This document discusses performance-based financing (PBF) models implemented in Rwanda. It provides background on PBF, outlines key principles like separating purchasers and providers, and describes the three initial PBF pilot models in Rwanda. It then discusses scaling up PBF nationwide, including developing national PBF models for health centers and hospitals. The results section highlights increased service volumes, improved quality of services, and enhanced provider motivation associated with PBF implementation in Rwanda.

1. Scaling-Up Performance-Based Financing
RandyWilson/IHSSProjectRWANDA
JimSetzer/AbtAssociatesUSA

2. Content
 PBF101 –guidingprinciples
 Casestudyof PBFinRwanda
 Typesof PBF
 Projectinterventions
 Results

3. Input vs Output
financing
 Paymentsinadvancefor
salaries,drugs& supplies,
runningcosts
 Fundsoftenmanagedat
higherlevels
 Needtojustifyexpenses
afterpayment(accounting&
audit)
 Tenuouslinkbetween
fundingandresults
 Fundspaidforservices
alreadydelivered
 Fundsmanagedatlocal
level
 Needstrongdatacollection
& qualitycontrol system
 Directlinkbetweenfunding
andresults

4. PBF model – key principles
 Separationbetweenproviders,
purchasersandcontrollers
 PBFfundingdoesnotcovercostof
service–justincentivizesit
 Traditional inputfinancingmust
continuetocomplementPBF
 Dataonserviceoutputsmustbe
highlyselective(10to15
indicatorsareplenty) andfrom
existingsources
 Strongserviceanddataquality
control mechanismsneededto
eliminateincentivetocheatand
ensurethatservicesaredelivered
accordingtonorms

5. PBF and RHIS
 PBFIndicatorsshouldbeasubsetof dataalready
collectedbytheRHIS
 “Indicators”aretypicallynumbersof serviceoutputsor
coveragerates.
 Rewardpositiveindicators(e.g.don’tincentivise#of
severelymalnourishedchildrendiagnosed)
 PBFpaymentsprovideanincentivefortimelyRHIS
reporting–noreport,nopayment!

6. PBF Control is NOT ‘business as
usual’ in data gathering
District
quality
assessment
team
checkingdata
qualityina
healthcenter

7. Assuring Data Quality – Multiple
levels of control
 ‘ ’Data quantity audits conductedeverymonthoneach
indicatorfromeverysite(registervsreport)
 Monthly report data are reviewed by district PBF steering
committees (comparingtopreviousperiods,identifying
outliers,requiringcorrections)
 Community client or “phantom patient” surveys every6
monthatasampleof sites–lookforphantompatientsand
seeksfeedbackfrompatientsonqualityof care
 National PBF cell reviews database each quarter forthe
entirecountry–correctionsaremadebeforepayment

8. Assuring service quality
 Quarterly Quality assessments areconductedateach
facilitytoassess13componentsof servicequality
 Administration,Hygiene,RespectforClinical protocolsfor
keyservices,Communityoutreach,etc.
 Controllers areDistrictHospital supervisorsanddata
managersforhealthcenters,bypeerdistricthospitalsfor
Hospital level PBF
 Theseassessment score isusedtooffsetPBFpayments

9. Rwanda PBF Background
 WhyPBF?
 Lowqualityof healthcare& services
 Diminishingcoverage: generallylowutilizationof healthservices
 Limitedincentivesforproviderstodeliverpreventiveservicesand
HIV/AIDScareandtreatment
 Financial barrierstoaccesshealthservices/demandsideproblems
 Pilotinitiatives:
 In2002, twoNGOsintroducedPBFpilotsschemesinCyanguguandButare
provinces
 Basedoninitial successMOHincludePBFin2005HealthPolicy
 In2005, theBelgianTechnical Cooperation(BTC) beganthirdPBFpilot

