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Integration and Health Systems Strengthening: Performance-Based Financing in Rwanda

Integration and Health Systems Strengthening: Performance-Based Financing in Rwanda. Jean Kagubare, MD, MPH, PhD Principal Technical Advisor, MSH July, 2010. Health challenges (1999) and GoR response. Low Utilization of Health Services ( 0.3/pc/year)

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Integration and Health Systems Strengthening: Performance-Based Financing in Rwanda

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  1. Integration and Health Systems Strengthening: Performance-Based Financing in Rwanda • Jean Kagubare, MD, MPH, PhD • Principal Technical Advisor, MSH • July, 2010

  2. Health challenges (1999) and GoR response • Low Utilization of Health Services ( 0.3/pc/year) • Financial barriers to access health services • Low Quality of Health Care and services • Poor Staff motivation • Lack of integration: Vertical programs (HIV, TB,…) • GoR’s response: 3 major health reforms • Performance Based Financing (PBF) • Community Based Health Insurance (CHBI) • Quality Assurance Policy

  3. Why PBF? PBF is a powerful means of increasing the quantity and quality of health services by providing incentives to suppliers to improve performance. PBF can address: Low utilization of health services; Low quality of health care and services; Poor staff motivation; Challenges of meeting Millennium Development Goals. Poor integration of health services (HIV)

  4. Design & Implementation of PBF Clear Goals: PHC and HIV minimum packages of service Measurable indicators : Quantity: 15 PHC and 10 HIV indicators Quality: HC: 118 composite indicators across 13 services; DH: 51 composite indicators Defined rewards and or penalties (and standards) Price for each indicator defined; criteria to validation outputs earnings= Quantity * %Quality Validation and accountability (separate control and verification functions) Transparency (TWG; PBF steering committees)

  5. PBF indicators: HIV & PHC 14 HIV/AIDS indicators: One VCT test = $1.10 One Pregnant woman tested (PMTCT) = $1.10 One couple tested voluntarily (PMTCT)= $1.10 One HIV+ client under CTX treatment = $1.10 HIV+ women treated with NVP = $1.10 16 Prim. Health Care indicators: New Curative Consultation = $0.27 Delivery at the HC = $3.63 Completely vaccinated child = $ 1.82 New FP user = $1.82, old user = $1.36

  6. Implementing Organizations

  7. How Rwanda Coordinates Donors to Align to Payment Practices GOR pays outputs throughout Rwanda Coordination of design phase through PBF technical working group PBF admin system pays straight into the health facility bank accounts., with database linked to payments PHC services protected by linking payments of HIV and PHC monies to levels of quality of general services One national approach (and with all donors), same institutional set-up, unit costs and admin system facilitates alignment Payments from donors pooled at the health facility level

  8. Community Based Health Insurance & HIV/AIDS • 1999: CBHI introduced to improve financial access • 2006: • R5: 5-year program funded by Global Fund focused on improving financial accessibility and quality of health care delivery for the poor, PLWHAs and vulnerable groups. • Grant monies (27.2 million $): finance or co-finance health insurance membership fees for the very poor, OVC and PLWHAs (15% of population) • Program also offers pre-service and in-service training to clinical and other health service staff and provides electricity to health facilities. • 2009: quasi universal coverage (91% of population); increased health services utilization (0.3 to 0.7 per pc/year) • Strategy for sustainability after GF project: • Micro credit to poor by community banks (BanquesPopulaires) • GoR committed to increase its health budget and to target the poor

  9. Major Achievements MDG 6 – HIV: 2009 81% of all health facilities offer VCT for HIV 85% of adults and 81% of children with advanced stage AIDS are on ART 74% of pregnant women receive ART prophylaxis (PMTCT) 47% of health facilities offer ART services (217/464). 85% of adults and children (of those in need) are accessing ART Decreased of HIV prevalence rate (12% (1998) to 2.8% (2008)

  10. Increase in volume of services (after 36 months)

  11. Health Impacts

  12. Conclusion • PBF led to the integration of HIV in the general health system: • Purchasing HIV services can be done through national systems while protecting and reinforcing the general quality of basic health services • Strong central coordination mechanisms have been created, both technical and financial (all major donors are purchasing performance indicators specific to HIV/AIDS, malaria and TB, using the same administrative model) • Data tend to be 100% complete, timely, and intensively used at all levels of the health system. • CBHI and PBF are synergetic! •  Sustainability?strong political and financial support, and better donor coordination

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