Scaling Up Performance Based Financing in Rwanda 2004-2008

1

Scaling Up Performance Based Financing in

Rwanda 2004-2008

Rwanda PBF team: Paulin Basinga, Ghyuri Fritsche,

Bruno Meessen, Laurent Musango, Louis Rusa, Claude Sekabaraga, Agnes Soucat et al 1

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Outline

1. Reconstruction and Innovations 2. Scaling Up Performance Based

Financing3. Results4. Reforms5. Impact Evaluation

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3

Outline

Reconstruction and Innovations Scaling Up Performance Based

Financing Results Reforms Impact Evaluation

The post-colonial times .. Modern health introduced in Rwanda free of charge to users and

funded through direct public subsidy : infrastructure, equipments, personnel etc

1980s : shortages and rationing, dilapidation of health services 1992: community participation for financing and management of

health care (Bamako Initiative). 1994 : Genocide 1995-97: Reconstruction after the genocide : emergency

situations, NGOs, services free of charge. 1998-Willingness to come back to development and government

leadership: drug revolving funds re-established and cost sharing reintroduced

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Innovation II: Scaling Up of Community Health Insurance

Source: Cellule d'appui aux mutuelles de sante. Ministry of Health / Rwanda 5

Innovation III: Scaling Up of Performance Based Financing

Phase -0 (white shaded): the three PBF pilot projectsPhase-1 (pink shaded): districts in which PBF was started in Jan 2006 Phase-2 (red shaded): the seven ‘control districts’ in which PBF was implemented in April 2008.

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Outline



Chronology of Performance-Based Financing in Rwanda

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The PBF pilot experiments (2002-2005)

Three pilot schemes: Butare (since 2002) Cyangugu (since 2003) BTC (since 2005)

Led at provincial level by International NGOs. Priority health interventions: child immunisation, ANC,

assisted deliveries, family planning, curative care. A fee-for service at health center level

Scaling up: 2005-2008 2004: Evaluation of Butare and Cyangugu pilots

2005: Institutionalization:

2006: Scaling Up to 23 districts with 7 controls

2008: All districts

Evaluation: Cyagungu and Butare PBF2004

Use of Assisted Deliveries over time

0

5

10

15

20

25

30

Butare Cyangugu Gikongoro Kibungo

% o

f b

irth

s

200120022004

Performance Based Contracts Control

Institutionalization: integration in country budget

Since 2005, government pays outputs through recurrent budget (PBF budget line): 2005 US$ 800,000 for 4 districts 2006 US$ 5,000,000 for the country

Funds flow quarterly from Treasury directly to health facilities’ Bank Account on the basis of results of previous quarter

Since 2007, budget line item for PBF scheme for the District Steering Committee activities based at District level

Institutionalization: the HIVAIDS money

One national approach, one institutional set-up, same unit costs and same admin system facilitates alignment: Global Fund pays for HIV indicators into their supported sites .

Payment through same Bank Account: e.g MSH and ICAP – USG contractor-, FHI and BTC

Careful assessment of incentives through HIV monies in PBF: protecting PHC services by linking payments of HIV and PHC monies to levels of quality of general services.

Unit Fee * Quantity * % Quality = Payment;

National PBF Model : 2005-2008

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National PBF model : 2005-2008

The national model for health centers is based on contracts between different levels: Steering Committee (comité de pilotage) with

representation of health authorities Three layers of contracts:

Contract between CAAC and comité de pilotage Contract between comité de pilotage and health facility Contract between Health facility and individual health workers

In-depth verification activities : Done by one focal point per administrative district for quantitative

evaluation Done by hospital for qualitative evaluation

Separation of functions

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PBF Payment at Facility Level

Payments for performance are based on the quantity of outputs achieved (through case-based remuneration) conditional on the quality of services rendered.

