RESULTS-BASED FINANCING Strengthening the Health Delivery System in Zimbabwe

June 2018 RBF

FOREWORD / SINCE 2012, MATERNITY WAITING HOMES 835 RURAL DISTRICTS HAVE HELPED CUT DOWN 42 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 AN ESTIMATED statement: “to provide, administer, things. This is not to mention that support 67 coordinate, promote and advocate for that is going to paying allowances to health 50%. HOSPITALS ACROSS 6,6 MILLION PEOPLE the provision of equitable, appropriate, staf in order to keep their morale high THE RBF PROGRAMME IS THE RBF PROGRAMME BEING IMPLEMENTED IN THE COUNTRY 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. opportunity to hear the real life stories of ?! This is why we are grateful for the support 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 NURSES NUMBER OF THE NATIONAL DATA in several districts have managed to IN 5 DISTRICTS OF ERROR RATE; DECLINED refurbish their infrastructure e.g. repairing Major General (Dr) G. Gwinji MASHONALAND WEST FROM 56% BEFORE RBF PROVINCE TRAINED IN and painting their premises and building of Secretary for Health and Child Care MIDWIFERY

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WHAT’S IN THIS ISSUE?

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

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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

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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, ASSISTANT EDITOR 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 RBFRBF RBF

ABOUT THE PUBLICATION /

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.

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Against this background, for Zimbabwe, the RBF programme is more than just a CHAPTER ONE / 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 THE RBF PROGRAMME IS staf morale and, as a result, helped shape 162 556 time as players in the sector seek efective 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 Health Development Fund (HDF), Crown RURAL HEALTH FACILITIES The RBF Programme is a key intervention 2 485 519 Agents has been implementing the RBF NUMBER OF CHILDREN 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 6,6 MILLION 1.1.1 What is the Results-Based in The results to be achieved and payments alternative for accessing health services 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

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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, under Health Development Fund). To date UNICEF sometimes coordinates visits by the HIS EXCELLENCY LIAM MACGABHANN AS WELL 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 IMPACT SYNOPSIS

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 communities. • 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.

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CHAPTER TWO / RBF STRENGTHENING HEALTH DELIVERY SYSTEMS 2.1 RBF Improves Data Management DID YOU KNOW? in Health Facilities / Health delivery works within a system. In March 2018, the World Health The service that clients access at the point Data management is an administrative Organisation issued an alert for of delivery is a result of many processes process that includes capturing, storing, a potential global pandemic. A and functions within this system. When ?! protecting, and analysing data pulled from team of medical scientists who patients receive a service, they tend to diferent sources (registers) to ensure ease convene annually to discuss what think that having a health worker and of accessibility of the data for its users. new diseases pose the greatest medicines is all one needs in a health It is the backbone of RBF and hence the 902 2% potential of turning into a global facility. Little do clients know that behind importance of proper data management. NUMBER OF FACILITIES THE NATIONAL DATA pandemic have concluded that what they interact with at the point of ERROR RATE; DECLINED TRAINED IN DATA they do not have any knowledge service, there is a complicated support MANAGEMENT FROM 56% BEFORE RBF Whether it’s an individual patient’s case on what it could be. However, they mechanism to the health delivery system or a public health issue afecting a wider are convinced that conditions are – there is data management that monitors indicators that inform the goal of the RBF community, decision makers and health ripe in many respects for a new and improves access to quality service, Programme, as supported by the Health service providers alike rely on access to pathogen to emerge and cause complex infrastructure that supports Development Fund. Since investments in good data to improve both the access to havoc for global health systems. service delivery as well as a myriad of the system itself are less visible to the eyes and quality of health services they provide. They have termed this ‘Disease administrative procedures and systems, of the public, they are oten not discussed Based on this data, health facilities X’. If any new disease emerges among several other components of the or understood. Hence stakeholders tend staf can measure the quality of health as have HIV, SARS and Ebola in health delivery system that clients do not to rush to complain that resources have services they provide and make necessary recent decades, the developing interact with every day. Needless to say, gone missing if they do not see them adjustments if there is a need to. Medical world is likely to bear the brunt accessing and enjoying quality services going into staf salaries, medicines or practitioners can also use holistic patient of the new pandemic – they have at a health facility is only possible when any other components of the health data to personalise treatment for patients weak health systems hence limited these various components are designed system that are at the point of accessing hence improving the general well-being of capacity to contain or respond and supported to deliver such services services. Government and its partners in the patient. At the broader national health to new pandemics should they efectively. health financing have an obligation to systems level, several benefits accrue emerge. The RBF’s intervention communicate to all stakeholders about the from good practices of data management. in strengthening health systems The RBF Programme is alive to the complexities of financing the health sector. Good data management practices can is therefore an important dynamism of the health delivery system. To If this is done clearly, it can even enhance help health systems to predict and prevent contribution in addressing the this end, Crown Agents and its partners have the participation of more stakeholders, public health catastrophes as well as public health systems’ capacity to invested a significant amount of resources, including communities in public health model public health programmes and respond, not only to known public including capacity strengthening, in these issues. In this edition we celebrate the policies that respond to certain diseases health issues of the day but also various components of the health delivery investments made by the RBF Programme and conditions deemed prevalent in the those of the future – pandemics system. The successes of these investments in the processes behind the scenes and we communities served. In essence, good now confirmed by science as are evident in both the state of the health bring this out to the public eye through data management strengthens the health inevitable. delivery system in the districts where RBF some visible changes that clients may delivery systems and increases individual 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.

