Condition category
Not Applicable
Date applied
Date assigned
Last edited
Retrospectively registered
Overall trial status
Recruitment status
No longer recruiting
Publication status

Plain English Summary

Background and study aims
This study will evaluate the impact of results-based financing (RBF) on priority maternal and child health services in rural districts of Zambia. RBF is an output-based financing mechanism where the health providers receive financial incentives on achieving a pre-agreed set of services upon verification of the achieved results. The overall objective of the HRBF is to increase access to, and the use of, key maternal and child health interventions. The impact evaluation will generate valuable evidence to determine whether this goal is attainable under the proposed policies. In addition, the impact evaluation will contribute to the government’s intentions to strengthen Central and Province-level capacities for evidence-based policy and program management for improving maternal and child health (MCH).The study will address the following three primary research questions: (a) What is the causal effect of the Zambian HRBF on the population health indicators of interest specifically on maternal and child health? (b) Do higher incentive payments in rural/remote areas result in increased health outcomes and greater retention of staff? (c) How does the likelihood of audit/external verification of results affect the accuracy of reported data?

Who can participate?
Participating health facilities from 30 rural districts triplet-matched on key health systems and outcome indicators and randomly allocated to three arms with ten districts per arm.

What does the study involve?
This study tests the effectiveness of RBF in comparison with input (equivalent) financing, and business-as-usual. Within each rural province, a triplet of districts with similar characteristics has been selected. Thus, 30 rural districts (10 triplets) have been selected from all rural provinces in the country. Within each matched triplet, districts have been randomly allocated to implement one of the three interventions (RBF, equivalent financing or business-as-usual). All health facilities (excluding private-for-profit) in these 30 districts participate in this study. Health facilities within the RBF intervention will receive RBF incentives every quarter conditional on their performance on a set of indicators related to maternal and child health. The facilities will receive incentives on achieving quantity (volume of services) and quality (adherence to national standards of care). Remote facilities in addition will receive a remoteness bonus. Health facilities within the equivalent financing intervention will receive resources matching with the RBF incentives. However, these resources will not be conditional on performance. Health facilities within the business-as-usual intervention will not receive any additional resources or inputs. The study measures the outcomes of the interventions at the population and health facility levels. The outcomes will be measured through two rounds of surveys involving health facilities and households within the catchment areas of these facilities selected for this intervention. The first round of survey was completed before the interventions were implemented and the second round of survey will be undertaken after the completion of the implementation. The study will also employ qualitative surveys and cost-effectiveness analysis.

What are the possible benefits and risks of participating?
Health facilities in the RBF intervention and the equivalent financing groups will benefit from financial resources tied with performance and not conditional on performance, respectively. There are no adverse effects or risks of this intervention.

Where is the study run from?
There are 523 health facilities from 30 rural districts participating in this study. The implementing agency is the Ministry of Health, Zambia.

When is study starting and how long is it expected to run for?
The intervention started in April 2012 and is expected to continue until July 2015.

Who is funding the study?
Governments of Norway and the UK through the Health Results Innovation Trust Fund administered by the World Bank.

Who is the main contact?
Ashis Das

Trial website

Contact information



Primary contact

Dr Jed Friedman


Contact details

1818 H St NW
United States of America

Additional identifiers

EudraCT number number

Protocol/serial number


Study information

Scientific title

Assessing the impact of results-based financing in health on maternal and child health access and utilization: Impact evaluation of Zambia's Health Results-Based Financing Pilot


Zambia RBF IE

Study hypothesis

Results based financing increases access to and utilization of maternal and child health services in rural Zambia

Ethics approval

Humanities and Social Sciences Research Ethics Committee, University of Zambia, 23/06/2011

Study design

Randomized controlled trial

Primary study design


Secondary study design

Randomised controlled trial

Trial setting


Trial type

Quality of life

Patient information sheet



Maternal and child health


Health facilities within RBF districts will receive incentives every quarter based on attaining:
1. Quantity (volume of services)
2. Quality (adherence to national standards of care)
Health facilities within equivalent financing districts will receive resources every quarter similar to the health facilities under their matching RBF district
Health facilities within business-as-usual districts will receive no additional resources or inputs.

Intervention type



Drug names

Primary outcome measure

Health utilization indicators:
1. Antenatal care
2. Institutional delivery
3. Postnatal care
4. Immunization
5. Adoption of family planning methods

Household level indicators:
1. Household health-seeking behavior
2. Out-of-pocket healthcare expenditure
3. Satisfaction on the service provider

Secondary outcome measures

Health facility infrastructure indicators:
1. Drug stockout rates
2. Availability of drugs
3. Availability of equipment
4. Updated records

Quality of care indicators:
1. Counseling and client interaction
2. Waiting time
3. Physical examination

Equity indicators:
1. Utilization of health care and quality of care indicators vis-à-vis clients' socio-economic and residence status

Health worker indicators:
1. Health worker training status
2. Knowledge
3. Motivation
4. Job satisfaction

Overall trial start date


Overall trial end date


Reason abandoned (if study stopped)


Participant inclusion criteria

Health facility inclusion criteria:
1. Health centers and health posts (public and faith-based) within the selected 30 rural districts
2. Health centers and health posts contracted under RBF project
3. All public and faith-based health centers and health posts in input financing and business-as-usual districts

Participant type


Age group




Target number of participants

All health facilities in participating rural districts (n=523)

Participant exclusion criteria

Health facility exclusion criteria:
1. Health centers and health posts outside the selected 30 rural districts
2. Private-for-profit health centers and health posts

Recruitment start date


Recruitment end date



Countries of recruitment


Trial participating centre

The World Bank
Washington, D.C.
United States of America

Sponsor information


Health Results Innovation Trust Fund, World Bank (USA)

Sponsor details

The World Bank
1818 H St NW
United States of America

Sponsor type




Funder type


Funder name

Health Results Innovation Trust Fund, World Bank (USA)

Alternative name(s)

Funding Body Type

Funding Body Subtype


Results and Publications

Publication and dissemination plan

Not provided at time of registration

Intention to publish date

Participant level data

Not provided at time of registration

Basic results (scientific)

Publication list

2018 results in (added 13/08/2020)

Publication citations

Additional files

Editorial Notes

13/08/2020: Publication reference added.