Tying Payments to Results: An Interview with Rwanda’s Performance-Based Financing Coordinator, Dr. Luis Rusa

MSH: What is your role in the Ministry of Health?
I am the coordinator of the support unit for contracting in the Ministry of Health of Rwanda. My mission was to set up a mechanism for introducing results-based financing into the health system, to make it functional and perform smoothly.

MSH: What is your background working in public health financing?

I have worked in the public health system since 1983. I was first a health program manager, including financial management. I began managing bilateral projects of the Belgium cooperation in 1999 and have managed output-based financing since 2005.

MSH: Why is performance-based financing (PBF) such an important tool in public health?

It stimulates health personnel to be more competitive and makes them feel like partners because they perceive that what they produce is coming from their own efforts. The allocation of funds is proportional to the work done; it is an equity tool. PBF has improved the regularity of supervision and the quality of indicators supervised. It has also permitted health facilities in rural areas to maintain their staff because the managers can motivate them.

MSH: How has PBF affected basic health and HIV services in Rwanda?

The health personnel know that they need to interact with the community to make their health facility competitive, so they do what they’re supposed to do. Some health facilities that didn’t have the whole package of services have used advocacy and asked for support to complete the package. For example, there were health centers without a maternity ward, centers without voluntary counseling and testing, and so on, so they tried to complete the minimum package.

 PBF has improved supervision and quality and permitted health facilities in rural areas to maintain their staff because the managers can motivate them.

MSH: What are some of the challenges in establishing PBF?
The training of health personnel is a challenge. The more you train them, the better they perform. And you need means of monitoring the results, because people may try to produce even bad results to gain more money. Another challenge is that you need a minimum standard of equipment for health facilities. Financing must continue for inputs such as equipment and rehabilitation or expansion of infrastructure. But the functioning of services must be supported through output financing to allow health managers and workers to be innovative and “owners” of the services.

MSH: How do you address the major implementation challenges of community PBF?

We verify the results coming from the districts, and when we discover swindlers, we punish them. We try to train health personnel regularly to build their capacity so that they understand better what we want from them. We also work with the unit in charge or the health center to find out where equipment is needed.

MSH: What are the keys to creating a sustainable PBF program?

  • norms and standards
  • allocation of essential equipment to all health facilities
  • budgeting of enough money so that there will be no overspending
  • training in all concepts and involvement of personnel in setting up the mechanisms and producing the tools you want them to use
  • autonomy of management in the health system at the levels you want to remunerate for outputs
  • a strong team to monitor and validate the results regularly
  • management tools, such as information technology to capture all information coming from the grassroots level

MSH: What does the future of the PBF program in Rwanda look like?
In the near future the Ministry of Health would like to link PBF and mutuelles (community-based health insurance) within one health financing unit. This will let us see how to really link the two models of financing and how to deal with the issue of sustainability.