Improving Health in Rwanda with Performance-Based Financing

Jean Kagubare, MSH's Performance-Based Financing Principal Technical Advisor. {Photo credit: MSH.}Photo credit: MSH.

After the Rwandan genocide in 1994, the Government of Rwanda has worked to rebuild its shattered health system. Management Sciences for Health (MSH) works in partnership with the US Agency for International Development (USAID) and the Rwanda Ministry of Health to develop innovative health financing initiatives to provide more effective, quality HIV and primary health services.

MSH spoke with Jean Kagubare, MSH's Performance-Based Financing Principal Technical Advisor, about implementing a national PBF model in Rwanda.

What was the state of the health system after the genocide in Rwanda?

After the war, the health system of Rwanda was completely destroyed in all senses – people, infrastructure, and systems. It took a while for the government to rebuild the entire health system.

The government took bold initiatives, to introduce, among other things, new health financing policies. The first initiative allowed people, particularly the rural population, to prepay for health services and get health care without paying too much out-of-pocket.

The second major decision was to introduce performance-based financing (PBF). PBF is an approach to structuring the flow of resources to pay for results—desired goals, outcomes, and even impacts—rather than simply paying for processes or reimbursing activity costs. In using a performance-based approach, the purchaser transfers to the provider (or contractor) significant power and authority over strategies and activities, and also the potential for reward or loss (respectively, as goals are met or if performance does not meet agreed-upon targets). The pilot phase began in Rwanda in 2001.

In 2003, the Government introduced the third pillar, the quality assurance policy which aims at providing high quality care to the population.

These three major initiatives have shaped the current health system in Rwanda.

As for disease burden, you can imagine Rwanda—as many other countries in sub-Saharan Africa—was battling communicable diseases. HIV & AIDS was actually among the highest in the region; there was 12% prevalence rate. Malaria, tuberculosis, and malnutrition were also major issues in Rwanda. The weak health system had to struggle with these burdens, and the war had wiped out the entire health workforce. Rwanda had to depend on personnel from neighboring countries until teaching institutions were fixed.

By 2004, Rwanda made great gains in stabilizing its own health system. The goal is that Rwandans would be able to pay for their health (at least part of it), and receive quality health services. PBF helped shift the focus of Rwanda's health system to provide results. Health care facilities are now paid based on the quantity and quality of services provided, not the process of delivering care. 

What role does performance-based financing play in Rwanda?

Rwanda now has a national PBF program integrated into its health system, but it took a while to get there. There were three pilot models that were conducted primarily by nongovernmental organizations (NGOs). The Minister of Health wanted to have several models at the district level to learn from them before scaling up to the national level.

By 2005, the Government of Rwanda decided to go to one national PBF model. There was a conference and all the key players discussed and negotiated to reach one plan, a combination of the three pilot programs.

The Ministry of Health is responsible for designing and overseeing the national PBF Program. All the key players and donors follow this model, stakeholders settled on the indicators, and a PBF steering committee was created. The committee oversees PBF at the district level and ultimately does the evaluation and signs off on the payments. The national mechanism is easy—once the committee approves the result, the money is pulled out of the finance pool and is paid directly to health facilities.

There is a set of indicators that address basic health services and other health issues. Donors place money into this national pool and the money is used to fund all the health results achieved. Donors cannot only fund disease specific health services: they have to fully support all services. Priority is no longer placed on one indicator over the other; it is balanced. This model has helped integrate health services provided in Rwanda.

The Government of Rwanda is becoming the biggest funder of the PBF program.

PBF helps a health system look at the health results—for example, how many children are immunized—and pay for it. With PBF, the donors and government do not worry about the details.

It is an attitude shift for many people. Now health facilities are given money and the Government is not looking for invoices. They trust the facilities to complete the process to achieve results.

There is a lot of responsibility on the health care staff and on the administrators to produce good data and results. You cannot say you have immunized 12,000 children unless you can prove it.

What is Management Sciences for Health's PBF approach?

MSH manages performance-based grants and contracts and provides technical assistance to governments, private organizations, and funding agencies to develop and implement their own PBF programs. These programs align with donor requirements and local circumstances and maximize synergy by sharing tools, approaches, and systems.

Performance-based financing is a relatively new results-oriented and practical approach that ties payments to achievement of agreed-upon, measureable performance targets. Incentives include financial payments, bonuses, and public recognition. Sanctions for non-performance include withholding or not awarding bonus or payments, termination or reduction of agreement, public disclosure of poor performance, or disbarment from participating in future work.