The outputs (quantity) are measured monthly The quality is measured quarterly through the use of an elaborate

supervisory checklist. (13 services) The formula : PBF Payment HC = Quantity * % Quality

‘PBF Payment HC’ is the consolidated quarterly health center invoice (for either general or HIV),

‘Quantity’ stands for the quarterly provisory health center invoice (the sum of all indicators multiplied with their unit fees),

‘% Quality’ stands for the consolidated score—expressed as a percentage—obtained from the quarterly quality supervisory checklist

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General health indicators and PBF prices Num INDICATEUR

Amount paid per case (Rwf)

Amount paid per case (US$)

1Number of New cases 100 $ 0.18

2Number of New cases received at the prenatal care (first visits) 50 $ 0.093Number of Women who received 4 prenatal consultations 200 $ 0.37

4

Number of women completed the 2 or 3 or 4 or 5 Tetanus vaccines 250 $ 0.46

5

Number of Women who received the 2nd dose of Intermittent Preventive Treatment of malaria 250 $ 0.46

6

Number of at risk pregnancies Referred before 9 months of pregnancy 1000 $ 1.83

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Number of child aged 12-59 months seen at the curative care service for growth monitoring 100 $ 0.18

8

Family planning P new users (DIU, Pills, injections, implants)100 $ 0.18

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Family planning : number of users: DIU, Pills, injections, implants 1000 $ 1.83

10Fully Vaccinated Child 500 $ 0.92 11Institutional Deliveries at the health center 2500 $ 4.5912Emergency referrals to the Hospital for obstetric care 2500 $ 4.5913Malnourished children referred 1000 $ 1.8314Others Emergency referrals 1000 $ 1.83

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HIV/AIDS indicators and PBF prices (1$ = 545 RWF)

Num INDICATORS

Amount paid per case (Rwf)

Amount paid per case (US$)

1Number of clients tested for HIV at the VCT center 500 $ 0.92

2Number of couples/partners tested during the reporting month 2500 $ 4.59

3Number of HIV+ pregnant women on ART treatment during labor 2500 $ 4.59

4Number of infants born to HIV+ mothers tested 5000 $ 9.175

Number of HIV positives patients who received CD4 test 2500 $ 4.59

6Number of HIV + patients traited with cotrimoxazole each month 250 $ 0.46

7Number of new adults HIV+ on ART treatment 2500 $ 4.598Number of new infants HIV+ on ART treatment 3750 $ 6.889Number of HIV+ women on contraception 1500 $ 2.75

10Total number of HIV+ patients tested for tuberculosis 1500 $ 2.75

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Process evaluation

Meeting of the Steering committee : quantity and quality assessment

Counter verification of the patients in the community : looking for the phantom patients

Counter verification of the quality score by hospital team: randomly selected site

Comparison of PBF data with HMIS data Peers evaluation (Hospital PBF)

Administrative & management coordination PBF admin system with internet based data entry and

retrieval facilitate decentralized management and future decentralized payments (by districts);

Semi-automated payment module, linked to central database, witch allow for ease of payments by MOF (Ministry of finances) and others (MSH; BTC; FHI and GF);

Central database allows for following trends and forecast accurately financial risk;

•INSERT GRAPHIC TO ADD MAP

•MAP IS 6.17” TALL

•ICT management tools: www.pbfrwanda.org.rw

http://www.pbfrwanda.org.rw/

How many persons to do that?

MOH central PBF Unit (CAAC): 1 coordinator and two full-time staffs;

A key role for partners (members of the CAAC and on the field)

An Extended team approach has been put in place to cover 23 districts, and includes PBF focal points from the MOH, eight NGOs and a bilateral agency as a coordination structure

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Outline



Results 1. Increases in the Volume of Services2. Increase of the Quality of Services3. Increase of staff productivity4. Provider Enthusiasm and Motivation

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Outline



Increase in Volume of Services (after 27 months)

PBF Indicator January 2006 average/month/

health center( 258 health centers on

average)

March 2008average/month/

health center(286 health centers on

average)

Percentage increase (linear/log R2)

Institutional Deliveries

21 37.5 78% (log 0.75)

New Curative Consultations

985 1,489 51% (log 0.19)

ANC: second dose of Tetanus Toxid

21 52.5 150% (log 0.63)

Family Planning new users

15.5 47.9 209% (linear 0.88)

