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 alongside individual-level variation in birth timing and health facility selection. 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 reduces 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 must ensure health interventions improve access and balance opportunities across various socioeconomic and demographic groups. This evidence supports RBF schemes to improve access to and equity in healthcare services, particularly in low-income settings such as Zimbabwe

Demand for prenatal care and its impact on neonatal, infant and child mortality in Zimbabwe: Evidence from the Demographic and Health Surveys

Abstract: The effect of the quality of prenatal care on child mortality outcomes has received less attention in sub-Saharan Africa. This study sought to explore the consequence of the quality of prenatal care and its individual components on neonatal, infant and under-five mortality using the three most recent rounds of the nationally representative Demographic and Health Survey data for Zimbabwe conducted in 1999, 2005/06 and 2010/11. The model for the demand for the quality of prenatal care is estimated using an OLS regression while the child mortality models are estimated using standard probit regressions. Since infant mortality rates and access to quality prenatal care might differ by rural and urban residence, we estimate separate models for the overall sample, urban and rural samples. The results indicate that a one-unit increase in the quality of prenatal care lowers the risks of neonatal, infant and under-five mortality by nearly 36%, 29.31%, and 27.53% respectively for the overall sample. The probability of neonatal, infant and under-five mortality is lowered by about 41.67%, 35.18%, and 30.77% respectively for urban-born children following a one-unit increase in the quality of prenatal care. For the rural sample, we found that a one-unit increase in the quality of prenatal care lowers the risks of neonatal, infant and under-five mortality by nearly 34.61%, 27.12%, and 25.35% respectively. These findings are all statistically significant at the 1% significance level. Examining the effect of individual prenatal care components on child mortality revealed that blood pressure checks, information on pregnancy complications, iron supplementations, and tetanus vaccinations are all important in lowering child deaths. Overall, our results suggest the need for public health policy makers in Zimbabwe to focus on ensuring high-quality prenatal care especially in low-income and rural segments of the population to save Zimbabwe’s children

Wealth-related inequalities in adoption of drought-tolerant maize and conservation agriculture in Zimbabwe

© 2019, International Society for Plant Pathology and Springer Nature B.V. This paper concerns Drought-Tolerant Maize (DTM) and Conservation Agriculture (CA) practices that were introduced into smallholder maize-based farming systems in Zimbabwe to enhance the productivity of maize and food security under a changing climate. Although these technologies are technically appropriate, there are difficulties with their use by smallholder farmers of relatively low socio-economic status, as measured through ownership of farm or household assets and endowments. Thus, we sought to quantify and explain wealth-related inequalities in the adoption of DTM and CA in smallholder farming communities and discuss their implications for food security. The analysis used cross-sectional household-level data gathered from 601 smallholder farmers from four districts in Zimbabwe. We found evidence of a pro-rich distribution of inequalities in the adoption of DTM and CA that were mostly explained by differences in household wealth, access to agricultural extension services and size of farm land. No meaningful differences in DTM adoption disparities were found across districts. Significant gender differences were observed for CA, and meaningful differences by district were noted. Results suggest the need for decision makers to consider implementing policies that focus on the poorer segments of the farming society to alleviate differences in the adoption of such agricultural technologies. For example, subsidizing the uptake of improved maize varieties including DTM and prioritizing equitable land distribution, coupled with specialised extension services for the poor in a cereal-based CA farming system, could reduce the observed gap between rich and poor in the uptake of these innovations and consequently improve food security

The Evolution of Socioeconomic-Related Inequalities in Maternal Healthcare Utilization: Evidence from Zimbabwe, 1994-2011

Abstract: Inequalities in maternal healthcare are pervasive in the developing world, a fact that has led to questions about the extent of these inequalities across socioeconomic groups. Yet, despite a growing literature on maternal health across Sub-Saharan African countries, relatively little is known about the evolution of these inequalities over time for specific countries. This study sought to examine and document the trends in the inequalities in prenatal care use, professional delivery assistance, and the receipt of information on pregnancy complications in Zimbabwe. We assess the extent to which the observed inequalities have been pro-poor or pro-rich. The empirical analysis uses data from four rounds of the nationally representative Demographic and Health Survey for Zimbabwe conducted in 1994, 1999, 2005/06 and 2010/11. Three binary indicators were used as measures of maternal health care utilization; (1) the receipt of four or more antenatal care visits, (2) the use of professional delivery assistance, and (3) the receipt of information regarding pregnancy complications for the most recent pregnancy. We measure and explain inequalities in maternal health care use using Erreyger’s corrected concentration index. A decomposition analysis was conducted to determine the contributions of each determining factor to the measured inequalities. We found a significant and persistently pro-rich distribution of inequalities in professional delivery assistance and knowledge regarding pregnancy complications was observed between 1994 and 2010/11. Also, inequalities in prenatal care use were pro-rich in 1994, 2005/06 and 2010/11 periods and pro-poor in 1999. Furthermore, we stratified the results by rural or urban status. The results reveal a rising trend in observed inequalities in maternal health care use over time. Our findings suggest that addressing inequalities in maternal healthcare utilization requires coordinated public health policies targeting the more poor and vulnerable segments of the population in Zimbabwe

