Strengthening the Health Delivery System in Zimbabwe
                      June 2018

                       THE RBF PROGRAMME IS
                                                                                                                                  FOREWORD /
                       BEING IMPLEMENTED IN
SINCE 2012,
                                              42  RURAL DISTRICTS
HAVE HELPED CUT DOWN                                                         RURAL HEALTH FACILITIES
                                              COVERING A TOTAL OF
MATERNAL                                                                                                   The Ministry of Health and Child                       maternity Waiting homes, and procurement
DEATHS                                                                       IT SERVES                     Care (MOHCC) runs under the mission                    of medicines and sundries amongst other
BY AT LEAST                                                                                                statement: “to provide, administer,                    things. This is not to mention that support
                                                                             AN ESTIMATED
50%.                                          67                             6,6 MILLION                   coordinate, promote and advocate for                   that is going to paying allowances to health
                                              HOSPITALS ACROSS                                             the provision of equitable, appropriate,               staf in order to keep their morale high
                                              THE COUNTRY                                         PEOPLE
                                                                                                           accessible, afordable and acceptable                   and improve their attitudes and quality
                                                                                                           quality health services and care to                    of service. Since 2012, in these districts
                                                                                                           Zimbabweans while maximizing the use of                we have seen maternal deaths being cut
                                                                                                           available resources, in line with the primary          down by at least 50 percent because of
                                                                                                           health care approach”. We believe that this            the intervention of building the maternity
                                                                                                           is a mission that is critical to a Zimbabwe            waiting homes alone.
                                                                                                           where every citizen enjoys their inalienable
                                                                                                           right to health. If this right is denied, the          These developments are not only in
                                                                                                           right to life itself, seen by many as the most         line with the government’s Zimbabwe
 162 556                   2 485 519                             902                                       important right, is denied. This centrality            Agenda for Sustainable Socio-Economic
 NUMBER OF WOMEN           NUMBER OF CHILDREN                    NUMBER OF FACILITIES                      of the right to health makes our mission               Transformation (ZIMASSET) blueprint but
 ACCESSING ANC4+           ATTENDING GROWTH                      TRAINED IN DATA                           a critical one. But that does not make it              are a great stride to our commitment,
 IN 2017                   MONITORING IN 2017                    MANAGEMENT                                an easy one; there is infrastructure to be             among other nations, to fulfil the
                                                                                                           expanded and developed, health staf to be              Sustainable Development Goals (SDGs).
                                                                                                           trained and deployed, medicines that need              We continue to cherish and nurture
                                                                                                           to be supplied as well as communities to be            partnerships that help us reach these goals.
                                                                                                           mobilized for health services provision and            Here, in this publication, you will have an
                                              ?!                                                           access. To achieve this, we need partners.
                                                                                                           This is why we are grateful for the support
                                                                                                                                                                  opportunity to hear the real life stories of
                                                                                                                                                                  the impact of our partners’ interventions
                                                                                                           we receive through Crown Agents under                  on people and their communities. As a
                                                                                                           the RBF programme.                                     ministry we are proud to be helping create
                                                                                                                                                                  these stories of impact.
 337                        2%                                                                             Through RBF, a number of health facilities
                                                                                                           in several districts have managed to
                                                                                                           refurbish their infrastructure e.g. repairing          Major General (Dr) G. Gwinji
 PROVINCE TRAINED IN                                                                                       and painting their premises and building of            Secretary for Health and Child Care

                                               RBF                          RBF


Foreword                                                               3
News: Public-Private Partnership Bears Innovation                      6
Contributors                                                           8
From the Editor                                                        9
About the Publication                                                  10

CHAPTER ONE                                                            12
Understanding RBF Impact: The Background                               13
What is the Results-Based in Health Financing Strategy?                13
The RBF Impact Synopsis                                                16

CHAPTER TWO                                                            18
RBF Strengthening Health Delivery Systems                              18
RBF Improves Data Management in Health Facilities                      19
MoHCC Lauds RBF Role in Improving Data Quality                         24
Quality Assessments: RBF beyond the Numbers                            24
Improved Quality Increases Earnings                                    27
Bangure Clinic: The Impact of QAs on Service Delivery                  29
Money Well-Managed is Lives Saved: RBF Helps Improve Financial
Management Practices in Health Facilities                              31
Electronic Platforms Introduce Ease of Transaction                     31

CHAPTER THREE                                                          35
RBF Impact in Perspective                                              35
Improved Earnings: Rewards for Producing Results                       35
Masvingo Province Leads in RBF Earnings                                35
Team Work: How Masvingo Province Got it Right                          37
The Story of Mushaviri Clinic                                          38
Nyahode Clinic Shines, thanks to the RBF Verification Process          39
Overview of the Impact of RBF on the Key Focus HDF Indicators          39

CHAPTER FOUR                                                           42
Crown Agents Eager to Deliver                                          42
Technology and Innovation for Health Systems through RBF               42
Crown Agents takes RBF to Second Level Hospitals: Rolls out Training   44
Highlights: Pictures from Hospitals RBF Training                       45

                                              4                             5
                                                  4                         5
RBF                                                                                                   RBF

                                                                                                       of the apps was proud of the novelty of              many challenges – incentives are keeping
NEWS                                                                                                   the idea of adopting technology and its              staf motivated to work towards achieving
                                                                                                       potential to transform and strengthen                key health outcomes, especially regarding
                                                                                                       the implementation of RBF in Zimbabwe.               maternal and child health,’ explained Dr.
            PUBLIC-PRIVATE PARTNERSHIP                                                                 ‘The development of these applications               Mudyiradima.
                BEARS INNOVATION /                                                                     witnessed the technical involvement and
                                                                                                       guidance of various MoHCC departments                He went further to say that the ‘innovation
         CROWN AGENTS AND THE MINISTRY OF HEALTH AND CHILD CARE                                        such as the Health Management                        is embedding technology at the heart of
           DEVELOPS APPS TO IMPROVE HEALTH SERVICES DELIVERY                                           Information Systems (HMIS) Department;               the Results-Based Financing programme
                                                                                                       the Quality Department; the Nursing                  which accelerates health outcomes leading
                                                                                                       Directorate; the Finance Department as               to the improving of deficiencies in the
The Results-Based Financing (RBF) for                                                                  well as the Information Communication                system around management, use of staf
Health program has demonstrated the                                                                    Technology (ICT) Department. The                     time, value for money and use of data for
immense potential that Public-Private                                                                  support received through adoption of the             decision making.’
Partnerships have in strengthening the                                                                 applications across the country reflects the
country’s health delivery system and                                                                   importance of these apps. Thanks to the              Dr. Mudyiradima hailed the partnership
its resultant maternal and child health                                                                Ministry’s partnership with Crown Agents,            between the MoHCC and Crown Agents. ‘We
care outcomes. One such development                                                                    the m-IC app is now being used by 80% of             value our partners in pursuit of our vision
is the Crown Agents-Ministry of Health                                                                 the primary health facilities in Zimbabwe            for the highest possible level of health
and Child Care (MoHCC) partnership                                                                     serving a total of 6.6 million people. The           and quality of life for all Zimbabweans,’
whose successes, among others, is using                                                                results of the mobile app innovation have            he said before adding that the ‘technology
technology to improve health programmes                                                                been immediate and significant.                      provides opportunities for eficiency and
implementation, as demonstrated by the                          Dr. Robert Mudyiradima
                                                          Principal Director for Policy, Planning                                                           ease of doing business,’ reiterating the new
development and recent launch of the                         and Monitoring and Evaluation             “Before the introduction of the m-IC                 dispensation’s well-received motto that
Mobile Incentive Calculator (m-IC) and                                                                 app, some health workers were receiving              ‘Zimbabwe is open for business.’
Mobile Client Satisfaction Survey (m-CSS)                                                              their incentives with delay, because the
Applications (Apps).                                  at the health facility level - the calculation   accountant was overwhelmed with data                 The innovations, as Dr. Mudyiradima said
                                                      of staf incentives for health personnel          from clinics around the region. Now the              during the launch of the apps, will help
Speaking at the launch and handover of the            in the case of the m-IC and the collection       app does the calculations automatically              sustain the RBF program. ‘Let me thank
applications to the MoHCC, Crown Agents               of patients’ feedback for m-CSS. These           thereby reducing the likelihood of human             the Crown Agents for their enormous
Director, Ms. Muchaneta Mwonzora said                 innovations came ater the two actors             error. The staf is now able to receive               contribution in the implementation of the
the applications were ‘a locally produced             noticed inordinate delays in the calculation     their dues in just two days ater the data            RBF program in the 42 districts and the
solution to challenges witnessed in the               and payment of RBF subsidies to health           is submitted. On the other hand, the                 institutionalisation of the program in the
process of implementing the RBF program,’             facilities and its resulting staf incentives     mobile Client Satisfaction Survey app                Ministry. The tools you handover today will
adding that the initiative was ‘a result of a         as well as the lack of timely client feedback    is helping facilities determine needs of             go a long way in supporting the Ministry to
public-private partnership between Crown              on whether health facilities’ services are       their clients in order to meet these and             institutionalise RBF and to eventually take
Agents and the Ministry of Health.’                   meeting the needs of their clients.              improve health outcomes. The payment of              over the program in all the districts.’
                                                                                                       mobile incentives under the RBF for Health
The two android-based and user-friendly               Dr. Robert Mudyiradima, the Principal            program, and particularly the timely                 Following the launch, the apps are in the
mobile apps were innovated through the                Director for Policy, Planning and Monitoring     payment as a result of the m-IC is a boon to         process of being rolled out to all districts
Crown Agents-MoHCC partnership in order               and Evaluation in the MoHCC who initiated        the country’s health sector that has faced           across the country.
to ofer convenience in service provision              and supported the designing and roll out