Family Planning users at the end of the month

175.2 711.6 306% (linear 0.98)

Results for Family Planning Users at the end of the Month

Family Planning, Modern Methods, Users at the End of the MonthAverage Per Health Center per Month

R2 = 0.9784

0

100

200

300

400

500

600

700

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

2006 2007

Ave

rage

num

ber

per

mon

th

175

640

FP Injections and oral methods at Health Centers % Increase in Prevalence over 24 months; •January 2006 through December 2007

Other improvements Over 16 months of PBF, the Quality increased on

average by 7% across these 13 services. A sharp increase in staff productivity. Whilst all providers appreciate the additional bonuses

that they earn through PBF, most also see clear advantages in the better services they provide, and take clear pride and ownership of these activities which originate ‘from within’ as opposed to being dictated from above.

Improvements confirmed by survey based data

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Assisted delivery – Modern contraceptive use

Meilleures pratiques en SM au Rwanda31Source : Enquêtes démographiques et de santé 1992, 2000 , 2005 et intérimaire 2007

Decrease of fertility

Fertility Rate 2005-2008

5.25.35.45.55.65.75.85.9

66.16.2

2005 2007

Source : Rwanda DHS 2005-2007

Dramatic Increase of Coverage of Insecticide Treated Nets

ITNs coverage 2005-2007Proportion of Children less than 5 sleeping under a

bed net

0%10%20%30%40%50%60%70%80%

2005 2007

Source : Rwanda DHS 2005-2007

Malaria out patient Non Malaria out patient

2001 2002 2003 2004 2005 2006 2007

0K

5K

10K

15K

20K

25K

Sum

of Con

f# o

utpa

tient

mal

aria

Sheet 1

Age group

5 years and above

Under 5 years

The trend of sum of Conf# outpatient malaria for Year G#C. Color shows details about Age group . The data is filtered on Country , which keeps Rwanda. The view is filtered on Age group , which keeps 5 years and above and Under 5 years.

2001 2002 2003 2004 2005 2006 2007

0K

20K

40K

60K

80K

100K

120K

140K

160K

180K

200K

220K

Sum

of Non

mal

aria

OPD

Sheet 1

Age group

5 years and above

Under 5 years

The trend of sum of Non malaria OPD for Year G#C. Color shows details about Age group . The data is filtered on Country , which keeps Rwanda. The view is filtered on Age group , which keeps 5 years and above and Under 5 years.

Decrease of malaria incidence

Malaria deaths decreased

Malaria death Non-Malaria Death

2001 2002 2003 2004 2005 2006 2007

0

50

100

150

200

250

300

Sum

of Mal

aria

dea

th (clin

ical

+ c

onf)

Sheet 1

Age group

5 years and above

Under 5 years

The trend of sum of Malaria death (clinical + conf) for Year G#C. Color shows details about Age group . The data is filtered on Country , which keeps Rwanda. The view is filtered on Age group , which keeps 5 years and above and Under 5 years.

2001 2002 2003 2004 2005 2006 2007

0

100

200

300

400

500

600

700

800

900

1000

Sum

of Non

Malaria

Dea

th

Sheet 1

Age group

5 years and above

Under 5 years

The trend of sum of Non Malaria Death for Year G#C. Color shows details about Age group . The data is filtered on Country , which keeps Rwanda. The view is filtered on Age group , which keeps 5 years and above and Under 5 years.

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Infant and Under 5 mortality rate

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Outline



Reforms 2000-2008

Autonomization

Performance Based Budgeting

Decentralization,

Reform I: Autonomization Based on Bamako Initiative Health centers and hospitals fully autonomous : 60%

healh centers public autonomous, 40% faith- based private not for profit

Facilities are financially autonomous: Commercial bank account, revenue from user payments and payments from community insurance

Subsidized by the government: Needs based block grant for wages, Performance Based Grant for recurrent costs, and specific financing from public health programs (vaccines, contraceptives, TB drugs and ARV etc)

Reform II: Performance Based Transfers “IMIHIGO”: contract between the President of

the Republic and the district mayors Key health indicators integrated in the contract (in

2007: ITNs, Mutuelles, FP, safe deliveries, hygiene..)

