1.
EXPANDING PERFORMANCE-BASED FINANCING POLICY
FROM HEALTH FACILITIES TO THE COMMUNITY HEALTH
WORKERS : THE RWANDAN EXPERIENCE
1
James Humuza, School of Public Health, Rwanda
Dar es Salaam, White Sands Hotel
24-26 November 2015

2.
Presentation outline
2
 Evolution of Facility PBF in Rwanda
 Expanding PBF from facilities to the community
 Research objective and questions
 Methods
 Results
 Main lessons
 Key Messages

3.
Background3

4.
Key Indicators
4
 Rwanda's population 11,262,564
 GDP per capita: US$ 605 (2013)
 Health insurance coverage (CBHI): 75%
 HIV prevalence is at 3%,
 MMR 210/100.000,
 U5MR 50/1000,
 Bed net coverage 82% & utilization: 80%,
 Total Fatality Rate: 4.2%,
 FP coverage among married women: 45%,
Source: DHS 2014/2015

5.
Evolution of PBF in Rwanda
5
 2001-2005: Three pilot schemes in 3 districts funded by
Cordaid, HealthNet, and BTC
 The PBF strategy supplemented input based financing
 2006-2008: IE shows promising results. A national roll-
out plan (30 districts) introduces PBF in all district
hospitals and health centers in a phased approach

6.
6
National Model (2006-2008) System Integration
Some interesting features
 MoH set up national PBF unit to oversee PBF operations
 Three layers of contracts:
 Contract between MoH Unit in charge of PBF and Steering Committee
 Contract between Steering Committee and health facility
 Contract between Health facility and health providers
 Steering Committee: verifies data, performance and
payment levels
 Development of a national PBF website
www.pbfrwanda.org.rw
 Central level communicate results, do forecasts, and auto
payments to individual health facilities
 All Administrative districts can access and enter their data
 HMIS data: data verification for the health facility level data

7.
7
Key enablers for Facility-based PBF Scale up
2004-2006
 GVT institutions and DPs believed in PBF, in part due to evidence
 Aid Policy (2006) which operationalized Paris Declaration (2005)
 Effective national DPs coordination mechanisms
 Scale up period coincided with increased DP funding commitments
for HIV/AIDS, Malaria, and TB that partly financed PBF
 Decentralization reforms: more functions & improved human
capacity created soft landing for PBF scale up
 Initial PBF functions were run with only donors money. Policy
makers were closely monitoring the outcome.
 Key stakeholders worked together: DPs, Researchers & GVT
agencies. There was a shared common vision for PBF
 Overall, there were limited opposing sides among stakeholders

8.
8
The Community PBF: Contractual model
Source: Community PBF User Guide, January 2009
District Steering
Committee

9.
The CPBF remunerated indicators
9
1. Deliveries: Women accompanied/referred to HC for
assisted deliveries
2. Antenatal Care: Women accompanied/referred to HC
for prenatal care within first 4 months of pregnancy
3. Nutrition Monitoring: % of children monitored for
nutritional status (6 -59 months)
4. FP: % of regular users using long term methods
(IUD, Norplant, Surgical/NSV contraception)
5. FP: new users referred by CHWs for modern family
planning methods

10.
The objective and research questions
10
 Objective: This study critically analyses how PBF policy
was expanded from the health facilities to the community
during the period 2005-2015.
 Research questions:
1. Who were the key actors involved in the expansion of PBF policy
from health facilities to the community,
2. What contextual factors and processes shaped the decision to expand
PBF policy from health facilities to community level
3. What policy contents informed the expansion process of the PBF
policy from facilities to the community
4. What policy implication can be drawn for Rwanda & other countries

11.
The data collection process & analysis
11
 We employed Walt and Gilson’s framework for policy
analysis (1994) to retrospectively understand how PBF
policy expanded from facilities to the community level
(2005 to 2015)
 Data Collection:
 Review of Literature
 Snowball techniques lead to selection of 20 Key Informants
 Interviews conducted by face-to-face, phone, and Skype.
 Analysis: CPBF timeline analysis; Interviews were transcribed, coded,
and emerging ideas considered as themes and organized as sub-titles of each
study question. Round of literature review

12.
Results12

13.
The Key events: 2005-2015
13
2005:
Idea is
born
2006:
financial
incentive
s to
CHWs
via
districts
2007:
First
experie
ment
fails.
2009: Grant
signed with
GoR share.
SOP developed
2010
CPBF
pilot
with IE
2011: Capacity
building. All
CHW are put
into
cooperatives
2012:
CPBF
is
scaled
up
2015:
CPBF
IE
results
shared

14.
Enablers (actors)
14
 State actors:
 Ministry of Finance
 MOH: PBF unit in MoH and CH directorate [improve indicators]
 Ministry of Local Government [community social protection]
 Non-states Actors
 International actors
 World Bank (interested in IE as part global RBF financing schemes)
 USG through USAID/ MSH, BTC, GTZ, Suisse Cooperation, Global
Fund to fight HIV, malaria and tuberculosis,
 National private actors [one NGO was involved]

15.
WB and GoR clearly drove the process: Very
little opposition to the move…
15
A former MoH staff and PBF expert
“…Some DPs were supportive of expanding PBF but a few were
skeptical and were not in agreement but you know in Rwanda leaders
don’t necessary go the way partners want to go. Once we understand
that an intervention is yielding results, we roll out it everywhere. Some
were advising that we expand progressively a district after another but
we felt: “why wait?” We decided to scale the program nationally
because we had sufficient funding...”

