1. What do we know and don’t know…
We know that high impact interventions lead to improved health outcomes ..
We do not know how to best produce demand and effective coverage with these interventions in specific contexts ….what economists call the “production function”…
We know the inputs.. But not the incentives, institutional and management arrangements
The “missing middle” or “black box” ..

2. When we do not know there are consequences…
Government ‘s policies are “shooting in the dark”
Public money is not used efficiently..
Aid effectiveness is low..
Ideology prevails..

3. An example of an ideology driven debate…user fees
Proponents: user fees provide incentives to providers, reduce absenteeism, improve quality, improve accountability to users/clients
Opponents: user fees reduce access and utilization, and are a burden on the poor’s households budgets
Evidence ?

4. An example of an ideology driven debate …user fees
Hundreds of publications on the topic..
Yet less than 5 rigorous studies based on population surveys of service use and randomized control group
Conclusions of these studies are mixed..

5. Uganda: Utilization of Curative Services Trending Upwards
Public Expenditure Review 2008
The World Bank
The World Bank

6. Uganda: little effect of user fees abolition on MDGs related High Impact Interventions
Source: DHS 2000 and 2006

7. The promise of Results Based Financing..
Setting Evidence Based Policies : The Rwanda example

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

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

10. Rwanda : Intake of Family planning tripled in three years..
One such existing user earns about $0.37. A new user earns $1.83 for the health center. The above graph shows the AVERAGE number of such services, per health center per month. This reflects 98.2% complete reporting for 2006, and 100% complete reporting for All 295 health centers in the 23 districts reported completely, and timely. 10

11. 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
Public and Private Health facilities providing services

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

14. 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

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

16. 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