The Evolution of Socioeconomic-Related Inequalities in Maternal Healthcare Utilization: Evidence from Zimbabwe, 1994-2011

Abstract: Inequalities in maternal healthcare are pervasive in the developing world, a fact that has led to questions about the extent of these inequalities across socioeconomic groups. Yet, despite a growing literature on maternal health across Sub-Saharan African countries, relatively little is known about the evolution of these inequalities over time for specific countries. This study sought to examine and document the trends in the inequalities in prenatal care use, professional delivery assistance, and the receipt of information on pregnancy complications in Zimbabwe. We assess the extent to which the observed inequalities have been pro-poor or pro-rich. The empirical analysis uses data from four rounds of the nationally representative Demographic and Health Survey for Zimbabwe conducted in 1994, 1999, 2005/06 and 2010/11. Three binary indicators were used as measures of maternal health care utilization; (1) the receipt of four or more antenatal care visits, (2) the use of professional delivery assistance, and (3) the receipt of information regarding pregnancy complications for the most recent pregnancy. We measure and explain inequalities in maternal health care use using Erreyger’s corrected concentration index. A decomposition analysis was conducted to determine the contributions of each determining factor to the measured inequalities. We found a significant and persistently pro-rich distribution of inequalities in professional delivery assistance and knowledge regarding pregnancy complications was observed between 1994 and 2010/11. Also, inequalities in prenatal care use were pro-rich in 1994, 2005/06 and 2010/11 periods and pro-poor in 1999. Furthermore, we stratified the results by rural or urban status. The results reveal a rising trend in observed inequalities in maternal health care use over time. Our findings suggest that addressing inequalities in maternal healthcare utilization requires coordinated public health policies targeting the more poor and vulnerable segments of the population in Zimbabwe

Demand for prenatal care and its impact on neonatal, infant and child mortality in Zimbabwe: Evidence from the Demographic and Health Surveys

Abstract: The effect of the quality of prenatal care on child mortality outcomes has received less attention in sub-Saharan Africa. This study sought to explore the consequence of the quality of prenatal care and its individual components on neonatal, infant and under-five mortality using the three most recent rounds of the nationally representative Demographic and Health Survey data for Zimbabwe conducted in 1999, 2005/06 and 2010/11. The model for the demand for the quality of prenatal care is estimated using an OLS regression while the child mortality models are estimated using standard probit regressions. Since infant mortality rates and access to quality prenatal care might differ by rural and urban residence, we estimate separate models for the overall sample, urban and rural samples. The results indicate that a one-unit increase in the quality of prenatal care lowers the risks of neonatal, infant and under-five mortality by nearly 36%, 29.31%, and 27.53% respectively for the overall sample. The probability of neonatal, infant and under-five mortality is lowered by about 41.67%, 35.18%, and 30.77% respectively for urban-born children following a one-unit increase in the quality of prenatal care. For the rural sample, we found that a one-unit increase in the quality of prenatal care lowers the risks of neonatal, infant and under-five mortality by nearly 34.61%, 27.12%, and 25.35% respectively. These findings are all statistically significant at the 1% significance level. Examining the effect of individual prenatal care components on child mortality revealed that blood pressure checks, information on pregnancy complications, iron supplementations, and tetanus vaccinations are all important in lowering child deaths. Overall, our results suggest the need for public health policy makers in Zimbabwe to focus on ensuring high-quality prenatal care especially in low-income and rural segments of the population to save Zimbabwe’s children

Changing the mindsets? Education and the intergenerational spread of tolerance for physical violence against women in Zimbabwe

We investigate the relationship between childhood exposure to interparental violence and adult tolerance for violent beliefs against women. For individuals who have witnessed parental violence in childhood, our analysis suggests a 14.3–15.2 percentage point (pp) increase in tolerance, highlighting the transmission of violent beliefs across generations. Leveraging Zimbabwe’s 1980 education reform as a natural experiment through a regression discontinuity design, we explore the potential of increased education to disrupt this intergenerational transmission. The reform led to an approximately two-year increase in female education, with a more pronounced impact in rural areas. This educational boost is associated with an estimated 4.1–7.9 pp reduction in tolerance for violence, especially among those who witnessed parental violence in childhood. We identify four primary mechanisms contributing to this reduction in tolerance: enhanced access to information, increased help-seeking behaviours, improved labour market outcomes, and higher educational levels among partners. Our findings underscore the effectiveness of educational policies in reducing tolerance for violence against women within low-income contexts such as Zimbabwe, thereby disrupting its intergenerational transmission. Moreover, these results emphasise the potential of education-based interventions in addressing the broader issue of violence against women in low-income countries

