In Rwanda, Health Performance Pays

February 26, 2010

  • Cash payments to clinics that meet government criteria result in increased use and quality of maternal and child health services.
  • Evaluation of Rwanda’s program is a first for low-income countries; will spur follow-up studies.
  • Study helps policymakers decide where to invest to improve maternal and child health.

February 26, 2010 — Although official development aid for health has increased dramatically in recent years, there has been limited improvement in better health outcomes for people in developing countries―a sobering reality considering that 2010 marks the five-year countdown to the Millennium Development Goals (MDGs).

That’s why a new impact evaluation of an experimental maternal and child health program in Rwanda--one that shows significant, verifiable improvements in attended birth deliveries and preventive child health visits-- is causing great excitement in health and development circles.

The evaluation, "Paying Primary Health Care Centers for Performance in Rwanda" is the first-ever rigorous study of Pay for Performance (P4P) programs in low-income countries, and will spur follow-up studies in other countries over the coming months. Dr. Paulin Basinga, one of the lead evaluators from the National University of Rwanda’s School of Public Health, recently presented study results in neighboring Burundi.

So what is Rwanda’s experience with P4P? In 2005, Rwanda decided to supplement its primary health care services with a ‘cash for performance’ program that would improve health worker morale and productivity and deliver better quality services for the country’s mothers and children. Using 14 maternal and child health care output indicators, the government committed to reward clinics and facilities that provided services to the satisfaction of patients with a series of bonus cash payments.

If, for example, the facility meets all of the government’s quality criteria, then it receives an index score of one and receives full payment for the services. However, if the facility is deficient in some of the quality criteria, then all of the payments are discounted: a score of 0.80 on the quality index brings only 80 percent of the payment for P4P services. Patient follow-up surveys and polling are the key determinants of whether services were considered satisfactory.

The evaluation studied 166 of Rwanda’s 401 primary care facilities over a 2-year period; its findings were based on random samples of 13 households living in local areas served by the clinics.

How to Spend Five Dollars

The P4P program offered Rwandan clinics the equivalent of $1.83 for each woman who was a new contraceptive user; $4.59 for each mother who delivered her baby safely on clinic premises with a skilled midwife in attendance; $1.83 for each referral of a malnourished child for treatment (almost 50 percent of children in Rwanda are stunted); and 92 cents for every child who completed vaccinations on time. As a result, the program achieved significantly increased use and quality of a number of critical maternal and child health services.

“What’s so gratifying about this study is that it helps governments answer the eternal question of how to use their money to best advantage when they only have five dollars to spend on better health for every woman and child in the country,” says Christel Vermeersch of the World Bank’s Human Development Network and one of the lead evaluators of the new Rwanda study.

 Agnes Soucat, World Bank Adviser in Health, Nutrition and Population for Africa, points out that results-based financing (RBF) initiatives, in which health programs are funded only when service providers can show verifiable results, have paid off for Rwanda.

“In three years, they tripled family planning, increased assisted deliveries from 39% to 52%, use of insecticide treated nets have increased by 70%, and under-five mortality has decreased by 30%. RBF is not a magic bullet, but it is definitely an important instrument to help countries accelerate progress toward the MDGs,” she says.

The Rwanda evaluation was financed by the Spanish Trust Fund for Impact Evaluation (SIEF), the largest trust fund ever established in the World Bank focused on impact evaluation. A €10.4 million program funded by Spain, complemented with a $1.5 million from the United Kingdom, its goal is to help the Bank harvest global knowledge on "what works" in pursuit of the MDGs and other human development gains.