1. 11 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

2. 22 Sample: Panel 165 Facilities 2006-08 2145 households in catchment areas  Random sample of 14 per clinic

3. 33 Log Expenditures Randomization balanced baseline Follow-up balanced, so difference in follow- up outcomes due to incentives not resources

4. 4 Rates of Assisted deliveries increased in both treatment and control groups A dramatic increase of utilization of services in Rwanda

5. 55

6. 66 6 Delivery at the health facility increased overall in Rwanda, but 7% more in PBF facilities ….

7. 77

8. 88

9. 99 Quality Conceptual Framework What They Know (Ability/Technology) What They Do: (Quality) Production Possibility Frontier

10. 10 Goal: Use Pay for Performance to Close Productivity Gap Ability/Technology What They Do Production Possibility Frontier Productivity Gap Conditional on Ability Actual Performance

11. 11 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

12. 12 In the last years, PBF has increased prenatal care quality significantly …

13. 13

14. 14

15. 15 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

16. 16 Discussion Rwanda is back on track towards the health MDGs because of many different factors including  Strong political leadership  Micro-Insurance (Mutuelles)  Autonomy and Fiscal Decentralization (Imihigo)  HIV services and earmarked funding PBF effect seen despite many other national level intervention: possible bigger effect in other countries 16

17. 17 Beware the “pre-post trap”: the example of Family Planning in Rwanda

18. 18 Conclusions Reaching the MDGs –or at least making a major dent towards reaching them- is possible even within the next five years.. Results Based financing can be a powerful way to address the problems of the “missing middle” and inject incentives into the implementation “black box” Only because of the rigorous impact evaluation conducted in Rwanda can we conclude that RBF played a role in the increased utilization of services Impact E valuation should systematically be nested into major policy interventions