rwandan performance-based financing process and tools gisenyi results-based financing workshop...
TRANSCRIPT
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REPUBLIQUE DU RWANDA
MINISTERE DE LA SANTE B.P. 84 KIGALI
Rwandan Performance-Based Financing Process and Tools
Gisenyi Results-Based Financing Workshop
October 21, 2008Dr Gyuri FRITSCHE
Management Sciences for Health
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REPUBLIQUE DU RWANDA
MINISTERE DE LA SANTE B.P. 84 KIGALI
Contents
1. Where to place this presentation2. Lifting the Veil on the Process of
Implementing National Performance-Based Financing Models in Rwanda
3. Explanation of the ‘Tools’ used in the National District Hospital and Health Center Performance-Based Financing Models
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REPUBLIQUE DU RWANDA
MINISTERE DE LA SANTE B.P. 84 KIGALI
Process of the Rwandan PBF National Model Creation
• Three PBF pilot programs:– Cyangugu PBF pilot by NGO Cordaid 2002 onwards– Butare PBF pilot by NGO HNI-TPO 2002 onwards– Kigali Ngali PBF pilot by bilateral cooperation agency
BTC 2005 start• End 2005/early 2006: process to create one common
national model for Health Centers and Hospitals• Series of information meetings and workshops with
stakeholders at the national level– 2 day workshop in January 2006– 4 day team ‘extended team retreat’ January 2006– 4 day workshop with all partners February 2006 for the
design of a national model for Health Centers– 2 day workshop with partners July 2006 to design the
national PBF model for District Hospitals
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REPUBLIQUE DU RWANDA
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Indicators? (i)
• Cyangugu Model 2002-2005:– Project covered 620,000 people– Fee for Service/Case based Reimbursement type of
incentive payment– Budget approximately $2/c/yr
• $0.5 to $0.75/c/yr for program costs• $0.41/c/yr for health center output payments• $0.84 to $1.09 for district hospital output payments
– Covering 4 DH and 26 health facilities (with 14 health posts and 19 private dispensaries as second tier contractees)
– 20 indicators at the health center ranging $0.09 to $5.40
– 18 indicators at the hospitals ranging $1.07 to $26.80
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REPUBLIQUE DU RWANDA
MINISTERE DE LA SANTE B.P. 84 KIGALI
Indicators? (i)
• Cyangugu Model 2002-2005:– District Health Team contracted for
performance-based supervision– ‘Bonus’ for excellent quality and good
community client survey results which included clients satisfaction and amount of out of pocket payments (15% additional)
– Business Plans– Community Client Satisfaction Surveys– NGO is purchaser and controller (“fund holder”)– Written purchase contracts with second tier
contracts by prime contractees– Public; FBOs and Private for Profit Sector
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REPUBLIQUE DU RWANDA
MINISTERE DE LA SANTE B.P. 84 KIGALI
Indicators? (ii)
• Butare PBF model 2002-2005– Project covering 384,209 population– Fee for Service/Case based Reimbursement type of
incentive payment– 36 health centers and, later, 3 district hospitals– Budget $0.24/c/yr of which $0.09 for program costs– 4 community outreach indicators ranging $0.18 and
$8.93– 23 health center indicators ranging $0.07 and $6.25– 19 district hospital indicators ranging $0.36 and $14.30– 9 performance indicators for the district health teams– “Quality” not taken into account purposefully– Steering Committee with NGO as secretariat/TA– Written contracts (three levels)
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Indicators? (iii)
• Kigali Ngali Model 2005-– 1.4 million catchment population– 75 health centers and three district hospitals– ‘Tacit’ (verbal) agreements– Value of indicators mitigated by composite indicators being
met (‘quantity * “quality”’) and expressed in ‘points’ and not in money (available budget spent 100%)
– Part of a larger traditional health project, ‘input’ financing with $1.57/c/yr funds, of which $0.08/c/yr for PBF
– 22 composite indicators at health center level ranging $0.18 and $5.36
– 48 composite indicators at district hospital level ranging -$44.50 (penalty) to $44.50
– 31 composite indicators for the district health team– Bilateral agency with PIU inside MOH department
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REPUBLIQUE DU RWANDA
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Initial National Health Center Model(s)
• National Health Center Model 2006 – December 2007– Covering 6.51 M population (entire 23 district
population)– Seven control districts – About 258 health centers– “Contracting In” approach– Fee for Service/Case Based Reimbursement– 16 primary health indicators (2008: 14) ranging
$0.09 to $4.46– 15 HIV service indicators (2008: 10) ranging $0.47
to $8.90• 10 districts singular PMA indicators; 23 districts
singular HIV indicators;• 13 districts ‘composite’ PMA indicators
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REPUBLIQUE DU RWANDA
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Initial National Health Center Model(s)
