Real World Implementation Challenges: Scaling-up Performance-Based Financing in Rwanda 2006-2008

1. Real World Implementation Challenges: Scaling-up Performance-Based Financing in Rwanda 2006-2008 CERDI Conference, 17-18 Dec, 2009 Session 3: ‘from pilot to national policy’ György Fritsche, HDNHE, the WB

2. Rwanda Health CenterRBF/Performance-Based Financing (PBF) Supply Side Intervention Demand-side phenomena Targeting Health Facilities that are made more autonomous Regular, significant incentives reach front line health workers District Support Functions incentivized (monitoring volume and quality: internal controls) District PBF Steering Committee incentivized Central MOH PBF-support department incentivized

3. Content • Context • Process and Actors • Implementation • Results • Challenges to Scaling Up • The Perfect Implementation Model

5. Context • Barrier to Access Services leading to low utilization 0.3/c/yr: • Very poor population: one third of the population lives on less than $0.25 per day and 57% of the population lives on less than $0.45 per day • Poor Health Indicators (2005): MMR 750/100,000; U-5 Mortality Rate 152/1,000 and U-1 Mortality Rate 82/1,000 • Inefficient Utilization of Existing Services: a study in Gicumbi (2005) documented less than 2 services/nurse per hour leading to an uptake of 0.8 services/capita/yr (curative and preventive combined)

6. Actors and Parallel Events • 3 PBF Pilots (Cordaid and HNI 2001-2005 and BTC 2005) • Strong GOR leadership: Inclusion of PBF in National Health Strategic Plan 2005-2009 • WB – HIPC • USAID – interest in PBF for HIV services • Lowering the barriers to access: CBHI – scaling up started January 2006 • Mobilizing decentralized government: Imihigo

7. Process

8. The WB “roll-out study”

11. Implementation • Strengthening existing Coordination Mechanism (TWG) • Information Technology solution to data collection and payment flows • Creating new Coordination Mechanism to bridge the gap between policy and implementation: the Extended Team Approach • Trainings • Continuous Technical Assistance to decentralized authorities

12. 1. Strengthening Existing Coordination Mechanism (TWG) • Regular and frequent meetings • Agenda setting • Effective documentation and dissemination of proceedings

13. 2. IT solutions to Data Collection and Payment Flows • Web site www.pbfrwanda.org.rw • Web application for data entry and data retrieval (invoices) • Server located with an internet service provider in country • A ‘real time database’ is created from the district level onward: Payment Orders can be generated easily

14. Internet Application Access Application Optional Local Copy of MySQL PBF database Internet Excel Pivot Tables and Graphs PBFBDD MySQL (ISP)

15. www.pbfrwanda.org.rw INSERT GRAPHIC TO ADD MAP MAP IS 6.17” TALL

16. Access to data through the website

17. Data entry menu

18. Data entry is easy

19. Quarterly district invoices

20. 3. Creating New Coordination Mechanisms: the ET • The Extended Team Approach is Bridging the Gap between Policy and Implementation: • 11 international agencies • 3 MOH departments • Meeting once per month last Thursday of each month ½ day, careful agenda setting and effective information dissemination. Minutes available on website • Retreats for capacity building (Excel Pivot Tables and Graphs) • Training of Trainers in PBF

21. 4. Trainings • Using ET mechanism to Train a Cadre of National Trainers in PBF • First start 2006 (after first wave of trainings) • Re-launched second half of 2007 • Jan-March 2008: 946 health workers trained through 50 trainings • April 2008: seven Phase-II districts: 356 health workers trained through 13 trainings

22. 5. Continuous TA to the Decentralized Authorities • Quarterly District PBF Steering Committee Meetings • Extended Team members: District PBF Focal points present in the District PBF Steering Committees • Assisting in control activities • Assisting in the quarterly quality counter-verification exercises • Assisting in the restitution of community client survey results

23. Results: Institutional Deliveries

24. Community Client Survey 3Q08:

25. The BIG news: RBF/PBF as a powerful method to increase also the quality of services

26. The BIG news: RBF/PBF as a powerful method to increase also the quality of services

27. Challenges to Scaling Up • Solution to Data Collection and Validation • Web application • Coordination challenges • TWG and ET mechanisms • Technical Assistance to the Central MOH and the Decentralized Authorities • TWG • ET mechanism • District PBF Steering Committees • Credible Performance Results • Use decentralized authorities (Min Local Admin; MOH) with strong TA support initially for internal control (ex ante) • Use NGOs as part of quorum in Decentralized District Level PBF Steering Committee, and for transparency (ex ante) • Use performance frameworks at all levels (Health Facility; Steering Committee; District Hospital; Central MOH) • Mix of third-party and transparent external verification mechanisms (ex post)

28. Hogwood and Gunn’s “Perfect Implementation Model”Perfect Implementation Model’, in Hogwood, B., Gunn, I., (1984) ‘Policy analysis for the real world’, Oxford University Press • The circumstances external to the implementing agency do not impose crippling constraints; • That adequate time and sufficient resources are made available to the program; • That the required combination of resources is actually available; • That the policy to be implemented is based on a valid theory of cause and effect; • That the relationship between cause and effect is direct and that there are few if any intervening links;

29. …Ten Preconditions for a Successful Top Down Implementation • That dependency relationship is minimal; • That there is understanding of, and agreement on objectives; • That tasks are fully specified in correct sequence; • That there is perfect communication and co-ordination, and • Those in authority can demand and obtain perfect compliance.

30. In Rwandan PBF, the MOH was confronted with:

31. In Rwandan PBF, the MOH was confronted with: