li>\n<li>Create a more competitive environment for supplying health commodities by removing restrictions that favor monopolies.<\/li>\n<li>Allow the Directorate of Pharmacy Services to accredit public and private wholesale pharmaceutical companies, including registration requirements and scope of work, to allow entry into PBF.<\/li>\n<\/ul>\n<p><strong>The World Bank-funded RBF program closed in December 2024. <\/strong><\/p>\n<p>The government did not abandon the RBF program and aims to integrate RBF systems or Strategic Purchasing into the national budget (see the National Health Financing Strategy 2026-2030). However, the financing plan is unclear, and the 2026 Mid-Term Budget shows no RBF-related budget lines. The budget mainly finances salaries (81%) and infrastructure inputs (12%), with only a negligible amount for direct support to health facilities. The government&#8217;s share of GDP spent on health fell from 6.4% in 2018 to 2.8% in 2025.<\/p>\n<p>The government&#8217;s Financing Strategy also aims to launch a National Health Insurance Scheme, similar to those in some other African Countries. Such schemes are feasible for the formal sector, companies, and affluent citizens, who pay substantial insurance premiums. Yet, they are inefficient at helping the poor informal population, who cannot afford substantial premiums and make up the majority of the population. For this social sector, the (obligatory) health insurance approach is far more expensive for the government than applying the six PBF equity instruments, as evidenced, for example, in Burundi and Mali. It lacks the funds to reimburse health facilities for lost income from treating the informal-sector insured population, as also evidenced in Benin, Ivory Coast and Ghana.<\/p>\n<p>Early signs after stopping the RBF program in 2025 without a viable alternative already show the return of informal user-fee payments, demotivation among health personnel, abandonment of rural postings, and worsening service quality.<\/p>","protected":false},"excerpt":{"rendered":"<p>Start: \u00a0 \u00a02011 &#8211; ended December 2024 Phase: Pilot started in 2 districts; upscaled in 2014 Coverage Estimate:\u00a0100% of the rural districts. Urban districts covered by voucher program PBF Feasibility Score: 64% (Cordaid); 32% (Crown Agents) Supported by:\u00a0MOH\/MOF,\u00a0World Bank; Health Development Fund, Trust Fund, other donors. Implemented by: Cordaid, Crown Agents The RBF program in [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":311,"menu_order":11,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"footnotes":""},"class_list":["post-95","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/pages\/95","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=95"}],"version-history":[{"count":43,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/pages\/95\/revisions"}],"predecessor-version":[{"id":5515,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/pages\/95\/revisions\/5515"}],"up":[{"embeddable":true,"href":"https:\/\/www.sina-health.com\/index.php?rest_route=\/wp\/v2\/pages\/311"}],"wp:attachment":[{"href":"https:\/\/www.sina-health.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=95"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}