Rwanda Community Performance-based Financing

1. Rwanda Community Performance-based Financing Ministry of Health 29 June 2010/ Mille Collines

2. The Problem • Providers was not rewarded for achieving health results. • This lack of connection between what is rewarded and the reason for providing health services to improve health was one of the underlying causes of poor health outcomes. • Compounding the problem was that households has limited ability to motivate service providers to be responsive to their needs.

3. Strengthening accountability in the health sector in Rwanda PERFORMANCE BASED, CASH AND IN KIND INVESTMENT INPUT SUBSIDIES TRANSFERS NATIONAL GOVERNMENT LOCAL GOVERNMENT VOICE Performance CONTRACTS Umushyikirano, Citizen Report Cards, Ombusdman CLIENT POWER Clients / Citizens AUTONOMOUS FACILITIES PROVIDERS COMMUNITY GOVERNANCE COMMUNITY HEALTH WORKERS PROVIDERS COMMUNITY HEALTH INSURANCES Mutuelles

4. Background • In 2005, MOH prioritized 3 major strategies aimed at improving the quality of health services at community level through: • Community-Based Health Insurance (CBHI) • Performance-Based Financing (PBF) • Quality Assurance • The concept of Community PBF was introduced in January 2006 in all districts of Rwanda, with funds channeled through local administration.

5. Background • 2006-2008 Community PBF Indicators • Number of enrollees (adherent) to Community-based Health Insurance (CBHI)in catchment zones • Sensitization aimed at institutional deliveries • Sensitization to use insect treated mosquito nests (ITN) • Treatment of dehydration for under 5 children • Hygiene • Report of community health activities by CHW

6. Background • 2006-2008 Community PBF Challenges • Diversion of funds for other priorities by District authorities • Delay to report on indicators • Delay in releasing funds to the districts • Lack of motivation to supervise and coordinate implementations at the community level • Lack of standard data collection tools • Delayed feedback reporting between district and MOH • Lack of verification mechanisms for data collected

7. 2009-2012 Community PBF Model • Developed as result of challenges of 2006-2008 Community PBF • Discussions led by PBF Technical Working Group • Mid-December 2007: revised Community PBF Model was drafted • New Model was discussed at different levels for amendment (MOH policy and planning department, MOH Senior Management Meeting, and PBF TWG), and adopted.

8. Evidence-based Decision Making • Results from Health Center PBF impact evaluation showed that MoH has achieved: • Improved utilization – deliveries, child care preventive care • Improved quality – prenatal care effort and tetanus vaccine • Evidence suggested that expansion of PBF to community level could reduce difficulties associated with achieving maternal and child health indicators: • Nutritional status • Timely prenatal care utilization • Institutional delivery • Timely postnatal care utilization • Modern contraceptive use

9. 2009-2012 Community PBF Model • Inspired andinformedby Health Center PBF • Purchaser: PBF Sector Steering Committee • Controller: Health center • Providers: CHW cooperatives

10. Separation of Functions • Contractual mechanisms between actors • Quarterly flat payments upon submission quarterly results • Conditioned on ….. quality of reports, timeliness, etc.

11. The Administration of the Community PBF Model

12. CommPBF Program Description • CHW cooperatives receive incentives payment for: • Timely submission of quality data reports on 22 maternal and child health indicators • Targeted improvements in 5 indicators (Nutrition monitoring, early antenatal care, institutional delivery, family planning: short and long terms). Paid for coverage levels in the indicators • Demand-side Incentives model • Introduce conditional in-kind incentive payment to women on 4 indicators • Early antenatal care, institutional delivery, timely postnatal care.

13. Program Challenges • Training: CHWs need training in essential service delivery, data reporting, use of mobile technology, and income generating activities; • Robust data verification mechanisms to ensure that minimum package of community health services has been delivered; • The logistics to deliver the minimum package of community health services; • Data verification mechanisms on reported indicators; • Communication issues: cell phones for reporting and sharing information regarding the community-based activities; • Issues related to the design and management of community health workers’ income generating activities (cooperatives)

14. Program Impact Evaluation: Aims and Objectives Do PBF incentives to CHW cooperatives and women for maternal and child health indicators: • Increase the quantity of health services for women referred to a health center? • Improve the health status of the population? • Improve the quality of the services provided. (CHW incentive only) ? • Improve the motivation and behaviors of the CHWs. (CHW incentive only) ? • Have no impact on the non-PBF services delivered ?

15. Impact Evaluation Methodology • 4 study arms = 200 sectors, 2400 households • 150 Treatment sectors begins April 2010 • 50 Control sectors incorporated January 2012

16. Program Status and Next Steps • Implementation manual and roll-out plan agreed and endorsed by Minister of Health January 2010 • Demand-side intervention implemented in 30 VUP sectors (excluded from impact evaluation) January – March 2010 • Impact Evaluation baseline data collection January – March 2010 • Identify technical support for establishment and management of cooperatives • CHW cooperatives start submitting data reports to the Community PBF Steering Committees in first quarter of 2010 • Demand-side incentive min-evaluation in 30 VUP sectors to inform scale-up of program • CHW cooperatives start receiving incentives payments for indicators by April 2010 • Health centers in 100 sectors scale-up demand-side incentives by April 2010

17. Thank you