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Paying Health Care Providers for Performance: Evidence from Rwanda. Paul Gertler UC Berkeley January 2009. Collaboration. Research Team Paulin Basinga, National University of Rwanda Paul Gertler, UC Berkeley Jennifer Sturdy, World Bank

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Paying health care providers for performance evidence from rwanda

Paying Health Care Providers for Performance: Evidence from Rwanda

Paul Gertler

UC Berkeley

January 2009

Collaboration Rwanda

  • Research Team

    • Paulin Basinga, National University of Rwanda

    • Paul Gertler, UC Berkeley

    • Jennifer Sturdy, World Bank

    • Christel Vermeersch, World Bank

  • Policy Counterpart Team

    • Agnes Binagwaho, Rwanda Rwanda MOH

    • Agnes Soucat, World Bank

Overview Rwanda

  • Background/Motivation

  • Rwanda

  • Program Description

  • Evaluation Design and Methodology

  • Baseline Descriptive Statistics

  • Impact of PBF

  • Next Steps

Context developing world
Context: Developing World Rwanda

  • Africa

    • Very poor health status

    • Weak health care systems

    • Brain drain – doctors & nurses leaving

    • Massive AID could be wasted

  • World Wide (WDR 2004)

    • Low Quality of Care

    • Training/technology have had small effect on Quality

    • Provider absenteeism high & effort low

Pay for performance
Pay For Performance Rwanda

  • Pay Medical Providers a bonus based on performance measurement

    • Improve quality of care and outcomes

    • Improve job satisfaction & retention

  • Organization Challenges

    • Individuals versus team incentives

    • Measuring performance

    • Cheating/Misreporting

Rwanda central african country
Rwanda: Central African Country Rwanda

  • 9 million people

  • Genocide in early 1990s

  • GNP per capita: 250 US$

  • Weak Health Care Infrastructure

    • 36 Hospitals, 369 health centers

    • Doctors: 1/50,000 inhabitants

    • Nurses: 1/3,900 inhabitants;

    • 17% of nurses in rural areas

  • Poor health status, but getting better

Performance based financing pbf
Performance-based Financing (PBF) Rwanda

  • Local Initiative

  • Objectives

    • Increase quantity & quality of health services provided

    • Increase health worker motivation

  • Financial incentives to providers to see more patients and provide higher quality of care

    • Increased resources

    • Financial incentives

  • Operates through contracts between

    • Government

    • Health facilities providing services

Quarterly payment to facility i in period t
Quarterly Payment to Facility Rwandai in period t

Pj = payment per unit of each PBF service j

Uijt= number of patients using service j in facility i in period t

Qit = facility i’s quality in period t

Pbf facility quality score
PBF Facility Quality Score Rwanda

Where Skit = facility i’s Quality index of Service k

  • Indicator types:

    • Structural: Availability of medical equipment/drugs needed to deliver adequate medical care

    • Process: Clinical content of care (CPGs)

Monitoring facility reporting
Monitoring Facility Reporting Rwanda

  • District Comite de Pilotage

    • Approves quarterly payment

    • Based on facility reports & independent audits

  • Random utilization audit (once quarterly)

    • One focal point per administrative district

  • Random quality audits (once quarterly)

    • District supervisors based in District Hospital

  • Interview random sample of patients

    • Identify phantom patients

    • MSH study – less than 3-5% phantom patients

Evaluation questions did pbf
Evaluation Questions: Did PBF… Rwanda

  • Increase the quantity of contracted health services delivered?

  • Improve the quality of contracted health services provided?

  • Improve child health status?

Identification strategy
Identification Strategy Rwanda

  • During decentralization, phased rollout at district level

  • Identified districts without complete PBF in 2005

  • Group districts into “similar pairs” based on population density & livelihoods

    • Decentralization reallocated districts

    • Some new districts had PBF in an area of the new district

    • Gov’t rolled PBF to remaining clinics (treatments)

    • Districts matched to these partials controls

    • Others: randomly assign one to treatment and other to control

    • 8 pairs

Isolating the incentive effect
Isolating the incentive effect Rwanda

  • PBF

    • Performance incentives

    • Additional resources

  • Compensate control facilities with equal resources

    • Average of what treatments receive

    • Not linked to performance

    • Money allocated by the health center management

Sample Rwanda

  • 165 health facilities

    • all rural health centers located in districts

  • 2145 households in catchment areas

    • Random sample of 14 per clinic

  • Panel data: 2006 and 2008

Survey content
Survey Content Rwanda

  • Health Facility Data

    • Financials and Human resources

    • Lab test, equipment and medicine availability

    • Provider interview for competency (vignette)

    • 8-10 patient exit Interviews for prenatal process quality

  • Household survey

    • Socio-economics

    • Utilization

    • Health outcomes

Health facility results
Health Facility Results Rwanda

  • Did we isolate incentives effect?

    • Log expenditure between Tr and Phase II

  • Did randomization balance treatment/control groups?

  • Did utilization increase?

  • Did structural quality improve?

  • Did process quality improve?

    • Prenatal Care (PBF pays for this)

    • Child Curative Care (PBF does not pay for this)

Log expenditures
Log Expenditures Rwanda

  • Randomization balanced baseline

  • Follow-up balanced, so difference in follow-up outcomes due to incentives not resources

Baseline balance
Baseline Balance Rwanda

  • Utilization (PBF)

  • Structural Quality

    • Availability of staff, equipment & drugs needed to deliver care (PBF)

    • Little room to improve

  • Process Quality

    • Competency (Vignettes)

    • Process Quality (Patient exit survey)

Prenatal competency quality
Prenatal Competency & Quality Rwanda

  • Standardized vignette presented to provider

    • Unprompted responses for competency

    • Measure of ability/knowledge

    • Based on Rwandan Clinical Practice Guidelines

  • Process quality

    • Patient exit interview for process quality

    • Clinical content of care

    • Provider effort

Quality conceptual framework
Quality Conceptual Framework Rwanda




What They Do: (Quality)

What They Know (Ability/Technology)

Returns to training technology low data from 12 countries
Returns to Training/Technology low (data from 12 countries) Rwanda


What They Do

Actual Performance

Ability/Technology (More Training & Equip/Drugs )

Goal use pay for performance to close productivity gap
Goal: Use Pay for Performance to Close Productivity Gap


What They Do

Productivity Gap Conditional on Ability

Actual Performance


Impact of pbf statistical methods
Impact of PBF: Statistical methods

  • Have balance at baseline on all key outcomes

  • Use difference in differences analysis

    • Not a pure randomized experiment

  • Clustered at district year level

  • Facility Fixed Effects

  • Year dummy

  • Controls: age, parity, education, household size, health insurance, land, value of assets

Impact on child height
Impact on Child Height

  • 0-11 months = +0.28***

  • 24-47 months = +0.86***

Results summary
Results Summary

  • Balanced at baseline

  • Expenditures same, so isolate incentives

  • Impact on utilization

    • Delivery & Child prevention, but not prenatal

  • Impact on prenatal quality

    • Bigger for better doctors

  • Reduced child morbidity

  • Taller children