1. Scaling up Family Planning through Performance-Based Financing in Rwanda Dr. Louis Rusa, Director PBF support Cell Ministry of Health, Rwanda

2. Content PBF 101 – guiding principles Case study of PBF in Rwanda Lessons learned

3. Input vs Output financing Payments in advance for salaries, drugs & supplies, running costs Funds often managed at higher levels Need to justify expenses after payment (financial audits) Tenuous link between funding and results  Funds paid for services already delivered  Funds managed at local level  Need strong data collection & quality control system  Direct link between funding and results

4. PBF model – key principles Separation between providers, purchasers and controllers PBF funding does not cover cost of service – just incentivizes it Traditional input financing must continue to complement PBF Data on service outputs must be highly selective and from existing sources Strong service and data quality control mechanisms needed to eliminate incentive to cheat

5. Key Rwanda health strategies In 2005, MOH introduced three complementary strategies to improve health services: Community Based Health Insurance to increased access Performance-based Financing to increase availability and quality of services Continuous Quality Assurance to enhance quality of care

6. Rwandan National PBF Models PBF model for health centers PBF model for district hospitals Community PBF Central level PBF for MoH department/units

7. PBF and Family Planning in Rwanda Health Center PBF system includes incentives for 2 indicators: # of new FP users # of FP users at the end of the month Community PBF includes provider-side and client-side indicators: # of new family planning users referred by CHWs (both) % of FP users using long-term methods (provider-side) # of FP users adopting long-term methods (client-side) Quarterly Quality Assessment process includes an assessment of FP service quality

8. PBF Control is NOT ‘business as usual’ in data gathering District quality assessment team checking data quality in a health center

9. Assuring Data Quality – Multiple checks and balances Data ‘quantity’ audits conducted every month on each indicator from every site (register vs report) Monthly report data are reviewed by district PBF steering committees Community client or “phantom patient” surveys every 6 month at a sample of sites – look for phantom patients and seeks feedback from patients on quality of care National PBF cell reviews database each quarter for the entire country – corrections are made before payment

10. How to strengthen supervision to assure high quality services Quarterly Quality assessments are conducted at each facility to assess 13 components of service quality Administration, Hygiene, Respect for Clinical protocols for key services, Community outreach, etc. Controllers are District Hospital supervisors and data managers for health centers, by peer district hospitals for Hospital level PBF This assessment score is used to offset PBF payments

11. Performance Payment Mechanism Performance Payments = Σ (# service outputs * Unit fees) * % Quality score NoIndicatorQuantityFeeAmount RWF 1FP: number of new family planning users40100040,000 2FP: Number of family planning users at end of month120 10012,000 62,000 Quarterly quality score X87% Payment amount53,940

12. Increase in Volume of FP Services (after 39 months) PBF IndicatorJanuary 2006 average/month/ health center ( 258 health centers on average) March 2009 average/month/ health center (297 health centers on average) Percentage increase (linear/log R2) Family Planning new users 15.558.6 278% (linear 0.79) Family Planning users at the end of the month 175.21005.6 473.9% (linear 0.98)

13. Increase in the Quality of Services in Health Centers (1)

14. Lessons learned Health workers benefit directly from a portion of the PBF funding that is shared as bonuses – motivation and retention of health workers has improved PBF reinforces decentralization strategy: Money is paid directly to the health facility and managed by local steering committee with considerable autonomy PBF can lead to a significant increase in service production and quality of services in a relatively short period of time