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Performances Based Financing scheme in Rwanda INVESTING MORE STRATEGICALLY 1 Performances Based Financing scheme in Rwanda INVESTING MORE STRATEGICALLY 1

Outline of Presentation p p p Rwandan Context PBF scheme in Rwanda n PBF Outline of Presentation p p p Rwandan Context PBF scheme in Rwanda n PBF approach n Implementation model and funds flows n PBF funding in Rwanda Some Achievements and Challenges 3

Background p The performance-based funding (PBF) is one of the pillars of health financing Background p The performance-based funding (PBF) is one of the pillars of health financing and strengthening the health system in Rwanda. This approach was introduced in order to strengthen the motivation of care providers and results (output) than traditional financing (for input) had not previously yielded

Historical p p p Started in 2002 as pilote by two NGOs in former Historical p p p Started in 2002 as pilote by two NGOs in former Butare and Cyangugu provinces. The Mo. H integreted the PBF in 2005 HSSPI and decided to implement PBF in the whole country’ health facilities. The scaling up started in early 2006 with the second phase of decentralisation.

Rwandan Context Population 10. 4 million; >90% are in the informal sector 45% living Rwandan Context Population 10. 4 million; >90% are in the informal sector 45% living under poverty line (EICV 2011) 96% health insurance coverage (91% CBHI) Per capita income 2011 = US$ 540 Health Budget as % of Total Budget: 16% (Abuja target attained) INDICATORS BASELINE 2005 MTR June 2008 MTR TARGET Aug 2011 2012 2015 Source of Information DHS 2005 I-DHS 2010 EDPRS MDGs Infant Mortality Rate / 1000 86 62 50 37 28 Under Five Mortality Rate / 1000 Maternal Mortality Rate / 100. 000 152 103 76 66 47 750 NA 487 455 268 IMPACT INDICATORS 6

Decentralized health organization National Level District Level Central Level 5 National Hospitals 30 Districts Decentralized health organization National Level District Level Central Level 5 National Hospitals 30 Districts District Hospitals 416 Sectors Health Centres Sector Cell Umudugudu Health Posts 7

Performance-Based Financing Value for Money approach Objectives: • Improve efficiency & rational use of Performance-Based Financing Value for Money approach Objectives: • Improve efficiency & rational use of health resources • Coverage of high impact interventions • Increase utilization of qualitative services care • Improve equity in resource allocation • Increase health worker motivation • Empower users of HF by giving them voice • Strengthen autonomy of health structures and build capacity of managers The national PBF model is composed of the following components: (1) PBF model for health centers; (2) PBF for district hospitals; and (3) Community PBF 8

Implementation model and funds flow 9 Implementation model and funds flow 9

INDICATORS ON MERGER DESEASES 1. HIV q The SSF/HIV Grant is currently providing PBF INDICATORS ON MERGER DESEASES 1. HIV q The SSF/HIV Grant is currently providing PBF funds to Health Facilities (DHs and HCs) q 18 indicators are paid (HIV/AIDS, TB/HIV, Reproductive Health/HIV) 2. TB q The PBF TB program has been scaled up at the national level within 498 health facilities including 42 Districts Hospitals, 147 Health Center – Center of Diagnosis and Treatment “CDT”, 296 Health Center – Center of Treatment “CT”, 8 Prisons – CDT and 6 Prisons – CT q 26 indicators are paid 10

Progress of implementation p p p CAAC submit the quarterly progress report Data verification Progress of implementation p p p CAAC submit the quarterly progress report Data verification and counter verification mechanism in place Payment verification mechanism in place Integration with other health financing initiatives (CBHI) Payment made 11

One of the achievement of PBF scheme 12 One of the achievement of PBF scheme 12

ONE OF THE RESULT: Trend of prenatal care quality between treatment and control facilities ONE OF THE RESULT: Trend of prenatal care quality between treatment and control facilities (2006 -2008). 13

Impact of PBF Two years into the national roll-out, the over-all performance of health Impact of PBF Two years into the national roll-out, the over-all performance of health facilities showed significant increase. As of 3 rd quarter 2010, quality score of district hospitals in the country is 72. 2% (range 33%-96%) (MSH, 2011). A rigorous impact evaluation of the health centre PBF found positive effect on HIV, MCH and TB outcomes. Institutional delivery increased over-all but 7% more in PBF facilities between 2006 -2008. PBF has increased prenatal care quality significantly (SPH/WB, 2010) Individual VCT for HIV has significantly increased but more so for married couple VCT 14

Successful role-out of performance based financing (PBF) p p p Careful phased approach Purchase Successful role-out of performance based financing (PBF) p p p Careful phased approach Purchase of verified quality services Increased discretionary resources for health facilities Improved motivation of staff (financial incentives and equalization of revenues) Strengthened quality assurance mechanisms (supervision and verification) Clarified supervision, evaluation and "coaching" (peer-review) The Rwandan example shows foremost the synergies of a number of reforms, i. e. difficult to attribute the percentages of success to each and every one of these reforms 15

Challenges for PBF p p p Clarify role in long term vision and strengthen Challenges for PBF p p p Clarify role in long term vision and strengthen links with demand side financing mechanisms Maintain momentum and improve assessment process Sustainability of PBF from Partners in this global financial crisis and economic downtown Need to continuously revise indicators and increase the PBF award to buy results Need to promote equity in PBF awarding 16

Thank you for your attention 17 Thank you for your attention 17