PerformanceBased Financing in Rwanda

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Performance-Based Financing in Rwanda

• Agnes Soucat, Adviser HNP Africa Region

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Background (1)

• Shortage of human resources for health services
• No cash resources in health facilities
• Low levels of productivity and motivation among
  medical personnel
• Low user satisfaction poor quality of service
  lead to low use.
• High levels of child and maternal mortality

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Background (3)

• In 2005 , 4/10 births attended by a health
  professional.
• Infant Mortality 86 per 1,000
• HIV 3.1

Source Rwanda 2005 results from the demographic
and health survey. 2008. Studies in family
planning, 39(2), pp. 147-152.
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Strengthening accountability in the health sector
in Rwanda
PERFORMANCE BASED, CASH AND IN KIND
INVESTMENT INPUT SUBSIDIES TRANSFERS
NATIONAL GOVERNMENT
LOCAL GOVERNMENT
VOICE
Performance CONTRACTS
Umushyikirano, Citizen Report Cards, Ombusdman
CLIENT POWER
AUTONOMOUS FACILITIES PROVIDERS
Clients / Citizens
COMMUNITY GOVERNANCE
COMMUNITY HEALTH WORKERS PROVIDERS
COMMUNITY HEALTH INSURANCES Mutuelles
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Rwanda has undertook major reforms to
strengthen accountability of all institutional
and individual actors for MDGs related results...

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..through a shift of paradigm..

• Decentralisation of health services with strong
  governance structures based community
  participation.
• Imihigo Performance contracts between President
  of Republic and mayor of Districts
• PBF Performance Based Financing
• CBHI Community Health Insurance
• Autonomy of health facilities, including hiring
  and firing of health personnel

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Decentralization

• Administrative, fiscal and financial
  decentralization has provided huge sums of money
  to local levels of government and given them much
  flexibility by providing them with block grants

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Total health personnel in publicly funded
facilities has almost doubled in 3 years
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Financing has more than tripled in four years
(going from USD 7.5 to 30.3 millions, of which
the PBF has grown more than tenfold from USD 0.8
to 8.9 millions)
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Rwanda Scaling up of community health insurance
Source MOH Rwanda 2005 EICV 2005
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Results show Rwanda is now back on track towards
the health MDGs

• Health outcomes
• Neonatal, infant and child mortality
• Malaria incidence and mortality
• HIV
• Improved financial access
• Reduction of catastrophic expenditures
• High Impact Interventions
• ITNs
• Family planning
• Assisted Deliveries
• Quality of care

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Rwanda is back on track to reach the MDGs
Under five mortality trends with MDG target for
2015
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All income groups benefit but inequities still
persist
Under five mortality trends by income quintile
(2005-2007)
Source DHS 2005 and 2007.
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At all income levels, those enrolled in mutuelles
are much more likely to use health services.
Rwanda Health Insurance
Source Shimeles et al, 2009
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Rwanda Effect on MDGs High Impact Interventions
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Rwanda Increase in utilization of high impact
services
Proportion () of children under 5 years of age
who have slept under a mosquito bed-net during
the night preceding the survey
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Increase in utilization of high impact services
Trends in assistance at delivery Years 2000,
2005, 2007 Percentage () of women delivered by a
health professional
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Performance-based Financing (PBF)

• Developed after extensive piloting from 2001-2005
  
• 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
• Health facilities providing services

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Quality Conceptual Framework
Production Possibility Frontier
What They Do (Quality)
What They Know (Ability/Technology)
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Goal Use Pay for Performance to
Close Productivity Gap
Production Possibility Frontier
What They Do
Productivity Gap Conditional on Ability
Actual Performance
Ability/Technology
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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
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Evaluation Questions Did PBF

• Increase the quantity of contracted
  maternal health services delivered?
• Improve the quality of contracted
  maternal health services provided?

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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

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Rollout of PBF in health centers in Rwanda, 2006
2008
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Isolating the incentive effect

• PBF
• Performance incentives
• Additional resources
• Compensate control facilities with equal
  resources
• Average of what treatments receive
• Not linked to performance
• Money allocated by the health center management

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Sample Panel 165 Facilities 2006-08

• 2145 households in catchment areas
• Random sample of 14 per clinic

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Log Expenditures

• Randomization balanced baseline
• Follow-up balanced, so difference in follow-up
  outcomes due to incentives not resources

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Baseline Expenditures Staffing
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Impact of PBF Statistical methods

• Have balance at baseline on all key outcomes
• Use difference in differences analysis
• Not a pure randomized experiment
• Clustered at district-year level
• Facility Fixed Effects
• Year dummy
• Controls age, parity, education, household size,
  health insurance, land, value of assets

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Delivery at the health facility increased overall
in Rwanda, but 7 more in PBF facilities .
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Prenatal Competency Quality

• Provider knowledge/competency
• Standardized vignette presented to provider
• Compare answers to Rwandan CPG
• Measure of ability/knowledge
• Process quality
• Patient exit interview of clinical services
  provided
• Clinical content of care
• Provider effort

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In the last years, PBF has increased prenatal
care quality significantly
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Impact of PBF on Prenatal Care Quality
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Impact of PBF on Child Health (z-scores)
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Results Summary

• Balanced at baseline
• Expenditures same, so isolate incentives
• Impact on utilization
• Delivery Child prevention, but not prenatal
• Impact on prenatal quality
• Bigger for better doctors
• Reduced child morbidity Taller children
• Effect sizes bigger than
  most other interventions

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Discussion

• PBF Effect seen despite many other national level
  intervention possible bigger effect in other
  countries
• Increase in utilization in country with national
  campaigns
• Mutuelle
• Imihigo
• HIV services
• Safe motherhood and PCIME
• Possible spill over effect to child health

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Discussions/ Policy implications

• You get what you pay for !
• Returns to effort important
• Bigger effects in things more in providers
  control
• Patient or community health workers for prenatal
  care/Immunization
• Provide incentives directly to pregnant women?
  (conditional cash transfer program).
• Financial incentive to community health workers
• Low quality of care additional training coupled
  with PBF
• Need to get prices right
• Evaluation feedback useful

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Limitations

• The original randomized designed was changed due
  to the political decentralization process But
  sample well balanced!
• Trend analysis with HMIS data ongoing
• No measure of all paid and some non paid
  indicators HMIS analysis
• Cost effectiveness analysis

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Acknowledgments

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