Community Health Workers'
Incentives in Rwanda
Performance-Based Financing is thoroughly embedded in the
Rwandan Health system. It is practiced in health centers and district hospitals
nationwide using common approaches. Ministry of Health Performance-Based
Financing has started at the central ministerial level (Basinga, 2009).
Performance-Based Financing systems are being designed for the
national Community Based Health Insurance system, and for the CDLS. A national
model for Community Performance-Based Financing has been developed, using a
broad consultative process. The model is based on experience gained during the
implementation of the health center and hospital Performance-Based Financing
models, and benefits from a close fit with these models. The purpose of this
Community Performance-Based Financing (PBF) Guide is to document the tools and
processes used in Community PBF. This guide is primarily meant as a background
document for trainers, sector PBF Steering Committee members, and the Community
Health Worker Cooperatives. However, it will be used by all working in the
Rwandan Health System (Basinga, 2009).
The community PBF is not for individual performance
remuneration. The purpose of the incentive is for community health workers to
increase the capital of their cooperatives. The cooperatives on their turn will
then start income generating activities to the benefit of the individual
members. The remuneration of individual community health workers will be from
the profit of the cooperative activities (MOH Rwanda, 2009).
Resource poor countries, particularly in sub-Saharan Africa,
face many challenges improving maternal health due to financial and human
capital constraints, lack of motivation among health providers and lack of
physical resources. One of the key policies implemented in Rwanda in response
to these issues is Performance Based Financing (MOH Rwanda, 2009).
PBF provides bonus payments to providers for improvements in
performance measured by indicators of specific types of utilization (e.g.
prenatal care) and quality of care. While the approach promises to improve
health system performance, there is little rigorous evidence of its
effectiveness, especially in low-income settings.
This study examines the impact of the incentives in the
Rwandan PBF scheme on prenatal care utilization, the structure and process
quality of prenatal care, institutional delivery, and modern contraceptive use.
The analysis uses data produced from a prospective quasi-experimental design
nested within the program's rollout. The rollout was implemented in two phases:
in 2006, 86 facilities (treatments) in rural areas enrolled in the PBF, and
another 79 facilities (control) enrolled two years later.
In order to isolate the incentive effect from the resource
effects, the control facilities were compensated by increasing their
traditional budgets with an amount equal to the average PBF payments to the
treatment facilities. Baseline and end line data were collected from all of the
facilities and a random sample of 14 households in each facility's catchment
area.
Using a different approach, PBF had a large and significant
impact on the quality of prenatal care measured by process indicators of the
clinical content of care and deliveries in facilities. However, no such effect
was found on prenatal care visits or on the use of modern contraceptives (MOH,
Rwanda2009).
The results provide evidence to support the hypothesis that
financial performance incentives can improve both the use and quality of
maternal health services. Policy recommendations include increasing incentives
for prenatal care service, complementary training to increase quality and
combining PBF with a demand-side intervention such as conditional cash transfer
involving community health workers (Basinga, 2009).
In the study conducted by JSI (2009), on the ''Non-financial
incentives for voluntary community health workers'' they concluded the
following: Community acceptance for voluntary CHWs and their own attitudes to
their work is generally positive. Nevertheless, continual efforts to enhance
recognition and understanding of their voluntary work in the community are
needed to maintain their morale. Their work was also found to be very `doable'
and expectations from them quite clear. The teaching materials and the support
provided to them by HEWs in the form of monthly meetings and work visits can be
further strengthened however.
The motivations of voluntary CHWs, in terms of their reasons
for being involved in their work and the benefits they expected, were strongly
characterized by their desire to promote health in their community including
themselves and their families. Steps taken to enhance their efficacy in this
regard will therefore have a positive impact on their motivation levels.
Volunteers were also strongly motivated by the responsibility and acceptance
they received from the community, as well as the recognition, respect,
credibility and political status they have gained. Conversely, they were
sometimes discouraged by misunderstanding of their voluntary role on the part
of the community. VCHWs can therefore be further motivated by promoting
community understanding and recognition of their work. Their aspirations for
learning and employment opportunities can also be considered in relation to
ways of sustaining volunteerism.
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