                                                6                                                                                                     7
RBF                                                                               RBF

CONTRIBUTORS /                                    FROM THE EDITOR /
                                                  Health services consumers are oten unaware
                                                  that the services they enjoy through health
                                                  facilities are a product of many functions of the
                                                  so-called ‘health delivery system.’ All they know
                                                  is the consumer-end infrastructure, personnel              implementing the RBF Programme, there are
                                                  and supplies – give them a clinic building,                noticeable changes in the system - changes
                                                  some medicines as well as a health worker and              worth celebrating. Such changes show that
                                                  they are happy. Do they know that there is a               RBF is building resilience in the health delivery
                                                  system consisting of processes and procedures              system.
  Nakita De Barros
                                                  deliberately designed to deliver such services.
                            Theresa Mundete       Probably not!                                              Through RBF, as you shall read in this edition,
                                                                                                             the quality of data collected, analysed and
                                                  However, no one should fault communities                   reported to support health delivery at many
                                                  for not understanding the complexities of this             levels has improved. For example, the story
                                                  system; there are just too many moving parts               RBF Improves Data Management in Health
                                                  to this machinery. Not many would care to                  Facilities shares how the eforts of Crown
                                                  explain how this system works and why it is                Agents and HDF partners have improved the
                                                  important. As Crown Agents, through our RBF                quality of data from a data error rate of about
                                                  Programme, we realise that communities are not             50 percent in 2014 to an average of 2 percent by
                                                  just helpless patients seeking medical attention.          end of 2017. We have also invested in building
                                                  They are active citizens who can help build and            the capacity of health facilities and players
 Taurayi Malunga           Shungurudza Mudereri   support such systems. That is why community                in the health delivery systems to improve the
                                                  participation is more than just a buzz word in the         management of financial resources. Read the
                                                  RBF Programme, it is a culture.                            story Money Well-Managed is Lives Saved:
                                                                                                             RBF Helps Improve Financial Management
                                                  To such an extent that communities are key                 Practices in Health Facilities and aterwards,
                                                  stakeholders in the strengthening of health                you will be agreeing with us that we need to
                                                  delivery systems, we submit this edition of                build the capacity of the system to eficiently
                                                  our bi-annual publication with a format and                manage the limited resources we have; it could
                                                  language that makes it accessible to them as               be the diference between life and death as it
                                                  it is to all other stakeholders. Our common                stretches the dollar we have. There are other
                                                  message throughout the publication is simple               stories in this edition that give testimony to
 Caroline Mubaira            Anthony Sibanda      yet important: investing in health for better              the contributions of the RBF Programme to the
                                                  outcomes requires models that recognise the                health sector. Whether it is to strengthen the
                                                  importance of investing in the system as a whole.          health system itself or improving maternal and
                                                                                                             newborn health outcomes, at Crown Agents we
                                                  Dear reader, our health system has sufered                 are proud of being a part of the RBF initiative.
                                                  under the economic hardships the country has               Crown Agents would not have achieved this
                                                  experienced. As a result, many functions of the            impact on its own. We are grateful to all the HDF
                                                  health system were compromised, the reason                 donors, the Ministry of Health and Child Care
                                                  why sometimes clients would walk into a facility           and UNICEF for their unwavering support to the
                                                  and leave disappointed; without accessing                  programme.
                                                  the help they needed. The RBF Programme
 Tafadzwa Mutete             Terrance Mlauzi      is intervening to strengthen the system and      Until the next edition, stay healthy!
                                                  ensure that the system can deliver again. Over
                                                  the past year, and indeed many more years        Marie-Jeanne Ofosse
                     8                            that Crown Agents and its partners have been 9 The Editor
                                                RBF                                                        RBF

Millions in public funds are being mobilised          This is the second edition of a periodical
and channelled to development aid every               publication. The first edition was titled:
year. The pursuit for results and the need            Results-Based       Financing:       The     Story
to demonstrate that, indeed, project                  of Hope and Caring in Zimbabwe. The
interventions are achieving results has               second edition, Results-Based Financing:
given birth to results frameworks and tools           Strengthening the Health Delivery System in
of a diverse nature. Understandably so,               Zimbabwe, continues from where the first
development organizations are obligated to            one let in celebrating in a human way, the                 SINCE ITS INTRODUCTION, THE RBF
illustrate that resources are being put to good       change attained through the RBF in health                  PROGRAMME HAS NOT ONLY HELPED IMPROVE
use. However, this has made development               programme. Oten expressed in technical                     PUBLIC HEALTH DELIVERY INFRASTRUCTURE,
work too technical and scientific to an               terms in reports and project documents, the                IT HAS ALSO RAISED STAFF MORALE AND, AS A
ordinary person who may want to track                 purpose of this series of publications is to               RESULT, HELPED SHAPE COMMENDABLE HEALTH
progress of development interventions.                simplify and tell the real life stories of how the         OUTCOMES IN LINE WITH THE NATIONAL AS
Reports based on log frames may not tell              RBF Programme is creating impact for health                WELL AS GLOBAL FRAMEWORKS FOR HEALTH
the full story; the human face of the impact          facilities and communities alike.                          DEVELOPMENT.
created by the work is sometimes lost and
people become data and statistics. Someone
has to tell the story and tell it diferently. This
is why this publication was conceived.

