1. National Community Health Performance-based Financing: design and implementation of supply-side model PBF workshop Bujumbura February 16 th, 2011 Ludwig De Naeyer (MSH)

2. Rwanda CPBF Interventions  Second generation of PBF to address remaining barriers for achieving improved MCH outcomes and TB outcomes Choice and unit fee based on national priorities and expected quantities mainly for preventive activities  CHW cooperatives receive incentives payment for: Timely submission of quality SIScom reports Offer for 5 MCH-indicators and 2 TB- indicators

3. Quantity Indicators (selection of SIScom) Indicator Unit fee in dollar Applied unit fee in RWF 1. Nutrition Monitoring: Number of children monitored for nutritional status (6 -59 mois) $ 3.24/12 RWF 150 2.ANC : Number of women accompanied/referred to HC for prenatal care within first 4 months of pregnancy $ 2.24 RWF 10,000 3.Deliveries: Number of women accompanied/referred to HC for assisted deliveries $ 2.73 RWF 13,000 4.FP: Number new Family Planing users referred by CHWs for modern family planning methods $ 2.90 RWF 4,000 5.FP: Number of regular users using long term methods (IUD, Norplant, Surgical/NSV contraception) $ 2.11 RWF 1,000 6.Nb of TB suspects examined referred by CHW $ 45 RWF 26,550 7.Nb of TB patients followed by CHW per month $ 51/6 RWF 5,000

4. Cooperative performance and Reporting (quality aspect)

5. Cooperative Income 2009 (data WB/SPH)

6. 2010 CHW Cooperative Data 6

7. Cooperative functioning (data WB/SPH)  47% of cooperatives and 38% of CHW charge patient fees

8. 2010 CHW Cooperative Data 8

10. Data validation and control  Payment per unit reported so possibility of gaming  Still mainly paper based  Done by HC supervisor monthly  External audits planned but not performed yet

11. PBF-Payment for cooperative  Quarterly via HC-account After validation of the data by sector steering committee (members are HC-head, the supervisor of the CHWs at the HC, the in charge of social affairs and a member of the civil society)  Two parts: Maximum amount for reporting depends on the target population of the cooperative. This is adjusted by the quality score. Productivity (i.e. offer services) = unit fee * Quantity  First payment made for October – November 2010: average of 3700 $ for indicator and 900 $ for report Cooperatives use earnings for income generating activities and for dividend for CHWs.

12. Cooperatives Reporting: 97% for 2010 to date out of 427 HC and Dispensaries

13. Cooperative performance reports  Started during the last quarter 2010 (n=261) Average quality score: 82%

14. Baseline data for “Incentivized” Indicators Indicator Monthly Average per cooperative for October- November 2010 1. Nutrition Monitoring: Number of children monitored for nutritional status (6 -59 mois) 1596 2.ANC : Number of women accompanied/referred to HC for prenatal care within first 4 months of pregnancy 26 3.Deliveries: Number of women accompanied/referred to HC for assisted deliveries 26 4.FP: Number new Family Planing users referred by CHWs for modern family planning methods 39 5.FP: Number of regular users using long term methods (IUD, Norplant, Surgical/NSV contraception) HMIS data 6.Nb of (TRUE) TB suspects examined referred by CHW Nl. HMIS data/ SIS: 4 7.Nb of TB patients followed by CHW (total fee) 4

15. Lessons learnt / challenges  PBF incentives ensured rapid increase in SISCom reporting  In the presence of a strong monitoring system PBF can be introduced for cooperatives to stimulate and reward activities of CHWs at community level.  Quarterly payments are feasible and will hopefully lead to an increase of MCH and TB-activities. The results of this intervention will be assessed by an independent unit through an Impact Evaluation study.  Data quality supervision and external audits still need to be introduced to verify data quality

16. 2010 CHW Cooperative Data  In the past 12 months, how many times was performance assessed? Members (internal): 3.97 Members (external): 1.18 Cooperative (external): 0.52 16