This document discusses performance-based financing (PBF) models implemented in Rwanda. It provides background on PBF, outlines key principles like separating purchasers and providers, and describes the three initial PBF pilot models in Rwanda. It then discusses scaling up PBF nationwide, including developing national PBF models for health centers and hospitals. The results section highlights increased service volumes, improved quality of services, and enhanced provider motivation associated with PBF implementation in Rwanda.
6. PBF Control is NOT ‘business as
usual’ in data gathering
District
quality
assessment
team
checkingdata
qualityina
healthcenter
7. Assuring Data Quality – Multiple
levels of control
‘ ’Data quantity audits conductedeverymonthoneach
indicatorfromeverysite(registervsreport)
Monthly report data are reviewed by district PBF steering
committees (comparingtopreviousperiods,identifying
outliers,requiringcorrections)
Community client or “phantom patient” surveys every6
monthatasampleof sites–lookforphantompatientsand
seeksfeedbackfrompatientsonqualityof care
National PBF cell reviews database each quarter forthe
entirecountry–correctionsaremadebeforepayment
11. Overview of the three Rwandan Pilot
PBF models
Model
No of Clinics
under
contract
No of
Hospitals
under
contract
DHT's
under
contract
Project
Budget per
capita per
year $
PBF Budget
reaching
clinics per
capita per yr $
Average
Health Worker
Income
$/month
“Cyangugu”
model
26
(+14 HP and
19 private
dispensaries)
4 4
$2
(2005)
$0.41(i)
(2004)
$117
(2004)
“Butare”
model
36 3 4
$0.3
(2005)
$0.13 (i)
(2004)
$110
(2004)
“BTC”
model
75 4 6
$1.57
(2005)
$0.08 (ii)
(2005)
Base salary +
$18
(2005)
PBF pilots covered 137 Health Centres (about 40% of total) and 11 District
Hospitals (about 30%) by end 2005
13. Quality Assurance
Performance based
financing
Community-Based
Health Insurance
High Performing
Facilities
Appropriateservices
and contentof care
defined
Goodorganization
andmanagementof
care
Appropriate
informationfor
decision-making
Functional referral
system
AdequateFinancial
andmaterial resources
StrongStaff
Motivationand
Competence
Active Participation of
the Population
High quality
healthcare
Incompliancewith
normsandmeets
expectations
Abilitytoactoncare
andpreventionneeds
Financial and
Geographical Access
Freedomtochoose
careoptions
Well informedand
competentclients
,Sustainable
Improved Health
Outcomes
Consistent Use
of Health
Services
Consistent
Adherence to
Care
14. Rwandan National PBF Models
PBFmodel forhealth
centers
PBFmodel fordistrict
hospitals
CommunityPBF
Central level PBFfor
MoHdepartment/units
17. Performance Payment Mechanism developed
Performance Payments = (# serviceoutputs* Unitfees) * %QualityscoreΣ
No Indicator Quantity Fee Amount RWF
1VCT: number of clients tested 899 500 449,500
2PMTCT: number of pregnant women tested 101 250 25,250
3PMTCT: Number of couples and partners tested 134 2,500 335,000
809,750
Quarterly quality score X 87%
Payment amount 704,483
18. Performance Payment Amounts
Combined PBF payments to Health Centers and Hospitals to date (from
USGpartners(Pepfarfunded), BelgianTechnical Cooperation,Global Fund)
Service package 2006 2007 2008 2009 YTDGrand Total
Primary Health Care
Package $186,093 $ 1,160,087 $2,918,035 $1,916,588 $6,180,804
HIV/AIDS package $27,874 $ 867,077 $2,490,787 $1,614,068 $4,999,806
Grand Total $213,967 $2,027,164 $ 5,408,823 $3,530,656 $11,180,610
25. Increase in Volume of Services
(after 39 months)
PBF Indicator 2006 /January average
/month
health center
(258 health centers on
)average
2009March
/ /average month
health center
(297 health centers on
)average
Percentage increase
( / 2)linear log R
Institutional
Deliveries
21 39.7 89%
(log 0.77)
New Curative
Consultations
985 1835 86.3%
(log 0.28)
ANC new cases 100.8 76.2 -24%
(log 0.05)
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)
26. Increase in Volume of Services
PBF Indicator October 2006 average/
month/
health center
(6 health centers)
December 2009
Average/month/
health center
(6 health centers)
Percentage increase
(linear R2)
VCT clients tested 158 372 135%
(0.45)
PMTCT children born
to HIV+ mothers seen
for CTX treatment
7 29 (dec 09) 325%
(0.75)
Number of HIV+
clients treated with
CTX
55 134 143%
(0.82)
In presenting the conceptual framework we start with the assumption that the goal of the health care provision system is the achievement of sustainable, improved health outcomes (Mouse Click) . These improved outcomes are achieved through the provision of high quality health services which adhere to norms and standards and also meet client needs (Mouse Click) . With the provision of good quality services, the population uses the services (Mouse Click) , adheres to the prescribed preventive and curative services (Mouse Click) and thus achieve the desired improved health outcomes. High quality services are only achieved if we have high performing facilities (Mouse Click) and the active participation of the population (Mouse Click) . To ensure that these exist, the ten determinants of quality must be present – six on the facility side (Mouse Click) , and four on the population side (Mouse Click) . By now looking at the inputs and supports to the system brought by the three core strategies, we can see how the determinants of quality are achieved: Performance based financing (Mouse Click) ensures that we have appropriate information for decision-making, adequate financial and material resources, and strong staff motivation and competence on the facility side, while also providing support to assuring financial and geographical access on the population side. Mutual Health Assurance (Mouse Click) ensures that the is financial and geographical access and that patients have the ability to act on their care and prevention needs. MHA also provide strong input into the definition of what are appropriate care services on the supply side. Quality Assurance activities (Mouse Click) come into play by defining and measuring performance, and establishing performance improvement loops to continuously improve the quality of care by impacting both the provider and population interactions.
Close collaboration with USG collaborating agencies on PBF for HIV/AIDS services has been initiated since the start of the project