                                                 10                                                        11
RBF                                                                                                 RBF

                                                                                                     Against this background, for Zimbabwe,
                  CHAPTER ONE /                                                                      the RBF programme is more than just a
                                                                                                     health financing model; rather it became
                                                                                                     an antidote to a failing health system.
                                                                                                     Since its introduction, the RBF Programme
Introduction /                                                                                       has not only helped improve public health
                                                                                                     delivery infrastructure, it has also raised
Health financing models have evolved over
time as players in the sector seek efective
                                                         THE RBF PROGRAMME IS                        staf morale and, as a result, helped shape                      162 556
                                                         BEING IMPLEMENTED IN                        commendable health outcomes in line with                        NUMBER OF WOMEN
ways of strengthening public health                                                                  the national as well as global frameworks                       ACCESSING ANC4+
delivery systems and ensure equitable                                                                for health development. This publication                        IN 2017
access to quality health services for all.                                                           brings to the fore some of these stories
The Results-Based Financing (RBF) in                                                                 of impact that came through the RBF
health, currently in use in Zimbabwe and                 42  RURAL DISTRICTS                         programme implemented by Crown Agents
other developing countries has shown                     COVERING A TOTAL OF                         and the MoHCC.
immense potential to develop the health
sector and improve access to health                                                                  1.1 Understanding RBF Impact:
services for marginalised communities.                                                               The Background /
In Zimbabwe, with the support of the                     835                                                                                                        2  485 519
Health Development Fund (HDF), Crown                     RURAL HEALTH FACILITIES                     The RBF Programme is a key intervention                        NUMBER OF CHILDREN
Agents has been implementing the RBF                                                                 of the HDF hence central to the attainment                     ATTENDING GROWTH
programme in partnership with the                                                                    of the goals of the coordinated funding                        MONITORING IN 2017
Ministry of Health and Child Care (MoHCC).                                                           mechanism, especially meeting the
                                                         67                                          targets for maternal and newborn health
The RBF Programme is being implemented                   HOSPITALS ACROSS THE COUNTRY                targets. However, to understand how this             (UHC). As a model, RBF in health rewards
in 42 rural districts covering a total of 835                                                        impact is being realised, it is important to         health facilities based on their performance
rural health facilities and 67 hospitals                 IT SERVES                                   understand what RBF is and how it works.             and achievements.
across the country. It serves an estimated               AN ESTIMATED
6,6 million people, most of them with no
alternative for accessing health services
                                                         6,6 MILLION                                 1.1.1 What is the Results-Based in                   The results to be achieved and payments
                                                         PEOPLE                                      Health Financing Strategy? /                         to be received are laid down in contractual
except for the public health system. The
                                                                                                     Results-Based Financing in Health is the             relationships between the diferent actors
nature and extent of the RBF programme
                                                                                                     transfer of resources to health providers            in the health system. Verification of the
makes sense when placed in the broader
                                                                                                     on condition that measurable action will/            results is conducted by the purchaser before
context of the state of health delivery               and AIDS as well as economic stresses on
                                                                                                     has been taken to achieve predefined                 payment is made. RBF intervenes on both
system in Zimbabwe in light of the                    the health delivery system is evident. In
                                                                                                     health system performance targets. RBF               the supply and demand side of services.
economic crisis the country has been                  response to these stressors, infrastructure
                                                                                                     is increasingly being promoted by leading
trapped in for the past two decades.                  for health delivery deteriorated, essential
                                                                                                     global actors as a way to eficiently and             Supply side financing is concerned with
Although government has made significant              medicines became scarce and staf morale
                                                                                                     efectively increase performance in terms             giving incentives to service providers for
strides, since independence, to improve               hit an all-time low. Client satisfaction and
                                                                                                     of service quality, service utilization as           the results obtained while the demand
access to quality and afordable health care           the confidence in the public health delivery
                                                                                                     well as improving staf motivation in a way           side angle finances the incentives to the
for the country’s citizens, the impact of HIV         system dipped significantly in response.
                                                                                                     that will ensure Universal Health Coverage           beneficiaries - that is the community

                                                12                                                                                                  13
RBF                                                                                               RBF

receiving the services. RBF for health               The Health Development Fund (HDF) is
facilities seeks to facilitate the removal           financially supported by the governments
of user fees, particularly for mothers and           of Canada, Ireland, Norway, Sweden, the
children in order to allow more people to            United Kingdom, the European Union
access health services. In the case of the           and GAVI. To date, through the RBF
HDF, and for the Crown Agents intervention,          programme, HDF donors have provided
performance indicators mostly relate to              over 22 million dollars to health facilities
maternal, new-born and children’s health.            in the country. UNICEF also plays a
                                                     prominent role in the management of
In Zimbabwe, RBF in health was piloted               the HDF as well as shaping reforms in the
in two front-runner districts in July 2011           RBF programme. The organization’s role
before it was scaled up to 16 additional             includes undertaking advocacy as well as
districts in March 2012. This initiative was         conducting evidence-based dialogue with
spearheaded by Cordaid with funding                  stakeholders for resource allocation. As
from the World Bank and the Government               the fund manager, UNICEF contracts Crown
of Zimbabwe. In 2014, the approach was               Agents to implement the RBF Programme          that support the programme. Recently,              UNICEF PLAYS A PROMINENT ROLE IN THE
further scaled up to the country’s 42 rural          taking the responsibility for the monitoring   UNICEF was instrumental in organising              MONITORING OF THE RBF PROGRAMME
                                                                                                                                                       IMPLEMENTATION. HERE, UNICEF COUNTRY
districts by Crown Agents, with funding from         of the programme implementation across         visits by among others, the Swedish                REPRESENTATIVE, DR. MOHAMED AG AYOYA
the Health Transition Fund (later, continued         the country. In the process of monitoring,     Members of Parliament, delegates from the          TOGETHER WITH THE IRISH AMBASSADOR,
                                                                                                                                                       HIS EXCELLENCY LIAM MACGABHANN AS WELL
under Health Development Fund). To date              UNICEF sometimes coordinates visits by the     EU as well as the Irish Ambassador and the         AS THE IRISH CRICKET TEAM VISIT RUTOPE
the program is being implemented in all the          donors as well as citizens of the countries    national Cricket Team.                             CLINIC IN BINDURA DISTRICT, MASHONALAND
rural districts of Zimbabwe.                                                                                                                           CENTRAL PROVINCE. THE CLINIC IS ONE OF THE
                                               14                                                                                                15    FACILITIES UNDER THE RBF PROGRAMME.
RBF                                            RBF


The RBF Programme has helped improve the health delivery system and, with it, the
key maternal and newborn health indicators. Over the years, and especially over the
past year, the Crown Agents RBF Programme has achieved the following, among other
results, in the districts where the organisation intervenes:
• Improved access and quality of health services for mothers and children. The
    number of women accessing ANC4+ rose from 32 874 women in 2014 to 162 556
    women in 2017 in the 42 districts where Crown Agents works. The number of
    children attending growth monitoring per year rose from 430 652 to 2 485 519
    children over the same period.
• Helped restore confidence in the public health delivery system. Through RBF many
    facilities have been refurbished or built, medicines supplied and staf morale
    boosted. The service delivery in these facilities has correspondingly improved and
    communities are expressing satisfaction on the services they receive.
• Empowered communities to take interest and participate in the delivery of health
    services at community level. Health Centre Committees have taken the centre
    stage in deciding on how to use resources prudently to meet the needs of the
• Piloted innovative and efective means of delivering health services as well as
    quality assurance in the delivery of the same. Through RBF innovations have been
    piloted and capacity of health staf as well as health facilities improved through
    such technologies as mobile health (mHealth) and the Mobile Incentive Calculator
    (mIC) which were developed and introduced by Crown Agents. Due to such
    innovations and capacity development, operations of health facilities, including a
    broad array of management functions have improved.

                                                                                               ALL THE 834 FACILITIES UNDER RBF
                                                                                               IN THE 42 DISTRICTS OF ZIMBABWE
                                                                                               WHERE CROWN AGENTS WORKS HAVE
                                                                                               BEEN CAPACITY BUILT TO MANAGE
                                                                                               DATA EFFECTIVELY FROM CAPTURING,
                                                                                               STORAGE, RETRIEVAL TO ANALYSIS IN
                                                                                               ORDER TO IMPROVE REPORTING AS
                                                                                               WELL AS THE SUBSEQUENT DECISION
                                                                                               MAKING OF HEALTH PRACTITIONERS AND
                                                                                               ADMINISTRATORS IN THE SECTOR.

