Performance-Based Financing Underpins Rebuilding of Health Services in Liberia

In January 2009, MSH was chosen to participate in a partnership to carry out the Rebuilding Basic Health Services Project in Liberia. The five-year, $47-million program will support the Ministry of Health and Social Welfare in rebuilding public health services in seven counties of Liberia, which experienced a devastating civil war that began in 1989 and ended only with the election of President Ellen Johnson Sirleaf in 2005.

The project, the US government’s flagship program in Liberia, represents a model for postconflict reconstruction of health services. MSH will help the country institute performance-based financing (PBF) as a standard practice for extending access to health care, building the capacity of local organizations and health facility staff to manage and lead health services, and creating systems of governance for health services to sustain them beyond the project period.

MSH has used PBF successfully and refined the approach, applying it in countries from Rwanda to Haiti over the past decade.

From September 2005 to the present, the Rwanda HIV/PBF Project has achieved impressive results in the areas of health finance reform, quality assurance, capacity building, and monitoring and evaluation in both district health centers and the Ministry of Health. These improvements to the health systems of Rwanda have greatly impacted the availability of HIV & AIDS services across the country, making them part of basic health services. A recent Demographic and Health Survey showed that between 2005 and 2007 the contraceptive prevalence rate increased from 10 percent to 27 percent, the mortalitA sign outside Rwamagana Hospital, a voluntary counseling and testing center supported by the Rwanda HIV/PBF Project, advises the public that “TB is an airborne disease acquired from an infected person. If you have been coughing for more than three weeks you should quickly seek a doctor’s advice.”y rate for children under five decreased from 152 per 1,000 to 103 per 1,000, and voluntary HIV testing and counseling increased by nearly 200 percent.

The Rural Expansion of Afghanistan’s Community-based Healthcare (REACH) Program is another example of the success of PBF. From 2003 to 2006, REACH expanded health services in 13 provinces by using performance-based grants to nongovernmental organizations (NGOs). MSH provided technical assistance to the NGO grantees to help them meet their predetermined health objectives. More than $68 million worth of grants to NGOs produced improved health services for one-third of the Afghan population.

The Haiti health services projects of 2004 and 2007 built on this experience by using contracts with a network of NGOs as the core of the entire public health sector. USAID had contributed more than $140 million to the Haiti projects by the end of 2007, and those programs continue to deliver services to more than 4 million Haitians.

The “payment for performance” concept is the cornerstone of these programs. In this approach, a contractor must take a measureable action or achieve a set performance target before receiving a transfer of money or goods. In Rwanda, through the US Agency for International Development (USAID), MSH provides funds and resources to public accounts used to strengthen both basic health and HIV services. Money from PEPFAR (the US President’s Emergency Plan for AIDS Relief) has contributed to a paradigm shift in national health services from inputs to outputs, meaning that “results-based” financing is now a routine operating procedure for all collaborating agencies working in HIV & AIDS in Rwanda.

The Rwanda HIV/PBF program has also recently implemented community PBF, which moves responsibility away from the Ministry of Health and into local organizations. By using voluntary community health insurance schemes (mutuelles) to complement public-sector financing, the program is meeting the Government of Rwanda’s targets for improved primary care, as well as PEPFAR standards for sustainable HIV & AIDS services. Targets include increased rates of HIV testing, prevention of mother-to-child transmission, and antiretroviral treatment.


 “South-to-South” Collaboration Advances PBF

MSH/Haiti hosted a technical exchange on performance-based financing (PBF) in late 2008, bringing together members of MSH’s Santé pour le Développement et la Stabilité d’Haïti Project—Pwojé Djanm (SDSH) with a delegation from Rwanda that included technical staff from MSH’s Kigali-based HIV/PBF Project and representation from Rwanda’s Ministry of Health. The groups met in Port-au-Prince, Haiti, to discuss and learn from one another’s experiences with implementing PBF in the health sectors of their respective countries.

Although Haiti and Rwanda have similarities—comparable populations and health indicators and a recent history of conflict and instability—and MSH PBF experts from Haiti were integrally involved in the evaluation of Rwanda’s program, the two programs are quite different. SDSH uses PBF to contract with private providers of health services and execute agreements with the public sector in Haiti, and the HIV/PBF Project uses contracts for PBF with the public sector in Rwanda. In Haiti, performance incentives are earned by reaching targets for achievements or service delivery; in Rwanda, payments are earned on the basis of progress toward agreed-upon goals. In both cases, reported data are validated in a transparent way.

Dr. Gyuri Fritsche, the Technical Director of the Rwanda HIV/PBF Project, noted that the same fundamental principles underlie the programs in Rwanda and Haiti but have been applied differently. This kind of exchange allows for “greater motivation for innovation,” according to Fritsche, and innovation continues to drive each project.


The full effects of PBF as an innovative strategy to strengthen health systems have demonstrated the importance of results-based work, whether it is rebuilding health services after conflict, improving HIV services, or reforming entire health systems. It remains clear that the continued success of each project depends on using PBF in a way that is unique to each situation, making it a scalable and effective method for improved health systems and services across the world.