Impact Evaluation of the Rwanda Community Performance-Based

Financing Program

College of Medicine and Health Sciences School of Public Health

  

Background: Health in RwandaRwanda has experienced dramatic changes in indicators of health outcomes and utilization of health services in recent years

DHS 2005 DHS 2010

DHS 2014-15

Under-5 mortality(per 1,000 live births) 152 76 50

Maternal Mortality(per 100,000 live births) 750 476 210

Delivery at Health Facility 28% 69% 91%ANC by skilled provider 94% 98% 99.8%Total Fertility Rate 6.1 4.6 4.2

Background: IE of PBF (First Generation)

Basinga, Gertler et al. 2012; Gertler and Vermeersch 2012; de Walque, Gertler et al 2015

PBF at the health facility level was scaled up nationally in 2008

Positive Impact

• Quantity:• Institutional deliveries• Preventative care visits by

children• VCT for couples

• Quality of prenatal care• Health Outcomes of children

No Impact

• Prenatal care utilization• Use of modern contraceptives

Background: Community PBF (Second Generation)• Since 2009, Community Health Workers (CHWs) were paid for reporting on

health indicators in their communities

• Additional components were added through the Community Performance-Based Financing Program in order to promote targeted services

• This study evaluates the impact of 2 interventions that were added to the scheme:

1. Performance incentives for CHW cooperatives2. Demand-side in-kind incentives

Background: organization of CHWs in RwandaEach village has 3 volunteers serving as Community Health Workers (CHWs).

Multidisciplinary CHWs

CHW in Charge of Maternal and

Neonatal Health

Criteria• Can read and

write• Age 20-50• Lives in the

village• Elected by the

village residents

Background: organization of CHWs in RwandaAll the CHWs within the catchment area of a health center are organized in a CHW cooperative.

Cooperative

Background: organization of CHWs in Rwanda70% of payments received by a cooperative must be invested in income generating activities (IGAs).

30% of the payments and revenues from the IGAs are given to cooperative members. It is up to the cooperatives to determine distribution rules.

Intervention #1: Performance Incentives for CHW CooperativesCHW cooperatives received financial rewards for:1. Nutrition monitoring: # children 6-59 months monitored2. Timely Antenatal Care: # of women accompanied/referred within first 4 months

of pregnancy3. In-Facility Delivery: # of women accompanied/referred for assisted delivery 4. New Family Planning users: # referred to health center5. Regular Family Planning Users: # regular users at health center

• 4 indicators related to TB and HIV were added at a later stage and not evaluated

Intervention #2: Demand-Side In-Kind TransfersWomen received gifts for seeking care for the following services:

* Women can only receive the gifts for one pregnancy every 3 years.

Eligibility* Value (Ceiling) Suggested Package

Initiation of Antenatal Care during first 4 months of pregnancy

5 USD Adult cloth and water treatment tablets OR baby cloth package and water treatment tablets

Delivery in health center 6.67 USD Baby soap, baby shawl and baby bed sheets

Initiation of Postnatal Care during the 10 days after delivery

3.33 USD An umbrella and water treatment tablets OR Adult cloths

Research Questions1. Do the demand-side in-kind transfers and the performance incentives to

CHW coops increase• Initiation of prenatal care within first 4 months of pregnancies?• Total prenatal care visit?• In-facility deliveries?• Rate of postnatal care within 10 days after delivery?

2. Is there a multiplicative effect when both interventions are implemented?

3. Do the performance incentives to CHW coops affect• Behavior and motivation of the CHWs?• Use of modern contraceptives?• Growth monitoring of children under 5

Study Design: RCT 198 sectors (sub-districts) were randomly allocated into 4 study arms:

* Coops paid for reporting received the average amount received by the coops paid for performance

Payments to CHW Coops

For Reporting*For

Performance

Demand-Side TransfersNo C S

Yes D D+S

Study Design: Selection and Randomization of Sectors• Study conducted in 19 districts in 4 provinces

• Excluding Kigali• 18 districts of previous IE

• A sector usually corresponds to a catchment area of a health center

• Include only sectors with a public or non-for-profit faith-based health centers

• Exclude 30 sectors where the demand-side intervention was piloted

• Sectors blocked by district and poverty ranking

Study Design: Randomization of Sectors

Study Design: Baseline Survey• 12 villages were randomly selected within the catchment area of each health

center

• Household survey • A field supervisor consulted village leader and/or CHW to identify household with most

recent birth or pregnancy (N = 2,376)• Household questionnaire• Interview with “core” respondent

• CHW survey• Target of 2 CHWS in each selected village (N = 4,668)• CHW in charge of maternal and neo-natal health should have been included

• Cooperative survey (N = 197)

Study Design: Follow Up Survey• Same villages were visited

• Household survey: two samples!• Women with most recent birth in their village (N = 2,343)• “Baseline” Women (N = 2,157)

