What PBF can achieve; Example from Rwanda

Claude SEKABARAGA, MD, MPH

World Bank, Nairobi Hub.

January 2010January 2010

U5MR (per 1,000) in sub-Saharan Africa – MDG4 Target and Actual

0

20

40

60

80

100

120

140

160

180

200

1990 1995 2000 2005 2010 2015

Target

Actual

184

158

61

Source: Global Monitoring Report 2008

Actual U5MR (DHS) vs. MDG4 target in Rwanda – 35% reduction from 2005 - 2008

0

40

80

120

160

200

1992 2000 2005 2008 2012 2015

Actual

Target

REDUCTION OF INFANT MORTALITY

1/3 in years

Modern contraception prevalence (% 15 -49 year-old women)

13

410

27

70

0

10

20

30

40

50

60

70

80

1990 2000 2005 2008 2015

63% of increase in three years

Births attended by skilled health personnel (% of births)

2631

39

52

95

0

10

20

30

40

50

60

70

80

90

100

1990 2000 2005 2008 2015

25% of increase in three years

MAL AR IA C AS E F AT AL IT Y R AT E IN H E AL T H C E NT E R

0.3

2

4.6

6.25.7

7.7

10.1

0.6

2.9

5.25.75.8

8.1

9.3

0

5

10

15

2001 2002 2003 2004 2005 2006 2007

Yea rs

Perc

entag

e

Malaria cas e fata lity rate < 5 Malaria cas e fata lity rate

IMIHIGO: Performance based services for territorial administration

Strong political commitment to results Contract between the President of the Republic

and the district mayors and different local administration levels;

Key health indicators integrated in the contract (in 2007: ITNs, Mutuelles, FP, safe deliveries, hygiene..)

Quartely review with Prime Minister, President attending twice a year

Autonomy of providers institutions

Based on Bamako Initiative Delegation of management Health centers and hospitals fully autonomous Subsidized by the government: PBF, needs

based block grant (initially for wages) Support to planning: Strategic and operational

planning are the fundament of the approach.

Human resources management

Decentralization of wages; Community through facility committee have the authority to

hire and fire; Community through facilities receive block grant from

government; “People follow the money”; Retention of health personnel in rural areas increased.

Trend in the financing of district health personnel

Evolution of the number of selected staff in rural and urban districts (public sector)

RESULTS BASED FINANCING PRINCIPLES

What is Results Based Financing?

Incentives targeting provider’s behavior to produce more results and to comply on quality standards;

Incentives targeting household or individual behavior to use more services

Financing mechanism for defined quantity and quality outputs and outcomes.

PURCHASER

PROVIDER

HealthResults

Financial Incentives

Verification of quantity and quality

Why to finance results vs. inputs?

Payment result

Financing strategy

Actions for results

Objective

Result

Equipment, consumables,Drugs, salaries, etc.

Supervision, training, audit

and Sanction?Investment ?TIME

RBF PRIORITY AREAS AND BENEFITS

Based on major bottlenecks; Priority to composite indicators and avoid

selective performance; Quantity preventive interventions and quality of

both prevention and curative services; Promotion of local creativity and spirit for

performance; Improvement of remuneration of personnel and

equipment linked to services to community: ACCOUNTABILITY.

How to finance results?

Evaluator/verificator

Regulator

ProviderPurchaserBeneficiary

What systems are needed to implement RBF successfully? Does the regulatory framework require

change? How will results be routinely monitored

(HMIS?) and verified?

How to sustain? How will the government decide if it will continue to fund through RBF mechanism? How will you show impact? How will you show cost-effectiveness?

Concerns

THE PERFORMANCE FINANCING SYSTEM

SUSTAINABILITY OF RWANDA PBF FINANCING

Results:Services produced (after 27 months of extention)

Results:Services produced (after 27 months of extention)

Indicateurs FBR Janvier 2006moyenne

mensuelle par centre pour 258 centres de santé

Mars 2008moyenne

mensuelle par centre pour 286 centres de santé

Pourcentage d’augmentation

Accouchements Assistés

21 37.5 78%

Nouvelles consultations curatives

985 1,489 51%

CPN: 2ième dose Anti-tétanique

21 52.5 150%

Nouvelles utilisatrices PF

15.5 47.9 209%

Utilisatrices de PF à la fin du mois

175.2 711.6 306%

FAMILY PLANNING

R2 = 0.8635

0

5

10

15

20

25

30

35

40

45

50

55

60

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

2006 2007

Per

cen

tag

e

50

194% increase

17

Impact on quality of prenatal care

-0.10

0

-0.13

0.15

-0.15

-0.10

-0.05

0.00

0.05

0.10

0.15

0.20

Baseline (2006) Follow up (2008)

Stan

dard

ized

Pre

nata

l eff

ort s

core

Control facilities Treatment (PBF facilities)

15 % Standard deviation increase due to PBF

24

Impact on institutional delivery

36.3

49.7

34.9

55.6

30.0

40.0

50.0

60.0

Baseline (2006) Follow up (2008)

Prop

ortio

n of o

f ins

tituti

onal

deliv

erie

s

Control facilities Treatment (PBF facilities)

7.3 % increasedue to PBF

25

HEALTH CENTER(46.8 M USD)

Mutuelles

Amount: 13.8 M USD User Fees

Amount: 6.6 M USD

RAMA, MMI, PRIVATE INSURANCES

Amount: 5 M USD

Earmarked transfers from Minecofin

Formula: Norms of personnelAmount: 13 . 6 M USD

Performance Based FinancingGovernment: 4.2 M USDDonors: 3.6 M USD USG and BELGIUM

Formula: performance

DISTRICT HOSPITAL

(31.162 M USD)

Performance Based Financing:

Formula: quality performance

Amount: 2.4 M USD

.

Mutuelles: 7 M USD

User FeesAmount: 5 M USD

RAMA, MMI, PRIVATE INSURANCES

Amount: 162, 000 USD

Earmarked transfers from MinecofinFormula: Norms personnelAmount: 16.6 M USD

COMMUNITY, HEALTH CENTER and

DISTRICT HOSPITAL

Development Partners in kind transfers

Total amount: 60.6 M USD

GoR In kind transfers

Total amount: 12.2 M USD

COMMUNITY PBF

To reduce child mortality: Malaria, pneumonia, diarrhea and monitoring of malnutition), and family planning;

Five CHW (a lady and a man for IMCI package) by village;

Organized in cooperatives and paid based on a package of services produced and checked by health center in term of quantity and quality.

Conclusion BUILDING CULTURE OF RESULTS MORE THAN

INPUTS AND PROCEDURES

For ACCOUNTABILITY:1. Separation of functions: Purchasers, providers and direct

beneficiaries;2. Clear link between public funds and direct services to

community; Priority on high impact interventions (Family planning &

reproductive health, prevention interventions and family & community services)