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