Project Information

Objective: The Health Sector Development Support Project seeks to increase health service utilization among pregnant women, children under five and couples of reproductive age.  The largest contributor to the PBF scheme is the Government of Burundi.
Status: Active
Date Effective: 04/08/2013 to 06/30/2017
Financing: HRITF $20 million and IDA $25 million
Other Financial Contributions: Government of Burundi; GAVI; European Union; Belgium Cooperation

Photo Credit: World Bank


Despite recent moderate improvements, Burundi’s health indicators continue to perform poorly. The maternal and under-five mortality rates remain high with respectively 500 maternal deaths per 100,000 live births and 96 child deaths per 1,000 live births (DHS, 2011).  Surveys and administrative data indicate that health services either do not reach or are not used by the population. The 2011 Demographic and Health Survey also indicates that 27 percent of children under five are suffering from severe acute malnutrition; only 33 percent of pregnant women attend four or more antenatal care visits ; and only 11 percent of married women use a modern method of contraception.


RBF Incentives

The Health Sector Development Support Project uses supply-side performance-based financing (PBF) to deliver a predefined package of services. Leveraging the Free Health Care policy targeting pregnant women and children under five, the PBF scheme operates at national level and involves a total of 643 health centers and 54 hospitals. Under this scheme, health facilities – at primary and secondary levels – are contracted by the Ministry of Health and incentivized quarterly through a fee-for-service mechanism. The PBF payments are based on quantity and quality-related performance thresholds as well as on an equity markup. Once disbursed, these payments can be autonomously used to motivate healthcare providers (35 percent) and improve health facility performance (65 percent).


The RBF verification function is multilayered. The quantity of services provided is verified monthly by provincial verification and validation committees using healthcare providers’ registers.  The technical quality of services delivered at health center level is assessed quarterly by district health officers. The technical quality of services delivered at hospital level is assessed quarterly by peer hospitals. Local non-governmental organizations conduct semi-annual patient tracing to both ascertain service delivery and measure patient satisfaction.  An independent entity runs counter-verifications semi-annually to ensure the accuracy of internal verifications and further assess reported performance.


Status and Achievements

The first Health Sector Development Support Project was first implemented from 2010 to 2014 to increase health service utilization among pregnant women and children under five in 513 health centers and 50 hospitals across Burundi. Financed by the HIRTF (14.8 million US$) and IDA (25 million US$), this first Project is now complete and fully disbursed (100%).  Although the first Project did not benefit from an impact evaluation – primarily because of its rapid expansion – performance-monitoring data show positive results with regard to the quality and the quantity of care provided.

The second Health Sector Development Support Project (2013-2017) draws on lessons learned from 2010 to 2014.  It is financed by the HIRTF (20 million US$) and IDA (25 million US$). Although monitoring results indicate improvements in the quantity and the quality of services provided, the political situation currently prevailing in Burundi continues to hamper project implementation. Despite this difficult situation, the cumulated disbursement rate in December 2016 exceeded 85 percent.

Lessons Learned

Continuous project monitoring is instrumental for timely and effective course corrections – enabling, for instance, the revision of performance frameworks and increased value-for-money.


The PBF component of the Health Sector Development Support Project includes a randomized impact evaluation aiming to assess the impact of RBF on service utilization and on the achievement of set targets. It will particularly focus on RBF indicators related to nutrition and the quality of care.  The Impact Evaluation completion report will be prepared before the project closing date (June 30, 2017).

The project will finance incentives to healthcare providers for the provision of additional services particularly vital for the development of the country. These services are directly related to nutrition and contraception.