Strong political commitment to results Quartely review with Prime Minister, President

attending twice a year

Reform III: Decentralization Administrative and fiscal

decentralization gives flexibility to local governments by providing them with needs and performance based block grants

Decentralization of wages sent as a block grant to facilities

Facilities have the authority to hire and fire

Facilities receive blockgrant from government

“People follow the money”

Fiscal and Financial Decentralization

0

20,000,000,000

40,000,000,000

60,000,000,000

80,000,000,000

Dis

burs

ed 2

002

Dis

burs

ed 2

003

Dis

burs

ed 2

004

Dis

burs

ed 2

005

Budg

et 2

006

Proj

ecte

d 20

07

Year

Am

ount

in R

WF

Transfers to Districts

CDF

Transfers to Provinces

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Outline



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Study Rationale

No examples of rigorously evaluated bonus payment schemes to public sector health care providers in developing countries

No distinction between the incentive effect and the effect of an increase in resources for the health facilities

No unbundling of extrinsic and intrinsic-altruistic- motivation

Link between worker motivation programs and quality of care

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Hypotheses

For both general health services and HIV/AIDS services, we test whether PBC:

Increases the quantity of contracted health services delivered

Improves the quality of contracted health services provided

Does not decrease the quantity or quality of non-contracted services provided,

Decreases average household out-of-pocket expenditures per service delivered

Improves the health status of the population

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Evaluation Design

Make use of expansion of PBC schemes over time The rollout took place at the District level; random assignment at the

district level Treatment and control facilities were allocated as follows:

Identified districts without PBC in health centers in 2005 Group the districts in “similar sets” based on characteristics:

rainfall population density livelihoods

Flip a coin to assign districts within each “similar” to treatment and control groups.

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More money vs. More incentives

Incentive based payments increase the total amount of money available for health center, which can also affect services

Phase II area receive equivalent amounts of transfers average of what Phase I receives Not linked to production of services Money to be allocated by the health center Preliminary finding: most of it goes to salaries

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Baseline Survey: Sampling Strategy47

Lessons Learned: PBF

Start with easy things and then go progressively to complexity. Health centers before hospitals Simple quality indicators

Need for strong leadership and political will from authorities

Need for strong implementation oriented coordination structures and large pool of trainers

Lessons Learned: PBF

Institutionalization is the key phase: Importance of institutional contracts

Critical role of validation institution

PBF was used as a lever for reform: Allowed to raise reuneration n assoication with

performance Progressively shifted management of humn resources Assoicated decentralization with rapid results

Lessons learned Fiscal decentralization can help increase resources for health

facilities if well designed.. To serve purpose of service delivery.. autonomy of provision is essential…

Results Based Financing is a powerful mechanism to achieve the twin objective of increased performance and increased retention of qualified service providers

Combining public subsidy and private funding leads to increased remuneration and better adequacy with needs

Delinking healh workers from the central wage bill and civil service is possible..and health workers like it ..

Rwanda is back on track to reach the MDGs including MDG5

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IMPACT EVALUATION OF PERFORMANCE BASED

FINANCING for

A collaboration between the Rwanda Ministry of Health, CNLS, and SPH, the INSP in Mexico, UC Berkeley and the World Bank

GENERAL HEALTH AND HIV/AIDS SERVICES in

RWANDA

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Roll-out plan Phase 0 districts (white) are those districts in which PBF

was piloted Cyangugu = Nyamasheke + Rusizi districts Butare = Huye + Gisagara districts BTC = Rulindo + Muhanga + Ruhango + Bugesera + Kigali ville

Phase 1 districts (yellow) are districts in which PBF is being implemented in 2006, following the ‘roll-out plan’

Phase 2 districts (green) are districts in which PBF is not yet phased in; these are the so-called ‘Phase 2’ or ‘control districts’ following the roll-out plan. According to plan, PBF will be introduced in these districts by 2008.