• CHW survey• CHW in charge of maternal and neo-natal health (N = 2,220)

• Cooperative survey (N = 197)

• Health Center Assessment (N = 197)

Timeline

2010

2011

2012

2013

2014

February-May 2010

•Baseline Survey

November 2013-June 2014

• Follow-up Survey

October 2010

•Interventions Introduced

February 2013

•Last transfer of funds for in-kind transfers

Descriptive Analysis: Baseline Sample Characteristics

Total D S DS C

Age 28.2 28.1 27.8 28.2 28.7

(6) (6) (5.8) (5.9) (6.2)

Married 0.91 0.91 0.91 0.9 0.91

Education

None 0.18 0.16 0.18 0.18 0.19

Primary 0.70 0.72 0.69 0.67 0.69

> primary 0.13 0.12 0.13 0.13 0.13

Covered by Mutelles 0.90 0.93 0.9 0.89 0.88

Number of live births 3.03 3.11 2.95 2.97 3.10

(2.12) (2.12) (2.18) (2.03) (2.18)

Ever used modern FP 0.4 0.4 0.37 0.41 0.41

Core Respondents

Descriptive Analysis: Baseline Sample Characteristics

Care during last pregnancyAt least one ANC visit 98%First ANC visit in first 4 months of pregnancy 63%At least 4 ANC visits 37%Skilled-attended in-facility delivery 79%PNC within 10 days of birth 38%Gift received for ANC* 5%Gift received for delivery* 4%Gist received for PNC 2%

*The reported value of gifts is about a third of those set by the program for the different services.

Descriptive Analysis: Comparison with the RDHS 2010

Baseline RDHS 2010

Age 28.2 29.1

Education

None 0.17 0.18

Primary 0.69 0.75

> primary 0.14 0.07

Number of births 3.01 3.34

Care during last pregnancy:

At least one ANC visit 0.98 0.98

First ANC visit in first 4 months of pregnancy

0.63 0.63

At least 4 ANC visits 0.37 0.36

Skilled-attended in-facility delivery 0.79 0.79

PNC within 10 days of birth 0.38 0.18

Comparing core respondents to RDHS sample of women with a pregnancy during the two previous years

Descriptive Analysis: Baseline Sample CharacteristicsCharacteristics of CHWs in charge of maternal and

neonatal health Mean SD

Age 39.1 (9.4)

Female 0.94

Education

Primary 0.61

> primary 0.39

Number of years as CHW 2.6 (3.7)

Number of HHs in village 122 (117)

Number of hours spent on health activities in past week

17.7 (28)

Distance to health center (in km) 4.1 (4.9)

Descriptive Analysis: Time Trends

Any ANC Timely ANC ≥ 4 ANC In-facility Delivery Timely PNC0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 98%

63%

36%

79%

34%

99%

72%

40%

94%

13%

Baseline Follow-up

Baseline and Follow-up rates among Control group

Descriptive Analysis: Program Implementation

Incentivized indicators Unit Fees (USD)

2010 2011 2012 2013 2014Nutrition Monitoring

3.24 0.57 0.43 0.43 0.43

Timely Antenatal Care2.24 1.12 0.81 0.81 0.81

In-facility Delivery2.73 1.37 0.99 0.99 0.99

New Family Planning User2.90 1.45 1.05 1.05 1.05

Regular Family Planning User2.11 1.06 0.77 0.77 0.77

Incentive amounts reduced during the implementation of the program

Descriptive Analysis: Program Implementation« D'habitude, est-ce que votre centre de sante donne des cadeaux aux femmes qui viennent pour les services suivants: »

Indicator D S DS CTimely ANC 0.94 0.16 0.90 0.08In-facility delivery 0.92 0.18 0.88 0.13Timely PNC 0.90 0.09 0.88 0.08

Descriptive Analysis: Program Implementation

19%

49%

18%

14%

Experience of stock outs by health centers

No stock outsSometimeOften Very Often

Availability of funds

Procurement

Supplier

69%

23%

6%

Reason for stock outs

Descriptive Analysis: Program Implementation

D S DS C Obs.D-C S-C DS-C

Mean Mean Mean Mean p-value p-value p-value

Demand-side incentives 1st ANC 0.16 0.10 0.16 0.10 0.00*** 0.93 0.00*** 3420 1st ANC within 4 months of pregnancy 0.18 0.11 0.18 0.11 0.00*** 0.84 0.00*** 2696 Delivery in health facility 0.14 0.04 0.12 0.05 0.00*** 0.77 0.00*** 3109 PNC 0.06 0.00 0.08 0.02 0.09* 0.16 0.01*** 718 PNC within 10 days of birth 0.06 0.00 0.09 0.03 0.29 0.05** 0.03** 538

