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

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

3. 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)

4. 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 2010. – 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)

5. Total PBF-incentives disbursed quarterly per facility type

6. Minim Package:average quantities and unit fees over time Average Quantity/HCUnit fee (rwf) (1$ = ±580 rwf) Indicator20062007200820092010 Grand Total yr2006yr2008 Yr2010 July OPD: new case 1,198 1,328 1,483 1,625 1,809 1,499 100 45 ANC: new case (2010: NC with MII) 80 76 80 68 64 74 50 180 ANC: 2nd dose of SP 39 45 28 3 32 250 ANC: vaccination 36 38 53 49 47 45 250 225 ANC: 4 standard visits 7 5 6 8 9 7 200 1500 ANC: at risk pregnancy referred 3 3 3 4 3 3 1000 Delivery at Health Facility 26 32 38 37 35 34 2500 3750 Delivery referred 4 5 9 11 10 8 2500 3750 Family planning: new user 26 44 56 66 53 1000 900 Family planning: users at the end of the month 258 490 772 1,128 1,450 842 100 90 Referral of emergency cases 10 13 47 59 61 41 1000 900 Referral for severe malnutrition - 1 1 1 1 20001800 Growth monitoring at the Health Center 257 331 404 470 480 393 100 Completely vaccinated child 64 71 66 69 65 67 500 450 Vesico-vaginal fistula referred 0.0160.02 1000na Malnourished: hospitalized and cured 0.57 1.00 0.02 2000 na

7. 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%

8. HIV indicators: average quantities and unit fees over time Average Quantity/HCUnit fee Services20062007200820092010 Grand Total Yr2006/7Yr2010 VCT : patients tested233.1343.6296.2311.1375.9 322.7 500550 PICT: patients tested 236.5236.7 236.6 770 PMTCT: pregnant women tested for HIV *76.469.9 70.2 250 PMTCT/VCT: couples and partners tested *92.783.7 84.0 2500 PMTCT: couples tested* 64.759.457.5 60.9 25003300 PMTCT: mother and child received ARV prophylaxis *1.92.6 2500 PMTCT: HIV+ women under ART during delivery * 2.41.91.8 2.1 25006600 PMTCT : exposed children under ART prophylaxis at birth 2.12.0 2.1 2500 PMTCT : HIV exposed children receiving CTX every month6.917.8 17.4 500na PMTCT: children tested for HIV (split 6w and 18m in 2010)2.53.74.54.24.9 4.4 50005500/11000 HIV prevention: HIV+ women using FP23.513.817.728.236.7 25.1 15001100 ARV: new adult patients on treatment4.84.75.03.94.3 4.4 25002600 ARV: new paediatric patients on treatment0.60.7 0.5 0.6 37504500 HIV care: CD4 every 6 months11.625.433.434.836.8 33.6 2500250 HIV care: CTX every month42.3141.8155.3188.0245.1 183.9 250na ARV: patients consulted at 6-month interval1.317.1 16.6 1000na ARV: patients consulted after 1 month3.35.5 5.4 2500na TB/STI: HIV+ patients screened for STI2.35.9 5.7 1500na TB/STI: HIV+ patients screened for TB0.62.83.96.16.7 5.2 15001100

9. 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%

10. 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%

11. 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%

12. 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%

13. 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)

14. 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?*

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

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