Integration and Health Systems Strengthening: Performance-Based

Financing in Rwanda

Jean Kagubare, MD, MPH, PhDPrincipal Technical Advisor, MSHJuly, 2010

Health challenges (1999) and GoR response

•Low Utilization of Health Services ( 0.3/pc/year)•Financial barriers to access health services•Low Quality of Health Care and services•Poor Staff motivation•Lack of integration: Vertical programs (HIV, TB,…)

GoR’s response: 3 major health reforms•Performance Based Financing (PBF) •Community Based Health Insurance (CHBI)•Quality Assurance Policy

Why PBF?

PBF is a powerful means of increasing the quantity and quality of health services by providing incentives to suppliers to improve performance.

PBF can address:– Low utilization of health services;– Low quality of health care and services;– Poor staff motivation;– Challenges of meeting Millennium Development Goals.–Poor integration of health services (HIV)

Design & Implementation of PBF• Clear Goals:

– PHC and HIV minimum packages of service

• Measurable indicators : – Quantity: 15 PHC and 10 HIV indicators– Quality: HC: 118 composite indicators across 13 services; DH: 51

composite indicators

• Defined rewards and or penalties (and standards)– Price for each indicator defined; criteria to validation outputs – earnings= Quantity * %Quality

• Validation and accountability (separate control and verification functions)

• Transparency (TWG; PBF steering committees)

PBF indicators: HIV & PHC

• 14 HIV/AIDS indicators: – One VCT test = $1.10 – One Pregnant woman tested (PMTCT) = $1.10 – One couple tested voluntarily (PMTCT)= $1.10– One HIV+ client under CTX treatment = $1.10– HIV+ women treated with NVP = $1.10

• 16 Prim. Health Care indicators: – New Curative Consultation = $0.27– Delivery at the HC = $3.63 – Completely vaccinated child = $ 1.82– New FP user = $1.82, old user = $1.36

Implementing Organizations

How Rwanda Coordinates Donors to Align to Payment Practices

• GOR pays outputs throughout Rwanda • Coordination of design phase through PBF technical

working group• PBF admin system pays straight into the health facility

bank accounts., with database linked to payments • PHC services protected by linking payments of HIV and

PHC monies to levels of quality of general services• One national approach (and with all donors), same

institutional set-up, unit costs and admin system facilitates alignment

• Payments from donors pooled at the health facility level

Community Based Health Insurance & HIV/AIDS

• 1999: CBHI introduced to improve financial access • 2006:

•R5: 5-year program funded by Global Fund focused on improving financial accessibility and quality of health care delivery for the poor, PLWHAs and vulnerable groups. •Grant monies (27.2 million $): finance or co-finance health insurance membership fees for the very poor, OVC and PLWHAs (15% of population) • Program also offers pre-service and in-service training to clinical and other health service staff and provides electricity to health facilities.

•2009: quasi universal coverage (91% of population); increased health services utilization (0.3 to 0.7 per pc/year)Strategy for sustainability after GF project:

•Micro credit to poor by community banks (Banques Populaires)•GoR committed to increase its health budget and to target the poor

Major Achievements MDG 6 – HIV: 2009

• 81% of all health facilities offer VCT for HIV

• 85% of adults and 81% of children with advanced stage AIDS are on ART

• 74% of pregnant women receive ART prophylaxis (PMTCT)

• 47% of health facilities offer ART services (217/464).

• 85% of adults and children (of those in need) are accessing ART

• Decreased of HIV prevalence rate (12% (1998) to 2.8% (2008)

Increase in volume of services (after 36 months)

PBF Indicator January 2006 average/month/

health center( 258 health centers

on average)

December 2008average/month/

health center(289 health centers

on average)

Percentage increase

Institutional Deliveries

21 36.1 72%

New Curative Consultations

985 1,613 63.8%

ANC new cases 100.8 76.7 - 24.3%

VCT: number of clients tested

193 326 69%

Family Planning new users

15.5 61.8 299%

Family Planning users at the end of the month

175.2 983 462%

Health Impacts

Indicator DHS 2005 DHS 2007

Total Fertility Rate 6.1/woman 5.5/woman

Contraceptive Prevalence Rate (married women; modern methods)

10% 27%

Births attended by Skilled Attendants

39% 52%

Under-five mortality 152/1,000 103/1,000

Infant mortality 82/1,000 62/1,000

Vacc coverage against measles children aged 12-23 months

75% 90%

Conclusion

PBF led to the integration of HIV in the general health system:• Purchasing HIV services can be done through national systems while protecting and reinforcing the general quality of basic health services•Strong central coordination mechanisms have been created, both technical and financial (all major donors are purchasing performance indicators specific to HIV/AIDS, malaria and TB, using the same administrative model)•Data tend to be 100% complete, timely, and intensively used at all levels of the health system.

CBHI and PBF are synergetic!

Sustainability? strong political and financial support, and better donor coordination