Real World Implementation
Challenges: Scaling-up
Performance-Based Financing in
Rwanda 2006-2008
CERDI Conference, 17-18 Dec, 2009
Session 3: ‘from pilot to national policy’
György Fritsche, HDNHE, the WB
Rwanda Health Center
RBF/PerformanceBased Financing (PBF)
1.
2.
3.
4.
5.
6.
7.
Supply Side Intervention
Demand-side phenomena
Targeting Health Facilities
that are made more
autonomous
Regular, significant
incentives reach front line
health workers
District Support Functions
incentivized (monitoring
volume and quality:
internal controls)
District PBF Steering
Committee incentivized
Central MOH PBFsupport department
incentivized
Content
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Context
Process and Actors
Implementation
Results
Challenges to Scaling Up
The Perfect Implementation Model
Context
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Barrier to Access Services leading to low utilization 0.3/c/yr:
Very poor population: one third of the population lives on less
than $0.25 per day and 57% of the population lives on less
than $0.45 per day
Poor Health Indicators (2005): MMR 750/100,000; U-5
Mortality Rate 152/1,000 and U-1 Mortality Rate 82/1,000
Inefficient Utilization of Existing Services: a study in Gicumbi
(2005) documented less than 2 services/nurse per hour leading
to an uptake of 0.8 services/capita/yr (curative and preventive
combined)
Actors and Parallel Events
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3 PBF Pilots (Cordaid and HNI 2001-2005 and BTC
2005)
Strong GOR leadership: Inclusion of PBF in National
Health Strategic Plan 2005-2009
WB – HIPC
USAID – interest in PBF for HIV services
Lowering the barriers to access: CBHI – scaling up
started January 2006
Mobilizing decentralized government: Imihigo
Process
The WB “roll-out study”
Implementation
1.
2.
3.
4.
5.
Strengthening existing Coordination Mechanism
(TWG)
Information Technology solution to data collection
and payment flows
Creating new Coordination Mechanism to bridge the
gap between policy and implementation: the
Extended Team Approach
Trainings
Continuous Technical Assistance to decentralized
authorities
1. Strengthening Existing
Coordination Mechanism (TWG)
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Regular and frequent meetings
Agenda setting
Effective documentation and dissemination of
proceedings
2. IT solutions to Data Collection and
Payment Flows
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Web site www.pbfrwanda.org.rw
Web application for data entry and data
retrieval (invoices)
Server located with an internet service
provider in country
A ‘real time database’ is created from the
district level onward: Payment Orders can be
generated easily
Internet Application
Access Application
Optional
Internet
Local Copy of
MySQL PBF
database
Excel Pivot Tables and Graphs
PBFBDD
MySQL
(ISP)
www.pbfrwanda.org.rw
INSERT GRAPHIC TO ADD MAP
MAP IS 6.17” TALL
Access to data through the
website
Data entry menu
Data entry is easy
Quarterly district invoices
3. Creating New Coordination
Mechanisms: the ET
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The Extended Team Approach is Bridging the Gap
between Policy and Implementation:
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11 international agencies
3 MOH departments
Meeting once per month last Thursday of each month
½ day, careful agenda setting and effective information
dissemination. Minutes available on website
Retreats for capacity building (Excel Pivot Tables and
Graphs)
Training of Trainers in PBF
4. Trainings
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Using ET mechanism to Train a Cadre of
National Trainers in PBF
First start 2006 (after first wave of trainings)
Re-launched second half of 2007
Jan-March 2008: 946 health workers trained
through 50 trainings
April 2008: seven Phase-II districts: 356 health
workers trained through 13 trainings
5. Continuous TA to the
Decentralized Authorities
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Quarterly District PBF Steering Committee Meetings
Extended Team members: District PBF Focal points
present in the District PBF Steering Committees
Assisting in control activities
Assisting in the quarterly quality counter-verification
exercises
Assisting in the restitution of community client
survey results
Results: Institutional Deliveries
Community Client Survey 3Q08:
The BIG news: RBF/PBF as a powerful
method to increase also the quality of
services
The BIG news: RBF/PBF as a powerful
method to increase also the quality of
services
Challenges to Scaling Up
1.
2.
3.
4.
Solution to Data Collection and Validation
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Web application
Coordination challenges
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TWG and ET mechanisms
Technical Assistance to the Central MOH and the Decentralized Authorities
 TWG
 ET mechanism
 District PBF Steering Committees
Credible Performance Results
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Use decentralized authorities (Min Local Admin; MOH) with strong TA
support initially for internal control (ex ante)
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Use NGOs as part of quorum in Decentralized District Level PBF
Steering Committee, and for transparency (ex ante)
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Use performance frameworks at all levels (Health Facility; Steering
Committee; District Hospital; Central MOH)
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Mix of third-party and transparent external verification mechanisms
(ex post)
Hogwood and Gunn’s “Perfect
Implementation Model”
Perfect Implementation Model’, in Hogwood, B., Gunn, I., (1984) ‘Policy analysis for the real
world’, Oxford University Press
1.
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5.
The circumstances external to the implementing
agency do not impose crippling constraints;
That adequate time and sufficient resources are made
available to the program;
That the required combination of resources is
actually available;
That the policy to be implemented is based on a
valid theory of cause and effect;
That the relationship between cause and effect is
direct and that there are few if any intervening links;
…Ten Preconditions for a Successful Top
Down Implementation
6.
7.
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10.
That dependency relationship is minimal;
That there is understanding of, and agreement on
objectives;
That tasks are fully specified in correct sequence;
That there is perfect communication and coordination, and
Those in authority can demand and obtain perfect
compliance.
In Rwandan PBF, the MOH was
confronted with:
No
Negative
Positive
1
Crippling circumstances
2
Time not adequate
*
Resources abundant
3
*
Required combination of resources
were available
4
*
Policy to be implemented based on
valid cause and effect
5
Many intervening links
between cause and effect
6
Strong dependency
relationship
7
No full agreement on
objectives
Relationship between cause and effect
is direct
*
Understanding of objectives
In Rwandan PBF, the MOH was
confronted with:
No
Negative
Positive
8
*
Tasks were fully specified in correct
sequence
9
*
Perfect Communication and
Coordination
10
*
Those in authority can demand and
obtain perfect compliance