                                           16                                            17
RBF                                                                                           RBF

                 CHAPTER TWO /                                                                                                                     2.1 RBF Improves
                                                                                                                                                   Data Management
                                                                                                        DID YOU KNOW?                              in Health Facilities /
Health delivery works within a system.
                                                                                                        In March 2018, the World Health            Data management is an administrative
The service that clients access at the point
of delivery is a result of many processes
and functions within this system. When
                                                                                      ?!                Organisation issued an alert for
                                                                                                        a potential global pandemic. A
                                                                                                        team of medical scientists who
                                                                                                                                                   process that includes capturing, storing,
                                                                                                                                                   protecting, and analysing data pulled from
                                                                                                                                                   diferent sources (registers) to ensure ease
patients receive a service, they tend to
                                                                                                        convene annually to discuss what           of accessibility of the data for its users.
think that having a health worker and
                                                                                                        new diseases pose the greatest             It is the backbone of RBF and hence the
medicines is all one needs in a health
facility. Little do clients know that behind
                                                     902                         2%                     potential of turning into a global         importance of proper data management.
                                                     NUMBER OF FACILITIES        THE NATIONAL DATA      pandemic have concluded that
what they interact with at the point of              TRAINED IN DATA             ERROR RATE; DECLINED
                                                                                 FROM 56% BEFORE RBF    they do not have any knowledge             Whether it’s an individual patient’s case
service, there is a complicated support              MANAGEMENT
                                                                                                        on what it could be. However, they         or a public health issue afecting a wider
mechanism to the health delivery system
                                                                                                        are convinced that conditions are          community, decision makers and health
– there is data management that monitors             indicators that inform the goal of the RBF
                                                                                                        ripe in many respects for a new            service providers alike rely on access to
and improves access to quality service,              Programme, as supported by the Health
                                                                                                        pathogen to emerge and cause               good data to improve both the access to
complex infrastructure that supports                 Development Fund. Since investments in
                                                                                                        havoc for global health systems.           and quality of health services they provide.
service delivery as well as a myriad of              the system itself are less visible to the eyes
                                                                                                        They have termed this ‘Disease             Based on this data, health facilities
administrative procedures and systems,               of the public, they are oten not discussed
                                                                                                        X’. If any new disease emerges             staf can measure the quality of health
among several other components of the                or understood. Hence stakeholders tend
                                                                                                        as have HIV, SARS and Ebola in             services they provide and make necessary
health delivery system that clients do not           to rush to complain that resources have
                                                                                                        recent decades, the developing             adjustments if there is a need to. Medical
interact with every day. Needless to say,            gone missing if they do not see them
                                                                                                        world is likely to bear the brunt          practitioners can also use holistic patient
accessing and enjoying quality services              going into staf salaries, medicines or
                                                                                                        of the new pandemic – they have            data to personalise treatment for patients
at a health facility is only possible when           any other components of the health
                                                                                                        weak health systems hence limited          hence improving the general well-being of
these various components are designed                system that are at the point of accessing
                                                                                                        capacity to contain or respond             the patient. At the broader national health
and supported to deliver such services               services. Government and its partners in
                                                                                                        to new pandemics should they               systems level, several benefits accrue
efectively.                                          health financing have an obligation to
                                                                                                        emerge. The RBF’s intervention             from good practices of data management.
                                                     communicate to all stakeholders about the
                                                                                                        in strengthening health systems            Good data management practices can
The RBF Programme is alive to the                    complexities of financing the health sector.
                                                                                                        is    therefore   an    important          help health systems to predict and prevent
dynamism of the health delivery system. To           If this is done clearly, it can even enhance
                                                                                                        contribution in addressing the             public health catastrophes as well as
this end, Crown Agents and its partners have         the participation of more stakeholders,
                                                                                                        public health systems’ capacity to         model public health programmes and
invested a significant amount of resources,          including communities in public health
                                                                                                        respond, not only to known public          policies that respond to certain diseases
including capacity strengthening, in these           issues. In this edition we celebrate the
                                                                                                        health issues of the day but also          and conditions deemed prevalent in the
various components of the health delivery            investments made by the RBF Programme
                                                                                                        those of the future – pandemics            communities served. In essence, good
system. The successes of these investments           in the processes behind the scenes and we
                                                                                                        now confirmed by science as                data management strengthens the health
are evident in both the state of the health          bring this out to the public eye through
                                                                                                        inevitable.                                delivery systems and increases individual
delivery system in the districts where RBF           some visible changes that clients may
is being implemented as much as they are             see but without understanding the story                                                       patients’ treatment outcomes.
in the key maternal and newborn health               behind them.

                                               18                                                                                            19
RBF                                                                                                               RBF

                                                      systems and outcomes, Crown Agents invested
                                                      a substantial amount of time, skills and other
                                                      resources in capacity development for better
                                                                                                               QUESTION AND ANSWER /
                                                      data management. Hence, all the 834 facilities
                                                                                                                         HOW THE RBF PROGRAMME HELPED IMPROVE DATA MANAGEMENT:
There are several benefits that come with             under RBF in the 42 districts of Zimbabwe where
                                                      Crown Agents works have been capacity built to                               CROWN AGENTS DATA MANAGER SPEAKS
efective data management practices:
o Help measure health care quality and                manage data efectively from capturing, storage,
    making improvements were there are                retrieval to analysis in order to improve reporting
    gaps.                                             as well as the subsequent decision making of
                                                      health practitioners and administrators in the        The Editor caught up with the Crown Agents                  is to be paid out to the said facility. RBF is all
o Readily available holistic patient data                                                                   Data Manager (DM) to discuss the role that                  about being incentivised to produce results and
    is helpful in personalising treatment for         sector. This process of capacity development is
                                                      bearing fruits.                                       Crown Agents has played in developing the                   good data is testimony to the results achieved.
    patients hence improve the general well-
                                                                                                            capacity of health facilities in managing
    being of individual patients.
                                                                                                            data efectively as well as the results of the               The Editor: In that case then, do you imply that
o Improvement in the day to day running
                                                                                                            intervention. Here are the snippets of the                  data management is self-serving – we only need
    of the facility allowing management to
                                                         WHAT IS DECLARED DATA?                             interview:                                                  good data for the purpose of paying facilities on
    plan ahead.
                                                         Declared data is the data recorded by health                                                                   the basis of results achieved?
o Improve population health outcomes
    by tracking current health trends and                facilities on the MoHCC T5 form. This data         The Editor: Can you explain to us what data
    predicting future ones.                              is sourced from the health facility registers.     management is, in the context of health systems             DM: Far from it, that is only one of the many
o Awareness campaigns are being planned                  The recorded data will in turn be entered          management?                                                 reasons. There are several other benefits that
    according to conditions reported to be in            in the MoHCC database called the District                                                                      accrue to the health system and patients. For
    need.                                                Health Information System (DHIS).                  DM: Data management is an administrative                    example, we need data to improve the quality of
o Disease prevention plans are made and                                                                     process that includes capturing, storing,                   service to individual patients as well as to plan
    executed according to area of need.                  UNDERSTANDING THE PROCESS                          protecting and analysing data pulled from                   and model public health programmes. Data tells
                                                         OF VERIFICATION IN RBF                             diferent sources (registers) to ensure ease of              us the prevalence of certain diseases in certain
                                                         Verification is a process of checking on the       accessibility of the data to its users. It is the           localities upon which responses and prevention
Despite these clear benefits of efective data            data declared against what is actually in the
                                                                                                            backbone of RBF and hence the importance of                 programmes can be fashioned.
management practices, the principles and                 registers which are the source documents.
practices of data management seemed to be                                                                   proper data management.
                                                         This process also entails checking for
                                                                                                                                                                        The Editor: Seeing to it that data management is
lost on health facilities before RBF. Lack of            completeness of a record thus checking for
                                                                                                            The Editor: You say that data management ‘is                that important, what role did Crown Agents play
capacity, competing priorities in the face of            date, sex, full address, age and full name
                                                                                                            the backbone of RBF and hence the importance                to improve data management practices in the
resource scarcity as well as demoralisation              of patients. The process of verification is
                                                                                                            of proper data management.’ Can you explain                 context of the RBF Programme?
of staf, among other factors, saw data                   important as such data has implications on
management practices in many health                      the national policy making as well as taking       what you mean by that?
facilities deteriorating over the years.                 key decisions at various levels of the health                                                                  DM: Our RBF programme invested in capacity
                                                         delivery system. In the end, verification          DM: While you may probably be interested in                 building on how data should be managed. For
The introduction of the RBF programme has                helps improve the quality of services ofered       how the RBF programme has helped develop                    all the 834 facilities we are working with, we
however, already, started turning around                 at health facilities.                              the capacity of health facilities to manage                 undertook on-the-job training. We believe that
the situation for health facilities and the                                                                 data efectively, you may also need to realise               this approach is more efective and practical
national health system at large. Of the                  The first level of verification is done by the     that data management is important in the RBF                compared to classroom learning. We also
total budget allocated to RBF Programmes,                management at the health facility. Crown                                                                       incentivised the correct capturing of data by
                                                                                                            programme. It is on the basis of this data that the
Crown Agents spent a significant percent                 Agents conducts the second level data              RBF programme thrives; through data HFOs are                the health facilities staf. In these trainings, we
of this amount on building the capacity of               verification as well as the quarterly exit
health facilities to deliver services. With                                                                 able to verify the results of each health facility          were emphasising the importance of data and
                                                         interviews. The organisation analyses the
efective data management strategies                                                                         and be able to determine or calculate how much              benefits of efective data management.
                                                         data and prepares reports that are shared
playing such a key role in improving health              with other stakeholders to demonstrate
                                                         progress on the indicators of the HDF
                                                20                                                                                                                21
RBF                                                                                      RBF

