Institutionalizing Results-Based Financing in Devolved Health Systems: Lessons from Zambia's Northern Province

Zambia has implemented significant health-sector decentralization since 1992, culminating in the devolution of district health services to local authorities under the 2016 Constitutional Amendment. Results-Based Financing (RBF) has been piloted as a performance incentive mechanism, but its institutionalization within devolved structures remains largely unexplored. This study explores the opportunities and challenges of embedding RBF within Zambia's devolved health system, with a focus on Northern Province. A qualitative case study design was used, involving forty-four participants from twelve districts. Purposive sampling selected health workers from provincial and district health offices, local authority representatives, and national stakeholders. Data collection included semi-structured interviews, document reviews, and observations, with thematic analysis conducted using NVivo 9. Most respondents (82%) reported involvement in RBF implementation, and fifty-three% believed that increased Constituency Development Fund (CDF) allocations improved district health services. Key benefits cited were increased accountability (81.8%) and greater community participation (77.3%). Challenges included insufficient funding (83.3%), delays in disbursing funds (91.7%), and limited understanding among local authority implementers. Infrastructure development and procurement of medical equipment were identified as primary areas for CDF improvements (56%). Respondents also agreed (53%) that the Ministry of Health and the Ministry of Local Government would support the institutionalization of RBF. Effective integration of RBF into devolved systems requires harmonizing policies between health and local government ministries, building capacity within local authorities, and aligning RBF with other domestic financing mechanisms, such as CDFs. A phased approach to integration, with clearly defined governance structures, is recommended to ensure sustainable scaling.