Performance Based Financing as a Means to Improve Quality of Care in Rwanda

Performance Based Financing was introduced into Rwanda in the early part of the decade and following positive evaluations of two pilot projects; the program has been rapidly scaled up and during 2008 achieved coverage of all 30 health districts in the country. Preliminary composite indicators of performance at health centers during the scale-up showed an increase from 30% to 80% in the first 15 months of roll-out, while key indicators such as family planning acceptors rose by over 160% in PBF sites, and institutional deliveries increased by 65%.

Starting in year three of the Project, continuous quality/performance improvement systems began to be integrated into the project. At the same time activities to strengthen supervision/performance-monitoring systems were initiated at the national, district, and community level involving clients, communities, service providers, and civil authorities.

A baseline of existing performance was established by an initial assessment of the quality at all facilities in Rwanda. Between January and December 2008 the volume of services (measured by 24 purchased indicators) rose by 48.7%. Average composite quality score for 284 health centers increased from 71.2% to 83%; average composite score for district hospitals rose from 42% to 76%. One of the most impressive improvements was a single hospital that moved from a score of 6.2% to 78.1%.

This paper presents how the HIV-PBF project addresses the distortion in a health system caused by disproportionate investment of funds into HIV/AIDS and how quality of care can be maintained and improved for all services defined in the government's packages. It presents two quality management tools developed for the district hospital and the health center, describes how these tools were scaled up to reach every government health facility in Rwanda, and how this approach can be institutionalized as a system of continuous quality improvement for the whole country.

Finally we will go on to discuss the transferability of this approach to other countries in the region: identifying the underlying characteristics of the health system and comparing them to neighbors; looking at the political, social, and environmental factors that enable this process to be effective; and, proposing a process that could be adapted in other country settings.