What PBF can achieve; Example from Rwanda Claude SEKABARAGA, MD, MPH World Bank, Nairobi Hub. January 2010

U5MR (per 1,000) in sub-Saharan Africa – MDG4 Target and Actual Source: Global Monitoring Report 2008

Actual U5MR (DHS) vs. MDG4 target in Rwanda – 35% reduction from

REDUCTION OF INFANT MORTALITY 1/3 in years

63% of increase in three years

25% of increase in three years

IMIHIGO: Performance based services for territorial administration Strong political commitment to results Contract between the President of the Republic and the district mayors and different local administration levels; Key health indicators integrated in the contract (in 2007: ITNs, Mutuelles, FP, safe deliveries, hygiene..) Quartely review with Prime Minister, President attending twice a year

Autonomy of providers institutions Based on Bamako Initiative Delegation of management Health centers and hospitals fully autonomous Subsidized by the government: PBF, needs based block grant (initially for wages) Support to planning: Strategic and operational planning are the fundament of the approach.

Human resources management Decentralization of wages; Community through facility committee have the authority to hire and fire; Community through facilities receive block grant from government; “People follow the money”; Retention of health personnel in rural areas increased.

Trend in the financing of district health personnel

Evolution of the number of selected staff in rural and urban districts (public sector)

RESULTS BASED FINANCING PRINCIPLES

What is Results Based Financing? Incentives targeting provider’s behavior to produce more results and to comply on quality standards; Incentives targeting household or individual behavior to use more services Financing mechanism for defined quantity and quality outputs and outcomes. PURCHASER PROVIDER Health Results Financial Incentives

Verification of quantity and quality Why to finance results vs. inputs? Payment result Financing strategy Actions for results Objective Result Equipment, consumables, Drugs, salaries, etc. Supervision, training, audit and Sanction? Investment? TIME

RBF PRIORITY AREAS AND BENEFITS Based on major bottlenecks; Priority to composite indicators and avoid selective performance; Quantity preventive interventions and quality of both prevention and curative services; Promotion of local creativity and spirit for performance; Improvement of remuneration of personnel and equipment linked to services to community: ACCOUNTABILITY.

How to finance results? Evaluator/ verificator Regulator Provider Purchaser Beneficiary

What systems are needed to implement RBF successfully? Does the regulatory framework require change? How will results be routinely monitored (HMIS?) and verified? How to sustain? How will the government decide if it will continue to fund through RBF mechanism? How will you show impact? How will you show cost-effectiveness? Concerns

THE PERFORMANCE FINANCING SYSTEM

SUSTAINABILITY OF RWANDA PBF FINANCING

Results: Services produced (after 27 months of extention ) Results: Services produced (after 27 months of extention ) Indicateurs FBRJanvier 2006 moyenne mensuelle par centre pour 258 centres de santé Mars 2008 moyenne mensuelle par centre pour 286 centres de santé Pourcentage d’augmentation Accouchements Assistés % Nouvelles consultations curatives 9851,48951% CPN: 2ième dose Anti-tétanique % Nouvelles utilisatrices PF % Utilisatrices de PF à la fin du mois %

Impact on quality of prenatal care 24

Impact on institutional delivery 25

COMMUNITY, HEALTH CENTER and DISTRICT HOSPITAL Development Partners in kind transfers Total amount: 60.6 M USD GoR In kind transfers Total amount: 12.2 M USD

COMMUNITY PBF To reduce child mortality: Malaria, pneumonia, diarrhea and monitoring of malnutition), and family planning; Five CHW (a lady and a man for IMCI package) by village; Organized in cooperatives and paid based on a package of services produced and checked by health center in term of quantity and quality.

Conclusion BUILDING CULTURE OF RESULTS MORE THAN INPUTS AND PROCEDURES For ACCOUNTABILITY: 1. Separation of functions: Purchasers, providers and direct beneficiaries; 2. Clear link between public funds and direct services to community; Priority on high impact interventions (Family planning & reproductive health, prevention interventions and family & community services)