                                                                                                                  2.1.1 Data Management and the Verification Process: The
                                                                                                                  Backbone of the RBF Programme /
                                                                                                                  Crown Agents has noticed a significant improvement in the quality of
                                                                                                                  declared data since the introduction of the RBF Programme. At the beginning
                                                                                                                  of the programme in the second quarter of the year 2014, the average
                                                                                                                  national error rate was a whopping 56 percent. Data registers were not
                                                                                                                  updated correctly and regularly hence incomplete. This poor management
                                                                                                                  of data weakened the health delivery system at both the level of the health
                                                                                                                  facility as well as collectively at the national systems level. Enter RBF, the
                                                                                                                  error rate went down significantly to 2 percent by the third quarter of 2017.

                                                                                                                  Once verification is done the data error rate is less than 5 percent, the
                                                                                                                  health facility is paid their dues based on the results demonstrated in the
                                                                                                                  data provided. In the end, one could argue that verification is a quality
                                                                                                                  assurance process and an extension of the capacity building process -
                                                                                                                  during verification, HFOs use the opportunity to further train and support
                                                                                                                  health facility staf in data management so as to help them improve their
                                                                                                                  earnings. In essence verification is critical to the RBF Programme because it
                                                                                                                  is the basis upon which health facilities are financed.

                                                                                                                                 VERIFICATION: WHO DOES WHAT?
                                                                                                                                •   Crown Agents Zimbabwe, through
The Editor: And, what results have you witnessed                                                                                    RBF, ofers support to the district
following this process?                                                                                                             by incentivising data verifications
                                                                                                                                    conducted by community nurses, and
DM: Before the inception of RBF some health                 national committee. For example, in Murehwa                             also incentivising quality supervisions.
facilities would record incomplete data that                and Uzumba Maramba Pfungwe districts, 90%                               Capacity building for performing these
was dificult to make use of. Registers were kept            of facilities are now operating at an error rate of                     supervisory roles is provided to maintain
haphazardly such that during the reporting                  less than 5% which is a positive development.                           high standards.
                                                                                                                                •   At provincial level the MoHCC makes sure
period, data would be misrepresented. We                    RBF has processes and procedures in place that
                                                                                                                                    that the data is captured in the system
undertake a process of verification for the data            promote data correctness and completeness
                                                                                                                                    at an agreed time and supervises the
kept by the health facilities to ensure that there          through a 5% rule that stipulates that if a                             performance of the district.
are no errors that can distort the interpretation           facility’s error rate on data completeness is                       •   At national level guidance is provided
of results attained by each facility. The process           below 5% the heath facility earns a subsidy;                            to the provinces that further cascades
of capacity building in data management as                  otherwise the facility earns nothing. Due to this                       down the same to the districts. Processes
well as the verification has greatly improved               intervention, the average national error rate has                       and procedures are defined to support
the quality of data. To date, almost all facilities         since declined from the 56% in 2014 to 2% in                            improved data management at provincial
have valid records which are useful to the                  2017.                                                                   and district levels.

                                                      22                                                                                        23    23
RBF                                                                                        RBF

      MOHCC LAUDS RBF ROLE IN                                                                         FIG 1: AVERAGE DATA QUALITY PROGRESSION FOR HDF - SUPPORTED FACILITIES

      IMPROVING DATA QUALITY /                                                                        60%

The Makoni District Health Information                Mr. Mushore is of the opinion that the
Oficer (DHIO) has commended the role that             Ministry has noted a vast improvement
the RBF Programme is playing in improving             in these areas and their district is grateful
data management in health facilities in               to the RBF Programme. Not only has data         30%
the district and country at large. Speaking           quality improved in Makoni district; such
about how RBF has helped facilities                   trends are noticeable countrywide as            10%
improve data management practices, Mr.                depicted in the graph below:
Tawanda Mushore said, ‘Completeness of                                                                 0%                                                                          2%
reports has improved and data registers are           2.2 Improving Quality of Services /                   2014 2014 2014 2015 2015 2015 2015 2016 2016 2016 2016 2017 2017 2017
now being updated regularly and correctly.’                                                                  Q2   Q3   Q4   Q1   Q2   Q3   Q4   Q1   Q2   Q3   Q4   Q1   Q2   Q3
He added that ‘Before the introduction of             As has already been noted, RBF concerns
the RBF Programme our registers across                itself with improving access to health
the district had lots of gaps. We are pleased         services by many people in rural, oten
to see that with the RBF intervention,                poor, communities. However, such access
data is now being verified; there is now              is not helpful if the services are not of an
data consistency. Even reporting is now               expected minimum standard of quality
comprehensive and timely.’                            required to successfully treat a patient.
                                                      To ensure such quality standards are met,
Before the introduction of the RBF                    the RBF supports the process of quality
Programme, the MoHCC faced many                       assessment by relevant supervisors in the
challenges with regards to data                       health system.
management. These include among
• Late submission of reports to the                   Quality assessments are monitoring
    district ofice from health facilities             activities conducted by DHEs to assess
• Incomplete registers leaving out                    whether structural, managerial and clinical
    important data                                    procedures are up to standard and are
• Inconsistences between data captured                being done properly.
    and the data in source documents.

                                                                                                                                                   NURSE VERIFYING THE ANC REGISTER.
                                                                                                                                                   VERIFICATION IS IMPORTANT IN
                                                                                                                                                   IMPROVING DATA QUALITY AND THE
                                                                                                                                                   OVERALL SUCCESS OF THE RBF

                                                24                                                                                          25
RBF                                                                                                     RBF

                                                                      Onsite data verification at            2.2.1 Quality Assessments: RBF
                                                                      Nhawa Clinic, Rushinga District        beyond the Numbers /
                                                                                                             While verifying numbers is easy in the
                                                                                                             context where data management practices
                                                                                                             are improving, quality assessments may
                                                                                                             be far more complicated and require a
                                                                      He added that ‘Before the              diferent mechanism. Yet, it is important
                                                                      introduction of the RBF                that the quality of service is guaranteed
                                                                      Programme our registers across
                                                                      the district had lots of gaps. We
                                                                                                             since it is quality that determines if the                      337
                                                                                                                                                                             NUMBER OF NURSES
                                                                      are pleased to see that with the       served patient is going to be satisfied
                                                                                                                                                                             IN 5 DISTRICTS OF
                                                                      RBF intervention, data is now          by the service or have their health issue
                                                                                                                                                                             MASHONALAND WEST
                                                                      being verified; there is now data      resolved. So how does the RBF Programme
                                                                      consistency. Even reporting is                                                                         PROVINCE TRAINED IN
                                                                                                             ensure the services provided and paid for                       MIDWIFERY
                                                                      now comprehensive and timely.’
                                                                                                             are of a high quality? The answer is in the
                                                                                                             District Health Executive (DHE) Quality

