Abstract
Background: As of June 2020, the World Bank had piloted or implemented results-based financing (RBF) in 27 countries; its cumulative investment in RBF was US$1.6 billion. Despite increasing evidence on the success of RBF on raising utilization and quality of key health care services in many settings, there is little information on the cost-effectiveness of such programs. As RBF competes for resources against other compelling programs, such evidence is critical. Zimbabwe piloted its RBF program from July 2011 through June 2014 to improve its maternal and child health (MCH) services through a controlled trial. To understand the usefulness of RBF in Zimbabwe and globally, this study assessed the cost-effectiveness of the country’s RBF program.
Methods: Using a pre-post design in 16 RBF and 16 matched control districts with 3.46 and 2.23 million inhabitants, respectively, the study’s impact evaluation found that RBF increased the share of institutional deliveries and post-partum tetanus vaccinations by 13.4 and 20.0 percentage points, respectively, compared to control districts (P<0.01). Extending the impact evaluation with data from household and facility surveys, this cost-effectiveness analysis used the Lives Saved Tool (LiST) and an expert panel to convert utilization and quality changes into lives saved and quality-adjusted life years (QALYs) gained in 2012 US dollars.
Results: The residents of RBF districts gained 658 lives and 15,498 QALYs annually, with quantity and quality improvements each contributing about half the gains. The net annual cost was $2.32 per capita. The incremental cost-effectiveness ratios (ICERs) were $636/QALY gained for Zimbabwe’s pilot RBF program and $479/QALY when projected to an ongoing program.
Conclusions: Both ICERs are below Zimbabwe’s per capita gross domestic product (GDP, $956 in 2012), making RBF a very cost-effective intervention for strengthening MCH services.