Balancing the scales? Evaluating the impact of results-based financing on maternal health outcomes and related inequality of opportunity in Zimbabwe

This study evaluates the impact of results-based financing (RBF) on maternal health outcomes and the inequality of opportunity (IOP) in these outcomes in Zimbabwe. We employ a difference-in-differences approach that leverages the staggered implementation of the programme across 60 districts, exploiting temporal variation in the introduction of RBF and individual-level variation in birth timing. Our analysis uses nationally representative, pooled cross-sectional data from the 2005/2006, 2010/2011, and 2015 Zimbabwe demographic and health surveys. Employing the extended two-way fixed effects (ETWFE) estimator to address biases associated with staggered rollouts, we find significant positive effects of RBF on maternal health outcomes. The programme is associated with an increase in the number of prenatal care visits by 0.185 units (p < 0.01), first-trimester care by 7.7 percentage points (pp) (p < 0.01), facility births by 8.6 pp (p < 0.01), and professional delivery assistance by 3.4 pp (p < 0.01), while reducing C-section rates by 1.3 pp (p < 0.01). Additionally, RBF is associated with reductions in IOP in prenatal care visits, early prenatal care, facility births, and professional delivery assistance by 3.8, 1.3, 8.4, and 4.9 pp (p < 0.01), respectively. These findings underscore the potential of RBF to enhance maternal health outcomes and promote health equity. Integrating equity considerations into health system strengthening initiatives is essential. Policymakers should ensure that health interventions improve access and balance opportunities across various socio-economic and demographic groups. This evidence suggests that RBF schemes can improve access to and equity in healthcare services, particularly in low-income settings such as Zimbabwe.