                                                                                                             The DHE is made up of the District Medical           Second is the Client Satisfaction Score
                                                                                                             Oficer, District Nursing Oficer, District            (CSS) where the basis of measure is the
                                                                                                             Health Services Administrator, District              clients’ perceived level of satisfaction with
                                                                                                             Accountant, District Environmental Health            the services provided by a particular health
WHY QUALITY ASSESSMENT MATTERS                            structures are suitable for service delivery or
                                                          plans are being implemented as well as how         Oficer and the District Pharmacist. They             facility.
Quality Assessments (QAs) allow supervisors
to observe, identify knowledge gaps as well as            staf is being allocated duties, among other        have a quality scoring system they use to
monitor and evaluate the activities of a health           supervisory functions. This allows DHEs to         assess the quality of facilities. Quality of         The third component, on the other hand,
facility. The assessment is concerned with                scrutinise the clinical services focussing on      service is assessed using a carrot and stick         focuses on the assessment of Crown
whether activities are done properly according            staf know-how and identify knowledge gaps in
                                                                                                             scoring system where health facilities are           Agents’ field staf (P/HFOs) and Ministry
to set procedures and, if not, define steps to            order to recommend trainings. These trainings                                                           of Health verifiers (SICC). This component
                                                          will then help to improve staf knowledge hence
                                                                                                             penalised for not having quality systems
improve the same. In essence, QAs allow DHEs to
                                                                                                             in place or rewarded if they do. The quality         is concerned with quality control, support
take lessons learnt and give instant feedback to          the quality of service. Post QAs, a total number                                                        and supervision whose basis for measuring
                                                          of 337 of nurses in 5 districts of Mashonaland     of service ofered by a health facility has
their subordinates as well as their supervisors.                                                                                                                  quality is accuracy of verification and
The mere fact that service providers know that            West province have been trained in midwifery       three components, the first two of which
                                                                                                             focus on the quality of the health facility          adherence to set programme guidelines.
they are being supervised pushes them to do               implying that most deliveries are now being
their best, especially if they know that delivery         conducted by trained midwives. In addition,        and their staf. The components include,
of high quality services will be incentivised and         QAs also allow the DHEs to monitor essential       to begin with, the DHE quality score where           2.2.2 Improved Quality Increases
poor quality punished.                                    medicines supply and the facility stocks. In       the basis of assessment is:                          Earnings /
                                                          the end they can recommend facilities to                                                                Already, we have documented how RBF
In addition, QAs allow the DHEs to be in touch            either maintain the available stocks or procure
                                                                                                             •   The quality of the health facility               links the numbers of people who are
with the health delivery system in a practical            additional drugs hence ensuring continued                                                               served by a health facility to the facility’s
                                                          improvement in the quality of service delivered
manner. Through the assessments, the DHEs
                                                                                                             •   The quality of management and                    earnings. However, there are other factors.
have an opportunity to check whether the                  to clients.                                                                                             The RBF recognises that reaching out
                                                                                                                 planning systems
                                                                                                             •   The quality of clinical management               to many people with health services is
                                                                                                                 and services provided                            only half the task. In order to deliver an

                                                    26                                                                                                      27
RBF                                                                                                           RBF

          efective public health service, the quality
          of the service equally matters. Against
                                                               both quantity and quality being essential
                                                               to the formula.                                           BANGURE CLINIC: THE IMPACT
          this background, quality just like quantity
          must be incentivised. Hence, the formula
          for facilities’ earnings looks beyond mere
                                                               From the diagram below, it is clear that
                                                               health facilities can earn more money by
                                                                                                                         OF QAS ON SERVICE DELIVERY /
          numbers; it also assesses the quality of the         improving the quality of services and not
          service among other factors that ensure              just the numbers. In turn, this money can
                                                                                                                        FIG 3: OVER THE YEARS, THE QUALITY OF SERVICES IN BANGURE CLINIC HAS GENERALLY
          equity and fairness in the disbursement of           be used to improve service delivery in the               BEEN ON AN UPWARD TRAJECTORY AND SO HAVE BEEN THE EARNINGS
          subsidies. The diagram below explains the            health facility as the story of Bangure clinic
          mechanism for calculating earnings with              below shows.
                                                                                                                        4000                                                                   4188.89
Total           Amount Paid for              Amount Paid for                 Amount Paid for Quality of Services        3000                                                                      3329.8
Subsidy         Quantity of Services         Remoteness Bonus                • Based on quality score attained          2500
                • Number of services X       (purposes of equity)            • Score is checked against the four
           =      unit price                 • Based on 5 remoteness
                                             • Each can attract a
                                                                               quality ranges in order to determine
                                                                               which percentage of the capped
                                                                               monthly amount the facility will earn
                                                                                                                        1000 467.95
                                               maximum bonus of 6%           • Maximum capped amount of quality          500
                                               (maximum 30%)                   bonus a facility will be getting per        0 0
                                             • Reviewed on a                   quarter is $4,615
                                                                                                                                Q2   Q3   Q4   Q1   Q2   Q3   Q4   Q1   Q2   Q3   Q4   Q1   Q2    Q3
                                               6-monthly basis by the        • Each component of the checklist
                                                                                                                               2014 2014 2014 2015 2015 2015 2015 2016 2016 2016 2016 2017 2017 2017
                                         +     DHE                             and the CSS tool is assigned prices
                                                                               based on their weight (weight is
                                                                               based on the 2017 Quality Supportive
                                                                                                                                                             Quantity            Quality
                                                                               Supervision checklist)

                                                                        +    • Structural (0.09) $413.1,
                                                                               Management and Planning (0.23)
                                                                               $1053.7, Clinical Management (0.48)
                                                                                                                        Located in the Buhera District of Manicaland
                                                                                                                        Province, Bangure clinic is a perfect case
                                                                                                                                                                             and work hard in order to deliver quality
                                                                                                                                                                             under whatever circumstances. Even
                                                                               $2225.5, Client Satisfaction Survey      study of how the RBF programme has                   when she went for upskilling in midwifery
          FIG 2: MECHANISM FOR CALCULATING THE                                 (0.20) $923.1.                           improved the quality of services through             in the 4th quarter of 2015, her team was
                                                                             • Calculation of quality bonus – if        the aid of quality assessments. Since the            motivated to work together to maintain
          SUBSIDY FOR A FACILITY: THE TOTAL SUBSIDY                            the overall quality score is
RBF                                                                                                                  RBF

