1. PERFORMANCE BASED FINANCING FOR HEALTH IN RWANDA Dr RUSA U. Louis Ministry of Health Kigali-Rwanda Montreux 16th- 19th

3. Outline 1.Bckground 2.Rwanda health sector context: 2000-2003 2. What is PBF/RBF? 3.Comparison Between Input and Output financing 4.Rwanda National PBF models 5. PBF Key Principles 6. PBF model for DHs 7. PBF model for HCs 8. PBF for CHWs Cooperatives 9. Strenghten supervision 10.Rwandan PBF information system for monitoring to assure high quality of services 11.Relationship between Building Blocks and PBF 12.Challenges

4. Background Rwandan’s Health System perceived as very weak by DHS 2000 – Utilisation rate health services: 21% – Maternal mortality rate: 1071 per 100,000 – Under 5 mortality rate: 196 per 1000 – Infant mortality rate: 107 per 1000 – Contraceptive coverage rate: 4% – Assisted deliveries: 26% – HIV prevalence : 11,1% (15-49 yrs) – Malnutrition prevalence : 45%

5. 1. Rwanda Health Sector: 2000-2003 Context Shortage of human resources for health services especially in rural areas Low levels of productivity and motivation among health staff Increased workload with new health services such as VCT, PMTCT, and ART No competitive salaries No additional financial resources in health facilities to motivate dedicated staff… Value for money ??? Status of PBFSlide 5

6. Rwanda Health Sector: 2000-2003 Context (cont’d) Low user satisfaction & poor quality of service lead to low use High morbidity and mortality, especially among women and children Since 2001 GoR after DHS 2000 results, health targets were not fully achieved, despite considerable input financing from the Gvt and its partners Political committment to achieve Rwanda Vision 2020 & Health MDGs by 2015 →Performance Based Financing (PBF/RBF), was identified as one of the strategies to adress these public health issues and strengthen the health system Status of PBFSlide 6

7. 2. What is PBF/RBF ? PBF/RBF is a complementary intervention as “output financing approach” to the traditional “input financing model” PBF at health facilities and community levels aims to improve justified demand for quality prevention & curatives services PBF/RBF aims to establish the missing accountability link among donors & Gvt, health providers, and beneficiaries PBF/RBF strengthens ownership of health services provision from providers and community health workers and ensure better knowledge of investments « Investments yield results»

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

9. 4. Rwandan National PBF Models  PBF model for district hospitals  PBF model for health centers  PBF model for Community health workers

10. 5. Rwanda 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 (10 to 15 indicators are plenty) and from existing sources Strong service and data quality control mechanisms needed to eliminate incentive to cheat and ensure that services are delivered according to norms.

11. The national PBF model for District Hospitals. 6. PBF for Health Services in Rwanda : The national PBF model for District Hospitals Performance Earnings = Gvt Quarterly budget * % Quality score Quality score is estimated on the basis indicators related to : Clinical services :13 indicators are reviewed, Support and Monitoring of HCs of the catchment area: 20 indicators Management of Hospital : 23 indicators Hiv package: 9 indicators

12. The national PBF model for health centres 7. PBF for Health Services in Rwanda : The national PBF model for health centres HC : Performance Earnings = (Σ Services * Unit Cost ) * % of Quality score Indicators reviewed: – 12 quantitative indicators from the minimum package of activities and evaluated monthly based on predefined criteria – 9 HIV & 8 Reproductive Health quantitative indicators measured monthly – 14 services assessed quarterly for Quality Assessment through a guideline using many indicators of the entire HC

13. 8. PBF at community level Performance Earnings = (Σ Services * Unit fees) * % Quality score – 5 HIV - Reproductive Health indicators and 2 TB community indicators – Basket fund payment model to pay Cooperatives of CHWs after assessment of the integrated quartely report – The assessment is done by the Sector steering committee – The payment is linked to a score generated by the Timeliness, completeness and accuracy

14. 9. Strengthen supervision to assure high quality services – The PBF system promotes regular supervision of health workers at each level through the PBF quality assessments. – The clinical PBF quality checklist at the Health Center level includes points for having completed a supervisory visit to each village during the course of the quarter. – CHW cooperatives cannot be paid their PBF funds if these visits are not completed and the quality scores are not reported.

15. 10. PBF Information System developed for monitoring the system PBF Database s Quarterly Quality assessment score Monthly PBF Evaluation Results PBF Contract s  INPUTS  OUTPUTS Contracts & Amendments Bank Payment Voucher Quarterly Payment Voucher Thematic Maps Indicator Trend Graph

16. 11. Relationship Between Building blocks and PBF Building Blocks Human Resources for Health Medecines, Vaccines, reagents Health Care financing Leadership management Health Information Health services delivery PBF Insure equity in HR distribution Improve availability and rational use Ensure financial accessibility to Health services for all and equitable financing sector Make providers accountables, reinforce planning & autonomy Improve quality of Datas & use Improve quality of care and coverage of preventives services

17. 12. Challenges Risk of gaming and unsafe earnings Burdensome but necessary oversight by MoH/CAAC, peer review teams & steering committees at different levels Timeliness, completeness, and accuracy of data can affect the PBF scheme, hence the importance of having a solid health information system. Since it is a dynamic strategy, PBF will need to be more flexible in order to adjust to innovative ideas benefiting the population and health care providers. Competences and retention of the management team and evaluators: Turn over Need of sufficient budget to avoid ceiling

18. Data restrictions The data shown in this presentation should not be quoted without permission of the authors.