Effects of performance payments to health workers in Rwanda

Summary of published research¹

A study just published in the Lancet set out to assess the effect of performance-based payment of healthcare providers on the use and quality of child and maternal care services in healthcare facilities in Rwanda. Payment for performance (P4P) schemes provide financial incentives to healthcare providers for improvements in utilisation and quality of specific care indicators. They can affect the provision of heath 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 can have a detrimental effect. 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. In this study, the researchers 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.

One hundred and sixty-six 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 inputbased funding until 23 months after study baseline (control group, n=86). Randomisation was done by toss of a coin. The researchers surveyed facilities and 2,158 households at baseline and after 23 months. The main outcome measures were prenatal care visits, institutional deliveries (births), quality of prenatal care, child preventive care visits and immunisation. The study team 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. The team 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.

The 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 children 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. The team also estimated 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. 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.

Researchers concluded that 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.

¹Basinga. P et al (2011). Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet 2011, 377: 1421-28