Performances Based Financing scheme in Rwanda

INVESTING MORE STRATEGICALLY

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Outline of Presentation

Rwandan Context PBF scheme in Rwanda

PBF approach Implementation model and funds flows PBF funding in Rwanda

Some Achievements and Challenges

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Background The performance-based funding (PBF) is one of the

pillars of health financing and strengthening the health system in Rwanda. This approach was introduced in order to strengthen the motivation of care providers and results (output) than traditional financing (for input) had not previously yielded

Historical

Started in 2002 as pilote by two NGOs in former Butare and Cyangugu provinces.

The MoH integreted the PBF in 2005 HSSPI and decided to implement PBF in the whole country’ health facilities.

The scaling up started in early 2006 with the second phase of decentralisation.

Rwandan Context Population10.4 million; >90% are in the informal sector 45% living under poverty line (EICV 2011) 96% health insurance coverage (91% CBHI) Per capita income 2011 = US$ 540 Health Budget as % of Total Budget: 16% (Abuja target

attained)

INDICATORS BASELINE 2005

MTR June 2008

MTR Aug 2011

TARGET 2012

TARGET 2015

Source of Information DHS2005 I-DHS DHS2010 EDPRS MDGs

IMPACT INDICATORS

Infant Mortality Rate / 1000 86 62 50 37 28

Under Five Mortality Rate / 1000 152 103 76 66 47

Maternal Mortality Rate / 100.000 750 NA 487 455 268 6

416 Sectors

Health Centres

Health Posts

30 Districts

District Hospitals

Central Level

5 National Hospitals

SectorCellUmudugudu

District Level

National Level

Decentralized health organization

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Performance-Based FinancingValue for Money approach

Objectives:• Improve efficiency & rational use of health resources• Coverage of high impact interventions• Increase utilization of qualitative services care• Improve equity in resource allocation• Increase health worker motivation• Empower users of HF by giving them voice• Strengthen autonomy of health structures and build

capacity of managers

The national PBF model is composed of the following components: (1) PBF model for health centers; (2) PBF for district hospitals; and (3) Community PBF

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Implementation model and funds flow

CAAC/MOHRegulation role, support and supervision

DISTRICT STEERING COMMITTEE

HOSPITAL

Sponsors (MINECOFIN GFTAM, USG agencies and Others)

(MANAGEMENT COMMITTEE)-HEALTH CENTER

Services providers Employee

Quantity Control (Monthly)

Quality Evaluation (Quaterly.)

Motivation

Funds Transfert

Beneficiairies

Quality score

Health services

District Health Director

Result transmission

PeersEvaluation and Central

levelevaluations

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INDICATORS ON MERGER DESEASES

1. HIV The SSF/HIV Grant is currently providing PBF funds to

Health Facilities (DHs and HCs) 18 indicators are paid (HIV/AIDS, TB/HIV, Reproductive

Health/HIV)

2. TB The PBF TB program has been scaled up at the national

level within 498 health facilities including 42 Districts Hospitals, 147 Health Center – Center of Diagnosis and Treatment “CDT”, 296 Health Center – Center of Treatment “CT”, 8 Prisons – CDT and 6 Prisons – CT

26 indicators are paid 10

Progress of implementation

CAAC submit the quarterly progress report Data verification and counter verification mechanism in

place Payment verification mechanism in place Integration with other health financing initiatives (CBHI) Payment made

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One of the achievement of PBF scheme

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ONE OF THE RESULT: Trend of prenatal care quality between treatment and control facilities (2006-2008).

-0.10

0

-0.13

0.15

-0.15

-0.10

-0.05

0.00

0.05

0.10

0.15

0.20

Baseline (2006) Follow up (2008)

Stan

dard

ized

Pre

nata

l eff

ort s

core

Control facilities Treatment (PBF facilities)

15 % Standard deviation increase due to PBF

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Impact of PBF

Two years into the national roll-out, the over-all performance of health facilities showed significant increase. As of 3rd quarter 2010, quality score of district hospitals in the country is 72.2% (range 33%-96%) (MSH, 2011).

 A rigorous impact evaluation of the health centre PBF found positive effect on HIV, MCH and TB outcomes. Institutional delivery increased over-all but 7% more in PBF facilities between 2006-2008. PBF has increased prenatal care quality significantly (SPH/WB, 2010)

Individual VCT for HIV has significantly increased but more so for married couple VCT

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Successful role-out of performance based financing (PBF) Careful phased approach Purchase of verified quality services Increased discretionary resources for health facilities Improved motivation of staff (financial incentives and equalization

of revenues) Strengthened quality assurance mechanisms (supervision and

verification) Clarified supervision, evaluation and "coaching" (peer-review)

The Rwandan example shows foremost the synergies of a number of reforms, i.e. difficult to attribute the percentages of success to each and every one of these reforms 15

Challenges for PBF Clarify role in long term vision and strengthen links with

demand side financing mechanisms Maintain momentum and improve assessment process Sustainability of PBF from Partners in this global

financial crisis and economic downtown Need to continuously revise indicators and increase the

PBF award to buy results Need to promote equity in PBF awarding

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Thank you for your attention

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