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Performance-Based Pay for Health Care Providers and the Effect on Maternal and Child Health in Rwanda

Development Challenge

Despite a substantial increase in development assistance for health during the past decade, most low-income countries are unlikely to reach the health-related 2015 Millennium Development Goals (MDG). Only ten of 67 countries with high child mortality rates are on track to meet the fourth MDG - a two-thirds reduction of mortality in children younger than 5 years by 2015. And, in most developing countries, the rate of decrease in maternal mortality is much lower than the rate needed to achieve the fifth MDG - a three-quarters reduction of maternal mortality rates by 2015. To accelerate progress towards meeting these goals, developing countries need to increase access to and quality of maternal and child health services. An intervention that shows promise for improving access and quality of such health services is performance-based payment of health-care providers (payment for performance, or P4P). P4P schemes provide financial incentives to health-care providers for improvements in utilization and quality of specific care indicators, and can affect the provision of health care in two ways: by giving incentives for providers to put more effort into specific activities, and by increasing the amount of resources available to finance the delivery of services.


As of 2006, Rwanda had a maternal mortality rate of 1400 (per 100,000 live births) – far above the average of 900 for the WHO Africa region - and an under-5 mortality rate of 203 (per 1,000 live births). Only 10 percent of the population received at least 4 antenatal care visits, and only 31 percent of births were attended by a skilled health professional. Thirteen percent of children under-5 with a fever received treatment with any antimalarial medicine, and 17.3 percent with diarrhea received oral rehydration therapy (ORT).1 In an attempt to improve these numbers, in 2005, the Rwandan Government decided to implement a national P4P scheme to supplement primary health centers budgets.

Evaluation Strategy

The purpose of this study is to evaluate the impact of the Rwandan P4P scheme on use and quality of child and maternal care services in health-care facilities. Eighty health facilities were randomly assigned to start the P4P scheme between June and October of 2006, while 86 facilities were assigned to a comparison group and would continue to receive traditional input-based financing. Under the P4P scheme, facilities submitted monthly activity reports and quarterly requests for payment to the district steering committee. The committee then verified all reports by sending auditors to the facilities every three months on an unannounced, randomly chosen day to verify that the data reported was the same as those in the facility’s records. The appropriate payments were then made directly to the facilities. Payments were based on 14 maternal and child health-care output indicators, which included both reasons for a visit, such as prenatal care or delivery, as well as services provided during a visit, such as a tetanus vaccination. The specific payment amounts differed for each service, between US$0.09 for an initial prenatal visit and US$4.59 for an institutional delivery.

Results and Policy Implications

Overall, the P4P scheme in Rwanda seemed to have the greatest effect on those services for which the facilities received larger financial incentives and those over which the provider had greater control, and the least effect on the services that depended on patients’ behavior.

Prenatal care visits and institutional deliveries: Facilities enrolled in the P4P program had a 23 percent increase in the number of births attended to by a professional, which carried the highest per unit-payment, at US$4.59. As such, providers not only encouraged women to deliver in facilities, but also partnered with community health workers to promote institutional delivery. However, no improvements were seen in the number of women completing four prenatal care visits. This is likely due to poor financial incentives – the payment rate for completion of at least four prenatal visits was only $0.37 – as well as a lack of commitment on the part of the patients themselves.

Quality of prenatal care: Treatment facilities demonstrated improvements in the quality of prenatal care (0.157 standard deviations) as measured by compliance with Rwandan prenatal care clinical practice guidelines. Again, this may be explained by the higher monetary payoff of prenatal care quality – every tetanus vaccination and malaria prophylaxis course yielded US$0.92, while improved compliance with the prenatal care guidelines raised a facility’s overall score and thereby the amount of P4P payments actually received.

Child preventive care visits and immunization: Treatment facilities had a 56 percent increase in the number of preventive care visits by children under two years old, and a 132 percent increase for children aged between two and five years old. However, no improvements were seen in the number of children receiving full immunization schedules.



1 World Health Organization (WHO). Country Health System Fact Sheet 2006: Rwanda.