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Exciting New Impact Study on Rwanda's Pay for Performance in Health

The first weeks of 2010 have not been kind to countries around the world looking for signs that the financial crisis is coming to an end. Even for those countries fortunate enough to register successive quarters of economic growth (normally an auspicious sign of things improving), somehow their recovery still looks tentative. Aid budgets in wealthy OECD donor capitals have become a reluctant casualty of crisis. With less development aid in circulation, a relentless search is on to find winning development results that those fewer aid dollars can maximize returns on.

This is especially true in the field of health.

Rwanda Health Center

Health Center in Rukara, Rwanda

Although official development for health has increased dramatically over 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 health MDGs.

This is why a new impact evaluation of an experimental maternal and child health program in Rwanda 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 or 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, has been invited to discuss the study next week in Burundi―such is the wave of interest in Rwanda’s P4Pexperience. 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 healthcare output indicators, the government committed to reward clinics and facilities which provided services to the satisfaction of patients with a series of bonus cash payments.

Rwanda baby vaccineIf, 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. For example, if the facility only scores 0.80 on the quality index, then it only receives 80 percent of the payment for the P4P services. Patient follow-up surveys and polling are the key determinants of whether the services were considered satisfactory or not. The evaluation studied 166 of Rwanda’s 401 primary care facilities over a 24 month

period and backed up these findings with random samples of 13 households living in the local areas served by the clinics. By offering the clinics the equivalent of US $1.83 for women who were new contraceptive users, $4.59 for each mother who delivered her baby safely on their premises with skilled midwives, $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, the P4P 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

To download Paying Primary Health Care Centers for Performance in Rwanda, click here.

For more on the World Bank’s work in Results-Based Financing for Health, visit: 

See also the World Bank’s Health Systems for Outcomes program in Africa:

HSO Team Member Paulin Basinga Receives Award From Rwandan President 

Contributed by Phillip Jeremy Hay, Communications Advisor, HDNOP

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