National Community Health
Performance-based Financing:
design and implementation of
supply-side model
PBF workshop Bujumbura February 16th, 2011
Ludwig De Naeyer (MSH)
Rwanda CPBF Interventions

Second generation of PBF to address
remaining barriers for achieving improved
MCH outcomes and TB outcomes


Choice and unit fee based on national priorities and
expected quantities mainly for preventive activities
CHW cooperatives receive incentives
payment for:


Timely submission of quality SIScom reports
Offer for 5 MCH-indicators and 2 TBindicators
Quantity Indicators
(selection of SIScom)
Unit fee in
dollar
Applied unit
fee in RWF
$ 3.24/12
RWF
150
$ 2.24
RWF
10,000
$ 2.73
RWF
13,000
$ 2.90
RWF
4,000
$ 2.11
RWF
1,000
6.Nb of TB suspects examined referred by CHW
$ 45
RWF
26,550
7.Nb of TB patients followed by CHW per month
$ 51/6
RWF
5,000
Indicator
1. Nutrition Monitoring: Number of children
monitored for nutritional status (6 -59 mois)
2.ANC : Number of women accompanied/referred to HC
for prenatal care within first 4 months of pregnancy
3.Deliveries: Number of women
accompanied/referred to HC for assisted deliveries
4.FP: Number new Family Planing users referred by
CHWs for modern family planning methods
5.FP: Number of regular users using long term
methods (IUD, Norplant, Surgical/NSV contraception)
Cooperative
performance
and
Reporting
(quality
aspect)
Cooperative Income 2009 (data WB/SPH)
2009 Income Amount in RWF
Donor
RWF 394,034
Central Govt
RWF 195,650
Other
RWF 103,142
Income Generating Activities
Mutuelle
RWF 52,548
Drugs
RWF 51,852
User Fees
Local Govt
RWF 24,715
RWF 12,458
RWF 355,906
2010 CHW Cooperative Data
2009 Annual Expenses
Investment
Other
RWF 37,828
Outreach activities
RWF 34,331
Salary
RWF 30,925
Per diems
Building Maintanence
Equipment Purchase
RWF 214,105
RWF 28,806
RWF 18,533
RWF 13,310
6
Cooperative functioning (data WB/SPH)

47% of cooperatives and 38% of CHW charge patient
fees
Preventive Care
Consultation
Copayment
Drugs
Curative
Consultation
Copayment
Drugs
CHW
COOPERATIVE
RWF 84
RWF 78
RWF 139
RWF 157
RWF 111
RWF 197
RWF 72
RWF 92
RWF 171
RWF 123
RWF 107
RWF 185
2010 CHW Cooperative Data
Main Difficulties in Delivering
Community Health
Lack of equipment
84.45%
Inadequate salary
83.50%
73.82%
Lack of training
51.56%
Lack of supplies
Lack of coordination with Cell SC
Lack of communication with HF
31.77%
27.60%
Lack of supervision
17.80%
Lack of community support
17.18%
Lack of coordination with HF
15.54%
8
Data validation and control




Payment per unit reported so
possibility of gaming
Still mainly paper based
Done by HC supervisor monthly
External audits planned but not
performed yet
PBF-Payment for cooperative

Quarterly via HC-account


Two parts:



After validation of the data by sector steering committee
(members are HC-head, the supervisor of the CHWs at the
HC, the in charge of social affairs and a member of the civil
society)
Maximum amount for reporting depends on the target
population of the cooperative. This is adjusted by the
quality score.
Productivity (i.e. offer services) = unit fee * Quantity
First payment made for October – November 2010:
average of 3700 $ for indicator and 900 $ for report

Cooperatives use earnings for income generating activities
and for dividend for CHWs.
Cooperatives Reporting: 97% for 2010 to date
out of 427 HC and Dispensaries
Cooperative performance reports

Started
during the
last quarter
2010 (n=261)

Average
quality
score: 82%
Contrat signe entre le Comite de Pilotage du secteur et Coopérative
d'ASC disponible
Coopérative d'ASC a obtenu l'autorisation du district
Coopérative d'ASC a un stock minimum de 2 mois pour le
rapportage mensuel des indicateurs (rapport SIS Com)
Coopérative d'ASC a un livre de caisse avec au moins la preuve de 3
transactions pour le trimestre passe
Réunion des membres de la Coopérative tenu ce trimestre et
compte rendu disponible
Président de la Coopérative d'ASC élu
Coopérative d'ASC a obtenu le statu légal
L'information complète du compte bancaire de Coopérative d'ASC
disponible: # du compte, nom de la banque, nom(s) du compte
Coopérative d'ASC a un plan d'affaires (couvrant la période actuelle)
Promptitude du Rapport
Exactitude du Rapport
Complétude du Rapport
4.3
4.2
4.9
4.3
4.7
4.8
1.4
4.9
7.1
13.9
14.4
13.3
Baseline data for “Incentivized”
Indicators
Indicator
Monthly Average per
cooperative for OctoberNovember 2010
1. Nutrition Monitoring: Number of children monitored for
nutritional status (6 -59 mois)
1596
2.ANC : Number of women accompanied/referred to HC for
prenatal care within first 4 months of pregnancy
26
3.Deliveries: Number of women accompanied/referred to HC
for assisted deliveries
26
4.FP: Number new Family Planing users referred by CHWs for
modern family planning methods
39
5.FP: Number of regular users using long term methods (IUD,
Norplant, Surgical/NSV contraception)
HMIS data
6.Nb of (TRUE) TB suspects examined referred by CHW
7.Nb of TB patients followed by CHW (total fee)
Nl. HMIS data/ SIS: 4
4
Lessons learnt / challenges




PBF incentives ensured rapid increase in SISCom
reporting
In the presence of a strong monitoring system PBF can
be introduced for cooperatives to stimulate and reward
activities of CHWs at community level.
Quarterly payments are feasible and will hopefully lead
to an increase of MCH and TB-activities. The results of
this intervention will be assessed by an independent unit
through an Impact Evaluation study.
Data quality supervision and external audits still need to
be introduced to verify data quality
2010 CHW Cooperative Data

In the past 12 months, how many times was performance
assessed?



Members (internal): 3.97
Members (external): 1.18
Cooperative (external): 0.52
Is Member Compensation
Linked to Performance
Assessment?
Yes
27%
No
73%
16