Results-Based Financing (RBF) in the health sector of a low-income country. From agenda setting to implementation: The case of Tanzania

Background: During the last decade there has been growing concern about lack of results in the health sector of many low-income countries. Prompted by a need to achieve progress, Results-Based Financing (RBF) has become an increasingly popular policy option and has been seen as a solution for the unmet Millennium Development Goals 4 and 5, for child health and maternal health. RBF pays for results of chosen health indicators rather than inputs and therefore appealing to both recipient and donor countries. In 2015, over 30 low-income countries with the majority in sub-Saharan Africa including Tanzania were implementing RBF programmes to improve health services provision. Tanzania implemented a provider side RBF, aiming to motivate health workers by paying them financial incentives based on predetermined performance targets. Despite the widespread uptake of RBF in low-income contexts, there is little evidence to support that it works. Studies on RBF show mixed results and most of these studies focus on aspects of effectiveness and efficiency of these programmes. What is explored less are the policy processes that lead to the introduction of RBF programmes in low-income countries and how RBF affects the working environment and the interaction between health workers and health service users. This may in turn affect the overall success of RBF programmes. Aim: The study aim to generate policy relevant knowledge on processes leading up to the introduction of RBF in a resource constrained health sector, and the challenges related to its implementation. To achieve this, the study investigates the roles played by both internal and external policy actors in the RBF policy process in Tanzania. It further critically examines the experiences of health workers with RBF and how they responded to it, paying particular attention to the social and cultural context. Methods: A qualitative case study design was used in the study. Data was collected in Mvomero and Rufiji districts and Dar es Salaam in Tanzania and in Oslo in Norway. The study followed both the local Tanzanian RBF programme in Mvomero and the donor-funded Pwani pilot in Rufiji district. In-depth interviews (IDIs), focus group discussions (FGDs), policy document reviews and participation in RBF meetings were the main methods for data collection. A total of 70 IDIs and 27 FGDs were conducted between 2010 and 2013. Field notes and informal conversations during fieldwork were other very important sources of data for the study. Results: The introduction of RBF in Tanzania was controversial. The process was long and contested. The actors, both external and internal, fought for their values and interests. It resulted in tensions, mistrust and frustrations in the health sector partnership, and in the end, Tanzania did not get space to act as an agent of her own development. The results further showed that the two RBF programmes that were implemented in Tanzania, one which received donor support and another which did not, were implemented differently. The locally funded RBF diverted from its programme design and paid health workers flat bonus regardless of performance. This was partly due to lack of capacity and partly due to concerns for equity and fairness. The donor funded RBF adhered to its design, including paying health workers according to performance and contribution towards RBF performance indicators that is, Reproductive and Child Health (RCH) staff, working directly with RBF performance indicators were paid more bonuses than non RCH staff. This system of payment was reported to be unfair and it was revealed that it had affected social relations at health facilities. Leadership at health facilities was concerned this would lead to the disruption of work and preferred a flat rate with a similar logic as in the local RBF programme. Moreover, the study revealed that in the local RBF programme, health workers used coercive strategies in order to meet RBF performance targets. It was noted that these strategies are detrimental to health outcomes. Discussion The study showed that understanding processes behind the implementation of RBF is important as these help to explain why RBF programmes may fail or succeed. Additionally, the study revealed that RBF programmes can affect social relations among health workers and with health service users. The Tanzanian experience presents a picture where the country was overwhelmed by external influence in the RBF policy process and in the end could not follow its own development trajectory. As the theory of partnership in development aid posits, donor countries prefer an instrumental version of partnership, which entails imposition of their priorities, while disregarding country ownership. When Tanzania chose to follow her own path by launching a local RBF programme, partners in the Health Basket Fund withdrew their funding. Tanzania went ahead with the local RBF programme, but with little success. Payment in the programme used flat rates, partly due to lack of resources and partly due to the concern of fairness. The donor-funded RBF was better managed and resourced but the payment system of bonuses, which paid health workers differently by their centrality to performance indicators, was reported as fundamentally unfairness as predicted by workplace social justice theory, the Referent Cognitions Theory. Health workers changed their behaviors in response to RBF, as presumed by the Principal- Agent Theory. In both districts, RBF negatively affected social relations among health workers and with their patients. It was revealed that RBF can lead to the use of coercive strategies as a means to reach performance targets in resource constrained settings. RBF has the potential of disrupting social relations, teamwork and intrinsic motivation among health workers. The Self-Determination Theory and Bourdieu’s concept of capital elucidates on how RBF is potentially detrimental to social relations and intrinsic motivation of health workers. Therefore the study recommends that caution is needed when implementing RBF programmes in low-income contexts, and that particular attention has to be paid to policy processes, social-cultural and contextual factors