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Sets Phase I Phase II1 Kibungo all Kirehe all2 Nyanza remaining Kamonyi all3 Gakenke remaining

Rulindo remainingByumba remaining

4 Rwamagana remaining Kayonza west, allGatsibo west, all

5 Gatsibo east, all Nyagatare east,allKayonza east, all

6 Rutsiro all, south west Kibuye west, allNyamasheke remaining

7 Ngororero all Kibuye east, allGasiza

8 Rutsiro all, except south west Kabaya all9 Nyaruguru remaining Gikongoro all10 Burera all Ruhengeri all

Nyagatare west, all

Rollout plan for PBC in General Health

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Immediately Phase I Phase IIThese places already have PBC in health centers for non-HIV / A IDS services

HIV / A IDS PBC to be introduced A FTER or SIMULA TEOUSLY with PBC for general services (ie. N OT before)

HIV / A IDS PBC to be introduced A FTER or SIMULA TEOUSLY with PBC for general services (ie. N OT before)

Rulindo Kibungo KireheKamonyi Nyanza KamonyiGisozi Gakenke Gisagara Rulindo Butare ByumbaBugesera Rwamagana KayonzaGasabo Gatsibo NyagatareNyarugenge Nyamasheke KibuyeCyangugu Ngororero Gasiza

Rutsiro KabayaNyaruguru GikongoroBurera Ruhengeri

Rollout plan for PBC in HIV/AIDS services

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Program and Evaluation Roll-Out Plan

Jan-06 Mar-06 Jun-06 2007 Feb-08 Apr-08 May-08 Jul-08Treatment Start of interventionControl

GH Household HIV HouseholdSURVEYS

Timeline

Program Implementation

Impact EvaluationBaseline

FACILITYFOLLOW-UP

Start of intervention

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Sampling Issues

Law of large numbers does not apply here… Proposed solution:

Propensity scores matching of communities in treatment and comparison based on observable characteristics

Over-sample “similar” communities in Phase I & Phase II It turned out

Couldn’t find enough characteristics to predict assignment to Phase I

Took a leap of faith and did simple stratified sampling

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Analysis Plan

All analyses will be clustered at the district level Compare the average outcomes of facilities and

individuals in the treatment group to those in the control group 24 months after the intervention began.

Use of multivariate regression (or non-parametric matching) : control confounding factors

Test for differential individual impacts by: Gender, poverty level Parental background (If infant : maternal education,

HH wealth)

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Difference in differences models To test the robustness of the analysis Control sample (both observed and unobserved) heterogeneity A two-way fixed effect linear regression:

α γ δ ε= + + + +∑Where:

is an outcome variable for facilitiy i in period t or for individual i who lives in the catchment area of facility i,

is an indicator of whether facility i

it it k itk i t itk

it

it

y PBC B X

y

PBC

δε

is being paid by PBC in period t, are time varying control variables,

i is a facility fixed effect, is a year fixed effect, is an error term.

itk

t

it

X

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SECTION 4:Impact evaluation Implementation

SECTION 4.1 :Baseline surveys

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Baseline Survey: Sampling Strategy60

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The baseline has 4 surveys

December 2005-March 2006: General Health facility survey (166 centers)

Phase 1 : 80 facilities Phase 2 : 86 facilities

General Health household survey (2,016 HH) August – November 2006:

HIV/AIDS facility survey (64 centers) HIV/AIDS household survey (1994 HH)

HIV/AIDS study for another presentation

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General Health Centers Survey:Content

General characteristics Human resources module: Skills, experience and

motivations of the staff Services and pricing Equipment and resources Vignettes: Pre-natal care, child care, adult care

VCT, PMTCT, AIDS detection services Exit interviews: Pre-natal care, child care, adult

care, VCT, PMTCT

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Baseline Health Facility: Utilization