T-test

Share of women who received gifts

Descriptive Analysis: Program Implementation

Share of eligible women who received gifts, by year of birth

2011 2012 20130%

5%

10%

15%

20%

25%

30%

35%

40%

Timely ANC

2011 2012 20130%

5%

10%

15%

20%

25%

30%

35%

40%

In-FacilityDelivery

2011 2012 20130%

5%

10%

15%

20%

25%

30%

35%

40%

Timely PNC

* Combining samples of recently pregnant women and “baseline” women; only pregnancies ending in live births

Results: Maternal Health Services• Indicators:

• Timely ANC• In-facility deliveries• Timely PNC

• Sample of women with most recent birth in their village• Pregnancies resulting in a live birth

Results: ANC visit within first 4 months of pregnancy

• A positive and significant (at the 1% level) impact of the demand-side in-kind incentives of about 10 percentage points

• The CHW incentives are not found to have a significant effect• No difference between the ‘Demand’ and the ‘Demand+Supply’ treatment arms

Control Demand Supply D + S50%

55%

60%

65%

70%

75%

80%

85%

Timely ANC

Results: at least 4 ANC visitsFirst ANC visit during the first 4 months

• Not targeted by the program!• Higher in the intervention sectors, but not statistically significant at the 10% level

Control Demand Supply D + S25%

30%

35%

40%

45%

50%

Four or more ANC visits

Results: Skilled-attended in-facility delivery

• No statistically significant difference between the treatment arms• Rate has increased substantially in the duration of the study for other reasons

Control Demand Supply D + S70%

75%

80%

85%

90%

95%

100%

In-Facility Delivery

Results: PNC within 10 days after delivery

• A positive and significant (at the 5% level) impact of the demand-side in-kind incentives of about 7 percentage points

• Not targeted by the CHW incentives intervention

Control Demand Supply D + S0%

5%

10%

15%

20%

25%

PNC within 10 days after delivery

Results: targeted maternal health indicators• Results are robust

• Inclusion of controls• Diff-in-diff specification• Exclusion of 3 misclassified sectors

• Negligible changes when sample weights are used• Using data on number of households in each sector

Results: Fertility and Family Planning• Indicators

• Birth since baseline• Ever used modern family planning method

• With and without adjustment for baseline response

• Sample of baseline women• Caveat: not optimal for estimating this• Caveat: higher attrition among treatment groups implementing the supply-

side intervention

Results: Fertility and Family Planning

Control Demand Supply D + S0%

10%

20%

30%

40%

50%

60%

70%

80%

• No statistically significant impact on any of the indicators

Results: Nutritional monitoring

• Indicator:• Child was measured in the past 6 months to determine nutritional status

• Sample of children 6-59 months• Of all women (recent pregnancies and baseline women)

Results: Fertility and Family Planning

Control Demand Supply D + S30%

40%

50%

60%

70%

80%

90%

Growth Monitoring in past 6 months

• No statistically significant impact

Other results: CHW• No Impact on CHW behavior

• Hours spent on health activities• Number of households visited• Consulting other CHWs

• No Impact on measures of satisfaction and motivation of CHWs

• No impact on CHW behavior reported by the women• CHWs referred or accompanied to ANC, Delivery or PNC services• CHWs provided information on these services• Interacted with CHWs in the past three months (in the community or home visits)• Satisfaction from CHWs

• Women in Demand and D+S sectors report CHWs were aware earlier of their pregnancies

Other results: Cooperatives

• No Impact on..• Number of meetings• Number of members recruited, dismissed, resigned in the past 12 month• Cooperative income• Whether payments are allocated by performance• Internal assessment of coop members

• The demand-side in-kind incentives caused an increase in timely ANC and PNC services

• Although some challenges in procurement and frequent stock outs

• Although some health centers independently implemented their own demand-side incentives strategies to promote utilization

• Although funding ended before end-line data collection

• Consistent with findings in other countries that implemented demand-side cash transfers

Key Findings: Demand-Side In-Kind Incentives

• No impact of incentives to CHW cooperative on targeted indicators, CHW behaviors and CHW motivation.

• Potential reasons for lack of impact– Incentives were too low–Collective reward but individual effort–Pay-for-reporting could have already oriented the CHWs towards targeted

indicators–Limited scope given the many supply-side programs targeting the same

indicators

Key Findings: Performance Incentives to CHW Coops

• Self-reported indicators

• Timing of survey relative to termination of the demand-side intervention• Hoping to include analysis of administrative data

• Not optimal sample for the analysis of fertility and family planning indicators

Caveats

• Ministry of Health • Fidel Ngabo • Cathy Mugeni

• University of Rwanda• Ina R. Kalisa• James Humuza• Jeanine Condo• Vedaste Ndahindwa

• The World Bank• Gil Shapira• Netsanet W. Workie• Jeanette Walldorf

Research Team

The study was funded by the Health Results Innovation Trust Fund (HRITF)

Thank you!