• National Health Center Model 2006 – December 2007– In 10 districts: Quarterly Quality Supervisory Checklist
185 composite indicators across 13 services (excluding HIV services)
• till end 2006 > 70% composite score = 100%, >40% <70%= 50%, <40% = 25%; after Jan 2007 linear relationship:
• Performance measure HCearnings = (Quantity * Unit Fees) * Quarterly Composite Quality Measure
– In 13 districts no Quarterly Quality Supervisory Checklist, but ‘composites’ for each indicator with Value = (Quantity * “% Composite Score” * Unit Fee)
– “Contracting in” type of intervention: three levels of contracts/agreements, creation of quasi market: GOR contracting with its own and FBO facilities (and in five districts with private for profit sector also)
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Initial National District Hospital PBF Model(s)
• National DH PBF model: July 2006 to December 2007:– 52 composite indicators with ‘point values’
• Budget allocated 20% administration; 30% quality assurance and 50% clinical activities in 13 hospitals
– Budget allocated $602/bed/yr• Budget allocated according to budget available
(variable point score = available budget gets consumed 100%) in 14 hospitals
– Budget allocated $35K to $130K per hospital per year based on number of staff
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2007
Funding Source
Community HC* DH CP Totals 2007
GOR 1,651,376 3,375,339 1,732,982 80,789 6,840,486
CTB 1,094,215 1,094,215
USG 702,145 992,305 1,694,450
WB/MAP 160,568 160,568
Subtotals $1,651,376 $4,238,052 $3,819,502 $80,789 $9,789,719
$/C/Yr $0.18 $0.46 $0.41 $0.01 $1.06
2007 PBF Disbursements (23 Districts)
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REPUBLIQUE DU RWANDA
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New National Health Center Model
• New National Health Center Model Jan 2008-– 405 health centers (since April 1, 2008)– 9.5 M population– Fee for Service/Case Based Reimbursement conditional on
‘validation’ criteria (composites) for basic health services (compromise) but no ‘validation’ criteria for HIV services
– Revised Quarterly Quality Supervisory Checklist with 118 composite indicators across 13 services, including HIV services
– Performance measure:
• PMA HCearnings = (((Quantity * ‘% Validated’) * Unit Fees) * Quarterly Composite Quality Measure)
• HIV HCearnings = ((Quantity * Unit Fees) * Quarterly Composite Quality Measure)
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REPUBLIQUE DU RWANDA
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New National DH PBF Model
• New National District Hospital PBF model: Jan 2008-– 52 composite indicators– All 39 Rwandan district hospitals– Available budget from all sources pooled and modeled 20%
administration; 25% supervision and 55% clinical activities– Administration 200 ‘points’ with varying point values $11.40
to $69.96 depending on ‘index burden’ (staff)– Supervision 295 ‘points’ with varying points values depending
on the number of health centers to be supervised with budget of $3,181/HC/yr
– Clinical Activities with one point value of $13.5, and 18 ‘categories’ (DRG look-a-likes), indicator values ranging $1.34 to $8.34
– All indicators subject to composites..– Annual global prospective budgets ranging from $54K to
$330K
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Nyabimata CS, Nyaruguru District (i)
Status of PBF Slide 14
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REPUBLIQUE DU RWANDA
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Nyabimata CS (ii)
Status of PBF Slide 15
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Nyabimata CS (iii)
Status of PBF Slide 16
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Nyabimata CS (iv)
Status of PBF Slide 17
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Nyabimata CS (v)
Status of PBF Slide 18
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REPUBLIQUE DU RWANDA
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Nyabimata CS (v)
Status of PBF Slide 19
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Nyabimata CS (vi)
Status of PBF Slide 20
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Nyabimata CS (vii)
Status of PBF Slide 21
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Nyabimata CS (viii)
Status of PBF Slide 22
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Nyabimata CS (ix)
Status of PBF Slide 23
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Nyabimata CS (x)
Status of PBF Slide 24
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National HC and DH PBF Guides
• Click for HC PBF Guide• Click for DH PBF Guide (Draft)
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Additional Resources
• Website www.pbfrwanda.org.rw under ‘documentation’:– Guide for Health Center PBF (May 2008)
containing all tools (FR)– MOH 2007 PBF Annual Report (EN)– DH InfoPath form (EN)– Rwanda: PBF in Health (Rusa and Fritsche) MfDR
2007
• On demand:– Excel file with list of indicators for the three pilots,
and the national PBF models (FR)– Guide for District Hospital PBF (Sept 08 draft) (EN)
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Status of PBF Slide 27
Thank you for your attention!