Num ber of Obs. cstd

Num ber of Obs. cstd

Curative child care 79 307.165 314.925 81 222.247 162.384 -2.151Curative adult care 79 581.608 799.890 81 461.543 632.451 -1.055Child grow th monitoring 74 129.770 227.201 70 152.100 357.436 0.450Prenatal care 77 77.065 45.741 77 76.013 62.327 -0.119Institutional delivery 74 17.041 17.940 74 13.230 12.221 -1.510Home delivery 49 1.408 5.330 49 1.776 7.811 0.272TB treatment 61 2.393 11.960 62 0.403 0.877 -1.307Malaria treatment 79 305.557 238.645 80 234.838 211.342 -1.979VCT 62 127.048 153.189 57 96.860 185.501 -0.971

NUMBER OF CONSULTATIONS IN AUGUST 2005

Services Provided

Phase I Phase II

T-Stat

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Identified sectors and cells served by each of the 164 health facilities in the sample,

Randomly selected four cells from the catchment area,

For each cell, obtained number of zones (10-15 hh) Randomly selected three zones in each cell Obtained household lists for each of the zones Randomly selected one household for each zone Produced random sample of 12 households per health

facility, with a final sample size of 2,016 households.

General Health Household Level: Sampling Method

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Baseline Field Sampling: GH HH

HEALTH FACILITY

CELL 1 CELL 2 CELL 3

HH 1

CELL 4

HH 4HH 3HH 2 HH 6HH 5 HH 7 HH 9HH 8 HH 10 HH 12HH 11

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Baseline General Household Sample 2159 HH, 10,880 individuals Average HH size is 5.71 individuals, 75% of the sample is under the age of 30 years old.

(Sampling strategy) Not a nationally representative sample:

Sample of rural households with children < 6 years old

Baseline General Household Content

Socio-economic information Anemia finger prick test: children 12-71 months old Malaria dip stick test: children under age 6 Anthropometrics: <6 years old Mental health: mothers, pregnant women, adults over

age 20 Sexual history and preventative behavior knowledge Pre-natal care utilization and results Parents or caretakers were asked for information

regarding child (<5 years) health status

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Baseline Household Data: Education68

Sam ple: ages 6 and up Variable Nr. Obs Mean St d. Error Nr. Obs M ean St d. Error T -st atEver at t ended 3104 79.68% 0.011 4042 80.88% 0.010 -0.825No schooling 2458 10.26% 0.007 3252 10.88% 0.007 -0.606At least som e P rim ary 2458 82.93% 0.010 3252 79.97% 0.010 2.195 **At least som e Secondary 2458 6.46% 0.008 3252 8.42% 0.007 -1.841 *At t ended school in last 12 m ont hs 2391 41.13% 0.015 3181 41.34% 0.012 -0.112Able t o read Kinyarwanda 2532 63.59% 0.015 3359 66.37% 0.014 -1.375

P HASE I (Int ervent ion) P HASE II (Cont ro l)

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Baseline Household Data: Assets

Variable Nr. Obs Mean Std. Error Nr. Obs Mean Std. Error T -st atComplet e sofa set 921 2.18% 0.005 1147 3.08% 0.007 -1.073Radio 921 49.63% 0.023 1147 50.27% 0.017 -0.221Radio-casset t e or music system 921 4.29% 0.009 1147 5.89% 0.008 -1.274Telephone Mobile 921 1.07% 0.005 1147 3.50% 0.007 -2.778 ***Mosquito net s 921 22.53% 0.023 1147 28.00% 0.027 -1.542Sewing m achine 921 0.76% 0.003 1147 1.18% 0.004 -0.883A bed 921 62.82% 0.023 1147 58.71% 0.022 1.290W ardrobe 921 4.53% 0.009 1147 6.07% 0.010 -1.155Metalic library 921 0.57% 0.002 1147 1.28% 0.004 -1.645T able 921 63.47% 0.022 1147 63.40% 0.021 0.021Chair 921 85.48% 0.018 1147 84.82% 0.019 0.255A bicycle 921 16.37% 0.020 1147 17.26% 0.027 -0.262

P HASE I P HASE II

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Baseline Household Data: Activities of Daily Living (21+ years)