                                                                        2.3 Money Well-Managed is                                       The financial management training covers
                                           Drums and tins used to       Lives Saved: RBF Helps Improve                                  the following key aspects that improve
                                           store water at the clinic                                                                    the facilities’ capability to prudently and
                                           before the installation of   Financial Management Practices in
                                                                                                                                        efectively manage resources for the
                                           the solar pump               Health Facilities /
                                                                                                                                        purposes of improving service provision:
                                                                        According to the Centre for Global
                                                                                                                                        •   How to record transactions in the cash
                                                                        Development, many countries sufer
                                                                        from ineficiency and corruption that
                                                                                                                                        •   How to use bank statements when
                                                                        compromise the public health delivery
                                                                                                                                            preparing bank reconciliations
                                                                        system.1 To address both of these related
                                                                                                                                        •   Procurement procedures when
                                                                        problems, it is important to improve
                                                                                                                                            procuring goods/services
                                                                        the systems through which finances are
                                                                                                                                        •   Good filing systems and keeping
                                                                        managed in the public health sector.
                                                                                                                                            auditable documents
                                                                        Research has shown that investment
                                                                                                                                        •   Financial planning and analysis
                                                                        in financial management systems ‘is
                                                                                                                                        •   Financial reporting
                                                                        worthwhile as a supporting mechanism
                                                                        to delivering better health services.’2
                                                                                                                                        When the financial systems of health
                                                                        Such financial management systems are
                                                                                                                                        facilities are strong, leakages of
                                                                        beneficial in the sense that they provide
                                                                                                                                        resources through financial management
                                                                        reliable financial transfers as well as
                                                                                                                                        malpractices and corruption are limited.
                                                                        provide useful data to inform policy
                                                                                                                                        This means more money going into
                                                                        choices on levels and equity of funding
                                                                                                                                        procurement of medicines and improving
                                                                        and, generally, can support accountability
                                                                                                                                        the quality of service, among other
                                                                        hence deal with leakages such as
                                                                                                                                        functions of the public health system.
                                                                        corruption or mismanagement of funds.
                                        Villagers ofloading river
                                        sand, stones and bricks
                                                                        The RBF Programme understands the link                          2.3.1 Electronic Platforms
                                        at Bangure Clinic as they
                                        help in the construction of     between financial management and public                         Introduce Ease of Transaction /
                                        a Waiting Mothers Shelter.      health outcomes hence the investment                            It is important to note, however, that the
                                                                        and innovation of Crown Agents in the                           support of Crown Agents under the RBF
                                                                        way financial resources are managed.                            Programme is not only concerned with
                                                                        To this end, Crown Agents is training                           ensuring that there are no leakages, it is
                                                                        and supporting all districts in financial                       also about improving the ease of financial
                                                                        management. In 2017, 38 percent of the                          management processes. To this end, Crown
                                                                        districts were trained and provided with                        Agents has been helping health facilities to
                                                                        supportive supervision. The remaining                           migrate to the electronic payment system.
Waiting Mothers’ Home in its final stages of construction at            districts will be trained and supported in
Bangure Clinic. With better quality, facilities earn more and with      the first half of 2018.                                         The electronic payment system is a way of
more earnings, facilities can do even more for the communities                                                                          making payments for goods and services
they serve.                                                                                                                             electronically instead of using cash or
                                                                        1 Working Paper Number 78, January 2006: Governance
                                                                          and Corruption in Public Health Care Systems, Maureen
                                                                                                                                        filling-in and submitting hard copies for
                                                                        2 Overseas Development Institute, 2017

              30                                                                                                                  31
RBF                                                                                                                                                                                     RBF

MAP 1: COVERAGE OF THE FINANCIAL                                                                                                                                                            MAP 2: STATE OF THE ELECTRONIC
MANAGEMENT TRAINING AND                                             CHIRUNDU
                                                                                                                                                                                            PAYMENT SYSTEM TRAINING AND
                                                                                                                      MBIRE                                                                                                                                      CHIRUNDU
SUPERVISION BY CROWN AGENTS                                                                                                          CENTENARY
                                                                                                                                                                                            SUPERVISION UPTAKE.                                                                                                MBIRE

ACROSS THE DISTRICTS                                            KARIBA URBAN
                                                                                          HURUNGWE                                                                    RUSHINGA
                                                                                                                                                                                                                                                             KARIBA URBAN
                                                                                                                                                                                                                                                                                                                                            MT DARWIN
                                                                                                                                                  MT DARWINI
                                                                                                                            GURUVE                                                                                                                                                                                  GURUVE
                                                                 KARIBA                                                                                                                                                                                       KARIBA
                                                                                                                                                    SHAMVA                                                                                                                                                                                  SHAMVA                       MUDZI
                                                                                                       MAKONDE                                                                                                                                                                                   MAKONDE
                                                                                                                               MAZOWE                                                                                                                                                                                  MAZOWE
                                                                                                       CHINHOYI                                                                                                                                                                                     CHINHOYI
                                                                   GOKWE NORTH                                                                                        MUTOKO                                                                                                                                                                                  MUTOKO
                                                                 GOKWE NORTH                                                                                                                                                                                  GOKWE NORTH
                                                                                                                   ZVIMBA                                                                                                                                                                                  ZVIMBA
                                                                                                                            HARARE URBAN                   MUREWA                                                                                                                                                       HARARE URBAN               MUREWA
       VICTORIA FALLS                      BINGA                                                                                                           NYANGA                                    VICTORIA FALLS                     BINGA
                                                                                                                            HARARE RURAL                                                                                                                                                                                HARARE RURAL
                                                                                                              NORTON                                                                                                                                                                                    NORTON
                                                                                                                  CHEGUTU                                                                                                                                                                                 CHEGUTU
                                                             GOKWE SOUTH                                                            SEKE                                                                                                                                                                                    SEKE
                                                                                                  KADOMA                                                  TASAMAKONI
                                                                                                                                                                                                                                                          GOKWE SOUTH                     KADOMA                                                            MAKONI        NYANGA
                   HWANGE URBAN                                                                                                                                     RUSAPE                                       HWANGE URBAN                                                                                                                               RUSAPE

                                                                                                                                                                                 MU                                                                                                                                                                                      MUTASA
                                                                                                                                                   HWEDZA                                                                                                                                                                                  HWEDZA
                         HWANGE                     LUPANE                                                                                                                                                             HWANGE                    LUPANE                         KWEKWE
                                                                  NKAYI                  KWEKWE                                     CHIKOMBA                                                                                                                                                                                CHIKOMBA
                                                                                                                                                                             MUTARE URBAN                                                                      NKAYI
                                                                                                                                                                                                                                                                                     REDCLIFFE                                                                       MUTARE URBAN
                                                                                                                  CHIRUMANZU                                                 MUTARE                                                                                                                                                                                  MUTARE
                                                                                          GWERU                                                                ANIMANI                                                                                                                                                                              BUHERA
                                  TSHOLOTSHO                                                                                                                                                                                    TSHOLOTSHO
                                                                        BUBI                                                                                                                                                                                         BUBI
                                                                                                                                           GUTU                 BUHERA                                                                                                                                                             GUTU
                                                       UMGUZA                                              SHURUGWI                                                                                                                                 UMGUZA                                         SHURUGWI
                                                                                                                                                                                CHIM                                                                                                                                                                                    CHIMANIMANI

                                                             BULAWAYO                                                  MASVINGO URBAN                                                                                                                     BULAWAYO                                               MASVINGO URBAN
                                                                                                                                                           BIKITA                                                                                                                                                                                    BIKITA
                                         BULILIMA                                        INSIZA                                                                                                                                       BULILIMA                                   INSIZA
                                                                                                        ZVISHAVANE                                                            CHIPINGE                                                                                                           ZVISHAVANE                               ZAKA                        CHIPINGE
                                                                                                                                                  ZAKA                                                                                                                                                                                    ZAKA
                                                                                                                               MASVINGO                                                                                                                                                                                 MASVINGO
                                                                                                      MBERENGWA             CHIVI                                                                                                                                                                MBERENGWA
                                                MANGWE                                                                                                                                                                                       MANGWE
                                                              MALOBO                                                                                                                                        COMPLETE                                       MALOBO

                                                                                GWANDA                                MWENEZI
                                                                                                                                                                                                            SENT TO BANK                                                    GWANDA                             MWENEZI
                                                                                                                                                         CHIREDZI                                                                                                                                                                                CHIREDZI
                                                                                                     BEITBRIDGE                                                                                                                                                                              BEITBRIDGE
                  PENDING SUPERVISION
                                                                                                  BEITBRIDGE URBAN                                                                                                                                                                        BEITBRIDGE URBAN

Real Time Gross Settlement (RTGS). It                                                             the RTGS cost. It is even more cost                                                       However, this process has not been
means payment of goods and services                                                               efective if one considers that no                                                         without challenges. Across all the rural
using an internet-based platform rather                                                           travelling costs to the bank are                                                          health facilities there seems to be fear and
than visiting the bank.                                                                           involved.                                                                                 lack of confidence in using technology
                                                                                     •            It is convenient and time-eficient as                                                     especially when it comes to finances. This
Although the map below shows that uptake                                                          payments can be done any time at                                                          is also compounded by poor connectivity
of the electronic payment system has been                                                         the DHE ofices. Notably, payments                                                         to the internet in many rural communities.
slow, the system has several benefits:                                                            are done concurrently when DHEs                                                           These challenges partly explain the slow
• It is faster and cheaper than cash or                                                           review and authorise procurement                                                          uptake of the electronic payment system.
     RTGS transactions hence saves time                                                           documents.
     and money. RTGS costs $5-$10 per                                                •            The electronic payment system in use
     transaction while electronic banking                                                         is user-friendly.
     costs only less than 20 percent of

