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Pay-for-Performance (P4P) for Health Services in Rwanda

Pay-for-Performance (P4P) for Health Services in Rwanda. Paulin Basinga Rwanda School of Public Health Christel Vermeersch World Bank. A collaboration between the Rwanda Ministry of Health, CNLS, SPH, INSP Mexico, UC Berkeley and the World Bank. Our team…. Research Team

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Pay-for-Performance (P4P) for Health Services in Rwanda

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  1. Pay-for-Performance (P4P) for Health Services in Rwanda Paulin Basinga Rwanda School of Public Health Christel Vermeersch World Bank A collaboration between the Rwanda Ministry of Health, CNLS, SPH, INSP Mexico, UC Berkeley and the World Bank

  2. Our team… • Research Team • PaulinBasinga, National University of Rwanda • Paul Gertler, UC Berkeley • Jennifer Sturdy, World Bank and UC Berkeley • ChristelVermeersch, World Bank • Policy Counterpart Team • Agnes Binagwaho, Rwanda MOH and CNLS • Louis Rusa, Rwanda MOH • Claude Sekabaraga, Rwanda MOH • Agnes Soucat, World Bank

  3. P4P for Health in Rwanda • Objectives • Focus on maternal and child health (MDGs 4 & 5) • Increase quantity and quality of health services provided • Increase health worker motivation • What? • Financial incentives to providers t • For more quantity • And more quality • How? • Contracts between government & health facilities • When? • Piloted in 2001-2005, fullscalefrom 2006

  4. Evaluating P4P in Rwanda:Evaluationdesign

  5. Evaluation Questions Did P4P improve… … the quality and quantity of maternal and child health services? … the health of the population?

  6. Conceptual framework for quality Production Possibility Frontier What They Do (Quality) Productivity Gap Conditional on Ability Actual Performance What they know (Ability/Technology)

  7. Identifying the impact of P4P • When we see a change in outcome, how do we know it is caused by P4P? • And not by something else • Evaluate the impact = identifying a comparison group • Equivalent to the treated group in all aspects • Except that they receive the treatment • Gold standard: randomized evaluation

  8. Evaluation Design • Phased roll-out at district level • Identified districts without P4P in 2005 • Group districts into “similar pairs” • based on population density, location & livelihoods • Randomly assign one to treatment and other to control • Phase I: 12 districts, started 2006 • Phase II: 7 districts, started 2008 • Unit of observation is health facility

  9. Rollout of P4P 2006 – 2008

  10. A few challenges • The decentralization “surprise” • A few new districts had some facilities with P4P– must be treatment • Exposure time to the “treatment” • Is it more money? Or more incentives? • Other interventions & time trends • Coordination with multiple donors

  11. Data • Independent data • Facilitieslevel • Utilization (quantity) • Structuralquality • Knowledge (vignettes) • Processquality (patientexitsurveys) • Householdlevel • Utilization • Processquality • Healthoutcomes

  12. Sample • Out of 30 districts • 12 Phase I (treatment) • 7 Phase II (comparison) • 165 health facilities • All rural health centers located in 19 districts • 2156 households in catchment areas • Power calculations based on expected treatment effect on prenatal care visits, institutional delivery • Panel data: 2006 and 2008

  13. Econometric model • Basic difference-in-differences model specified as a two-way fixed effect cross-sectional time-series regression models. • where : • Yijt is the outcome of interest for individual i living in facility j’s catchment • area in year t; • PBFj,2008 = 1 if facility j was paid by PBF in 2008 and 0 if otherwise; • jare facility fixed effects; • γ2008 =1 if the year is 2008 and 0 if 2006; • Xitk are time varying individual characteristics; • ijt is a zero mean error term.

  14. Evaluation design challenges • Organizational • Managing expectations • The John Henry effect in practice • Building capacity • Time & effort • Technical • Small sample size • Reconciling provider and client data

  15. Baseline, health facilities

  16. Baseline, utilization of maternal health services

  17. Baseline, women 15-49 with birth in last 24 months

  18. Evaluating P4P in Rwanda:Evaluationresults

  19. Impact on structure quality

  20. Impact on quality of prenatal care

  21. Impact on quality of prenatal care

  22. Impact on use of prenatal care

  23. Impact on use of maternal services

  24. Impact on institutional delivery

  25. What our results tell us • You get what you pay for ! • Need to get prices “right” • Returns to effort important • Bigger effects in things more in provider’s control • Patient or community health workers for prenatal care/Immunization • Provide incentives directly to pregnant women? (conditional cash transfer program). • Financial incentive to community health workers • Low quality of care : additional training coupled with P4P • Evaluation feedback useful

  26. Thankyou!

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