Adults, mothers and pregnant womenVariable Obs Mean std Obs Mean std tstatTotal SampleAccepts to perform ADL 1705 79.71% 0.011 2081 81.28% 0.012 -0.988Nr of seconds for 1 sit-to-stand 1376 8.815 0.796 1680 8.807 0.680 0.008Nr of seconds for 5 sit-to-stand 1373 16.991 0.406 1676 16.161 0.437 1.392Nr of sit-to-stand in previous 1329 4.932 0.019 1619 4.904 0.015 1.114Squat for 30 seconds, seconds 1373 29.194 0.228 1676 28.879 0.231 0.970Balance on right foot, seconds 1374 29.074 0.223 1676 28.278 0.240 2.429 **Balance on left foot, seconds 1373 28.893 0.238 1674 28.190 0.248 2.046 **

Phase I Phase II

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Baseline Household Data: Prenatal Care71

Variable Nr.Obs. Mean Std.Error Nr.Obs Mean Std.Error T -st atOf all b irths since Jan. 2005In facility birth 1238 32.05% 0.026 1462 34.87% 0.025 -0.777Of most recent pregnancyTimes received PNC 723 2.781 0.046 900 2.687 0.052 1.368Injection to prevent tetanus 728 74.52% 0.023 900 72.56% 0.019 0.654

P hase I P hase II

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Baseline Household Data: Child Immunization

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Variable Nr.Obs. Mean Std.Error Nr.Obs Mean Std.Error T -st at

12-23 months oldfully_immunized 262 75.36% 0.03 295 77.04% 0.04 -0.3312-71 months oldfully_immunized 1154 63.77% 0.03 1387 65.28% 0.02 -0.43

P hase I P hase II

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Baseline Household Data: Child Health Care Utilization (<6 years)

Variable Nr.Obs. Mean Std.Error Nr.Obs Mean St d.Error T -st at

days_sick 1438 1.96 0.12 1717 2.59 0.13 -3.54 ***receive_care 597 25.21% 0.02 803 25.58% 0.02 -0.13times_receive_care 143 1.58 0.10 218 1.44 0.08 1.12cost_fees 135 246.20 43.80 213 285.71 42.82 -0.65cost_supplies 132 93.05 52.04 208 101.43 28.25 -0.14cost_medicine 133 287.77 64.66 207 475.54 76.57 -1.87 *cost_medicine_nopres162 73.48 19.46 283 109.43 30.67 -0.99cost_lab 134 77.13 21.38 208 78.92 21.43 -0.06cost_other 134 21.35 8.28 204 45.29 19.51 -1.13

P hase I P hase II

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Baseline Household Data:Child Biomarkers (<6 years)

18.67%

7.51%

22.16%

27.82%

19.53%

7.33%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Anemic Malaria Fever and Malaria

Phase IPhase II

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Validity of Sample

Require two different validations: Validate the sampling for the evaluation design

Diff in means tests between Phase I and Phase II to determine if intervention and comparison groups balanced at baseline

Validate the quality of data Compare descriptive stats to other sources of national data

(i.e.: 2005 & 2007 DHS, MOH data)

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Validity of Sample and Data76

Evaluation design Of 110 key characteristics and output variables of HF, the

sample is balanced on 104 of the indicators.

Of 80 key HH output variables, the sample is balanced on 73

of the variables. Majority of the indicators which differ between Phase I and Phase II are

results from patient exit interview, which is not a random sample. Quality of data

HH Results comparable to the 2005 DHS, MOH data

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SECTION 4.2 :Program implementation and

monitoring

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Timeline of Activities

200512 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9

General Health Facility General Health HouseholdHIV/ AIDS FacilityHIV/ AIDS Household

PBF TRAINING PHASE I DISTRICTSPHASE I DISTRICTS: OUTPUTPHASE II DISTRICTS: INPUT

MONITORING DATA COLLECTION

Health FacilityGeneral Health HouseholdHIV/ AIDS HouseholdPHASE I DISTRICTSPHASE II DISTRICTS

2006 20082007

BASELINE DATA COLLECTION

PBF PAYMENTS

FOLLOW UP DATA COLLECTION

PBF TRAINING

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Monitoring Program Roll-out

Regular participation in the PBF technical committee meetings by the impact evaluation team members

