Performances BasedFinancing 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 thepillars of health financing and strengthening the healthsystem in Rwanda. This approach was introduced inorder to strengthen the motivation of care providers andresults (output) than traditional financing (for input) hadnot previously yielded
Historical
Started in 2002 as pilote by two NGOs in former Butareand Cyangugu provinces.
The MoH integreted the PBF in 2005 HSSPI anddecided to implement PBF in the whole country’ healthfacilities.
The scaling up started in early 2006 with the secondphase 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 targetattained)
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
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416 Sectors
Health Centres
Health Posts
30 Districts
District Hospitals
Central Level
5 NationalHospitals
Sector
Cell
Umudugudu
DistrictLevel
NationalLevel
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 buildcapacity of managers
The national PBF model is composed of the followingcomponents: (1) PBF model for health centers; (2) PBFfor district hospitals; and (3) Community PBF
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Implementation model and funds flow
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INDICATORS ON MERGERDESEASES
1. HIV
The SSF/HIV Grant is currently providing PBF funds toHealth Facilities (DHs and HCs)
18 indicators are paid (HIV/AIDS, TB/HIV, ReproductiveHealth/HIV)
2. TB
The PBF TB program has been scaled up at the nationallevel within 498 health facilities including 42 DistrictsHospitals, 147 Health Center – Center of Diagnosis andTreatment “CDT”, 296 Health Center – Center ofTreatment “CT”, 8 Prisons – CDT and 6 Prisons – CT
26 indicators are paid
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Progress of implementation
CAAC submit the quarterly progress report
Data verification and counter verification mechanism inplace
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 betweentreatment and control facilities (2006-2008).
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Impact of PBF
Two years into the national roll-out, the over-all performanceof health facilities showed significant increase. As of 3rdquarter 2010, quality score of district hospitals in the countryis 72.2% (range 33%-96%) (MSH, 2011).
A rigorous impact evaluation of the health centre PBF foundpositive effect on HIV, MCH and TB outcomes. Institutionaldelivery increased over-all but 7% more in PBF facilitiesbetween 2006-2008. PBF has increased prenatal care qualitysignificantly (SPH/WB, 2010)
Individual VCT for HIV has significantly increased but moreso for married couple VCT
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Successful role-out of performancebased financing (PBF)
Careful phased approach
Purchase of verified quality services
Increased discretionary resources for health facilities
Improved motivation of staff (financial incentives and equalizationof revenues)
Strengthened quality assurance mechanisms (supervision andverification)
Clarified supervision, evaluation and "coaching" (peer-review)
The Rwandan example shows foremost the synergies of a number ofreforms, i.e. difficult to attribute the percentages of success to each andevery one of these reforms
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Challenges for PBF
Clarify role in long term vision and strengthen links withdemand side financing mechanisms
Maintain momentum and improve assessment process
Sustainability of PBF from Partners in this globalfinancial crisis and economic downtown
Need to continuously revise indicators and increase thePBF award to buy results
Need to promote equity in PBF awarding
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Thank you for your attention
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