Transcript Slide 1

Performances Based
Financing scheme in Rwanda
INVESTING MORE STRATEGICALLY
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Outline of Presentation
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Rwandan Context
PBF scheme in Rwanda
 PBF approach
 Implementation model and funds flows
 PBF funding in Rwanda
Some Achievements and Challenges
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Background
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The performance-based funding (PBF) is one of the
pillars of health financing and strengthening the health
system in Rwanda. This approach was introduced in
order to strengthen the motivation of care providers and
results (output) than traditional financing (for input) had
not previously yielded
Historical
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Started in 2002 as pilote by two NGOs in former Butare
and Cyangugu provinces.
The MoH integreted the PBF in 2005 HSSPI and
decided to implement PBF in the whole country’ health
facilities.
The scaling up started in early 2006 with the second
phase of decentralisation.
Rwandan Context
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Population10.4 million; >90% are in the informal sector
45% living under poverty line (EICV 2011)
96% health insurance coverage (91% CBHI)
Per capita income 2011 = US$ 540
Health Budget as % of Total Budget: 16% (Abuja target
attained)
INDICATORS
BASELINE
2005
MTR
June 2008
MTR
Aug 2011
TARGET TARGET
2012
2015
Source of Information
DHS2005
I-DHS
DHS2010
EDPRS
MDGs
Infant Mortality Rate / 1000
86
62
50
37
28
Under Five Mortality Rate / 1000
152
103
76
66
47
Maternal Mortality Rate / 100.000
750
NA
487
455
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IMPACT INDICATORS
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Decentralized health organization
National
Level
District
Level
Central Level
5 National
Hospitals
30 Districts
District Hospitals
416 Sectors
Health Centres
Sector
Cell
Umudugudu
Health Posts
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Performance-Based Financing
Value for Money approach
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Objectives:
• Improve efficiency & rational use of health resources
• Coverage of high impact interventions
• Increase utilization of qualitative services care
• Improve equity in resource allocation
• Increase health worker motivation
• Empower users of HF by giving them voice
• Strengthen autonomy of health structures and build
capacity of managers
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The national PBF model is composed of the following
components: (1) PBF model for health centers; (2) PBF
for district hospitals; and (3) Community PBF
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Implementation model and funds flow
CAAC/MOH
Regulation role, support
and supervision
Result transmission
DISTRICT STEERING COMMITTEE
Sponsors
(MINECOFIN
GFTAM, USG
agencies and
Others)
Quality
score
HOSPITAL
District Health
Director
Quality
Evaluation
(Quaterly.)
Quantity
Control
(Monthly)
Funds Transfert
Peers
Evaluation
and Central
level
evaluations
(MANAGEMENT COMMITTEE)-HEALTH CENTER
Services
providers
Motivation
Beneficiai
ries
Employee
Health services
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INDICATORS ON MERGER
DESEASES
1. HIV
 The SSF/HIV Grant is currently providing PBF funds to
Health Facilities (DHs and HCs)
 18 indicators are paid (HIV/AIDS, TB/HIV, Reproductive
Health/HIV)
2. TB
 The PBF TB program has been scaled up at the national
level within 498 health facilities including 42 Districts
Hospitals, 147 Health Center – Center of Diagnosis and
Treatment “CDT”, 296 Health Center – Center of
Treatment “CT”, 8 Prisons – CDT and 6 Prisons – CT
 26 indicators are paid
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Progress of implementation
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CAAC submit the quarterly progress report
Data verification and counter verification mechanism in
place
Payment verification mechanism in place
Integration with other health financing initiatives (CBHI)
Payment made
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One of the achievement of PBF scheme
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Standardized Prenatal effort score
ONE OF THE RESULT: Trend of prenatal care quality between
treatment and control facilities (2006-2008).
0.20
0.15
0.15
0.10
15 % Standard deviation
increase due to PBF
0.05
0
0.00
-0.05
-0.10
-0.15
-0.10
-0.13
Baseline (2006)
Control facilities
Follow up (2008)
Treatment (PBF facilities)
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Impact of PBF
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Two years into the national roll-out, the over-all performance
of health facilities showed significant increase. As of 3rd
quarter 2010, quality score of district hospitals in the country
is 72.2% (range 33%-96%) (MSH, 2011).
A rigorous impact evaluation of the health centre PBF found
positive effect on HIV, MCH and TB outcomes. Institutional
delivery increased over-all but 7% more in PBF facilities
between 2006-2008. PBF has increased prenatal care quality
significantly (SPH/WB, 2010)
Individual VCT for HIV has significantly increased but more
so for married couple VCT
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Successful role-out of performance
based financing (PBF)
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Careful phased approach
Purchase of verified quality services
Increased discretionary resources for health facilities
Improved motivation of staff (financial incentives and equalization
of revenues)
Strengthened quality assurance mechanisms (supervision and
verification)
Clarified supervision, evaluation and "coaching" (peer-review)
The Rwandan example shows foremost the synergies of a number of
reforms, i.e. difficult to attribute the percentages of success to each and
every one of these reforms
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Challenges for PBF
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Clarify role in long term vision and strengthen links with
demand side financing mechanisms
Maintain momentum and improve assessment process
Sustainability of PBF from Partners in this global
financial crisis and economic downtown
Need to continuously revise indicators and increase the
PBF award to buy results
Need to promote equity in PBF awarding
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Thank you for your attention
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