Post on 01-Apr-2015
transcript
Scaling up Family Planning through Performance-Based Financing in Rwanda
Dr. Louis Rusa, Director PBF support Cell
Ministry of Health, Rwanda
Content
PBF 101 – guiding principles
Case study of PBF in Rwanda
Lessons learned
Input vs Output financing
Payments in advance for salaries, drugs & supplies, running costs
Funds often managed at higher levels
Need to justify expenses after payment (financial audits)
Tenuous link between funding and results
Funds paid for services already delivered
Funds managed at local level
Need strong data collection & quality control system
Direct link between funding and results
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 and from existing sources
Strong service and data quality control mechanisms needed to eliminate incentive to cheat
Key Rwanda health strategies
In 2005, MOH introduced three complementary strategies to improve health services: Community Based Health Insurance to
increased access Performance-based Financing to
increase availability and quality of services
Continuous Quality Assurance to enhance quality of care
PBF and Family Planning in Rwanda
Health Center PBF system includes incentives for 2 indicators:# of new FP users# of FP users at the end of the month
Community PBF includes provider-side and client-side indicators:# of new family planning users referred by CHWs
(both)% of FP users using long-term methods (provider-side)# of FP users adopting long-term methods (client-side)
Quarterly Quality Assessment process includes an assessment of FP service quality
PBF Control is NOT ‘business as usual’ in data gathering
District quality assessment team checking data quality in a health center
Assuring Data Quality – Multiple checks and balances
Data ‘quantity’ audits conducted every month on each indicator from every site (register vs report)
Monthly report data are reviewed by district PBF steering committees
Community client or “phantom patient” surveys every 6 month at a sample of sites – look for phantom patients and seeks feedback from patients on quality of care
National PBF cell reviews database each quarter for the entire country – corrections are made before payment
How to strengthen supervision to assure high quality services
Quarterly Quality assessments are conducted at each facility to assess 13 components of service qualityAdministration, Hygiene, Respect for Clinical
protocols for key services, Community outreach, etc.
Controllers are District Hospital supervisors and data managers for health centers, by peer district hospitals for Hospital level PBF
This assessment score is used to offset PBF payments
Performance Payment Mechanism
Performance Payments = Σ (# service outputs * Unit fees) * % Quality score
No Indicator Quantity Fee Amount RWF
1FP: number of new family planning users 40 1000 40,000
2FP: Number of family planning users at end of month 120 100 12,000
62,000
Quarterly quality score X 87%
Payment amount 53,940
Increase in Volume of FP Services
(after 39 months)PBF Indicator January 2006
average/month/health center( 258 health centers on average)
March 2009average/month/health center(297 health centers on average)
Percentage increase
(linear/log R2)
Family Planning new users
15.5 58.6 278%(linear 0.79)
Family Planning users at the end of the month
175.2 1005.6 473.9%(linear 0.98)
Increase in the Quality of Services in Health Centers (1)
Lessons learned Health workers benefit directly from a
portion of the PBF funding that is shared as bonuses – motivation and retention of health workers has improved
PBF reinforces decentralization strategy: Money is paid directly to the health facility and managed by local steering committee with considerable autonomy
PBF can lead to a significant increase in service production and quality of services in a relatively short period of time