Health system changes under pay-for-performance: the effects of Rwanda’s national programme on facility inputs

Abstract

Pay-for-performance (P4P) programmes have been introduced in numerous developing countries with the goal of increasing the provision and quality of health services through financial incentives. Despite the popularity of P4P, there is limited evidence on how providers achieve performance gains and how P4P affects health system quality by changing structural inputs. We explore these two questions in the context of Rwanda's 2006 national P4P programme by examining the programme's impact on structural quality measures drawn from international and national guidelines. Given the programme's previously documented success at increasing institutional delivery rates, we focus on a set of delivery-specific and more general structural inputs. Using the programme's quasi-randomized roll-out, we apply multivariate regression analysis to short-run facility data from the 2007 Service Provision Assessment. We find positive programme effects on the presence of maternity-related staff, the presence of covered waiting areas and a management indicator and a negative programme effect on delivery statistics monitoring. We find no effects on a set of other delivery-specific physical resources, delivery-specific human resources, delivery-specific operations, general physical resources and general human resources. Using mediation analysis, we find that the positive input differences explain a small and insignificant fraction of P4P's impact on institutional delivery rates. The results suggest that P4P increases provider availability and facility operations but is only weakly linked with short-run structural health system improvements overall.

Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries

“…Measuring the necessary inputs to care provided limited insight on the process quality of care delivered in primary care services as well as in more resource-intensive delivery care. These findings amplify a study of pay-for-performance interventions in Rwanda, demonstrating that increased availability of inputs for delivery care explained an insignificant fraction of increased delivery volume [ 45 ]. Although we would not expect perfect correlation due to the breadth of the infrastructure measures relative to the specific items of evidence-based care, the limited associations and high variability in observed clinical quality at similar levels of facility infrastructure was striking, even for well-equipped facilities.…”

Combining Theory-Driven Evaluation and Causal Loop Diagramming for Opening the ‘Black Box’ of an Intervention in the Health Sector: A Case of Performance-Based Financing in Western Uganda

“…The improved work environment and health worker performance combined with the increased number of patients increases the health facility budget, which can trigger further improvements in the work environment (KIs 1, 4, 5, 7, 8, 11–14), closing the reinforcing feedback loop. An important influencing factor of this loop is the ability of the management team to plan well and to use the newly received funds in an efficient and effective way (KI 2) [ 51 , 55 , 56 ].…”

Causes of Morbidity and Mortality among Neonates and Children in Post-Conflict Burundi: A Cross-Sectional Retrospective Study

“…For example, in 2004, the government of Burundi institutionalized output-based financial support or performance-based financing (PBF) of the facilities [ 22 ]. Performance-based financing has shown to be a promising reform approach to improving the utilization, the quantity and quality of maternal and child health services in Burundi and in neighboring countries such as Rwanda [ 3 , 10 , 47 , 48 ]. Other effective intervention programs for the management of childhood diarrhea have been those to do with the “social marketing intervention that promoted the Population Services International (PSI) ORASEL Kit, a low osmolarity oral rehydration salt (ORS), a product developed by FDC limited ( ).…”