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systems and outcomes, Crown Agents invested BENEFITS OF GOOD DATA a substantial amount of time, skills and other QUESTION AND ANSWER / MANAGEMENT PRACTICES resources in capacity development for better data management. Hence, all the 834 facilities HOW THE RBF PROGRAMME HELPED IMPROVE DATA MANAGEMENT: under RBF in the 42 districts of Zimbabwe where There are several benefits that come with CROWN AGENTS DATA MANAGER SPEAKS efective data management practices: Crown Agents works have been capacity built to 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 Crown Agents has played in developing the good data is testimony to the results achieved. patients hence improve the general well- bearing fruits. being of individual patients. capacity of health facilities in managing o Improvement in the day to day running data efectively as well as the results of the The Editor: In that case then, do you imply that of the facility allowing management to intervention. Here are the snippets of the data management is self-serving – we only need plan ahead. WHAT IS DECLARED DATA? interview: good data for the purpose of paying facilities on o Improve population health outcomes Declared data is the data recorded by health the basis of results achieved? 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. proper data management. practices of data management seemed to be 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 that important, what role did Crown Agents play capacity, competing priorities in the face of date, sex, full address, age and full name The Editor: You say that data management ‘is to improve data management practices in the resource scarcity as well as demoralisation of patients. The process of verification is the backbone of RBF and hence the importance context of the RBF Programme? of staf, among other factors, saw data important as such data has implications on of proper data management.’ Can you explain 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 programme. It is on the basis of this data that the incentivised the correct capturing of data by 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 able to verify the results of each health facility were emphasising the importance of data and health facilities to deliver services. With interviews. The organisation analyses the and be able to determine or calculate how much benefits of efective data management. efective data management strategies 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 programme. 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 promote data correctness and completeness undertake a process of verification for the data 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.

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FIG 1: AVERAGE DATA QUALITY PROGRESSION FOR HDF - SUPPORTED FACILITIES MOHCC LAUDS RBF ROLE IN (2014-2017)

IMPROVING DATA QUALITY / 60%

50% 49%

The Makoni District Health Information Mr. Mushore is of the opinion that the 40% Oficer (DHIO) has commended the role that Ministry has noted a vast improvement 30% 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 others: • 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 PROGRAMME.

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 since it is quality that determines if the 337 the district had lots of gaps. We NURSES served patient is going to be satisfied NUMBER OF are pleased to see that with the 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 PROVINCE TRAINED IN consistency. Even reporting is ensure the services provided and paid for now comprehensive and timely.’ MIDWIFERY are of a high quality? The answer is in the District Health Executive (DHE) Quality Assessments.

