Rwanda Performance Based Financing and Family Planning.ppt by jizhen1947


									Scaling up Family Planning through
Performance-Based Financing in Rwanda

 Dr. Louis Rusa, Director PBF support Cell
       Ministry of Health, Rwanda
 PBF 101 – guiding principles
 Case study of PBF in Rwanda
 Lessons learned
          Input                  vs       Output
  Payments in advance for               Funds paid for services
   salaries, drugs & supplies,            already delivered
   running costs
 Funds often managed at                 Funds managed at local
   higher levels                          level
 Need to justify expenses               Need strong data
  after payment (financial                collection & quality
  audits)                                 control system
 Tenuous link between                   Direct link between
  funding and results                     funding and results
PBF model – key principles
                 Separation between providers,
                    purchasers and controllers
                   PBF funding does not cover cost
                    of service – just incentivizes it
                   Traditional input financing must
                    continue to complement PBF
                   Data on service outputs must be
                    highly selective and from
                    existing sources
                   Strong service and data quality
                    control mechanisms needed to
                    eliminate incentive to cheat
      Key Rwanda health strategies
 In 2005, MOH introduced three complementary
 strategies to improve health services:
   Community Based Health Insurance to
    increased access
   Performance-based Financing to increase
    availability and quality of services
   Continuous Quality Assurance to enhance
    quality of care
     PBF and Family Planning in
 Health Center PBF system includes incentives for 2
    # of new FP users
    # of FP users at the end of the month
 Community PBF includes provider-side and client-side
    # of new family planning users referred by CHWs (both)
    % of FP users using long-term methods (provider-side)
    # of FP users adopting long-term methods (client-side)
 Quarterly Quality Assessment process includes an
  assessment of FP service quality
PBF Control is NOT ‘business as
 usual’ in data gathering
                         data quality
                         in a health
      Assuring Data Quality –
       Multiple checks and balances
 Data ‘quantity’ audits conducted every month on each
  indicator from every site (register vs report)
 Monthly report data are reviewed by district PBF
  steering committees
 Community client or “phantom patient” surveys every
  6 month at a sample of sites – look for phantom patients
  and seeks feedback from patients on quality of care
 National PBF cell reviews database each quarter for
  the entire country – corrections are made before payment
       How to strengthen supervision
        to assure high quality services
 Quarterly Quality assessments are conducted at
  each facility to assess 13 components of service
    Administration, Hygiene, Respect for Clinical
     protocols for key services, Community outreach, etc.
 Controllers are District Hospital supervisors and
  data managers for health centers, by peer district
  hospitals for Hospital level PBF
 This assessment score is used to offset PBF
               Performance Payment Mechanism

Performance Payments = Σ (# service outputs * Unit fees) * % Quality

No Indicator                                             Quantity        Fee   Amount RWF
  1FP: number of new family planning users                    40        1000       40,000
  2FP: Number of family planning users at end of month       120        100        12,000
   Quarterly quality score                                          X                87%
   Payment amount                                                                  53,940
               Increase in Volume of FP Services
                 (after 39 months)
PBF Indicator                 January 2006           March 2009        Percentage increase
                            average/month/         average/month/        (linear/log R2)
                              health center         health center
                          ( 258 health centers   (297 health centers
                               on average)           on average)
Family Planning new              15.5                   58.6                  278%
users                                                                     (linear 0.79)
Family Planning                 175.2                 1005.6                 473.9%
users at the end of the                                                   (linear 0.98)
Increase in the Quality of
  Services in Health Centers (1)
        Lessons learned
 Health workers benefit directly from a portion of
  the PBF funding that is shared as bonuses –
  motivation and retention of health workers has

 PBF reinforces decentralization strategy: Money is
  paid directly to the health facility and managed by
  local steering committee with considerable autonomy

 PBF can lead to a significant increase in service
  production and quality of services in a relatively
  short period of time

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