Going beyond incentivizing formal health providers: Evidence from the Rwanda Community Performance-Based Financing...

Area of Science:

• Global Health
• Health Economics
• Public Health Policy

Background:

• Pay-for-performance (PFP) programs aim to reduce maternal and child mortality in low- and middle-income countries by improving healthcare quality and utilization.
• Existing PFP programs primarily incentivize formal health providers, potentially overlooking other actors and demand-side constraints.

Purpose of the Study:

• To evaluate the impact of two novel incentive schemes—community health worker cooperative rewards and user in-kind transfers—added to Rwanda's national PFP program.
• To assess whether demand-side incentives can enhance health service utilization when implemented alongside supply-side PFP.

Main Methods:

• A randomized controlled trial was conducted in Rwanda.
• Two intervention arms were compared: cooperative performance payments and in-kind transfers to service users.
• Outcomes measured included service coverage, community health worker behavior, and cooperative-level results.

Main Results:

• Cooperative performance payments had no discernible impact on targeted service coverage or community health worker behavior.
• Despite frequent stock-outs of in-kind transfers at health centers, the demand-side intervention significantly increased timely antenatal care (9.3 pp) and timely postnatal care (8.6 pp).

Conclusions:

• Demand-side incentives, such as in-kind transfers to users, can effectively increase the utilization of specific maternal and child health services.
• Incentivizing users directly can be a viable strategy to complement existing supply-side PFP programs, even with logistical challenges.