Abstract
Background: This paper presents findings from a study which sought to understand why health workers working
under the results-based financing (RBF) arrangements in Zimbabwe reported being satisfied with the improvements
in working conditions and compensation, but paradoxically reported lower motivation levels compared to those not
working under RBF arrangements.
Methods: A qualitative study was conducted amongst health workers and managers working in health facilities that
were implementing the RBF arrangements and those that were not. Through purposeful sampling, 4 facilities in RBF
implementing districts that reported poor motivation and satisfaction, were included as study sites. Four facilities located
in non-RBF districts which reported high motivation and satisfaction were also included. Data was collected through
in-depth interviews and analyzed using the framework approach.
Results: Results based financing arrangements introduce a wide range of new institutional arrangements, roles, tasks,
and ways of doing things, for facility staff, facility managers and, district and provincial health management teams.
Findings reveal that insufficient preparedness of people and processes for this change, constrained managers and workers
performance. Results based financing arrangements introduce explicit and tacit changes, including but not limited to,
incentive logics, in the system. Findings show that unless systematic efforts are made to enable the absorption of these
changes in the system: eg, through reconfiguring the decision space available at various levels, through clarification
of accountability relationships, through building personnel and process capacities, before instituting changes, the full
potential of the RBF arrangements cannot be realised.
Conclusion: Our study demonstrates the importance of analysing existing institutional, management and governance
arrangements and capabilities and taking these into account when designing and implementing RBF interventions.
Introducing RBF arrangements cannot alone overcome chronic systemic weaknesses. For a system wide change, as RBF
arguably is, to be effected, explicit organisational change management processes need to be put in place, across the system.
Carefully designed processes, which take into account the interest and willingness of various actors to change, and which
are cognizant of and constructively engage with potential bottlenecks and points of resistance, should accompany any
health system change initiative.