the impact of performance-based financing on the cost of health services in rwanda first global...
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The Impact of Performance-Based Financing on the Cost of Health Services in Rwanda
First Global Symposium on Health Systems ResearchMontreux, November 2010
Presenter: David CollinsManagement Sciences for Health
Rwanda IHSS Project
Authors Dr Agnes Binagwaho, Permanent Secretary, MOH, Rwanda Dr Bonaventure Nzeyimana, MOH, Rwanda Dr Richard Gakuba, MOH, Rwanda Dr Gyorgy Fritsche, World Bank Thomas McMennamin, University of California, Berkeley Christine Mukantwali, USAID/IHSSP, Rwanda David Collins, USAID/IHSSP, Rwanda
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PBF in Rwandan health system
Following successful pilots, PBF was introduced in all government health facilities in 2006.
Main objectives - improve the coverage, the quantity and quality of priority services.
Incentives paid for total visits and services such as ANC, <5 growth monitoring, FP, immunization, assisted deliveries, VCT, PMTCT and TB/HIV.
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Other factors
CBHI rolled out nation-wide, with enrollment reaching 74% by December 2006. CBHI only reimburses for curative services.
Performance contracts were signed by the President and the Mayors to increase and improve health services.
Greater autonomy given to health facilities and HR management was decentralized.
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Other factors
Emphasis placed on the expansion of key services.
Renovation of buildings, renewal of equipment and additional ambulances.
Staff received large salary increases. Significant donor support was received.
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Study objectives
Reportedly, the PBF contributed to increases in key services and better quality of care
Study objective was to see what changes in costs occurred, specifically:– Did service increases or shifts result in more total
costs?– Did unit costs decrease (because more services were
produced from available resources)?
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Methods
Used 2005 – 2007 data collected previously to cost HIV services at 6 health centres.
Activity-based costing using standard costs based on Rwandan protocols.
Spreadsheet tool called CORE Plus was used. Preliminary findings follow……………………..
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0
5,000
10,000
15,000
20,000
25,000
30,000
2005 2006 2007Serv
ices
Years
Total and per capita average numbers of preventive and curative services per health centre
Curative Services
Preventive services
1.37
1.08
1.40
72%
28%
62%
38%
46%
54%
Total and per capita average numbers of preventive and curative services per health centre
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$9,594 $20,131
$42,171 $31,720
$31,740
$48,646
$9,838
$18,261
$31,246
$-
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
2005 2006 2007
Average expenditure by category and per capita per health centre (US$)
Salaries
Drugs and tests
Operating costs
$2.72
$3.64
$6.16
Average expenditure by category and per capita per health centre (US$)
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Top services by number and by expenditure
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
2005 2006 2007
Top 6 services in terms of average number per health centre
Upper respiratory infections - adult
Upper respiratory infections - child
Family planning
Well child
Other illnesses
VCT6%11%
18%
15%
8%
11%
7%
7%
39%
56%
65%
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
2005 2006 2007
Top 6 services in terms of average expenditure per health centre
PMTCT
Lower respiratory infections - adult
Family Planning
Well child
Other illnesses
VCT9% 16%
22%
11%
14%
11%
4%4%
43%
57%
67%
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Average cost per VCT service for 2005 to 2007 (US$)
VCT Average cost per service 2005 2006 2007Average number of VCT services per health centre 1,161 2,849 4,847
Average cost per service (US$)Medical supplies 0.69 0.63 0.57Lab tests 1.53 1.53 1.53Direct staff time 0.26 0.30 0.59Indirect staff time 0.01 0.02 0.01Operating costs 0.75 1.24 2.40Total 3.23 3.72 5.10
Actual number of clinical staff
Needed number of clinical staff
Actual services per
provider hour
Ideal services per
provider hour
2005 13 19 2.08 1.90 2006 11 22 2.06 1.82 2007 14 23 1.76 1.68
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Actual and needed clinical staffing
Staffing
Insufficient clinical staff meant that either staff worked longer hours than they should or quality of care was weak for some services.
The data were not detailed enough to allow for the above to be analyzed but, reportedly, staff worked longer hours than previously. And previous studies have concluded that quality of care improved during this period.
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Conclusions
PBF and other factors resulted in more services and a shift toward preventive services.
Additional expenditure (eg staff and equipment) was incurred because more funding became available and was needed for quality improvements and increases in services.
Cost per service increased because of the additional indirect expenditure, shifts to higher paid staff and increased salaries.
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Conclusions
Based on the results of these 6 health centres If a PBF results in more services or shifts to higher-
cost services and a increased quality then total expenditures will need to increase.
If the indirect costs of services are under-funded then the average expenditure for each service will also need to increase.
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Limitations
The health centres were not selected randomly.
Data were not collected for any control group Only expenditures made by, or for, the facility
are included. The original data collected for drug
expenditures was incomplete and standard costs were used instead.
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Limitations (continued)
Capital expenditures, depreciation and training costs were not included.
Operating costs include some non-recurrent expenditures and some expenditures that should be included in other expense categories.
PBF was introduced in May 2006 but data were only available for whole years.
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Data restrictions
• The data shown in this presentation will be subject to further review and should not be quoted without permission of the authors.
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Thank you