Involving the Community in Performance-Based Financing in Rwanda

After successfully supporting the national scale-up of performance-based financing (PBF) for health centers in Rwanda, Management Sciences for Health (MSH) is now providing technical assistance to the Rwandan Ministry of Health (MoH) to sustain and improve this model and to introduce PBF at the community level. PBF is an innovative health financing solution that structures the flow of resources to pay for results rather than simply paying for processes or reimbursing activity costs. Health facilities are paid based on the quantity and quality of services they provide, not on the processes it took to provide these services.

MSH's Integrated Health Systems Strengthening Project (IHSSP), which is funded by USAID, supports the MoH in the implementation of an innovative model by developing a national procedure manual and organizing trainings in a cascade approach throughout the country. Monitoring and evaluation of IHSSP  has been set up by MSH and includes a central web-based database system, data control mechanisms, and an automated payment mechanism generated through the web-based database. All of these are crucial elements to manage this innovative program.

Providing incentives to health facilities, in combination with a strong monitoring and evaluation system, has increased the use of a number of maternal and child health services such as family planning and deliveries. But, there are still a large number of pregnant women delivering at home in Rwanda (49% in period 2003-2008), as well as women who could benefit from modern family planning methods (only 27% were using family planning methods at the end of 2007).

To further increase access to and use of facility-based services, community health workers (CHW) are now actively involved in bringing these clients to health facilities. CHW cooperatives, groups of 20 to 150 CHWs, have been established by the Government. Financial incentives are awarded to each cooperative based on the number of clients that are followed, referred, and/or accompanied to a health center for specific maternal child health-services. The cooperative receives $2 to $3.50 per service performed depending on the services. On average, each CHW cooperative earns approximately $4,000 dollars per quarter.

IHSSP is assisting the Rwanda MoH in widening its scope to the strengthening of information systems and human resources management in a decentralized structure. Institutionalizing the practice of systematic quality improvement, the Project is working to support the government's efforts to extend quality public health services to the entire country.