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Adapting results-based financing to respond to endogenous and exogenous moderators in Zimbabwe

Artwell Kadungure (Training and Research Support Centre, Harare, Zimbabwe)
Garrett Wallace Brown (POLIS, University of Leeds, Leeds, UK)
Rene Loewenson (Training and Research Support Centre, Harare, Zimbabwe)
Gwati Gwati (Ministry of Health and Child Care, Harare, Zimbabwe)

Journal of Health Organization and Management

ISSN: 1477-7266

Article publication date: 5 January 2021

Issue publication date: 5 May 2021




This study examines key adaptations that occurred in the Zimbabwean Results-Based Financing (RBF) programme between 2010 and 2017, locating the endogenous and exogenous factors that required adaptive response and the processes from which changes were made.


The study is based on a desk review and thematic analysis of 64 policy and academic literatures supplemented with 28 multi-stakeholder interviews.


The programme experienced substantive adaption between 2010 and 2017, demonstrating a significant level of responsiveness towards increasing efficiency as well as to respond to unforeseen factors that undermined RBF mechanisms. The programme was adaptive due to its phased design, which allowed revision competencies and responsive adaptation, which provide useful insights for other low-and-middle income countries (LMICs) settings where graduated scale-up might better meet contextualised needs. However, exogenous factors were often not systematically examined or reported in RBF evaluations, demonstrating that adaptation could have been better anticipated, planned, reported and communicated, especially if RBF is to be a more effective health system reform tool.


RBF is an increasingly popular health system reform tool in LMICs. However, there are questions about how exogenous factors affect RBF performance and acknowledgement that unforeseen endogenous programme design and implementation factors also greatly affect the performance of RBF. As a result, a better understanding of how RBF operates and adapts to programme level (endogenous) and exogenous (external) factors in LMICs is necessary.



This paper has been produced as part of a research programme on “Performance-based financing mechanisms for health systems strengthening in Africa” (PEMBA), a research project that is systematically assessing the effects of performance-based financing on health systems in Zimbabwe and Mozambique. The authors acknowledge technical contributions and support from all PEMBA team members, including: London School of Hygiene and Tropical Medicine, United Kingdom (Josephine Borghi, Neha Singh, Roxanne Kovacs) University of Manchester, United Kingdom: (Laura Anselmi, Soren Rud Kristensen, Mathew Sutton) University of Bath, United Kingdom: (Eleonora Fichera) Mozambique National Institute of Health, Mozambique: (Sergio Chicumbe, Amilcar Magaco, Pedroso Nhassengo Pedro).Funding: This research was supported by a Health Systems Research Initiative grant number MR/P014429/1 jointly funded by the Medical Research Council, Wellcome Trust, Economic and Social Research Council, Department for International Development.


Kadungure, A., Brown, G.W., Loewenson, R. and Gwati, G. (2021), "Adapting results-based financing to respond to endogenous and exogenous moderators in Zimbabwe", Journal of Health Organization and Management, Vol. 35 No. 3, pp. 287-305.



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