In addition, MSH uses five key strategies to strengthen health systems and reach public health impact goals: 1) effective management of performance contracts, 2) host country capacity building, 3) quality improvement of health services, 4) strategic use of data 5) ensure sustainability including community involvement to increase demand and participation.

In our approach of PBF we have incorporated quality indicators: if you do well in terms of quantity we also verify that the delivery was done in good conditions and in a quality way.

It is not only just contracting, we also check the quality and make sure the quality is thoroughly investigated before making payments.

If a health worker completes a lot of immunizations, but the vaccines were not properly kept in the fridge, the desired result is not met and the health facility is not paid. We visit communities to verify that quality services were actually received. PBF works because health providers know they cannot cheat.

So far, MSH has supported the design and implementation of PBF for health care in 14 countries on three continents. These programs focus on MSH's priority areas, including HIV & AIDS, maternal, newborn, and child health; family planning and reproductive health; and primary health care services.

In Rwanda, MSH managed USAID's PBF/HIV project, which provided technical assistance to the Ministry of Health in implementing national PBF initiatives that fund the delivery of HIV and primary health care services through health centers and hospitals in most districts of the country. MSH is helping implement the USAID-funded program Integrated Health Systems Strengthening Project (IHSSP) which assists the Rwanda MoH in widening its scope to the strengthening of information systems and human resources management in a decentralized structure. The Project is working to support the government's efforts to extend quality public health services to the entire country through awarding PBF grants.

What health indicators does the national PBF model monitor and reward in Rwanda?

The Government and stakeholders selected two types of indicators: quantity and quality indicators. Quantity indicators have two subsets: 1) 14 core for general basic health package services (such as: curative consultations, immunization, family planning, etc.) and 2) 10 HIV specific indicators related to voluntary counseling and testing, prevention of mother- to-child transmission, ARVs, and TB/HIV interventions.

There are about 140 quality indicators that cover areas from general management of health facilities (hygiene, financial management, drug management, etc.) to quality of specific clinical interventions (family planning, curative consultation, immunization, referrals, etc.).

You mentioned that HIV, Malaria, and TB are the major health challenges in Rwanda. Are those still the major health challenges in Rwanda?

They are still, but Rwanda has successfully controlled a lot of the disease burden. The most recent HIV prevalence study (Demographic Health Survey) showed that HIV prevalence dropped from 12% to 3% in 6 years.

As for malaria, the latest indications show the mobility and mortality of malaria have decreased by 60% in Rwanda. Rwanda is going to be one of the few countries to successfully reach Millennium Development Goals 4 and 5 in 2015. (MDG 4 focuses on improving infant mortality and MDG 5 focuses on improving maternal health.)

PBF has provided a mechanism for Rwanda to reach these achievements.

What are the biggest challenges of implementing PBF at the national level?

One of the biggest challenges was agreeing on one model. There were so many competing models, but eventually we overcame that and focused on Rwanda's needs. The driver's seat should be a national program, not a program that is run by donors.

The second challenge is sustainability. Once you put a system in motion you do not want it to stop, particularly if it is yielding good results. However, financial sustainability is important. When we started, donors were the major funders of the programs, and now more and more the Government is taking responsibility. In Rwanda we are comfortable; if donors were to pull, the government could certainly do the funding. We still have a need for support because it is a lot of money that the government would not otherwise be able to fund completely.

The third challenge is how to implement a verification mechanism, which is not parallel to the existing health information system. In Rwanda, we can report that this challenge was overcome. MSH was instrumental in building a website that captured all this information in one place. The information is flowing back and forth and it has become powerful. Data from the health districts are input and the committee reviews it—and, once the results are approved, the money is automatically transferred into each health facility account. The web platform also increases the availability of real-time data to improve reporting and compare results.

Why is PBF an important intervention in states emerging from conflict?

In some countries emerging from conflict, for example Afghanistan, you have a weak government that is providing a few services, or you have countries where multiple NGOs are doing things for the government.

In Afghanistan, MSH and the World Bank subcontracted with local NGOs to provide health services to the population where there were no government health facilities. The PBF program was used and yielded very impressive health results in a short time period.

In Haiti, for over a decade MSH has been working with local NGOs to provide basic health services through PBF contracts. MSH is now helping the MOH introduce a PBF program at the community level to provide key preventive health services.

For fragile states where usually large amounts of donor money is coming in, PBF shows health providers that results have to be achieved to get paid.

Why is health financing an important pillar of a strong health system?

For some time, people have forgotten that money is needed so the engine can run. Financing is critical to not only fix infrastructure and equipment, but also to motivate and pay the health workforce. Without money, we can ask people to do whatever, but if they do not have the fuel to run the engine they cannot achieve results.