Elsevier

The Lancet

Volume 377, Issue 9775, 23–29 April 2011, Pages 1421-1428
The Lancet

Articles
Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation

https://doi.org/10.1016/S0140-6736(11)60177-3Get rights and content

Summary

Background

Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based payment of health-care providers (payment for performance; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda.

Methods

166 facilities were randomly assigned at the district level either to begin P4P funding between June, 2006, and October, 2006 (intervention group; n=80), or to continue with the traditional input-based funding until 23 months after study baseline (control group; n=86). Randomisation was done by coin toss. We surveyed facilities and 2158 households at baseline and after 23 months. The main outcome measures were prenatal care visits and institutional deliveries, quality of prenatal care, and child preventive care visits and immunisation. We isolated the incentive effect from the resource effect by increasing comparison facilities' input-based budgets by the average P4P payments made to the treatment facilities. We estimated a multivariate regression specification of the difference-in-difference model in which an individual's outcome is regressed against a dummy variable, indicating whether the facility received P4P that year, a facility-fixed effect, a year indicator, and a series of individual and household characteristics.

Findings

Our model estimated that facilities in the intervention group had a 23% increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger (56%) and aged between 24 months and 59 months (132%). No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules. We also estimate an increase of 0·157 standard deviations (95% CI 0·026–0·289) in prenatal quality as measured by compliance with Rwandan prenatal care clinical practice guidelines.

Interpretation

The P4P scheme in Rwanda had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider. P4P financial performance incentives can improve both the use and quality of maternal and child health services, and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health.

Funding

World Bank's Bank-Netherlands Partnership Program and Spanish Impact Evaluation Fund, the British Economic and Social Research Council, Government of Rwanda, and Global Development Network.

Introduction

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.1 Only ten of 67 countries with high child mortality rates are on track to meet the fourth Millennium Development Goal—a two-thirds reduction of mortality in children younger than 5 years by 2015.2 And, in most developing countries, the rate of decrease in maternal mortality is much lower than the rate needed to achieve the fifth Millennium Development Goal—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; P4P).3 P4P schemes provide financial incentives to health-care providers for improvements in utilisation 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. However, P4P schemes could have a detrimental effect on a health service. For example, when P4P payments depend on completion of reports, providers might spend more time on administrative duties and less time ensuring that patients receive the best quality care.4

In this study we assessed the potential of a P4P scheme to increase use and quality of key maternal and child health services. The impact evaluation was done prospectively in parallel with the rollout of a national P4P programme in Rwanda.

Section snippets

The Rwandan P4P scheme

In 2005, after encouraging reports from pilot P4P schemes run by non-governmental organisations, the Rwandan Government decided to implement a national P4P scheme to supplement primary health centres' input-based budgets. In this P4P scheme, payments are made directly to facilities and are used at each facility's discretion. The 14 key maternal and child health-care output indicators for which P4P payments are given are listed in table 1. Some of these output indicators are reasons for a visit,

Results

The figure shows the study design. 2·1% of households in the intervention group and 1·9% of households in the control group refused to participate in the interview. 88% of the baseline households were re-interviewed at the end of the trial. Slight differences exist in sample sizes between baseline and follow-up because incomplete household surveys were dropped from the sample in each round. The rate of attrition in the number of households available for a second interview was not statistically

Discussion

In this assessment of the P4P programme in Rwanda, our estimates suggest that P4P led to increased use and quality of several crucial maternal and child health care services, but had no effect on use of prenatal care or on the timely completion of child immunisation schedules. The estimates showed larger effects on services for which facilities receive larger financial incentives and those over which the provider has greater control (eg, prenatal care quality and tetanus vaccination during a

References (43)

  • Reference module for family planning training: for use of trainers, supervisors and providers at the health facility level

    (2008)
  • Rapport d' Enquête de Contre-Vérification par la Communauté dans les Districts de Nyamasheke, Nyaruguru et Rulindo. Kigali

  • A Donabedian

    The quality of care: how can it be assessed?

    JAMA

    (1988)
  • Normes du District de Santé au Rwanda

    (2003)
  • Normes du District Sanitaire au Rwanda

    (1997)
  • Standards de prestation des services au Centre de Santé: soins préventifs en SMI/PF/Nutrition (Volume 1, Première Edition)

    (1993)
  • M Grosh et al.

    A manual for planning and implementing the living standards measurement study survey: living standards measurement study working paper, No 126

    (1996)
  • C Vermeersch et al.

    Performance based contracting in Rwanda: evaluation design and methods

    (2010)
  • 2002—General census of population and housing (population)

  • Making decentralized service delivery work in Rwanda: putting the people at the center of service provision

    (2006)
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