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 the services provided by a particular health structures are suitable for service delivery or Accountant, District Environmental Health WHY QUALITY ASSESSMENT MATTERS facility. Quality Assessments (QAs) allow supervisors plans are being implemented as well as how Oficer and the District Pharmacist. They to observe, identify knowledge gaps as well as staf is being allocated duties, among other have a quality scoring system they use to The third component, on the other hand, monitor and evaluate the activities of a health supervisory functions. This allows DHEs to assess the quality of facilities. Quality of 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 order to recommend trainings. These trainings to set procedures and, if not, define steps to penalised for not having quality systems of Health verifiers (SICC). This component will then help to improve staf knowledge hence 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 of service ofered by a health facility has and supervision whose basis for measuring their subordinates as well as their supervisors. of 337 of nurses in 5 districts of Mashonaland quality is accuracy of verification and West province have been trained in midwifery three components, the first two of which The mere fact that service providers know that adherence to set programme guidelines. they are being supervised pushes them to do implying that most deliveries are now being focus on the quality of the health facility conducted by trained midwives. In addition, and their staf. The components include, their best, especially if they know that delivery 2.2.2 Improved Quality Increases of high quality services will be incentivised and QAs also allow the DHEs to monitor essential to begin with, the DHE quality score where 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 additional drugs hence ensuring continued with the health delivery system in a practical infrastructure 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. planning systems The RBF recognises that reaching out • 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 both quantity and quality being essential of the service equally matters. Against to the formula. BANGURE CLINIC: THE IMPACT this background, quality just like quantity must be incentivised. Hence, the formula From the diagram below, it is clear that OF QAS ON SERVICE DELIVERY / for facilities’ earnings looks beyond mere health facilities can earn more money by 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. 4500 4000 4188.89 3500 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 quality ranges in order to determine 2000 1500 = indicators which percentage of the capped 882.4 • Each can attract a 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 + Quantity Quality based on the 2017 Quality Supportive Supervision checklist) • Structural (0.09) $413.1, Located in the Buhera District of Manicaland and work hard in order to deliver quality + Management and Planning (0.23) $1053.7, Clinical Management (0.48) Province, Bangure clinic is a perfect case 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 SUBSIDY FOR A FACILITY: THE TOTAL SUBSIDY • – if the aid of quality assessments. Since the motivated to work together to maintain the overall quality score is <60%, PER FACILITY IS THE SUM OF QUANTITY, QUALITY the facility will not get any quality RBF Programme started in April 2014, the quality of service. The team worked AND REMOTENESS PAY OUTS bonus and if the overall quality score Bangure Clinic has earned a total of $39, together successfully. As a result, the team is ≥60%, the quality bonus will be 783 by generally managing to keep its has earned significantly over the period calculated as follows: quality of services on an upward trajectory under review. The earnings made have • % of score of structural section* as shown in the graph above. impacted the clinic and the community maximum available quality bonus for the structural section) + (% of score in many ways. The clinic managed to of Management Section*maximum The Nurse-in-charge at Bangure clinic install a solar-powered borehole which available quality bonus for the knows that it is important to deliver has made it possible for waiting mothers management section) + (% of score high quality services in order increase and staf to access clean without travelling of Clinical management section* maximum available quality bonus earnings. While it appears to be a chicken long distances. The same water has also for the clinical management section) and egg scenario when it comes whether been used to start a nutritional garden for + (% of score of CSS* maximum quality improves earnings or vice-versa, waiting mothers. available bonus for CSS section) she advises her team to work together

28 29 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 books 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 2.3.1 Electronic Platforms at Bangure Clinic as they The RBF Programme understands the link 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 filling-in and submitting hard copies for and Corruption in Public Health Care Systems, Maureen Lewis 2 Overseas Development Institute, 2017

30 31 RBF RBF

MAP 1: COVERAGE OF THE FINANCIAL MAP 2: STATE OF THE ELECTRONIC PAYMENT SYSTEM TRAINING AND MANAGEMENT TRAINING AND CHIRUNDU SUPERVISION BY CROWN AGENTS MBIRE SUPERVISION UPTAKE. CHIRUNDU MBIRE CENTENARY CENTENARY HURUNGWE HURUNGWE KARIBA URBAN KARIBA URBAN MT DARWIN ACROSS THE DISTRICTS HURUNGWE MT DARWINI RUSHINGA HURUNGWE RUSHINGA GURUVE GURUVE

KARIBA KARIBA SHAMVA MUDZ SHAMVA MUDZI MAKONDE MAKONDE MAKONDE MAZOWE MAZOWE CHINHOYICHINHOYI CHINHCHINHOYIOYI 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 MARONDERA MARONDERA HWANGE URBAN RUSAPE HWANGE URBAN RUSAPE

