How did Rwanda Operationalize Performance-based Financing ? Results Based Financing Workshop October 20-24, 2008 Gisenyi, Rwanda

I. Context (before PBF) : Reconstruction after the genocide (emergency situations, NGOs). Free of charge …Willingness to come back to development and government leadership. User fees. 1999: health facility indicators are degradating. 2001: Butare: willingness to move away from fixed bonus and observation of heterogenous performance across health centres.

Chronology of Performance-based financing in Rwanda

The PBF pilot experiments ( ) Led at provincial level. International NGOs. Priority health interventions: child immunisation, ANC, assisted deliveries, family planning, curative care. Recipients: health centres. A fee-for service. E.g. 500 frw for a fully immunised child X quantity reported by the health centre.

Scale up: Roll-out Phases

Scale up / national policy 2005: GOR decided to scale up PBF in the entire country; need for strong coordination; decision to set up a technical working group to implement the strategy: MoH Strategic Plan 2006: From harmonization to creating a national model; PBF Budget line in the GOR budget; ICT management tools; extension to hospitals.

How did Rwanda coordinate partners to align payment? 1.GOR: –pays outputs throughout Rwanda through recurrent budget –inserted, since 2007, a budget line item for a PBF scheme for the District Steering Committee activities which are based at District level 2.PBF admin system allows for GOR and donor monies to flow through one channel: straight into the health facility bank accounts. E.g. MSH – USG contractor- pays HIV PBF in same account as GOR. Use of same management module, with database linked to payments. Other donors: ICAP-USG contractor, FHI and BTC do the same.

How did Rwanda coordinate partners to link payment to results? A challenge: the HIVAIDS money 3. Careful assessment of incentives through HIV monies in PBF: solution found by protecting PHC services by linking payments of HIV and PHC monies to levels of quality of general services. Unit Fee * Quantity * % Quality = Payment; 4. Global Fund is joining other partners in paying for HIV indicators into their supported sites (R7); 5. One national approach, same institutional set-up, same unit costs and same admin system facilitates alignment

Payment to results: taking quality into account Monthly at the HC the quantity/volume of activities are assessed (PHC & HIV); Once per quarter the Quality of 13 services at the HC is determined (185 indicators!) ; Quantity * Unit fee * % Quality Index leads to the amount to be paid as performance to the HC;

Institutional set-up

Contractual arrangements GOR contracts have been written at all levels: (i) between the Mayors and the district PBF steering committees (multilateral); (ii) between the local administration and the health center management committees and – in some cases- (iii) between the health center management committees and the individual health workers.

Administrative & management coordination PBF admin system with internet based data entry and retrieval facilitate decentralized management and future decentralized payments (by districts); Semi-automated payment module, linked to central database, witch allow for ease of payments by MOF (Ministry of finances) and others (MSH; BTC; FHI and GF); Central database allows for following trends and forecast accurately financial risk;

INSERT GRAPHIC TO ADD MAP MAP IS 6.17” TALL ICT management tools:

Monitoring and evaluation Internal Controls by health facilities and District (Quantity and Quality) is sometimes complemented by ‘External Controls’ i.e. from outside the District. Protocols exist for counter-verifying Quality and Quantity data. A challenge / a risk: No systematic control at community level.

How many persons to do that? The task at hand is too large for any one single technical agency or understaffed and lean central MOH department –MOH central PBF Unit (CAAC): 1 coordinator and two full- time staffs; –A key role for partners (members of the CAAC and on the field) –An Extended team approach has been put in place to cover 23 districts, and includes PBF focal points from the MOH, eight NGOs and a bilateral agency as a coordination structure

Results 1.Increases in the Volume of Services 2.Increase of the Quality of Services 3.Increase of staff productivity 4.Provider Enthusiasm and Motivation

Increase in Volume of Services (after 27 months) PBF IndicatorJanuary 2006 average/month/ health center ( 258 health centers on average) March 2008 average/month/ health center (286 health centers on average) Percentage increase (linear/log R2) Institutional Deliveries % (log 0.75) New Curative Consultations 9851,48951% (log 0.19) ANC: second dose of Tetanus Toxid % (log 0.63) Family Planning new users % (linear 0.88) Family Planning users at the end of the month % (linear 0.98)

Results for Family Planning Users at the end of the Month

FP Injections and oral methods at Health Centers % Increase in Prevalence over 24 months; ( average absolute increase from 3.89% to 10.63%) January 2006 through December 2007

Other improvements Over 16 months of PBF, the Quality increased on average by 7% across these 13 services. A sharp increase in staff productivity. Whilst all providers appreciate the additional bonuses that they earn through PBF, most also see clear advantages in the better services they provide, and take clear pride and ownership of these activities which originate ‘from within’ as opposed to being dictated from above.

Some challenges we met HIV/AIDS money! Building consensus on indicators Existing players with their own models resist change. Coordination of partners and activities on the ground.

Lessons Learned Start with easy things and then go progressively to complexity. Need for strong implementation oriented coordination structures Need for creating a large pool of trainers Need for strong leadership and political will from authorities Massive increases in service volume whilst maintaining or increasing the quality of these services is possible CBHI and PBF are synergetic!