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 CenterRBF/Performance-Based Financing (PBF)

1. Supply Side Intervention

2. Demand-side phenomena

3. Targeting Health Facilities that are made more autonomous

4. Regular, significant incentives reach front line health workers

5. District Support Functions incentivized (monitoring volume and quality: internal controls)

6. District PBF Steering Committee incentivized

7. Central MOH PBF-support department incentivized

Content

Context Process and Actors Implementation Results Challenges to Scaling Up The Perfect Implementation Model

Context

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

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. Strengthening existing Coordination Mechanism (TWG)

2. Information Technology solution to data collection and payment flows

3. Creating new Coordination Mechanism to bridge the gap between policy and implementation: the Extended Team Approach

4. Trainings

5. Continuous Technical Assistance to decentralized authorities

1. Strengthening Existing Coordination Mechanism (TWG)

Regular and frequent meetings Agenda setting Effective documentation and dissemination of

proceedings

2. IT solutions to Data Collection and Payment Flows

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

PBFBDDMySQL(ISP)

Internet

Access ApplicationInternet Application

Local Copy of MySQL PBF

database

Optional

Excel Pivot Tables and Graphs

INSERT GRAPHIC TO ADD MAP

MAP IS 6.17” TALL

www.pbfrwanda.org.rw

Access to data through the website

Data entry menu

Data entry is easy

Quarterly district invoices

3. Creating New Coordination Mechanisms: the ET

The Extended Team Approach is Bridging the Gap between Policy and Implementation: 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

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

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. Solution to Data Collection and Validation Web application

2. Coordination challenges TWG and ET mechanisms

3. Technical Assistance to the Central MOH and the Decentralized Authorities TWG ET mechanism District PBF Steering Committees

4. Credible Performance Results Use decentralized authorities (Min Local Admin; MOH) with strong TA

support initially for internal control (ex ante) Use NGOs as part of quorum in Decentralized District Level PBF

Steering Committee, and for transparency (ex ante) Use performance frameworks at all levels (Health Facility; Steering

Committee; District Hospital; Central MOH) 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. The circumstances external to the implementing agency do not impose crippling constraints;

2. That adequate time and sufficient resources are made available to the program;

3. That the required combination of resources is actually available;

4. That the policy to be implemented is based on a valid theory of cause and effect;

5. 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. That dependency relationship is minimal;

7. That there is understanding of, and agreement on objectives;

8. That tasks are fully specified in correct sequence;

9. That there is perfect communication and co-ordination, and

10. 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

Relationship between cause and effect is direct

6 Strong dependency relationship

*

7 No full agreement on objectives

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