Implementing Performance-Based Financing in the Rwandan National Health System

1. Implementing Performance-Based Financing in the Rwandan National Health System Dr Louis RUSA, National PBF Coordinator, MOH Rwanda - 28 June, 2010

2. Outline How PBF incentivize for improving supervision, Steering committees for decision making using datas Supervision vs Assessment M&E system using ICT Results Lessons Learnt • Rwanda map • Background • Key weakenesses of governance & management identified before reforms • Changing the situation: Reforms • Comparizon between inputs & outputs • Rwanda PBF model • PBF for HC and DH Status of PBF

3. RWANDA Status of PBF

4. Background(1) • Free care during the pre and post independance. • 1978: Alma Ata declaration • 1986: Bamako initiative • 1987: HIV/AIDS a major threat In 1992, Based on Bamako Initiative, Rwanda introduced community participation for financing and management of health care. 1994: Génocide followed by reconstruction. • 1998: End of emergency period. • 2000: DHS & MDGs Status of PBF

5. Key weaknesses of governance and management • Why PBF? • Low quality of health care & services • Diminishing coverage: generally low utilization of health services • Limited incentives for providers to deliver preventive services and HIV/AIDS care and treatment • Financial barriers to access health services/demand side problems • Limited quality, availability and use of data for program management

6. Changing the situation: Reforms start • 2001: Vision 2020/PRSP, 1rst Phase of Decentralization • 2001 Starting of 1rst PBF Pilote in Health • Quality assurances techniques introduced in our policies and our Health Facilities. • 2004: Exciting results from PBF experiences • PRSP/HSSP I 2005-2009 : PBF(RBF) one of the major pilars. • 2005 PBF scalling up with CAAC to accomplish the mission. • 2005 MTEF included PBF budget line for HF. Status of PBF

7. Comparison between In puts and Out puts financing In Puts Out puts Funds paid for services already delivered Funds managed at local level Need strong data collection & quality control system Direct link between funding and results • Payments in advance for salaries, drugs & supplies, running costs • Funds often managed at higher levels • Need to justify expenses after payment (accounting & audit) • Tenuous link between funding and results Status of PBF

8. Rwanda PBF model – key principles Separation between providers, purchasers and controllers PBF funding does not cover cost of service – just incentivizes it Traditional input financing must continue to complement PBF Data on service outputs must be highly selective (10 to 15 indicators are plenty) and from existing sources Strong service and data quality control mechanisms needed to eliminate incentive to cheat and ensure that services are delivered according to norms Status of PBF

9. PBF for Health Services in Rwanda (1) • Various models: health center PBF; district hospital PBF; community PBF • Total resources now about $1.80-2,00 per capita/yr • Health Center: • Performance Earnings = (Σ Services * Unit fees) * % Quality • 14 PHC quantitative indicators + 10 HIV quantitative indicators; unit fees $0.18-$8.90, measured monthly • 13 services assessed quarterly for quality through a guide using indicators of the entire HC from norms.

10. PBF for Health Services in Rwanda (2) • Hospital PBF model: • Balanced score card approach: (2009) 59 composite indicators, over 350 data elements • Annual global prospective budgets between $80K and $350K depending on the activities of the hospital. • Transparent peer-evaluation mechanism

11. How PBF provides incentives for improving supervision and service delivery • The PBF system incentivizes health service providers to recruit and retain users essentially in preventive cares (FP, Nutritional Monitoring, ANC, Immunization etc….). • New operations research in community PBF is also testing client side-incentives – in-kind payments to beneficiaries • It also ensures that performance data are reported routinely and on-time • It includes incentives for completing supervisory visits – and disincentives for not conducting them (health facilities where the quality assessments are not conducted cannot be paid their PBF funds). Status of PBF

12. How PBF stimulates use of data for decision-making. • A PBF steering committee is established in each district. During the quarterly steering committee meetings, selected trends are presented and an action plan is developed to address findings. • Quarterly quality assessments are conducted determine whether or not administrative and clinical services continue to meet established norms – including for data use. The score from these assessments will offset the amount of money received as a PBF payment. Status of PBF

13. How to strengthen supervision to assure high quality services? • The PBF system promotes regular supervision of health workers at each level through the PBF quality assessments. • The clinical PBF quality checklist at the Health Center level includes points for having completed a supervisory visit to each village during the course of the quarter. • CHW cooperatives cannot be paid their PBF funds if these visits are not completed and the quality scores are not reported. Status of PBF

14. PBF Application Environment PBF Application Environment PBF Database (MySQL) Status of PBF

15. PBF Information System developed INPUTS OUTPUTS Thematic Maps Contracts & Amendments • PBF Contracts Indicator Trend Graph Monthly PBF Evaluation Results PBF Database Quarterly Quality assessment score Quarterly Payment Voucher Bank Payment Voucher Status of PBF

16. Exemples of some Results Status of PBF

17. Results (2) Status of PBF

18. Results (3) Status of PBF

19. Lessons Learnt • Pre–conditionalities: Infrastructure well distributed & Minimum equipement for delivering the PHC, Effective Decentralization with Management Autonomy of the HS. • M&E system established from the beginning, • Costing study of the health care in order to fixe easily the budget needed. • Strong coordination is essential • Government budget is important for sustanability purpose Status of PBF

20. Thank you for your attention! Status of PBF