1. Rwandan Performance-Based Financing Process and Tools Gisenyi Results-Based Financing Workshop October 21, 2008 Dr Gyuri FRITSCHE Management Sciences for Health

2. Contents 1.Where to place this presentation 2.Lifting the Veil on the Process of Implementing National Performance-Based Financing Models in Rwanda 3.Explanation of the ‘Tools’ used in the National District Hospital and Health Center Performance- Based Financing Models

3. Process of the Rwandan PBF National Model Creation Three PBF pilot programs: –Cyangugu PBF pilot by NGO Cordaid 2002 onwards –Butare PBF pilot by NGO HNI-TPO 2002 onwards –Kigali Ngali PBF pilot by bilateral cooperation agency BTC 2005 start End 2005/early 2006: process to create one common national model for Health Centers and Hospitals Series of information meetings and workshops with stakeholders at the national level –2 day workshop in January 2006 –4 day team ‘extended team retreat’ January 2006 –4 day workshop with all partners February 2006 for the design of a national model for Health Centers –2 day workshop with partners July 2006 to design the national PBF model for District Hospitals

4. Indicators? (i) Cyangugu Model 2002-2005: –Project covered 620,000 people –Fee for Service/Case based Reimbursement type of incentive payment –Budget approximately $2/c/yr $0.5 to $0.75/c/yr for program costs $0.41/c/yr for health center output payments $0.84 to $1.09 for district hospital output payments –Covering 4 DH and 26 health facilities (with 14 health posts and 19 private dispensaries as second tier contractees) –20 indicators at the health center ranging $0.09 to $5.40 –18 indicators at the hospitals ranging $1.07 to $26.80

5. Indicators? (i) Cyangugu Model 2002-2005: –District Health Team contracted for performance-based supervision –‘Bonus’ for excellent quality and good community client survey results which included clients satisfaction and amount of out of pocket payments (15% additional) –Business Plans –Community Client Satisfaction Surveys –NGO is purchaser and controller (“fund holder”) –Written purchase contracts with second tier contracts by prime contractees –Public; FBOs and Private for Profit Sector

6. Indicators? (ii) Butare PBF model 2002-2005 –Project covering 384,209 population –Fee for Service/Case based Reimbursement type of incentive payment –36 health centers and, later, 3 district hospitals –Budget $0.24/c/yr of which $0.09 for program costs –4 community outreach indicators ranging $0.18 and $8.93 –23 health center indicators ranging $0.07 and $6.25 –19 district hospital indicators ranging $0.36 and $14.30 –9 performance indicators for the district health teams –“Quality” not taken into account purposefully –Steering Committee with NGO as secretariat/TA –Written contracts (three levels)

7. Indicators? (iii) Kigali Ngali Model 2005- –1.4 million catchment population –75 health centers and three district hospitals –‘Tacit’ (verbal) agreements –Value of indicators mitigated by composite indicators being met (‘quantity * “quality”’) and expressed in ‘points’ and not in money (available budget spent 100%) –Part of a larger traditional health project, ‘input’ financing with $1.57/c/yr funds, of which $0.08/c/yr for PBF –22 composite indicators at health center level ranging $0.18 and $5.36 –48 composite indicators at district hospital level ranging -$44.50 (penalty) to $44.50 –31 composite indicators for the district health team –Bilateral agency with PIU inside MOH department

8. Initial National Health Center Model(s) National Health Center Model 2006 – December 2007 –Covering 6.51 M population (entire 23 district population) –Seven control districts –About 258 health centers –“Contracting In” approach –Fee for Service/Case Based Reimbursement –16 primary health indicators (2008: 14) ranging $0.09 to $4.46 –15 HIV service indicators (2008: 10) ranging $0.47 to $8.90 10 districts singular PMA indicators; 23 districts singular HIV indicators; 13 districts ‘composite’ PMA indicators