16.
Enablers (contextual factors)
16
 Country’s readiness to use PBF for quick results:
“…. Around 2005-2006, the President repeated that he did want to see
that we did not perform because of long procedures and from then we
decided to focus more on results not much on the procedures.” A
senior MoH staff
 DPs coordination: align resources to national agenda
 Existing network of CHWs
 National & International momentum to achieve MDGs
 Community social protection system in place
 Decentralized system: financing and management

17.
Enablers (content)
17
 Convincing evidence from facility-based PBF IE
 MoF Aid policy: inspired by Paris Declaration on
Aid Effectiveness (2005)
 Funding: WB and other DPs [GF, USG]
 Integrated PBF strategy in national policies
 Policy guidelines: indicators, CHMIS (for data:
reporting, verification, payment system)

18.
Enablers (process)
18
 Earlier policy and strategic plans endorsed PBF as a
strategy to achieve health outcomes
 Facility PBF inspired CPBF designed process
 Ownership process already advanced
 Building on the international visibility momentum
 District health teams formally requested to prepare
and plan training meetings for C-PBF
 Policy makers and DPs were familiar with process

19.
Lessons19

20.
Enablers: some were the same
 Several enablers for expanding PBF from facility
to the community are quite similar to those which
allowed the scale up of Facility-based PBF
 Aid policy on DPs coordination (2006)
 Complimentary interests from DPs [WB] and GoR
[MoF, MoH, and Local Government]
 Comparative advantages [relatively small nation, one
language, one culture]
 Evidence [Impact Evaluation]
20

21.
Enablers: some new ones
 New enablers [specific to CPBF)
 Existing well established system of CHWs in the country
 A design component of income generation [cooperatives]
 Decentralization: functions, resources, and management
 Increased demand [CBHI] complemented supply [CPBF]:
“… there was CBHI already which came almost at the same time
and this boosted the demand side so we needed to reinforce it with
the supply—and PBF came just at the right time…”
21

22.
Three key messages…..
22
 Success with facility-based PBF (and evidence!) will create
a window of opportunity for other reforms such as C-PBF
or in other sectors. Policy makers need to seize window of
opportunity to build momentum to become champions.
 Ministry of Finance is a key player at all stages — its buy-
in is critical to ensure future financing.
 Risk: self-satisfaction. E.g. indicator plateauing may be
deceptive to policy makers and this may hinder creativity
and dynamisms of continuous innovation—detrimental for
PBF as a strategy for reform.

23.
23
Thanks for your attention

24.
Facility PBF timeline in Rwanda
Oct 10
Start of C-PBF
Evaluation
Jan 09
Start of C-HMIS
Jan 09 Jan 10

25.
Table 1: Output Indicators (U’s) and Unit Payments for PBF Formula
OUTPUT INDICATORS Amount paid per unit (US$)
Visit Indicators: Number of …
1 curative care visits 0.18
2 first prenatal care visits 0.09
3 women who completed 4 prenatal care visits 0.37
4 first time family planning visits (new contraceptive users) 1.83
5 contraceptive resupply visits 0.18
6 deliveries in the facility 4.59
7 child (0 - 59 months) preventive care visits 0.18
Content of care indicators: Number of …
8 women who received tetanus vaccine during prenatal care 0.46
9
women who received malaria prophylaxis during prenatal
care
0.46
10 at risk pregnancies referred to hospital for delivery 1.83
11 emergency transfers to hospital for obstetric care 4.59
12 children who completed vaccinations (child preventive care) 0.92
13 malnourished children referred for treatment 1.83
14 other emergency referrals 1.83

26.
Content: Community PBF Indicators
26
Incentivized indicators
Unit Fees (USD) (2010-2014/15)
2010 2011 2012 2013 2014
1 Deliveries: Women accompanied/referred to
HC for assisted deliveries 2.73 1.37 0.99 0.99 0.99
2. Antenatal Care: Women
accompanied/referred to HC for prenatal care
within first 4 months of pregnancy
2.24 1.12 0.81 0.81 0.81
3. Nutrition Monitoring: % of children
monitored for nutritional status (6 -59
months)
3.24 0.565 0.433 0.433 0.433
4. Family Planning: % of regular users using
long term methods (IUD, Norplant,
Surgical/NSV contraception)
2.11 1.06 0.77 0.77 0.77
5. FP: new users referred by CHWs for
modern family planning methods 2.9 1.45 1.05 1.05 1.05

27.
Enablers for the emergence
27
 2005: idea to provide financial incentives to
CHWs emerges
 Presence of donor resources for HIV/AIDS, Malaria, TB
 WB, GF and other DPs commitment to fund PBF
 Facility PBF IE showed little improvement on indicators
outside provider’s control (FP, Prenatal care, acute Mal)
 Concept of “high impact interventions” at community level
promoted by some actors
 Through comprehensive process, PBF was expanded from
facilities to the community