Is poor sanitation killing more children in rural Zimbabwe? Results of propensity score matching method

Abstract: While studies in developing countries have examined the role of maternal and socio-demographic factors on child mortality, the role of poor sanitation (open defecation) on child mortality outcomes in rural communities of sub-Saharan Africa has received less attention. This study sought to examine the link between poor sanitation and child mortality outcomes in rural Zimbabwe. The analysis uses data from four rounds of the nationally representative Demographic and Health Survey for Zimbabwe conducted in 1994, 1999, 2005/06, and 2010/11. Using propensity score matching, we find that children living in households with no toilet facilities are 2.43 percentage points more liable to be observed dead by the survey date, 1.3, and 2.24 percentage points more likely to die before reaching the age of one and five years respectively. We also examined the possible differences in survival among female and male children. Our results indicate that male children are more liable to be observed dead by the survey date than female children. Also, female children have a slight survival advantage over boys during the under-five period. Our results suggest the need for more investments in basic sanitary facilities in Zimbabwe’s rural areas to mitigate the potential devastating impacts of poor sanitation on child survival

Demand for prenatal care and its impact on neonatal, infant and child mortality in Zimbabwe: Evidence from the Demographic and Health Surveys

Abstract: The effect of the quality of prenatal care on child mortality outcomes has received less attention in sub-Saharan Africa. This study sought to explore the consequence of the quality of prenatal care and its individual components on neonatal, infant and under-five mortality using the three most recent rounds of the nationally representative Demographic and Health Survey data for Zimbabwe conducted in 1999, 2005/06 and 2010/11. The model for the demand for the quality of prenatal care is estimated using an OLS regression while the child mortality models are estimated using standard probit regressions. Since infant mortality rates and access to quality prenatal care might differ by rural and urban residence, we estimate separate models for the overall sample, urban and rural samples. The results indicate that a one-unit increase in the quality of prenatal care lowers the risks of neonatal, infant and under-five mortality by nearly 36%, 29.31%, and 27.53% respectively for the overall sample. The probability of neonatal, infant and under-five mortality is lowered by about 41.67%, 35.18%, and 30.77% respectively for urban-born children following a one-unit increase in the quality of prenatal care. For the rural sample, we found that a one-unit increase in the quality of prenatal care lowers the risks of neonatal, infant and under-five mortality by nearly 34.61%, 27.12%, and 25.35% respectively. These findings are all statistically significant at the 1% significance level. Examining the effect of individual prenatal care components on child mortality revealed that blood pressure checks, information on pregnancy complications, iron supplementations, and tetanus vaccinations are all important in lowering child deaths. Overall, our results suggest the need for public health policy makers in Zimbabwe to focus on ensuring high-quality prenatal care especially in low-income and rural segments of the population to save Zimbabwe’s children

Closing the gap? Results-based financing and socioeconomic-related inequalities in maternal health outcomes in Zimbabwe.

The results-based financing (RBF) program, first implemented in Zimbabwe in 2011 and gradually expanded to other districts, aimed to address disparities in maternal health outcomes by improving the utilisation of health services. This study leverages the staggered rollout of the program as a quasi-experimental design to assess its impact on asset wealth-related inequalities in selected maternal health outcomes. The objective is to determine whether RBF can effectively reduce these disparities and promote equitable healthcare access. We employ an extended two-way fixed effects (ETWFE) model to exploit temporal variation in RBF implementation as well as individual-level variation in birth timing for identification. Utilising pooled cross-sectional and nationally representative data from the Zimbabwe demographic and health surveys collected between 1999 and 2015, our analysis reveals significant reductions in relative and absolute maternal health inequalities, especially in the frequency and timing of prenatal care, delivery by caesarean section, and family planning. Specifically, the RBF program is associated with reductions in disparities for completing at least four or more prenatal care visits (-0.026, p < 0.01), first-trimester prenatal care (-0.033, p < 0.01), delivery by caesarean section (-0.028, p < 0.005), and family planning (-0.033, p < 0.005). Additionally, the program is associated with improved prenatal care quality, as evidenced by progress on the prenatal care quality index (-0.040, p < 0.01). These effects are more pronounced among lower socioeconomic groups in RBF districts, highlighting RBF's potential to promote equitable healthcare access. Our findings advocate for targeted policy interventions prioritising expanding access to critical maternal health services in underserved areas and incorporating equity-focused measures within RBF frameworks to ensure inclusive and effective healthcare delivery in Zimbabwe