9. Initial National Health Center Model(s) National Health Center Model 2006 – December 2007 –In 10 districts: Quarterly Quality Supervisory Checklist 185 composite indicators across 13 services (excluding HIV services) till end 2006 > 70% composite score = 100%, >40% <70%= 50%, <40% = 25%; after Jan 2007 linear relationship: Performance measure HC earnings = (Quantity * Unit Fees) * Quarterly Composite Quality Measure –In 13 districts no Quarterly Quality Supervisory Checklist, but ‘composites’ for each indicator with Value = (Quantity * “% Composite Score” * Unit Fee) –“Contracting in” type of intervention: three levels of contracts/agreements, creation of quasi market: GOR contracting with its own and FBO facilities (and in five districts with private for profit sector also)

10. Initial National District Hospital PBF Model(s) National DH PBF model: July 2006 to December 2007: –52 composite indicators with ‘point values’ Budget allocated 20% administration; 30% quality assurance and 50% clinical activities in 13 hospitals –Budget allocated $602/bed/yr Budget allocated according to budget available (variable point score = available budget gets consumed 100%) in 14 hospitals –Budget allocated $35K to $130K per hospital per year based on number of staff

11. 2007 Funding Source CommunityHC*DHCPTotals 2007 GOR1,651,3763,375,3391,732,98280,7896,840,486 CTB1,094,215 USG702,145992,3051,694,450 WB/MAP160,568 Subtotals$1,651,376$4,238,052$3,819,502$80,789$9,789,719 $/C/Yr$0.18$0.46$0.41$0.01$1.06 2007 PBF Disbursements (23 Districts)

12. New National Health Center Model New National Health Center Model Jan 2008- –405 health centers (since April 1, 2008) –9.5 M population –Fee for Service/Case Based Reimbursement conditional on ‘validation’ criteria (composites) for basic health services (compromise) but no ‘validation’ criteria for HIV services –Revised Quarterly Quality Supervisory Checklist with 118 composite indicators across 13 services, including HIV services –Performance measure: PMA HC earnings = (((Quantity * ‘% Validated’) * Unit Fees) * Quarterly Composite Quality Measure) HIV HC earnings = ((Quantity * Unit Fees) * Quarterly Composite Quality Measure)

13. New National DH PBF Model New National District Hospital PBF model: Jan 2008- –52 composite indicators –All 39 Rwandan district hospitals –Available budget from all sources pooled and modeled 20% administration; 25% supervision and 55% clinical activities –Administration 200 ‘points’ with varying point values $11.40 to $69.96 depending on ‘index burden’ (staff) –Supervision 295 ‘points’ with varying points values depending on the number of health centers to be supervised with budget of $3,181/HC/yr –Clinical Activities with one point value of $13.5, and 18 ‘categories’ (DRG look-a-likes), indicator values ranging $1.34 to $8.34 –All indicators subject to composites.. –Annual global prospective budgets ranging from $54K to $330K

14. Nyabimata CS, Nyaruguru District (i) Status of PBF Slide 14

15. Nyabimata CS (ii) Status of PBF Slide 15

16. Nyabimata CS (iii) Status of PBF Slide 16

17. Nyabimata CS (iv) Status of PBF Slide 17

18. Nyabimata CS (v) Status of PBF Slide 18

19. Nyabimata CS (v) Status of PBF Slide 19

20. Nyabimata CS (vi) Status of PBF Slide 20

21. Nyabimata CS (vii) Status of PBF Slide 21

22. Nyabimata CS (viii) Status of PBF Slide 22

23. Nyabimata CS (ix) Status of PBF Slide 23

24. Nyabimata CS (x) Status of PBF Slide 24

25. National HC and DH PBF Guides Click for HC PBF GuideClick Click for DH PBF Guide (Draft)Click

26. Additional Resources Website www.pbfrwanda.org.rw under ‘documentation’:www.pbfrwanda.org.rw –Guide for Health Center PBF (May 2008) containing all tools (FR) –MOH 2007 PBF Annual Report (EN) –DH InfoPath form (EN) –Rwanda: PBF in Health (Rusa and Fritsche) MfDR 2007 On demand: –Excel file with list of indicators for the three pilots, and the national PBF models (FR) –Guide for District Hospital PBF (Sept 08 draft) (EN)

27. Status of PBF Slide 27 Thank you for your attention!