PERFORMANCE BASED FINANCING FORHEALTH IN RWANDA
Dr RUSA U. Louis
Ministry of Health
Kigali-Rwanda
Montreux 16th- 19th
Outline
1.Bckground
2.Rwanda health sector
context: 2000-2003
2. What is PBF/RBF?
3.Comparison Between Input
and Output financing
4.Rwanda National PBF
models
5. PBF Key Principles
6. PBF model for DHs
7. PBF model for HCs
8. PBF for CHWs Cooperatives
9. Strenghten supervision
10.Rwandan PBF informationsystem for monitoring toassure high quality ofservices
11.Relationship between
Building Blocks and PBF
12.Challenges
Background
•Rwandan’s Health System perceived as veryweak by DHS 2000
–Utilisation rate health services: 21%
–Maternal mortality rate: 1071 per 100,000
–Under 5 mortality rate: 196 per 1000
–Infant mortality rate: 107 per 1000
–Contraceptive coverage rate: 4%
–Assisted deliveries: 26%
–HIV prevalence : 11,1% (15-49 yrs)
–Malnutrition prevalence : 45%
1. Rwanda Health Sector: 2000-2003Context
•Shortage of human resources for health services especially inrural areas
•Low levels of productivity and motivation among health staff
•Increased workload with new health services such as VCT,PMTCT, and ART
•No competitive salaries
•No additional financial resources in health facilities tomotivate dedicated staff… Value for money ???
Status of PBF
Slide 5
Rwanda Health Sector: 2000-2003 Context(cont’d)
•Low user satisfaction & poor quality of service lead to low use
•High morbidity and mortality, especially among women and children
•Since 2001 GoR after DHS 2000 results, health targets were not fullyachieved, despite considerable input financing from the Gvt and itspartners
•Political committment to achieve Rwanda Vision 2020 & Health MDGs by2015
→Performance Based Financing (PBF/RBF), was identified as one of thestrategies to adress these public health issues and strengthen the healthsystem
Status of PBF
Slide 6
2. What is PBF/RBF ?
•PBF/RBF is a complementary intervention as “output financingapproach” to the traditional “input financing model”
•PBF at health facilities and community levels aims to improvejustified demand for quality prevention & curatives services
•PBF/RBF aims to establish the missing accountability link amongdonors & Gvt, health providers, and beneficiaries
•PBF/RBF strengthens ownership of health services provision fromproviders and community health workers and ensure betterknowledge of investments
« Investments yield results»
3. Comparison Between Input & Outputfinancing
Input financing
•Payments in advance forsalaries, drugs & supplies,running costs
•Funds often managed athigher levels
•Need to justify expensesafter payment (accounting& audit)
•Tenuous link betweenfunding and results
Output financing
Funds paid for servicesalready delivered
Funds managed at locallevel
Need strong datacollection & quality controlsystem
Direct link betweenfunding and results
4. Rwandan National PBF Models
PBF model fordistrict hospitals
PBF model forhealth centers
PBF model forCommunity healthworkers
5. Rwanda PBF model – key principles
Separation between providers,purchasers and controllers
PBF funding does not cover cost ofservice – just incentivizes it
Traditional input financing mustcontinue to complement PBF
Data on service outputs must behighly selective (10 to 15 indicatorsare plenty) and from existingsources
Strong service and data qualitycontrol mechanisms needed toeliminate incentive to cheat andensure that services are deliveredaccording to norms.
The national PBF model for District Hospitals.6. PBF for Health Services in Rwanda :The national PBF model for District Hospitals
•Performance Earnings = Gvt Quarterly budget * % Qualityscore
•Quality score is estimated on the basis indicators related to :
Clinical services :13 indicators are reviewed ,
Support and Monitoring of HCs of the catchment area: 20 indicators
Management of Hospital : 23 indicators
Hiv package: 9 indicators
The national PBF model for health centres7. PBF for Health Services in Rwanda :The national PBF model for health centres
•HC : Performance Earnings = (Σ Services * Unit Cost ) * % ofQuality score
•Indicators reviewed:
–12 quantitative indicators from the minimum package ofactivities and evaluated monthly based on predefined criteria
–9 HIV & 8 Reproductive Health quantitative indicatorsmeasured monthly
–14 services assessed quarterly for Quality Assessment througha guideline using many indicators of the entire HC
8. PBF at community level8. PBF at community level
Performance Earnings = (Σ Services * Unit fees) * % Quality score
–5 HIV - Reproductive Health indicators and 2 TB communityindicators
–Basket fund payment model to pay Cooperatives of CHWs afterassessment of the integrated quartely report
–The assessment is done by the Sector steering committee
–The payment is linked to a score generated by the Timeliness ,completeness and accuracy
9. Strengthen supervision to assure high qualityservices
–The PBF system promotes regular supervision ofhealth workers at each level through the PBFquality assessments.
–The clinical PBF quality checklist at the HealthCenter level includes points for having completeda supervisory visit to each village during thecourse of the quarter.
–CHW cooperatives cannot be paid their PBF fundsif these visits are not completed and the qualityscores are not reported.
10. PBF Information System developed for monitoringthe system
PBF Database
s
QuarterlyQualityassessmentscore
MonthlyPBFEvaluation
Results
PBFContracts
INPUTS
OUTPUTS
Contracts & Amendments
Bank PaymentVoucher
Quarterly PaymentVoucher
Thematic Maps
Indicator Trend Graph
11. Relationship Between Building blocks andPBF
Building Blocks
•Human Resources forHealth
•Medecines, Vaccines,reagents
•Health Care financing
•Leadership management
•Health Information
•Health services delivery
PBF
•Insure equity in HRdistribution
•Improve availability andrational use
•Ensure financial accessibility toHealth services for all and equitablefinancing sector
•Make providers accountables,reinforce planning & autonomy
•Improve quality of Datas & use
•Improve quality of care andcoverage of preventivesservices
12. Challenges
• Risk of gaming and unsafe earnings
•Burdensome but necessary oversight by MoH/CAAC, peer review teams& steering committees at different levels
•Timeliness, completeness, and accuracy of data can affect the PBFscheme, hence the importance of having a solid health informationsystem.
•Since it is a dynamic strategy, PBF will need to be more flexible in order toadjust to innovative ideas benefiting the population and health careproviders.
•Competences and retention of the management team and evaluators:Turn over
• Need of sufficient budget to avoid ceiling
Data restrictions
•The data shown in this presentation shouldnot be quoted without permission of theauthors.