Choice of indicator and amount in the Performance Based Financing Rwanda IHSS Project First Global Symposium on Health Systems Research Montreux, November 2010

Authors NDIZEYE, Cedric, USAID/IHSSP Rwanda RUSA, Louis, MoH Rwanda DE NAEYER, Ludwig, USAID/IHSSP Rwanda KANTENGWA, Kathy, Management Sciences For Health

BACKGROUND PBF principles in choice indicators  Choice quantity – National public health priority (e.g. health facility delivery) – Neglected and/or less well functioning service/activity (e.g. post-natal visit) – Avoid diversion of attention and negligence in important and well running services (e.g. immunization) – Can indicator be well monitored (e.g. avoid “ORS for diarrhea”)  Choice amount – Same criteria as above plus ­ Available budget ­ Importance of service to be stimulated ­ Estimated workload to increase use of service (production)

Objective  Evaluate the importance of the key indicators and the unit fee on the revenues generated per health center for HIV and non-HIV services along the different activities  Methodology: national routine data from PBF- affiliated sites are assessed from July 2006 to June – Minimum Package Activities (only health centers) Indicators used for >600 reports are retained. Total of nearly 20,000 reports were assessed – HIV (all health facilities): all indicators for total of 12,000 reports (only 7 HC for 2006)

Total PBF-incentives disbursed quarterly per facility type

Minim Package:average quantities and unit fees over time Average Quantity/HCUnit fee (rwf) (1$ = ±580 rwf) Indicator Grand Total yr2006yr2008 Yr2010 July OPD: new case 1,198 1,328 1,483 1,625 1,809 1, ANC: new case (2010: NC with MII) ANC: 2nd dose of SP ANC: vaccination ANC: 4 standard visits ANC: at risk pregnancy referred Delivery at Health Facility Delivery referred Family planning: new user Family planning: users at the end of the month ,128 1, Referral of emergency cases Referral for severe malnutrition Growth monitoring at the Health Center Completely vaccinated child Vesico-vaginal fistula referred na Malnourished: hospitalized and cured na

Minimum Package Activities revenues 28.1% 15.7% 15.2% 9.8% 8.0% 7.4% 6.3% 3.7% 2.1% 1.5% 0.7% 0.6% 0.3% 0.0%

HIV indicators: average quantities and unit fees over time Average Quantity/HCUnit fee Services Grand Total Yr2006/7Yr2010 VCT : patients tested PICT: patients tested PMTCT: pregnant women tested for HIV * PMTCT/VCT: couples and partners tested * PMTCT: couples tested* PMTCT: mother and child received ARV prophylaxis * PMTCT: HIV+ women under ART during delivery * PMTCT : exposed children under ART prophylaxis at birth PMTCT : HIV exposed children receiving CTX every month na PMTCT: children tested for HIV (split 6w and 18m in 2010) /11000 HIV prevention: HIV+ women using FP ARV: new adult patients on treatment ARV: new paediatric patients on treatment HIV care: CD4 every 6 months HIV care: CTX every month na ARV: patients consulted at 6-month interval na ARV: patients consulted after 1 month na TB/STI: HIV+ patients screened for STI na TB/STI: HIV+ patients screened for TB

HIV revenues 15.9% 11.7% 1.8% 21.1% 15.1% 0.8% 0.7% 1.0% 2.8% 4.3% 1.6% 0.4% 10.6% 5.1% 2.3% 1.9% 1.2% 1.1%

HIV revenues 15.9% 11.7% 1.8% 21.1% 15.1% 0.8% 0.7% 1.0% 2.8% 4.3% 1.6% 0.4% 10.6% 5.1% 2.3% 1.9% 1.2% 1.1% Testing: 65.6%

HIV revenues 15.9% 11.7% 1.8% 21.1% 15.1% 0.8% 0.7% 1.0% 2.8% 4.3% 1.6% 0.4% 10.6% 5.1% 2.3% 1.9% 1.2% 1.1% PMTCT: 6.0%

HIV revenues 15.9% 11.7% 1.8% 21.1% 15.1% 0.8% 0.7% 1.0% 2.8% 4.3% 1.6% 0.4% 10.6% 5.1% 2.3% 1.9% 1.2% 1.1% HIV-care: 24.2%

Conclusion  Choice of indicator and its unit fee: take also into consideration expected volume.  Even with low unit fees, cumulative indicators weigh heavy on the generated revenues  Quantity indicators with low productivity and reasonable unit fee yield very low revenue – They will not necessarily prompt health care workers to increase offer of services (due to income to be gained) but can remain in list to draw attention to the importance of the activity – No need a very high unit fee because increased change for fraud*  For HIV-services: revenues for preventive services outweigh to a large extent revenue for HIV-care and follow-up  Budget forecasting helps in defining how much PBF-incentives should be used in which programmatic area  HIV-funds should be integrated in Minimum Package-funds (common basket)

Remaining questions/challenges  Should we not shift increasingly to payment of quality instead of using it as a mere adjustment factor of productivity? (in order to focus on the public health priorities – quality more an issue than access)  Should not only preventive services be covered since curative services (OPD) are already paid for by CBHI and they are not in the hands of the provider?  For HIV (“chronic” patients): should we not pay specifically for follow-up care assessed through medical file review?*

Data restrictions The data shown in this presentation should not be quoted without permission of the authors.

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