Monitor threat to internal validity of sample from: Political pressure to expand PBF into Phase II districts

before 2008 Many facility directors and providers in Phase II districts

heard of PBF through colleagues or media so attempt to imitate treatment

Ensure exposure to PBC for enough time Avoid contamination: Training of phase 2 started after

data collection for HF in May 2008

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Monitoring Program Roll-out Additional data collection effort focused on

monitoring PBF roll-out at facility level Date received training Relationship with Comite de Pilotage: Number of

audits conducted Amounts received at facility due to PBF Allocation of PBF to salaries and other

Monitoring helped to ensure the evaluation team understood the actual roll-out

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Monitoring Program Roll-out Key points for GH analysis

Baseline: Collected prior to training or first payments. Found little evidence of imitation of treatment in Phase

II Follow-up: The MOH initiated a revised training

course for ALL districts in 2008. Phase I districts received March-April 2008, and Phase II

districts received in May 2008 May look at indicators up to March 2008 for all health

facilities as health facility data collection didn’t end until July 2008

82

SECTION 4.3 :Follow up surveys

83

Follow-up surveys February-September 2008 3 surveys:

Combined health facilities survey for General Health - HIV/AIDS

Household survey for General Health (panel data) Household survey for HIV/AIDS (panel data)

84

Follow-up Field Sampling: GH HF Return to 166 facilities

Some GH facilities began offering HIV/AIDS services (VCT, PMTCT and/or ARV) between 2006-2008

Identified in the field and used the HIV/AIDS HF questionnaire; all GH HF questions still asked but in different format

94 (56.63%) GH 2006 & 2008 60 (36.14%) GH 2006; HIV/AIDS 2008 12 (7.23%) incomplete information

85

Follow-up Field Sampling: GH HH

Objective: Return to the same households to create panel data set

(2006-2008) Print baseline roster (names, codes) and keep consistent

across waves Account for household members who left and new

arrivals from 2006-2008

86


Return to same households: In total 2159 were suppose to be surveyed in the

catchment area of 167 facilities. 1888 (87%) were interviewed in 2006 and 2008 267 (12%) were replaced 4 (0.2%) were not found and not replaced

% of replacement by region: South (24%), North (14%), East (4%) and West (13 %)

87


External reasons: Migration result of 1) avoiding Gacaca, 2) employment in Kigali,

3) famine in South during the last 2 years Decentralization in 2006 renamed some areas in study sample;

impossible to locate based on baseline location Internal reasons:

For some health facilities, the baseline HH team didn’t follow sampling procedure

Given a cell to survey by the SPH team but difficult to reach Used the same cell information but surveyed households in another

area Health facilities with 10-13 hh replaced

88


WHAT DOES THIS MEAN FOR ANALYSIS? Restrict to only matched households

1,888 households

89

Assisted delivery – Modern contraceptive use

Meilleures pratiques en SM au Rwanda89Source : Enquêtes démographiques et de santé 1992, 2000 , 2005 et intérimaire 2007

90

P ropo rtio nnal Malaria morb id ity in Health C entres vs Health Utiliz ation R ate

73,570,3

67,4

50,4

37,9

28,4

15

2527,4 29,9

37,8

44,4

71,175

0

10

20

30

40

50

60

70

80

2001 2002 2003 2004 2005 2006 2007

Malaria morbidity Health utilis ation rate

91

Infant and Under 5 mortality rate

92

Trend of Maternal Mortality ratio

Source : Demographic and Heath survey 1992, 2000 et 2005.

93

Section 5:Current and next steps

Current and Next Steps

Reformat, clean data bases to create panel data Initial GH HF results: January 2009 Initial GH HH results: March 2009 Plan dissemination workshop in Kigali to discuss

initial results with key stakeholders and TWG

95

QUESTIONS? SUGGESTIONS?

Performance Based Financing

Rwanda : Increase in utilization of services 2006-2008

(average of 206 health centers)

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Health Interventions

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Date post:	07-Jun-2015
Category:	Health & Medicine
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Scaling Up Performance Based Financing in Rwanda 2004-2008

Health & Medicine