ArticlesEffect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation
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
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These authors shared first authorship