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

BULAWAYO BULAWAYO MASVINGO URBAN BIKITA MASVINGO URBAN BIKITA BULILIMA INSIZA BULILIMA INSIZA ZVISHAVANE CHIPINGE ZVISHAVANE ZAKA CHIPINGE ZAKA ZAKA MASVINGO MASVINGO CHIVI MBERENGWA CHIVI MBERENGWA MANGWE MANGWE MALOBO COMPLETE MALOBO GWANDA MWENEZI SENT TO BANK GWANDA MWENEZI CHIREDZI CHIREDZI PENDING SUPERVISED 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 THERE IS NOW DATA CONSISTENCY. EVEN stories of how health facilities REPORTING IS NOW COMPREHENSIVE AND Gutu Rural Hospital 45,163.82 Gutu Masvingo are working hard to increase TIMELY.’ Bikita Rural Hospital 46,713.42 Bikita Masvingo their earnings as well as the investments they are making Chikuku Rural Hospital 47,040.78 Bikita Masvingo in their facilities through such Dotito Rural Health Centre 48,827.96 Mt. Darwin Mash Central

34 35 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. Centre ‘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 and are willing to play it. Masvingo province invested significantly in the training Muzokomba Clinic 1,708.76 2,336.76 2,319.13 4,311.93 6,865.79 5,157.03 29% 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

36 37 RBF RBF

Earnings are not an end in themselves. to encourage the health staf who had a As if the impact on the infrastructure was But is that enough to get staf go an extra Their success is heralded in how they negative attitude towards RBF programme,’ not enough, improved subsidy earnings mile and sacrifice their spare time? ‘All are used to improve the facilities’ she says. ‘However, I continued to utilize have also improved staf motivation. The staf members are motivated by the staf infrastructure, stocks and services. The every verification round and nurses previously unmotivated health team has incentives they receive,’ she added. Staf stories of Mushaviri and Nyahode clinics meetings to build the capacity of the health now become highly motivated with team members are aware that they will only earn below are some of the many examples of staf. I kept on reassuring them that their spirit is oozing among the health staf. incentives if their facility performs. And to how, through RBF earnings, health facilities earnings would rise if they adopt strategies demonstrate this performance, they need are changing for the better. such as data validation and conduct health 3.2.2 Nyahode Clinic Shines, to manage their data properly as this is facility initiated outreaches.’ thanks to the RBF Verification necessary in the verification process. 3.2.1 The Story of Mushaviri Clinic / Process / Overtime, the fortunes of Mushaviri RHC The motivation among staf to go an STAFF ACCOMODATION BEFORE have turned around. They have started Nyahode Clinic in Chimanimani District, extra mile is not just for staf selfish ends. RENOVATION conducting outreaches to boost their Manicaland province is one example of a It primarily benefits the facility and the volumes. As a result, institutional deliveries health facility that has embraced the RBF services users. Because Nyahode Clinic has by pregnant mothers have increased from calls for efective data management hence improved its data management and with it 6, in 2014, to 15 in 2017. In response, their earning high subsidies. This facility started the earnings, notable developments have earnings have since shot from $93 to an of with an average error rate of 58 percent taken shape in the facility. ‘The subsidies average of $1300 per quarter in 2017. in 2014 and now (2017) the average error have assisted us to construct a maternity rate is within the acceptable 5 percent home, procure equipment and to maintain With the improved earnings, they have range (see graph below). As the error rate uninterrupted supply of essential drugs. managed to spruce up the health facility goes down, the subsidy earnings for this Our service to the clients has improved as through renovations and giving the facility facility have shot up from $479.06 in 2014 a result. Overall, the clinic standards have STAFF ACCOMODATION AFTER a new look through a sparkling paint. to $3 133.87 in the same period. really improved and we are planning to RENOVATION WITH RBF FUNDS Courtesy of the RBF subsidies the health extend the clinic structure so as to have staf in conjunction with the HCC have ‘Working as a team at our Clinic has brought more space for in-patients,’ remarked the managed to construct an incinerator. good results for us. We have managed to PCN. reduce our error rate to the acceptable The Nurse-in-charge at the facility, Mr. ±5% error rate,’ remarks Ms Caroline 3.3 Overview of the Impact of RBF Tausa was full of praise for Mrs. Nhau, Mandishare, a PCN at Nyahode Clinic. on the Key Focus HDF Indicators / the HFO who tirelessly implored and ‘When it’s time to do our statistics, everyone encouraged the health staf to work as at the clinic sacrifices their spare time so as Increased numbers served by a facility a team and to employ strategies which to assist and count the source documents as well as improved quality of services would help to boost demand for health physically. We do physical count from the does lead to better earnings. In turn, high Similary to Kamutsenzere, Mushaviri RHC is services. This demand creation helped to source documents and counter verify by a earnings do improve the infrastructure and a low volume health facility located in Gutu push volumes up with an ultimate knock- second person,’ she explains. services provided by a facility. However, district. At the onset of the RBF programme on efect on the health facility’s subsidy until the key maternal and newborn health the health facility was characterized by earnings. According to the nurse in charge, Speaking on how they have managed to indicators respond, the RBF may not truly pathetic earnings. In the second quarter plans for constructing a waiting mother’s improve their data management through be considered a success. As a result, Crown of 2014, the facility only earned a paltry shelter are already at an advanced stage. the RBF process, the PCN was full of praise Agents is pleased that the intended chain $93. The local HFO, Faith Nhau recalls Mr. Tausa averred that the community is for the MoHCC and Crown Agents support. of results has taken shape – not only have the negativity among staf as demoralized very grateful and willing to assist ater they ‘Capacity building and encouragement facilities increased their earnings; they staf viewed the verification process with were charmed with developments at the from the DNO, Community Sisters and have also helped contribute to better skepticism. ‘It was a nightmare for me clinic. the Provincial Health Field Oficer really maternal and newborn health as defined pushed us to perform better,’ she said. by the HDF. This impact is summarised in the following graphics:

