1. How did Rwanda Operationalize Performance-based Financing ?
Results Based Financing Workshop
June 23-27, 2008
Kigali Rwanda

2. 1999: health facility indicators are degradating.
I. Context (before PBF)
: Reconstruction after the genocide (emergency situations, NGOs). Free of charge.
1998-…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. 2

3. Chronology of Performance-based financing in Rwanda
Key Messages:
Performance-based financing in Rwanda has not been implemented overnight; it went through a long phase of pilot projects.
in 2005, PBF was mentioned implicitly in the new national Health Policy and explicitly in the new national Health Strategy.
Community Based Health Insurance (CBHI) was rolled out nationwide starting January 2006,
PBF was rolled-out nationwide as of January 2006 also (formally after the design of the new national PBF model for health centers in Feb 06),

4. The PBF pilot experiments (2002-2005)
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.

5. Scale up: Roll-out Phases
The three phases of the ‘Roll-out’ plan:
Phase -0 (white shaded): the three PBF pilot projects
Phase-1 (pink shaded): districts in which PBF was started in Jan 2006 (Phase-0 and Phase-1 district cover 23 out of the 30 Rwandan Districts)
Phase-2 (red shaded): the seven ‘control districts’ in which PBF will be implemented in April 2008.
Phase-2 area health facilities receive an amount equal to the average income earned in PBF districts, in form of ‘input financing’, i.e. they do not need to earn this money through any performance measure. A baseline study was done in 2005, its results are available. A follow-up study will attempt to document a differential impact in these two areas. This study, consisting of a batch of four studies, will start early 2008. 5

6. 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.

7. How did Rwanda coordinate partners to align payment?
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
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. 7

8. Unit Fee * Quantity * % Quality = Payment;
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

9. 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;

10. Institutional set-up

11. 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.

12. 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;

13. ICT management tools: www.pbfrwanda.org.rw
INSERT GRAPHIC TO ADD MAP
MAP IS 6.17” TALL

14. 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.

15. 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

16. Increases in the Volume of Services
Results
Increases in the Volume of Services
Increase of the Quality of Services
Increase of staff productivity
Provider Enthusiasm and Motivation

17. Increase in Volume of Services (after 27 months)
PBF Indicator
January 2006 average/month/
health center
( 258 health centers on average)
March 2008
average/month/
(286 health centers on average)
Percentage increase (linear/log R2)
Institutional Deliveries 21
37.5
78%
(log 0.75)
New Curative Consultations
985
1,489
51%
(log 0.19)
ANC: second dose of Tetanus Toxid
52.5
150%
(log 0.63)
Family Planning new users
15.5
47.9
209%
(linear 0.88)
Family Planning users at the end of the month
175.2
711.6
306%
(linear 0.98)
A high R2 value indicates a strong tendency. When the R2 is above 0.5 this shows a relative strong trend (maximum is around 1). An R2 of for instance 0.19 is weak, which can be due, in the case of New Curative Consultations, to seasonal fluctuations (malarial season).

18. Results for Family Planning Users at the end of the Month
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. 18

19. January 2006 through December 2007
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
The barred areas are the Phase 2 districts, not yet under PBF with data to be released by the World bank in June of In shades of blue, with the bluest the highest, the percentage increase from baseline for the coverage in health centers of Family Planning (pills and inject able methods only) is given. The absolute prevalence for, in these 23 districts, increased from 3.89% in January 2006 (100% complete reporting for January 2006) to 10.63% in December 2007 (also 100% complete reporting).
These data do NOT represent overall Contraceptive Prevalence since permanent and longer-term methods such as Norplant and IUDs are provided in hospitals and natural family planning data are not presented here, and neither are traditional methods or alternative methods. 19

20. A sharp increase in staff productivity.
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.
As of Jan 1, 2008, a revised quality supervisory tool has been implemented. It measures 111 composite indicators, across 13 services, including HIV services. It allocates 500 ‘quality points’, the HIV services have a weighting of 9% of the total quality score.
For the increase in quality: it reflects 60 HF in which these data have been measured during six months of 2006 (the tool was introduced after July 1, 2006), and 12 months’ measurement for 95 health facilities during As of Jan 1, 2008, this tool has been introduced in all 295 HF in 23 districts, and will be rolled out to all Rwandan health centers as of April 1, 2008.

21. Building consensus on indicators
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.
* “The only person who likes change is a wet baby” Roy Blitzer, pedagogue.

22. Start with easy things and then go progressively to complexity.
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!