10. Timeline of Performance-based financing in Rwanda

11. Overview of the three Rwandan Pilot
PBF models
Model
No of Clinics
under
contract
No of
Hospitals
under
contract
DHT's
under
contract
Project
Budget per
capita per
year $
PBF Budget
reaching
clinics per
capita per yr $
Average
Health Worker
Income
$/month
“Cyangugu”
model
26
(+14 HP and
19 private
dispensaries)
4 4
$2
(2005)
$0.41(i)
(2004)
$117
(2004)
“Butare”
model
36 3 4
$0.3
(2005)
$0.13 (i)
(2004)
$110
(2004)
“BTC”
model
75 4 6
$1.57
(2005)
$0.08 (ii)
(2005)
Base salary +
$18
(2005)
PBF pilots covered 137 Health Centres (about 40% of total) and 11 District
Hospitals (about 30%) by end 2005

12. Key Rwanda health strategies
 In2005,MOHintroducedthreecomplementary
strategiestoimprovehealthservices:
 CommunityBasedHealthInsurance
 Performance-basedFinancing
 ContinuousQualityAssurance

13. Quality Assurance
Performance based
financing
Community-Based
Health Insurance
High Performing
Facilities
Appropriateservices
and contentof care
defined
Goodorganization
andmanagementof
care
Appropriate
informationfor
decision-making
Functional referral
system
AdequateFinancial
andmaterial resources
StrongStaff
Motivationand
Competence
Active Participation of
the Population
High quality
healthcare
Incompliancewith
normsandmeets
expectations
Abilitytoactoncare
andpreventionneeds
Financial and
Geographical Access
Freedomtochoose
careoptions
Well informedand
competentclients
,Sustainable
Improved Health
Outcomes
Consistent Use
of Health
Services
Consistent
Adherence to
Care

14. Rwandan National PBF Models
 PBFmodel forhealth
centers
 PBFmodel fordistrict
hospitals
 CommunityPBF
 Central level PBFfor
MoHdepartment/units

15. Key PBF Project Achievements
 Theprojectreachednationwidecoverageinall 30districtsinApril 2007
 Supportfornational implementationof PBF:
 Coordinateddesignof newnational PBFmodels(HC, DH,
communityandcentral MOHdepartments).
 Setupinstitutional structures–Extendedteam, PBFcoordinatingcell
 Definedperformanceindicatorsandtheirvalues
 Refinedtoolsforqualityassessment
 Developeddatabasetoissuecontracts,monitorprogress, andissuepayment
orderstohealthfacilities
 ContractedwithsitesforHIV services
 BuiltcapacitytomanagePBFactivitiesatall levels
 ProvidedTA toUSGpartnerstoimplementPBFintheirfacilities

16. Performance Indicators Defined
HealthCenterlevel:
 :Outputs 14PHCindicators+ 10HIV indicators; unitfees$0.18-
$8.90, measuredmonthly
 :Quality 111 compositeindicators(1,058dataelements) across14
services/departments, measuredquarterlybyDHstaff–usingpaper
checklist
DistrictHospital level:
 :Outputs 9HIV indicators; unitfees$0.18-$8.90,measuredmonthly
 :Quality Balancedscorecardapproach: (2009) 59composite
indicators,over350dataelements–measuredquarterlyusingInfoPath
form

17. Performance Payment Mechanism developed
Performance Payments = (# serviceoutputs* Unitfees) * %QualityscoreΣ
No Indicator Quantity Fee Amount RWF
1VCT: number of clients tested 899 500 449,500
2PMTCT: number of pregnant women tested 101 250 25,250
3PMTCT: Number of couples and partners tested 134 2,500 335,000
809,750
Quarterly quality score X 87%
Payment amount 704,483

18. Performance Payment Amounts
Combined PBF payments to Health Centers and Hospitals to date (from
USGpartners(Pepfarfunded), BelgianTechnical Cooperation,Global Fund)
Service package 2006 2007 2008 2009 YTDGrand Total
Primary Health Care
Package $186,093 $ 1,160,087 $2,918,035 $1,916,588 $6,180,804
HIV/AIDS package $27,874 $ 867,077 $2,490,787 $1,614,068 $4,999,806
Grand Total $213,967 $2,027,164 $ 5,408,823 $3,530,656 $11,180,610

