Performance-based financing and changing the district health system: experience from Rwanda

Area of Science:

• Health economics
• Public health policy
• Health systems strengthening

Background:

• Traditional input financing mechanisms often fall short in improving health service delivery.
• Performance-based financing (PBF) has shown success in low-income Asian countries.
• The applicability of PBF in sub-Saharan Africa requires further investigation.

Purpose of the Study:

• To demonstrate the feasibility of performance-based financing in a sub-Saharan African context.
• To explore the necessary structural changes for implementing PBF in district health systems.
• To highlight the role of community engagement in verifying health facility performance.

Main Methods:

• Field experience in Rwanda implementing a PBF strategy.
• Introduction of an independent fundholder organization to manage purchasing and disbursement.
• Utilization of local community groups for patient surveys and satisfaction monitoring.
• Emphasis on autonomous health facility management and competition for public subsidies.

Main Results:

• Performance-based financing was demonstrated as a feasible strategy in Rwanda.
• The implementation required a new actor: an independent fundholder organization.
• Community groups successfully verified facility performance and monitored consumer satisfaction.
• Respect for autonomous facility management was identified as a key success factor.

Conclusions:

• Performance-based financing is a viable and effective strategy for improving health service delivery in sub-Saharan Africa.
• Implementing PBF necessitates a clear separation of roles within the district health system.
• Community involvement and autonomous facility management are crucial for successful PBF implementation, leading to more transparent and efficient health districts.