Performance-Based Financing in Rwanda Agnes Soucat, Adviser HNP Africa Region 1

Background (1) Shortage of human resources for health services No cash resources in health facilities Low levels of productivity and motivation among medical personnel Low user satisfaction & poor quality of service lead to low use. High levels of child and maternal mortality

Background (3) In 2005 , 4/10 births attended by a health professional. Infant Mortality : 86 per 1,000 HIV : 3.1% Source: Rwanda 2005: results from the demographic and health survey. 2008. Studies in family planning, 39(2), pp. 147-152. 3

Strengthening accountability in the health sector in Rwanda PERFORMANCE BASED, CASH AND IN KIND INVESTMENT INPUT SUBSIDIES TRANSFERS NATIONAL GOVERNMENT LOCAL GOVERNMENT VOICE Performance CONTRACTS Umushyikirano, Citizen Report Cards, Ombusdman CLIENT POWER Clients / Citizens AUTONOMOUS FACILITIES PROVIDERS COMMUNITY GOVERNANCE COMMUNITY HEALTH WORKERS PROVIDERS COMMUNITY HEALTH INSURANCES Mutuelles

Rwanda has undertook major reforms to strengthen accountability of all institutional and individual actors for MDGs related results...

..through a shift of paradigm.. Decentralisation of health services with strong governance structures based community participation. Imihigo: Performance contracts between President of Republic and mayor of Districts; PBF: Performance Based Financing; CBHI: Community Health Insurance; Autonomy of health facilities, including hiring and firing of health personnel;

Decentralization Administrative, fiscal and financial decentralization has provided huge sums of money to local levels of government and given them much flexibility by providing them with block grants

Total health personnel in publicly funded facilities has almost doubled in 3 years …

Financing has more than tripled in four years (going from USD 7 Financing has more than tripled in four years (going from USD 7.5 to 30.3 millions, of which the PBF has grown more than tenfold from USD 0.8 to 8.9 millions)

Rwanda: Scaling up of community health insurance Source: MOH Rwanda; 2005 EICV 2005

Results show Rwanda is now back on track towards the health MDGs… Health outcomes Neonatal, infant and child mortality Malaria incidence and mortality HIV Improved financial access Reduction of catastrophic expenditures High Impact Interventions ITNs Family planning Assisted Deliveries Quality of care

Rwanda is back on track to reach the MDGs Under five mortality trends with MDG target for 2015

All income groups benefit but inequities still persist … Under five mortality trends by income quintile (2005-2007) Source: DHS 2005 and 2007.

Rwanda Health Insurance At all income levels, those enrolled in mutuelles are much more likely to use health services. Source: Shimeles et al, 2009

Rwanda: Effect on MDGs High Impact Interventions

Rwanda : Increase in utilization of high impact services Proportion (%) of children under 5 years of age who have slept under a mosquito bed-net during the night preceding the survey

Increase in utilization of high impact services Trends in assistance at delivery : Years 2000, 2005, 2007 Percentage (%) of women delivered by a health professional

Performance-based Financing (PBF) Developed after extensive piloting from 2001-2005 Objectives Focus on maternal and child health as well as communicable diseases (MDGs 4 & 5) Increase quantity and quality of health services provided Increase health worker motivation Financial incentives to providers to see more patients and provide higher quality of care Operates through contracts between Government Health facilities providing services

Quality Conceptual Framework Production Possibility Frontier What They Do: (Quality) What They Know (Ability/Technology)

Goal: Use Pay for Performance to Close Productivity Gap Production Possibility Frontier What They Do Productivity Gap Conditional on Ability Actual Performance Ability/Technology

Researcher & Policy Maker Collaboration Research Team Paulin Basinga, National University of Rwanda Paul Gertler, UC Berkeley Jennifer Sturdy, World Bank and UC Berkeley Christel Vermeersch, World Bank Policy Counterpart Team Agnes Binagwaho, Rwanda MOH and CNLS Louis Rusa, Rwanda Rwanda MOH Claude Sekabaraga, Rwanda MOH Agnes Soucat, World Bank A collaboration between the Rwanda Ministry of Health, CNLS, and SPH, the INSP in Mexico, UC Berkeley and the World Bank

Evaluation Questions: Did PBF… Increase the quantity of contracted maternal health services delivered? Improve the quality of contracted maternal health services provided?

Evaluation Design During decentralization, phased rollout at district level Identified districts without PBF in 2005 Group districts into “similar pairs” based on population density & livelihoods Randomly assign one to treatment and other to control MOH reallocated some districts to treatment With decentralization, some new districts had PBF in an area of the new district – must be treatment Unit of observation is health facility

Rollout of PBF in health centers in Rwanda, 2006 – 2008

Isolating the incentive effect PBF Performance incentives Additional resources Compensate control facilities with equal resources Average of what treatments receive Not linked to performance Money allocated by the health center management

Sample: Panel 165 Facilities 2006-08 2145 households in catchment areas Random sample of 14 per clinic

Log Expenditures Randomization balanced baseline Follow-up balanced, so difference in follow-up outcomes due to incentives not resources

Baseline Expenditures & Staffing

Impact of PBF: Statistical methods Have balance at baseline on all key outcomes Use difference in differences analysis Not a pure randomized experiment Clustered at district-year level Facility Fixed Effects Year dummy Controls: age, parity, education, household size, health insurance, land, value of assets

Delivery at the health facility increased overall in Rwanda, but 7% more in PBF facilities ….

Prenatal Competency & Quality Provider knowledge/competency Standardized vignette presented to provider Compare answers to Rwandan CPG Measure of ability/knowledge Process quality Patient exit interview of clinical services provided Clinical content of care Provider effort

In the last years, PBF has increased prenatal care quality significantly …

Impact of PBF on Prenatal Care Quality

Impact of PBF on Child Health (z-scores)

Results Summary Balanced at baseline Expenditures same, so isolate incentives Impact on utilization Delivery & Child prevention, but not prenatal Impact on prenatal quality Bigger for better doctors Reduced child morbidity & Taller children Effect sizes bigger than most other interventions

Discussion Increase in utilization in country with national campaigns: PBF Effect seen despite many other national level intervention: possible bigger effect in other countries Increase in utilization in country with national campaigns: Mutuelle Imihigo HIV services Safe motherhood and PCIME Possible spill over effect to child health

Discussions/ Policy implications You get what you pay for ! 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 PBF Need to get prices “right” Evaluation feedback useful

Limitations The original randomized designed was changed due to the political decentralization process: But sample well balanced! Trend analysis with HMIS data ongoing No measure of all paid and some non paid indicators : HMIS analysis Cost effectiveness analysis

Acknowledgments Funding by: World Bank Government of Rwanda (PHRD grant) Bank-Netherlands Partnership Program (BNPP) ESRC/DFID GDN