38 39 RBF RBF

CROWN AGENTS EAGER TO DELIVER

40 41 RBF RBF

report to the district accountant for improved transparency in the payment of approval. The district accountant will incentives as well as enhanced spot checks CHAPTER FOUR / subsequently forward the approved file to and improved record keeping. CROWN AGENTS EAGER TO DELIVER the Crown Agents server for aggregation and analysis. For Crown Agents, the app 4.2.1.1 The m-IC Roll Out / makes monitoring of payment of incentives “The m-IC has made our lives better in easy. Using the m-IC as a data collection terms of time taken to approve and receive 4.1 Introduction / We have already discussed how the capacity tool together with the data visualization our incentives. Previously, we used to send of health facilities is being built to improve web application, Crown Agents staf is information to the district accountant but In this chapter we celebrate the role eficiency and efectiveness in managing able to view and analyze Zimbabwe rural now calculations are done at the facility of Crown Agents in facilitating the financial resources including, particularly, health facilities’ staf incentives at the click using our phones making the process faster implementation of the RBF Programme. In the ease of carrying out transactions. One of a button. Moreover, data can be easily than before. This incentive also comes as this edition we focus on how Crown Agents cutting-edge innovation of Crown Agents analyzed at national level and at facility extra income on top of our salaries; this is leveraging on technology to support the that is improving the ease of transacting level. motivates us to do more. We feel appreciated RBF Programme implementation. Also in is the Mobile Incentive Calculator (m-IC). for the work we do.” - Sister Nyandebvu, focus are the trainings conducted by the Whereas before the introduction of the Since its introduction, the m-IC has helped Nurse-in-Charge. organization to build the capacity of health m-IC, facility management and Crown improve data analysis which in turn is service providers. We explain how these Agents HFOs were tediously using excel supporting efective decision making at The roll out of the m-IC involves installing interventions of Crown Agents add value to spreadsheets to calculate incentives for the facility as well as district, provincial the app on mobile devices as well as the the whole process. staf, with the m-IC, calculations have been and national levels. While the app is a training of health facilities’ managers in made easier, faster and less prone to errors. mechanism designed to provide health the use of the app. To date, roll out is at 100 4.2 Technology and Innovation for facility managers with convenience percent with every facility in all the districts Health Systems through RBF / 4.2.1 About the m-IC? / in undertaking their work, it has also covered by Crown Agents using the m-IC. The m-IC is an android-based, understandable, user-friendly application (app) that ofers a convenient way to calculate staf incentives of a particular health facility. The app was developed for health facility managers (the Nurse in charge and/or Medical Superintendent). The managers feed the app with the health facility and staf data. This is done on a quarterly basis. The app will automatically generate amounts due for incentives using a predefined algorithm.