19. M&E Mechanism developed: Multiple
levels of control
 Setupof validationandaccountabilityfunctions
(conductedbyDistrictHospital staff fortheirownHC,andas
peerevaluationsfortheDHlevel)
 Harmonizedquantity verification tools(dataquality)
 Developedquality evaluation checklists(servicequality)
 Twonational protocolsforcounterverificationof
reportedservicesinPBFweretestedandadopted
 “ /Phantom patient” client satisfaction surveys conductedby
local NGO
 Quality counter verification bytheExtendedTeam

20. PBF Information System developed
MonthlyPBF
Reports PBF
Database
Quarterly
Quality
Assessments
PBFContracts
Contracts & Amendments
Indicator Trend Graph
Quarterly Payment Voucher
Bank Payment Voucher
Thematic Maps
INPUTS
OUTPUTS

21. PBF Application Environment
PBF Database
(MySQL)
Internet
Access Application
Internet Application (PhP)
Excel Pivot Tables and Graphs

22. Contract Management Procedures
 PerformanceContracts(withbusiness
plan) havebeendevelopedandsigned:
 MSHsigned88subcontractswith
HFtopurchaseHIV services.
 Contractswith9DH(forPCA)
 MSHassistMOHtocontract416
HCforPHCand39DH
 and30contractswithsteering
committees
 Creationof adatabaseapplicationto
managecontracts, amendmentsand
payments

23. Coordination with Partners
 Closecollaborationwithall collaboratingagencies(USG&
other) onPBFforHIV/AIDSserviceswasinitiatedthrough
extended team forum:
 Monthlymeetingsforinformationsharingandexplanationof the
technical developmentssurroundingPBF
 Regulartrainingsessionstostrengthenpartners’TA capacity:
 PBFdatabasedataentryandPivottableanalysis
 PBFmodel andprocedures
 Trainingof Trainers
 Financial riskforecastingandelectroniccontractmanagement
 WorkshopstobuildconsensusonPBFmodel

24. Results
1. IncreaseintheVolumeof Services
3. Increaseof theQualityof Services
5. ProviderEnthusiasmandMotivation

25. Increase in Volume of Services
(after 39 months)
PBF Indicator 2006 /January average
/month
health center
(258 health centers on
)average
2009March
/ /average month
health center
(297 health centers on
)average
Percentage increase
( / 2)linear log R
Institutional
Deliveries
21 39.7 89%
(log 0.77)
New Curative
Consultations
985 1835 86.3%
(log 0.28)
ANC new cases 100.8 76.2 -24%
(log 0.05)
Family Planning new
users
15.5 58.6 278%
(linear 0.79)
Family Planning
users at the end of
the month
175.2 1005.6 473.9%
(linear 0.98)

26. Increase in Volume of Services
PBF Indicator October 2006 average/
month/
health center
(6 health centers)
December 2009
Average/month/
health center
(6 health centers)
Percentage increase
(linear R2)
VCT clients tested 158 372 135%
(0.45)
PMTCT children born
to HIV+ mothers seen
for CTX treatment
7 29 (dec 09) 325%
(0.75)
Number of HIV+
clients treated with
CTX
55 134 143%
(0.82)

27. Results for Institutional Deliveries

28. Increase in the Quality of Services in
Health Centers (1)

29. Increase in the Quality of Services in
Health Centers (2)

30. RwandaCommunityPBFModel
 :Purchasers theSector(HealthCenterlevel) SteeringCommittees
 :Controllers theHCstaff underguidancefromtheSectorSteeringcommittees
 :Providers theCommunityHealthWorkerCooperatives(representing60,000
CHWs)
 22 indicators selected–samereportforCHWMISandPBF
 Different models beingtested:
 Onelumpsumpaymentforonequarterlydeliverable: theCHWcompiledreport
 Variablepaymentbasedonselectedoutputs
 Clientincentives–e.g.clothingfornewbornsdeliveredinfacilities
 Aligning incentives (HCPBFqualitygridincludesincentivestomonitor
CHWoutputs, CHWindicatorscanbevalidatedagainstHCdata)
 :Data transmission from15,000villagesusingcell phones(inprogress)