Performance-based financing in Rwanda: a qualitative analysis of healthcare provider perspectives

Results-based healthcare financing policies have been adopted in countries worldwide, including those with limited resources. We conducted a retrospective, semistructured interview study to evaluate healthcare providers' experiences with Rwanda's performance-based financing (PBF) policy and the factors influencing its implementation. Guided by the health policy evaluation model-context, content, process, and actors-as a deductive framework supplemented by inductive coding, we analysed data from 21 participants (doctors, n = 13; nurses, n = 5; midwives, n = 3). Providers described PBF as a key motivator, supplementing incomes, increasing accountability, and fostering teamwork to meet performance targets. PBF was credited with improving patient outcomes, particularly in incentivized services; however, concerns arose regarding disparities in service prioritization. Key facilitators of and barriers to the implementation of PBF were identified, providing insights into its operational dynamics. Strong political commitment and integration into national strategies, such as Imihigo, along with decentralization through district steering committees, were key contextual enablers, enhancing the program's flexibility and alignment with local priorities. The content factors centred on a two-tiered contracting system, combining national accreditation processes with individual performance incentives. Process factors supporting PBF were characterized by decentralized evaluations, audits, and multilevel communication, which collectively bolstered accountability mechanisms. The engagement and capacity of stakeholders were highlighted as crucial to the success of PBF. Nonetheless, significant barriers, such as payment delays, manual documentation, untimely evaluations, insufficient training, limited provider participation in decision-making, and the exclusion of patients as stakeholders, were identified. These findings offer practical recommendations for policymakers aiming to improve or adapt provider payment mechanisms in similar contexts.