Scaling up Family Planning through Performance-Based Financing in Rwanda

1. Scaling up Family Planning through Performance-Based Financing in Rwanda Dr. Louis Rusa, Director PBF support Cell Ministry of Health, Rwanda

2. Content • PBF 101 – guiding principles • Case study of PBF in Rwanda • Lessons learned

3. Input vs Output financing • Payments in advance for salaries, drugs & supplies, running costs • Funds often managed at higher levels • Need to justify expenses after payment (financial audits) • Tenuous link between funding and results • Funds paid for services already delivered • Funds managed at local level • Need strong data collection & quality control system • Direct link between funding and results

4. 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 and from existing sources • Strong service and data quality control mechanisms needed to eliminate incentive to cheat

5. Key Rwanda health strategies • In 2005, MOH introduced three complementary strategies to improve health services: • Community Based Health Insurance to increased access • Performance-based Financing to increase availability and quality of services • Continuous Quality Assurance to enhance quality of care

6. PBF and Family Planning in Rwanda • Health Center PBF system includes incentives for 2 indicators: • # of new FP users • # of FP users at the end of the month • Community PBF includes provider-side and client-side indicators: • # of new family planning users referred by CHWs (both) • % of FP users using long-term methods (provider-side) • # of FP users adopting long-term methods (client-side) • Quarterly Quality Assessment process includes an assessment of FP service quality

7. PBF Control is NOT ‘business as usual’ in data gathering District quality assessment team checking data quality in a health center

8. Assuring Data Quality – Multiple checks and balances • Data ‘quantity’ audits conducted every month on each indicator from every site (register vs report) • Monthly report data are reviewed by district PBF steering committees • Community client or “phantom patient” surveys every 6 month at a sample of sites – look for phantom patients and seeks feedback from patients on quality of care • National PBF cell reviews database each quarter for the entire country – corrections are made before payment

9. How to strengthen supervision to assure high quality services • Quarterly Quality assessments are conducted at each facility to assess 13 components of service quality • Administration, Hygiene, Respect for Clinical protocols for key services, Community outreach, etc. • Controllers are District Hospital supervisors and data managers for health centers, by peer district hospitals for Hospital level PBF • This assessment score is used to offset PBF payments

10. Performance Payment Mechanism Performance Payments = Σ (# service outputs * Unit fees) * % Quality score

11. Increase in Volume of FP Services (after 39 months)

12. Increase in the Quality of Services in Health Centers (1)

13. Lessons learned • Health workers benefit directly from a portion of the PBF funding that is shared as bonuses – motivation and retention of health workers has improved • PBF reinforces decentralization strategy: Money is paid directly to the health facility and managed by local steering committee with considerable autonomy • PBF can lead to a significant increase in service production and quality of services in a relatively short period of time