What PBF can achieve Example from Rwanda Claude
What PBF can achieve; Example from Rwanda Claude SEKABARAGA, MD, MPH World Bank, Nairobi Hub. January 2010
U 5 MR (per 1, 000) in sub-Saharan Africa – MDG 4 Target and Actual Source: Global Monitoring Report 2008
Actual U 5 MR (DHS) vs. MDG 4 target in Rwanda – 35% reduction from 2005 - 2008
REDUCTION OF INFANT MORTALITY 1/3 in years
63% of increase in three years
25% of increase in three years
IMIHIGO: Performance based services for territorial administration l l Strong political commitment to results Contract between the President of the Republic and the district mayors and different local administration levels; Key health indicators integrated in the contract (in 2007: ITNs, Mutuelles, FP, safe deliveries, hygiene. . ) Quartely review with Prime Minister, President attending twice a year
Autonomy of providers institutions l l l Based on Bamako Initiative Delegation of management Health centers and hospitals fully autonomous Subsidized by the government: PBF, needs based block grant (initially for wages) Support to planning: Strategic and operational planning are the fundament of the approach.
Human resources management l l l Decentralization of wages; Community through facility committee have the authority to hire and fire; Community through facilities receive block grant from government; “People follow the money”; Retention of health personnel in rural areas increased.
Trend in the financing of district health personnel 25 21. 4 20 18. 5 Basic salaries (Million USD) 15 Performance based financing (Million USD) 11. 2 Linear(Basic salaries (Million USD)) 10 8. 9 8 6. 7 5 3. 6 0. 8 0 2005 2006 2007 2008
Evolution of the number of selected staff in rural and urban districts (public sector)
RESULTS BASED FINANCING PRINCIPLES
What is Results Based Financing? l l Financing mechanism for defined quantity and quality outputs and outcomes. Incentives targeting provider’s behavior to produce more results and to comply on quality standards; Incentives targeting household or individual behavior to use more services PURCHASER Financial Incentives PROVIDER Health Results
Why to finance results vs. inputs? Financing strategy Actions Objective for results Supervision, Equipment, consumables, training, audit Drugs, salaries, etc. and Sanction? Investment? TIME Payment result Verification of quantity and quality Result
RBF PRIORITY AREAS AND BENEFITS l l l Based on major bottlenecks; Priority to composite indicators and avoid selective performance; Quantity preventive interventions and quality of both prevention and curative services; Promotion of local creativity and spirit for performance; Improvement of remuneration of personnel and equipment linked to services to community: ACCOUNTABILITY.
How to finance results? Regulator Evaluator/ verificator Purchaser Beneficiary Provider
Concerns l What systems are needed to implement RBF successfully? l l l Does the regulatory framework require change? How will results be routinely monitored (HMIS? ) and verified? How to sustain? How will the government decide if it will continue to fund through RBF mechanism? l l How will you show impact? How will you show cost-effectiveness?
THE PERFORMANCE FINANCING SYSTEM
SUSTAINABILITY OF RWANDA PBF FINANCING 100% 19% 90% as % of total Source of funding 80% 70% 47% 28% 60% 81% 85% 50% 100% 40% 30% 53% 20% 19% 15% 0% Total Health Expenditure (NHA) Donors Community PBF Private Health Center PBF District Hospital PBF Public (including parastatal) ALL PBF
Results: Services produced (after 27 months of extention) Indicateurs FBR Accouchements Assistés Nouvelles consultations curatives CPN: 2 ième dose Anti-tétanique Nouvelles utilisatrices PF Utilisatrices de PF à la fin du mois Janvier 2006 moyenne mensuelle par centre pour 258 centres de santé Mars 2008 moyenne mensuelle par centre pour 286 centres de santé Pourcentage d’augmentation 21 37. 5 78% 985 1, 489 51% 21 52. 5 150% 15. 5 47. 9 209% 175. 2 711. 6 306%
FAMILY PLANNING 194% increase 60 50 55 50 45 2 40 R = 0. 8635 Percentage 35 30 25 20 17 15 10 5 0 1 2 3 4 5 6 7 2006 8 9 10 11 12 1 2 3 4 5 2007 6 7 8
1. 2 PBF Impact on Prenatal Care Quality 1 0. 8 2006 0. 6 2008 No PBF 2008 PBF 0. 4 0. 2 0 Low Ability Ave Ability High Ability
Impact on quality of prenatal care 24
Impact on institutional delivery 25
Go. R In kind transfers Total amount: 12. 2 M USD Development Partners in kind transfers Total amount: 60. 6 M USD COMMUNITY, HEALTH CENTER and DISTRICT HOSPITAL
COMMUNITY PBF To reduce child mortality: Malaria, pneumonia, diarrhea and monitoring of malnutition), and family planning; l Five CHW (a lady and a man for IMCI package) by village; l Organized in cooperatives and paid based on a package of services produced and checked by health center in term of quantity and quality. l
Conclusion BUILDING CULTURE OF RESULTS MORE THAN INPUTS AND PROCEDURES l 1. 2. l For ACCOUNTABILITY: Separation of functions: Purchasers, providers and direct beneficiaries; Clear link between public funds and direct services to community; Priority on high impact interventions (Family planning & reproductive health, prevention interventions and family & community services)
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