Authors: Jean-Benoit Falisse; Petra Vergeer; Joy Gebre Medhin; Maud Juquois; Alphonse Akpamoli; Jake Robyn; Walters Shu; Michel Zabiti; Rifat Hasan; Bakary Jallow; Musa Loum; Cedric Ndizeye; Michel Muvudi; Baudouin Booto; Jean Claude Taptue Fotso; Severin Sokegbe; Ibrahim Magazi; Gil Shapiro

More than 20 countries in Africa are scaling up performance-based financing (PBF), but its impact on equity in access to health services remains to be documented. This paper draws on evidence from Rwanda to examine the capacity of PBF to ensure equal access to key health interventions especially in rural areas where most of the poor live. Specifically, it focuses on maternal and child health services, distinguishing two wealth groups, and uses data from a rigorous impact evaluation.

Over recent decades, paying healthcare providers against agreed performance targets has gained momentum in high income countries and more recently in low and middle income countries (LMIC).

Ensuring that women and children receive quality health care is a key to alleviating poverty, but in many developing countries, access to appropriate medi­cal care is limited. In recent years, policymakers and health experts have promoted the use of performance-based bonuses to motivate health-care workers to fol­low best practices and ensure that patients receive key medical services. How such pay-for-performance programs are most effective? Can bonus payments have a positive impact on the type and quality of care provided by health centers and how, in turn, can affect health outcomes?

Le Rwanda, mené par son Ministère de la Santé, a été le premier pays africain à implémenter le Financement basé sur la Performance (PBF) dans ses centres de santé et dans ses hôpitaux et cela, à l’échelle nationale.Le pays a ensuite piloté le Financement Basé sur les Résultats (FBR) au niveau communautaire. Récompenser les membres de la communauté qui fournissent et utilisent les services de Santé Maternelle et Infantile (SMI) représente une forme novatrice de FBR.

Current global health policies emphasize institutional deliveries as a pathway to achieving reductions in newborn mortality in developing countries.

There is however remarkably little evidence regarding a causal relationship between institutional deliveries and newborn mortality.


Since 2000 performance-based financing (PBF) made its way to sub-Saharan health systems in an attempt to improve service delivery. In Rwanda initial experiences in 2001 and 2002 led to a scaling up of the initiative to all health centers (HC) and district hospitals (DH). In 2008 PBF became national strategy.

Paying for performance provides financial rewards to medical care providers for improvements in performance measured by utilization and quality of care indicators. In 2006, Rwanda began a pay for performance scheme to improve health services delivery, including HIV/AIDS services. Using a prospective quasi-experimental design, this study examines the scheme’s impact on individual and couples HIV testing. We find a positive impact of pay for performance on HIV testing among married individuals(10.2 percentage points increase).

Rwanda, led by its Ministry of Health, was the first African country to implement Performance- Based Financing (PBF) nationwide in its health centers and hospitals. The country then went on to pilot RBF interventions at the community level. Rewarding community members who provide and use Maternal and Child Health (MCH) services is an innovative form of Results-Based Financing (RBF). The supply-side of this community PBF scheme focuses on cooperatives of Community Health Workers (CHWs).

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