                                                                               32                                                                                                                                                                                       33
RBF                                                                                                 RBF

                                                                 CHAPTER THREE /
                                                                                RBF IMPACT IN PERSPECTIVE

                                                  The stories in this publication have                    earnings. Masvingo province (see story
                                                  illustrated massive investments that                    below) is an example of the impact of RBF
                                                  have been made in the health systems,                   evident in earnings.
                                                  particularly for rural health facilities. These
                                                  investments have helped support facilities to           MASVINGO PROVINCE LEADS IN RBF
                                                  improve the quality of services they provide,           EARNINGS /
                                                  increase the reach of their services as well            Between the third quarter of 2016 and the
                                                  as strengthen their financial management                third quarter of 2017, Masvingo Province
                                                  systems in order to maximise on the limited             was leading in terms of earnings (see
                                                  resources available. The results of such                table below). Earnings are one of the
                                                  huge investments must be visible for both               components that reflect the success of
                                                  the clients and other stakeholders in the               the RBF programme since they are tied
                                                  health delivery sector. In this chapter, we             to maintaining high quality of services
                                                  highlight some of the visible results of the            and the reach of the same. In the light of
                                                  RBF Programme.                                          this knowledge, there is no doubt that
                                                                                                          the teams in the health facilities and the
                                                  3.1 Improved Earnings: Rewards for                      province worked hard throughout the
                                                  Producing Results /                                     year. With high quality of services and
                                                                                                          high numbers of clients served, it is only
                                                  The quantity and quality of services provided           a matter of time before statistics come
                                                  are among the determinants of health                    through to demonstrate the impact
                                                  facility earnings in RBF. Over the years,               through key health indicators of concern to
                                                  many facilities have been realising increased           the HDF.
                                                  earnings under the RBF
      ‘BEFORE THE INTRODUCTION OF THE RBF         Programme. While increased TABLE 1: TOP RBF EARNERS FOR THE PERIOD Q3 2016 –
      PROGRAMME OUR REGISTERS ACROSS THE          earnings themselves are a Q3 2017, MASVINGO DOMINATES
      DISTRICT HAD LOTS OF GAPS. WE ARE           sign of the RBF impact in some
      PLEASED TO SEE THAT WITH THE RBF            respects, the importance of FACILITY                        AMOUNT ($)   DISTRICT    PROVINCE
      INTERVENTION, DATA IS NOW BEING VERIFIED;   RBF is made prominent by the Bota Clinic                      44,880.80       Zaka    Masvingo
                                                  stories of how health facilities Gutu Rural Hospital          45,163.82       Gutu    Masvingo
                                                  are working hard to increase Bikita Rural Hospital
      TIMELY.’                                                                                                  46,713.42      Bikita   Masvingo
                                                  their earnings as well as the
                                                                                     Chikuku Rural Hospital     47,040.78      Bikita   Masvingo
                                                  investments they are making
                                                  in their facilities through such Dotito Rural Health Centre   48,827.96 Mt. Darwin Mash Central

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RBF                                                                                                  RBF

Earning such a prestigious spot takes                  province team is only representative of                TEAM WORK: HOW MASVINGO PROVINCE GOT IT RIGHT
concerted eforts of many stakeholders.                 the team spirit, commitment and desire                 When, decades ago, Henry Ford remarked that, “If everyone is moving forward
However, one can never discount the                    to serve communities that exists in all the            together, then success takes care of itself,” he knew nothing about RBF or the team
support of the provincial team – both                  provinces. The province may be leading                 in Masvingo working on this program. The great American captain of industry
the MoHCC and Crown Agents provincial                  in the past year but many other provinces              was probably just sharing conventional wisdom he had gleaned from years of
support teams. It is unlikely that the                 have put equal investment and dedication.              experience in business.
prevalence of success in one province                  This is why the list of consistent performers
                                                                                                              But, wisdom knows no limits in time and space; it endures all confines and, hence,
over a single year could happen without                is made up by diferent provinces. (See                 many years ater Ford’s demise, what he learnt about teamwork found currency a
such support. However, Masvingo                        table below)                                           thousand miles away in Zimbabwe’s oldest town, Masvingo. Ater dominating the
                                                                                                              top 5 of RBF earners for the year 2016 to 2017, the Provincial Medical Director for
                                                                                                              the Masvingo province, Dr Shamu tends to agree with Ford’s observation. ‘We are
                                                                                                              happy to know that our province has realised such huge success. Teamwork is at
TABLE 2: RBF CONSISTENT EARNERS (Q3 2016 TO Q3 2017)                                                          the centre of our success,’ he observed.

 FACILITY                 TIMELINE                                                                            With a total of 119 clinics under RBF program in the province, Masvingo occupies
                          Q3 2016    Q4 2016    Q1 2017     Q2 2017     Q3 2017      (Q3 17 )   % increase    all the top 4 spots amongst the highest earners for the period Q3 2016 to Q3 2017,
                                                                                    - (Q3 16)   in earnings   with Mashonaland Central grabbing the fith. Ater training the various actors and
                                                                                                              adhering to the prescriptions of the RBF program, the Provincial Health Promotion
 Dewure II Rural Health    964.65    1,209.33   1,420.35    1,976.77     4,684.3    3,719.65          36%
                                                                                                              (PHP) Oficer, Mr. Casper Nhemachena observes that everyone is playing their part.
                                                                                                              ‘Team work is the catchword in Masvingo,’ he emphasised.
 Epworth Mission Clinic    858.31     866.28    1,586.28    1,264.64    3,656.14    2,797.83          34%
 Hozvi Clinic              899.15    1,039.95   1,495.45    1,406.03    3,337.92    2,438.77          30%     Teamwork is only possible when the various actors know their place in the team
 Muzokomba Clinic         1,708.76   2,336.76   2,319.13    4,311.93    6,865.79    5,157.03          29%
                                                                                                              and are willing to play it. Masvingo province invested significantly in the training
                                                                                                              of various stakeholders among them the DHEs, health facility staf and the HCCs.
 Bikita Rural Hospital    4,761.09   4,546.89   7,903.58   11,382.03   18,119.83   13,358.74          29%     And such capacity development eforts are paying of. ‘The RBF in Masvingo is
 Mandara Clinic           2,397.40   2,196.61   4,522.70    6,436.13    9,503.70    7,106.30          28%     community driven and communities work with health workers. Ownership has
 Chikuku Rural Hospital   2,741.83   2,708.80   9,703.27   15,929.36   15,957.52   13,215.69          28%
                                                                                                              moved to communities with HCCs spearheading all health facility development
                                                                                                              issues. This has lessened the burden for health workers, who are now focusing on
                                                                                                              their core business of improving the quality of care,’ said the PHP.
Since Masvingo province dominates the list of our top earners for the period Q3 2016 to                       Just like every team needs a leader, the Masvingo province leadership was
Q3 2017, we caught up with the provincial leadership team consisting of the Provincial                        exceptional in this regard. They availed themselves throughout to support and
Medical Director, the Provincial Nursing Oficer and the Provincial Health Promotion                           mentor the health facilities. It helped that the health workers themselves were
Oficer, who all shared important insights into their success story.                                           already motivated, noted the Provincial Nursing Oficer, Mrs. Mavis Gumbo. ‘The
                                                                                                              25 percent incentives payment is motivating our health workers to do their best.

                                                                                                              No doubt, there is all the ingredients for success in Masvingo – a motivated team
                                                                                                              and a leadership willing to serve. What if we add a community that is willing and
                                                                                                              able to participate in the running of their own health facility? One can only wait
                                                                                                              and see if Masvingo province can outdo itself in the coming months.
                                                                                                              3.2 Using Earnings to Improve Health Facilities: Stories of Impact

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