Photo Credit: World Bank/ A'Melody Lee
At the time of the project’s appraisal, Rwanda had made significant progress in the health sector. The use of modern contraceptives had increased from 4 percent (RDHS, 2005) to 27 percent (IDHS, 2008) resulting in a drop in total fertility rates from 6.2 (RDHS, 2005) to 5.5 (IDHS, 2008); and under-five mortality declined steadily from 196 to 103 deaths per 1,000 live births during the same period. The maternal mortality rate nevertheless remained significantly high at 750 deaths per 100,000 live births (RDHS, 2005).
High fertility rates, maternal mortality, and child malnutrition remained serious concerns, and low service utilization and severe shortages in medical personnel continued to hamper maternal and child health outcomes. And, while the proportion of people identified as poor had slightly decreased from 60 percent in 2000-01 to 57 percent in 2005-06, rapid population growth led the total number of people living in poverty to rise from 4.8 million in 2000/2001 to 5.4 million in 2005-06. Over 90 percent of those who were poor lived in rural areas, and poverty remains pervasive and deep.
RBF AT A GLANCE
The Community Living Standards Grant Project simultaneously used performance-based financing (PBF) to improve maternal and child health outcomes at community level throughout the country. On the supply-side, the Ministry of Health (MOH) – through local administrative sectors – contracted and incentivized cooperatives of community health workers (CHWs) to provide promotional and referral services at community level, and enhance data quality at sector level. Related PBF payments were made quarterly by the National Treasury based on the quantity of services delivered and on the completeness, timeliness and quality of cooperatives’ reporting. PBF payments were used to reinvest in cooperatives and ensure further income generation (i.e. 70 percent), and to provide performance-based incentives to individual CHWs (i.e. 30 percent). The MOH leads the RBF regulation function, ensuring compliance with RBF objectives and principles and alignment with national norms and guidelines. Health centers as representatives of the MOH supervise CHWs at community level.
On the demand side, the Community Living Standards Grant Project provided in-kind incentives to encourage eligible women to use essential maternal and child health services. Under this scheme, the MOH transferred cash and sent vouchers for the purchase of incentive material (i.e. cloth, umbrella, etc.) at the health center level. In turn, CHWs conducted regular community sensitization to inform, encourage and accompany eligible women to health centers – particularly for antenatal care, institutional deliveries, postnatal care and family planning. When a woman comes to the health center for any of the pre-defined services, she receives an in-kind incentive. The health center is responsible for distributing the incentives and for renewing stock when appropriate.
The community RBF interventions implemented in Rwanda used four methods to verify the performance of CHW cooperatives (i.e. supply-side scheme) as well as to verify the distribution of in-kind incentives (i.e. demand-side scheme):
- The first method concerns the verification of the quantity of services provided by CHWs, which is performed monthly for every cooperative (no sampling) by the affiliated health center and validated quarterly by a steering committee headed by the local government administration. Data is checked against referral forms submitted by clients referred by CHWs.
- The second method pertains to the assessment of the quality of CHW cooperatives, using a quality checklist. It entails the health center assessing the quality of reporting (i.e. timeliness, completeness, accuracy) monthly and the local steering committee validating this information every quarterly. It also involves the district hospital evaluating the quality of cooperatives’ management and the district steering committee validating this evaluation.
- The third method involves the verification of the quantity of in-kind incentives distributed, which is performed by the district hospital (optional) during monthly routine monitoring visits to health centers.
- The fourth method entails the counter-verification of the above-mentioned mechanisms, carried out by the health center, the sector and the district hospital or by the Ministry of Health (MoH) on either a purposive or systematic basis.
Status and achievements
The Community Living Standards Grant Project was closed on 30 June 2012.
The existence of decentralized governance and management structures highly facilitates successful implementation of community-targeted social protection reforms. This is particularly true when related targeting systems draw on community-driven development (CDD).
Incentives matter. There is a growing body of empirical evidence of the use of incentives to reward health service providers for specific types of results and to motivate individuals for health-related behaviors. The experiences in the health sector have been led to a large extent by findings of the impact evaluation of the PBF in Rwanda. These finding follow the experiences with conditional cash transfers, and confirm that individuals (whether mothers, pregnant women or service providers) respond to incentives and that these incentive-driven effects can be used to yield sustainable health results.
Investing in collaboration with a national research team not only strengthens in-country capacity in this technical area, but also contributes greatly to the successful implementation, management and ownership of an evaluation.
EVALUATION AT A GLANCE
The impact evaluation assessed the impact of supply-side incentives for community health worker cooperatives, demand-side in-kind incentives for mothers and their children, and the combination of both on maternal and child health outcomes. The impact evaluation used an experimental design with the interventions having been assigned at the sector (sub-district) level.
The impact evaluation was completed and a report completed. The analysis found no impacts of the incentives to CHW cooperatives on the rates of utilization of the targeted services, nor on the motivation and behavior of the CHWs. The low incentive amounts, together with the fact that the payments were made through the cooperatives made the financial reward to personal effort negligible. Conversely, demand-side incentives were shown to significantly increase rates of timely antenatal and postnatal care, although the transfers were in-kind and many eligible women did not receive the gifts due to stock-outs.