National Community Health Performance-based Financing:design and implementation of supply-side modelPBF workshop Bujumbura February 16th, 2011

Ludwig De Naeyer (MSH)

Rwanda CPBF Interventions Second generation of PBF to address

remaining barriers for achieving improved MCH outcomes and TB outcomes Choice and unit fee based on national

priorities and expected quantities mainly for preventive activities

CHW cooperatives receive incentives payment for: Timely submission of quality SIScom

reports Offer for 5 MCH-indicators and 2 TB-

indicators

Quantity Indicators (selection of SIScom)

IndicatorUnit fee in

dollarApplied unit fee in RWF

1. Nutrition Monitoring: Number of children monitored for nutritional status (6 -59 mois) $ 3.24/12 RWF 150 2.ANC : Number of women accompanied/referred to HC for prenatal care within first 4 months of pregnancy $ 2.24 RWF 10,000 3.Deliveries: Number of women accompanied/referred to HC for assisted deliveries $ 2.73 RWF 13,000 4.FP: Number new Family Planing users referred by CHWs for modern family planning methods $ 2.90 RWF 4,000 5.FP: Number of regular users using long term methods (IUD, Norplant, Surgical/NSV contraception) $ 2.11 RWF 1,000 6.Nb of TB suspects examined referred by CHW $ 45 RWF 26,550 7.Nb of TB patients followed by CHW per month $ 51/6 RWF 5,000

Cooperative

performance and Reportin

g(quality aspect)

Cooperative Income 2009 (data WB/SPH)

Local Govt

User Fees

Drugs

Mutuelle

Income Generating Activities

Other

Central Govt

Donor

RWF 12,458

RWF 24,715

RWF 51,852

RWF 52,548

RWF 103,142

RWF 195,650RWF 355,906

RWF 394,034

2009 Income Amount in RWF

2010 CHW Cooperative Data

Equipment Purchase

Building Maintanence

Per diems

Salary

Outreach activities

Other

Investment

RWF 13,310

RWF 18,533

RWF 28,806

RWF 30,925

RWF 34,331

RWF 37,828RWF 214,105

2009 Annual Expenses

6

Cooperative functioning (data WB/SPH)

47% of cooperatives and 38% of CHW charge patient fees

CHW COOPERATIVEPreventive Care

Consultation RWF 84 RWF 157Copayment RWF 78 RWF 111Drugs RWF 139 RWF 197

CurativeConsultation RWF 72 RWF 123Copayment RWF 92 RWF 107Drugs RWF 171 RWF 185

2010 CHW Cooperative Data

Lack of coordination with HF

Lack of community support

Lack of supervision

Lack of communication with HF

Lack of coordination with Cell SC

Lack of supplies

Lack of training

Inadequate salary

Lack of equipment

15.54%

17.18%

17.80%

27.60%

31.77%

51.56%

73.82%

83.50%

84.45%

Main Difficulties in Delivering Community Health

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Data validation and control Payment per unit reported so

possibility of gaming Still mainly paper based Done by HC supervisor

monthly External audits planned but

not performed yet

PBF-Payment for cooperative Quarterly via HC-account

After validation of the data by sector steering committee (members are HC-head, the supervisor of the CHWs at the HC, the in charge of social affairs and a member of the civil society)

Two parts: Maximum amount for reporting depends on the

target population of the cooperative. This is adjusted by the quality score.

Productivity (i.e. offer services) = unit fee * Quantity

First payment made for October – November 2010: average of 3700 $ for indicator and 900 $ for report Cooperatives use earnings for income generating

activities and for dividend for CHWs.

Cooperatives Reporting: 97% for 2010 to date out of 427 HC and Dispensaries

Cooperative performance reports

Started during the last quarter 2010 (n=261) Average

quality score: 82%

Contrat signe entre le Comite de Pilotage du secteur et Coopérative d'ASC disponible 4.3 Coopérative d'ASC a obtenu l'autorisation du district 4.2

Coopérative d'ASC a un stock minimum de 2 mois pour le rapportage mensuel des indicateurs (rapport SIS Com) 4.9 Coopérative d'ASC a un livre de caisse avec au moins la preuve de 3 transactions pour le trimestre passe 4.3 Réunion des membres de la Coopérative tenu ce trimestre et compte rendu disponible 4.7 Président de la Coopérative d'ASC élu 4.8 Coopérative d'ASC a obtenu le statu légal 1.4

L'information complète du compte bancaire de Coopérative d'ASC disponible: # du compte, nom de la banque, nom(s) du compte 4.9

Coopérative d'ASC a un plan d'affaires (couvrant la période actuelle) 7.1 Promptitude du Rapport 13.9 Exactitude du Rapport 14.4 Complétude du Rapport 13.3

Baseline data for “Incentivized” Indicators

Indicator

Monthly Average per cooperative for October-

November 20101. Nutrition Monitoring: Number of children monitored for nutritional status (6 -59 mois) 15962.ANC : Number of women accompanied/referred to HC for prenatal care within first 4 months of pregnancy 263.Deliveries: Number of women accompanied/referred to HC for assisted deliveries 264.FP: Number new Family Planing users referred by CHWs for modern family planning methods 395.FP: Number of regular users using long term methods (IUD, Norplant, Surgical/NSV contraception) HMIS data

6.Nb of (TRUE) TB suspects examined referred by CHW Nl. HMIS data/ SIS: 4

7.Nb of TB patients followed by CHW (total fee) 4

Lessons learnt / challenges PBF incentives ensured rapid increase in

SISCom reporting In the presence of a strong monitoring system

PBF can be introduced for cooperatives to stimulate and reward activities of CHWs at community level.

Quarterly payments are feasible and will hopefully lead to an increase of MCH and TB-activities. The results of this intervention will be assessed by an independent unit through an Impact Evaluation study.

Data quality supervision and external audits still need to be introduced to verify data quality

2010 CHW Cooperative Data

In the past 12 months, how many times was performance assessed? Members (internal): 3.97 Members (external): 1.18 Cooperative (external): 0.52

Yes27%

No73%

Is Member Compensation Linked to Performance

Assessment?

16