Rwanda

Start: 2002
Phase: Started from 2002 onwards in three pilot areas, expanded to the national level in 2006
Coverage Estimate: 100%
Feasibility: Successful scaling up, experience exported to other countries such as DRC and Burundi
Supported by: MOH/MOF – PEPFAR-USAID; GF; WB, Belgians, and others

Description: 

Rwanda in 2001 was the first country in Africa to pilot PBF and scaled it up nationwide in 2006. The results were very favorable and especially for the quality of care. The results were also published in several scientific articles. Other strengths were the harmonization of PBF with obligatory health insurance and that the government pays 60% of the PBF budget. For many years, Rwanda was the PBF flagship country in Africa and several countries studied their case and visited the country.

However, despite these advances in the PBF approach, improvements are needed to benefit from the innovations in other countries in recent years. One way to analyze these innovations is by applying the 23 purity criteria and the course participant from Rwanda scored 60%.

Recommendations Rwanda:

  • Review the PBF system in Rwanda and adapt it to become more in line with international best practices and innovations.
  • Increase the PBF budget from the current USD 2 per capita per year to USD 5. This can be done first of all by transforming inefficient government input budget lines (= in-kind financing) into output- or PBF funding. Studies showed that US $ 4 invested in inputs equals US $ 1 invested in PBF. Moreover, partner funds can also be used more efficiently by transforming input budget lines into PBF lines;
  • Promote free competition whereby health facilities area lowed to purchase their medicines, equipment, and other medical consumables from different distributing operating in competition;
  • Make health facilities more autonomous for the recruitment, application of sanctions and even dismissal staff in case of need;
  • Introduce the PBF system also among private (for profit) health facilities in order to benefit from their comparative advantages. The government should therefore also develop contracts and pay PBF subsidies to private health facilities with the aims to achieve government objectives and to improve their quality of care.

Reference:
Meessen, B., L. Musango, et al. (2006). “Reviewing institutions of rural health centres: the Performance Initiative in Butare, Rwanda.” TMIH 11(8): 1303-1317.

Meessen, B., J.-P. Kashala, et al. (2007). “Output-based payment to boost staff productivity in public health centers: contracting in Kabutare district, Rwanda.” Bulletin of the World Health Organization 85(2): 108-115.

Soeters, R., C. Habineza, et al. (2006). “Performance-based financing and changing the district health system: experience from Rwanda.” Bulletin of the World Health Organization 84(11).

Rusa, L. and G. Fritsche (2007). Rwanda: Performance-Based Financing In Health. Emerging Good Practice in Managing for Development Results: Sourcebook -2nd edition, the World Bank: 55-60.

Rusa, L., W. Janssen, et al. (2009). “Performance-based financing for better quality of services in Rwandan health centers: 3-year experience.” TMIH 14: 830-837.

Basinga, P., P. Gertler, et al. (2011). “Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation.” The Lancet 377: 1421-1428.

Basinga, P., P. Gertler, et al. (2011). “Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation.” The Lancet 377: 1421-1428.

Walque, D. d., P. J. Gertler, et al. (2013). Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda. Policy Research Working Paper No 6364. Washington DC, The World Bank.

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