The application is installed on the mobile phone of the health facility manager who later conveys the generated incentive MOHCC OFFICIALS, CROWN AGENTS STAFF AND REPRESENTATIVES OF OTHER SISTER NYANDEBVU, NURSE IN CHARGE, PARTNERS DURING THE LAUNCH OF THE CHIRAU CLINIC CAPTURING DATA USING THE M-IC AND M-CSS APPS M-IC APPLICATION 42 43 RBF RBF

Following the adoption of the m-IC app, districts. In order to achieve this, trainings reports have indicated ease, transparency were required for district teams, hospital HIGHLIGHTS / and fairness in the calculation and staf as well as their community health disbursement of incentives. Workers in the councils. These trainings took place at PICTURES FROM HOSPITALS RBF TRAINING health facilities covered are reporting high two levels, a Training of Trainers (ToT) and morale and the benefits of this motivation some on-the-job training, covered RBF are enjoyed by the clients who are now management and implementation and getting eficient and high quality services. included the 8 modules. MASH WEST PROVINCE, SANYATI DISTRICT

4.3 Crown Agents Takes RBF to TABLE 4: M-IC ROLL OUT PROGRESS AS AT Second Level Hospitals: Rolls out 31 JANUARY 2018 Training / HFS WITH M-IC HFS WITH M-IC FACILITIES INSTALLED ON TRAINED ON IMPLEMENTING Mash West, Sanyati District Following its success in rural health MOBILE DEVICE USING THE M-IC Sanyati Baptist Hospital facilities and clinics, the HDF steering MODULE TECHNOLOGY Practical session on verification guidelines committee, in December 2017, took a Number % Number % Number % decision to introduce the programme in secondary level hospitals in all the 42 401 8 401 48 95 11

Masvingo District, Zaka Province Musiso Mission Mr Gwati from Ministry of Health doing a presentation on Hospital Quality Checklist

THROUGHOUT THE COUNTRY, HDF, RBF PROGRAMME IS COVERING 67 HOSPITALS INCLUDING CHINHOYI PROVINCIAL HOSPITAL.

WHAT ARE STAFF INCENTIVES? A total of 25 percent of the quarterly subsidy earned by any health facility is shared among staf members as incentives. Staf incentives are paid to motivate staf and encourage Matebeleland North, Hwange District health workers to thrive for better performance and high quality service delivery. All Victoria Falls Hospital employees stationed at a facility supported under the RBF Programme are entitled to Staf during the Operational plans incentives. and contracts presentation

The calculation of the subsidy for the health facility itself, as has already been explained, is done on the basis of both quality and quantity of services provided. However, the amount that an individual gets as an incentive is arrived at ater taking into consideration a number of factors such as responsibility, position, years worked, hours worked, quarterly health facility DHE quality supervision score and the subsidy earned. 44 45 RBF RBF

USE OF RBF SUBSIDY SANYATI CLINIC

Matebeleland North, Hwange District Victoria Falls Hospital Nurse doing a recap from notes that were taken down from the previous day presentations

Mash West Province, Makonde District Makonde Christian Hospital HFO during a practical session on Verification Guidelines

Waiting mothers home

“Our old waiting mothers shelter was too small to accommodate a large number of mothers. We began construction of our new waiting mothers shelter in 2016 with RBF subsidies. The new structure is very spacious and can accommodate 15 – 18 mothers. We are yet to procure beds and ater this we will start using this shelter”. Sister C. Chamauya Mash West Province, Hurungwe District Chidamoyo Hospital Practical session on Verification Guidelines

MASH EAST, MUREHWA DISTRICT KADZERE CLINIC

Water Tank bought using RBF subsidies

“Before RBF we did not have a water tank at the clinic. This resulted in us not being able to carry out our day to day running of the clinic as we would Training of trainers at UNICEF Harare sometimes have no water. Thanks to RBF we now have a water tank and as such the clinic always has clean running water”. Sister Mangombe, Nurse

46 47 RBF

KADENGE CLINIC

Suction Machine

“Due to RBF subsidies, we managed to buy a suction machine which we use for babies that would have ingested the amniotic fluids during birth and will not be failing to breathe well and so we use the machine to suction them”. R Mashona, Nurse

Patients waiting shed

“Our patients would visit the clinic and have nowhere to sit while they waited for the doctor/ nurse to attend to them. With RBF we were able to construct a waiting shed for our patients”. Sister P Tsuro, NIC

Fridge

“RBF enabled us to procure a fridge in which we store our diluted medicines”. Sister P Tsuro NIC

48 49 This document is produced by Crown Agents. The HDF and supporting donors do not necessarily share the views expressed in this document. Responsibility for its contents rests entirely with the author.

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