Real world implementation challenges scaling up performance based financing in rwanda 2006 2008
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Real World Implementation Challenges: Scaling-up Performance-Based Financing in Rwanda 2006-2008. CERDI Conference, 17-18 Dec, 2009 Session 3: ‘from pilot to national policy’ György Fritsche, HDNHE, the WB. Rwanda Health Center RBF/Performance-Based Financing (PBF). Supply Side Intervention

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Real World Implementation Challenges: Scaling-up Performance-Based Financing in Rwanda 2006-2008

CERDI Conference, 17-18 Dec, 2009

Session 3: ‘from pilot to national policy’

György Fritsche, HDNHE, the WB


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Rwanda Health Center Performance-Based Financing in Rwanda 2006-2008RBF/Performance-Based Financing (PBF)

Supply Side Intervention

Demand-side phenomena

Targeting Health Facilities that are made more autonomous

Regular, significant incentives reach front line health workers

District Support Functions incentivized (monitoring volume and quality: internal controls)

District PBF Steering Committee incentivized

Central MOH PBF-support department incentivized


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Content Performance-Based Financing in Rwanda 2006-2008

  • Context

  • Process and Actors

  • Implementation

  • Results

  • Challenges to Scaling Up

  • The Perfect Implementation Model


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Context Performance-Based Financing in Rwanda 2006-2008

  • Barrier to Access Services leading to low utilization 0.3/c/yr:

  • Very poor population: one third of the population lives on less than $0.25 per day and 57% of the population lives on less than $0.45 per day

  • Poor Health Indicators (2005): MMR 750/100,000; U-5 Mortality Rate 152/1,000 and U-1 Mortality Rate 82/1,000

  • Inefficient Utilization of Existing Services: a study in Gicumbi (2005) documented less than 2 services/nurse per hour leading to an uptake of 0.8 services/capita/yr (curative and preventive combined)


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Actors and Parallel Events Performance-Based Financing in Rwanda 2006-2008

  • 3 PBF Pilots (Cordaid and HNI 2001-2005 and BTC 2005)

  • Strong GOR leadership: Inclusion of PBF in National Health Strategic Plan 2005-2009

  • WB – HIPC

  • USAID – interest in PBF for HIV services

  • Lowering the barriers to access: CBHI – scaling up started January 2006

  • Mobilizing decentralized government: Imihigo


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Process Performance-Based Financing in Rwanda 2006-2008


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The WB “roll-out study” Performance-Based Financing in Rwanda 2006-2008


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Implementation Performance-Based Financing in Rwanda 2006-2008

  • Strengthening existing Coordination Mechanism (TWG)

  • Information Technology solution to data collection and payment flows

  • Creating new Coordination Mechanism to bridge the gap between policy and implementation: the Extended Team Approach

  • Trainings

  • Continuous Technical Assistance to decentralized authorities


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1. Strengthening Existing Coordination Mechanism (TWG) Performance-Based Financing in Rwanda 2006-2008

  • Regular and frequent meetings

  • Agenda setting

  • Effective documentation and dissemination of proceedings


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2. IT solutions to Data Collection and Payment Flows Performance-Based Financing in Rwanda 2006-2008

  • Web site www.pbfrwanda.org.rw

  • Web application for data entry and data retrieval (invoices)

  • Server located with an internet service provider in country

  • A ‘real time database’ is created from the district level onward: Payment Orders can be generated easily


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Internet Application Performance-Based Financing in Rwanda 2006-2008

Access Application

Optional

Local Copy of

MySQL PBF

database

Internet

Excel Pivot Tables and Graphs

PBFBDD

MySQL

(ISP)


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www.pbfrwanda.org.rw Performance-Based Financing in Rwanda 2006-2008

INSERT GRAPHIC TO ADD MAP

MAP IS 6.17” TALL


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Access to data through the website Performance-Based Financing in Rwanda 2006-2008


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Data entry menu Performance-Based Financing in Rwanda 2006-2008


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Data entry is easy Performance-Based Financing in Rwanda 2006-2008


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Quarterly district invoices Performance-Based Financing in Rwanda 2006-2008


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3. Creating New Coordination Mechanisms: the ET Performance-Based Financing in Rwanda 2006-2008

  • The Extended Team Approach is Bridging the Gap between Policy and Implementation:

    • 11 international agencies

    • 3 MOH departments

    • Meeting once per month last Thursday of each month ½ day, careful agenda setting and effective information dissemination. Minutes available on website

    • Retreats for capacity building (Excel Pivot Tables and Graphs)

    • Training of Trainers in PBF


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4. Trainings Performance-Based Financing in Rwanda 2006-2008

  • Using ET mechanism to Train a Cadre of National Trainers in PBF

  • First start 2006 (after first wave of trainings)

  • Re-launched second half of 2007

  • Jan-March 2008: 946 health workers trained through 50 trainings

  • April 2008: seven Phase-II districts: 356 health workers trained through 13 trainings


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5. Continuous TA to the Decentralized Authorities Performance-Based Financing in Rwanda 2006-2008

  • Quarterly District PBF Steering Committee Meetings

  • Extended Team members: District PBF Focal points present in the District PBF Steering Committees

  • Assisting in control activities

  • Assisting in the quarterly quality counter-verification exercises

  • Assisting in the restitution of community client survey results


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Results: Institutional Deliveries Performance-Based Financing in Rwanda 2006-2008


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Community Client Survey 3Q08: Performance-Based Financing in Rwanda 2006-2008




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Challenges to Scaling Up the quality of services

  • Solution to Data Collection and Validation

    • Web application

  • Coordination challenges

    • TWG and ET mechanisms

  • Technical Assistance to the Central MOH and the Decentralized Authorities

    • TWG

    • ET mechanism

    • District PBF Steering Committees

  • Credible Performance Results

    • Use decentralized authorities (Min Local Admin; MOH) with strong TA support initially for internal control (ex ante)

    • Use NGOs as part of quorum in Decentralized District Level PBF Steering Committee, and for transparency (ex ante)

    • Use performance frameworks at all levels (Health Facility; Steering Committee; District Hospital; Central MOH)

    • Mix of third-party and transparent external verification mechanisms (ex post)


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Hogwood and Gunn’s “Perfect Implementation Model” the quality of servicesPerfect Implementation Model’, in Hogwood, B., Gunn, I., (1984) ‘Policy analysis for the real world’, Oxford University Press

  • The circumstances external to the implementing agency do not impose crippling constraints;

  • That adequate time and sufficient resources are made available to the program;

  • That the required combination of resources is actually available;

  • That the policy to be implemented is based on a valid theory of cause and effect;

  • That the relationship between cause and effect is direct and that there are few if any intervening links;


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…Ten Preconditions for a Successful Top Down Implementation

  • That dependency relationship is minimal;

  • That there is understanding of, and agreement on objectives;

  • That tasks are fully specified in correct sequence;

  • That there is perfect communication and co-ordination, and

  • Those in authority can demand and obtain perfect compliance.




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