1. Performance-Based Financing in Rwanda
Agnes Soucat, Adviser HNP Africa Region 1

2. Background (1) Shortage of human resources for health services
No cash resources in health facilities
Low levels of productivity and motivation among medical personnel
Low user satisfaction & poor quality of service lead to low use.
High levels of child and maternal mortality

3. Background (3)
In 2005 , 4/10 births attended by a health professional.
Infant Mortality : 86 per 1,000
HIV : 3.1%
Source: Rwanda 2005: results from the demographic and health survey Studies in family planning, 39(2), pp 3

4. Strengthening accountability in the health sector in Rwanda
PERFORMANCE BASED, CASH AND IN KIND INVESTMENT INPUT SUBSIDIES TRANSFERS
NATIONAL GOVERNMENT
LOCAL GOVERNMENT
VOICE
Performance CONTRACTS
Umushyikirano, Citizen Report Cards, Ombusdman
CLIENT POWER
Clients / Citizens
AUTONOMOUS FACILITIES PROVIDERS
COMMUNITY
GOVERNANCE
COMMUNITY HEALTH WORKERS PROVIDERS
COMMUNITY HEALTH INSURANCES
Mutuelles

5. Rwanda has undertook major reforms to strengthen accountability of all institutional and individual actors for MDGs related results...

6. ..through a shift of paradigm..
Decentralisation of health services with strong governance structures based community participation.
Imihigo: Performance contracts between President of Republic and mayor of Districts;
PBF: Performance Based Financing;
CBHI: Community Health Insurance;
Autonomy of health facilities, including hiring and firing of health personnel;

7. Decentralization
Administrative, fiscal and financial decentralization has provided huge sums of money to local levels of government and given them much flexibility by providing them with block grants

8. Total health personnel in publicly funded facilities has almost doubled in 3 years …

10. Financing has more than tripled in four years (going from USD 7
Financing has more than tripled in four years (going from USD 7.5 to 30.3 millions, of which the PBF has grown more than tenfold from USD 0.8 to 8.9 millions)

11. Rwanda: Scaling up of community health insurance
Source: MOH Rwanda; 2005 EICV 2005

12. Results show Rwanda is now back on track towards the health MDGs…
Health outcomes
Neonatal, infant and child mortality
Malaria incidence and mortality
HIV
Improved financial access
Reduction of catastrophic expenditures
High Impact Interventions
ITNs
Family planning
Assisted Deliveries
Quality of care

13. Rwanda is back on track to reach the MDGs
Under five mortality trends with MDG target for 2015

14. All income groups benefit but inequities still persist …
Under five mortality trends by income quintile ( )
Source: DHS 2005 and 2007.

15. Rwanda Health Insurance
At all income levels, those enrolled in mutuelles are much more likely to use health services.
Source: Shimeles et al, 2009

16. Rwanda: Effect on MDGs High Impact Interventions

17. Rwanda : Increase in utilization of high impact services
Proportion (%) of children under 5 years of age who have slept under a mosquito bed-net during the night preceding the survey

18. Increase in utilization of high impact services
Trends in assistance at delivery : Years 2000, 2005, 2007
Percentage (%) of women delivered by a health professional

19. Performance-based Financing (PBF)
Developed after extensive piloting from
Objectives
Focus on maternal and child health as well as communicable diseases (MDGs 4 & 5)
Increase quantity and quality of health services provided
Increase health worker motivation
Financial incentives to providers to see more patients and provide higher quality of care
Operates through contracts between
Government
Health facilities providing services

22. Quality Conceptual Framework
Production
Possibility
Frontier
What They Do: (Quality)
What They Know (Ability/Technology)

23. Goal: Use Pay for Performance to Close Productivity Gap
Production Possibility Frontier
What They Do
Productivity Gap Conditional on Ability
Actual Performance
Ability/Technology

24. Researcher & Policy Maker Collaboration
Research Team
Paulin Basinga, National University of Rwanda
Paul Gertler, UC Berkeley
Jennifer Sturdy, World Bank and UC Berkeley
Christel Vermeersch, World Bank
Policy Counterpart Team
Agnes Binagwaho, Rwanda MOH and CNLS
Louis Rusa, Rwanda Rwanda MOH
Claude Sekabaraga, Rwanda MOH
Agnes Soucat, World Bank
A collaboration between the Rwanda Ministry of Health, CNLS, and SPH, the INSP in Mexico, UC Berkeley and the World Bank

25. Evaluation Questions: Did PBF…
Increase the quantity of contracted maternal health services delivered?
Improve the quality of contracted maternal health services provided?

26. Evaluation Design
During decentralization, phased rollout at district level
Identified districts without PBF in 2005
Group districts into “similar pairs” based on population density & livelihoods
Randomly assign one to treatment and other to control
MOH reallocated some districts to treatment
With decentralization, some new districts had PBF in an area of the new district – must be treatment
Unit of observation is health facility

27. Rollout of PBF in health centers in Rwanda, 2006 – 2008

28. Isolating the incentive effect
PBF
Performance incentives
Additional resources
Compensate control facilities with equal resources
Average of what treatments receive
Not linked to performance
Money allocated by the health center management

29. Sample: Panel 165 Facilities 2006-08
2145 households in catchment areas
Random sample of 14 per clinic

30. Log Expenditures Randomization balanced baseline
Follow-up balanced, so difference in follow-up outcomes due to incentives not resources

31. Baseline Expenditures & Staffing

33. Impact of PBF: Statistical methods
Have balance at baseline on all key outcomes
Use difference in differences analysis
Not a pure randomized experiment
Clustered at district-year level
Facility Fixed Effects
Year dummy
Controls: age, parity, education, household size, health insurance, land, value of assets

35. Delivery at the health facility increased overall in Rwanda, but 7% more in PBF facilities ….

36. Prenatal Competency & Quality
Provider knowledge/competency
Standardized vignette presented to provider
Compare answers to Rwandan CPG
Measure of ability/knowledge
Process quality
Patient exit interview of clinical services provided
Clinical content of care
Provider effort

37. In the last years, PBF has increased prenatal care quality significantly …

40. Impact of PBF on Prenatal Care Quality

43. Impact of PBF on Child Health (z-scores)

44. Results Summary Balanced at baseline
Expenditures same, so isolate incentives
Impact on utilization
Delivery & Child prevention, but not prenatal
Impact on prenatal quality
Bigger for better doctors
Reduced child morbidity & Taller children
Effect sizes bigger than most other interventions

45. Discussion Increase in utilization in country with national campaigns:
PBF Effect seen despite many other national level intervention: possible bigger effect in other countries
Increase in utilization in country with national campaigns:
Mutuelle
Imihigo
HIV services
Safe motherhood and PCIME
Possible spill over effect to child health

46. Discussions/ Policy implications
You get what you pay for !
Returns to effort important
Bigger effects in things more in provider’s control
Patient or community health workers for prenatal care/Immunization
Provide incentives directly to pregnant women? (conditional cash transfer program).
Financial incentive to community health workers
Low quality of care : additional training coupled with PBF
Need to get prices “right”
Evaluation feedback useful

47. Limitations
The original randomized designed was changed due to the political decentralization process: But sample well balanced!
Trend analysis with HMIS data ongoing
No measure of all paid and some non paid indicators : HMIS analysis
Cost effectiveness analysis

48. Acknowledgments Funding by: World Bank
Government of Rwanda (PHRD grant)
Bank-Netherlands Partnership Program (BNPP)
ESRC/DFID
GDN