Management Sciences for Health notes that, “PBF is a powerful means for increasing the quantity and quality of health services by providing incentives to health providers to improve performance. A PBF program typically includes performance?based grants or contracts. Health clinics and their staff are rewarded for reaching or exceeding health indicators.” MSH cautioned that, “while PBF is expected to reduce unit costs in the long?term by increasing productivity, unit costs may actually increase in the short term when services have previously been underfunded???as salaries rise to appropriate levels, missing equipment and supplies are purchased, and facilities are upgraded.” In the long term they explained that PBF had a, “crucial impact on revenues received at health centers, motivated access to quality services for the people served, and allowed the Government of Rwanda to actively manage its investments in pursing national health goals.”
Between 2001 and the mid-2000s Rwanda introduced and began scaling up PBF. The focus of health care shifted from inputs to outputs to outcomes. “Performance improvements that have been documented in Rwanda after the introduction of performance incentives for primary health care and HIV/AIDS service products have been impressive.” In two pilot districts health care consultations per capita more than doubled. Institutional deliveries tripled. Child immunization, maternal immunization and contraceptive prevalence rates also increased.
There is national policy and political support for PBF as it fits into government desired for accountability. Financial support comes from government and specific programs within the Ministry of Health such as malaria elimination and TB control who have invested in specific performance indicators. Donors such as USAID, World Bank, and Global Fund, play a major role in providing the technical and financial support that pays for performance.
PBF in Rwanda operates at all levels of the health system, but of interest to PHC are the front-line health centers and the local cooperatives and community health workers (CHWs). CHW support came about in 2008 as a strategy to sustain the CHWs system. PBF in Rwanda is based on two kinds of contracts, contracts on the performance of the health unit and contracts on the performance of individual health workers.
The PBF procedures manual explains that, “Community PBF (C-PBF) is implemented at the village level through the trained community health workers (CHW) operational within each community. Health posts are located at the cell level and due to their private or faith-based organizations affiliation they are not integrated into the PBF system. Health Center PBF is implemented at the sector’s level health center while district and provincial hospitals are implementing the district hospital PBF model (recently linked with accreditation).”
Under the USAID MCHIP Project, Jhpiego conducted a malaria program implementation assessment in Rwanda that examined the health systems building blocks including financing. The report noted that, “Cooperatives have been set up for CHW; there are usually about 120 people (depending on the number of CHWs in the catchment area of the health center) per cooperative with a president, vice president, secretary, treasurer, and three advisors. Cooperatives can engage in many different types of income-generating activities, based on the agreement among the members, and the executive committee makes final decisions and determines how income will be disbursed among members.”
The aspect of PBF contracting is undertaken with the CHW Cooperative. “Through the PBF, CHW cooperatives can earn ~250USD per quarter from the government. The total amount is based on the completeness of CHW reports and their performance on 20 set indicators. These indicators include elements such as timeliness and completeness of reports, number of pregnant women receiving consultation in the first trimester, number of women accepting family planning (new and continuing clients), and infant growth monitoring.”
Rwanda has also introduced a quality of services element known as Pay-4-Performance, and entities such as health centers and CHW cooperatives are also given a quality score arising from supervisory processes. The quality component has helped “cooperatives linked to the PBF address issues of attrition and motivation. The division of supervision among cell leaders also reduces the work burden for facility-based supervisors.” Practical service delivery problems such as stock-outs of commodities are less likely to occur at the community level when PBF is in place. The challenge moving forward may be the stress created by adding more responsibilities to the duties of the CHWs.
The MCHIP report concluded that, “PBF has set up a system of
accountability so that not only is funding spent appropriately, but results are
also expected and rewarded. PBF addresses the challenges of motivation that so
often plague health care workers and managers in other countries who do not see
rewards for working hard and doing a good job. The fact that the system of
emphasis on quality services in sufficient quantities radiates from the
national to the district to the community level (i.e., districts reporting to
the President’s office, and CHWs reporting on indicators to health center
supervisors) ensures that a culture of rewarding good performance is
developing.” A systems challenge is dependence on donor support in terms of
both continuity and donor focus, as many donors focus on particular
interventions (malaria, family planning), leaving gaps among the service
 Management Sciences for Health. The Health Impact of Performance-Based Financing in Rwanda. Published: 2010?12?23 http://blog.msh.org/2010/12/23/the-health-impact-of-performance-based-financing-in-rwanda/
 Louis Rusa, (National PBF Coordinator-Ministry of Health Rwanda), and Gyuri Fritsche, (Health Care Financing Specialist-Management Sciences for Health). Rwanda: Performance-Based Financing in Health. Sourcebook: Second Edition. http://www.ccoms-imsuerj.org.br/capfts/2011/uploads/4-3RwandaPBF.pdf
 Ministry of Health, Rwanda. Performance Based Financing Procedures Manual for Health Facilities (Hospitals and Health Centers). April 2018.
 Maternal and Child Health Intergrated Program (USAID, Jhpiego). Analysis of the Status of Prevention and Control of Malaria in Rwanda: Best Practices and Challenges to Program Implementation. November 2013.