Paying Primary Health Care Centers for Performance in Rwanda

Paying for performance (P4P) provides
financial incentives for providers to increase the use and
quality of care. P4P can affect health care by providing
incentives for providers to put more effort into specific
activities, and by increasing the amount of resources
available to finance the delivery of services. This paper
evaluates the impact of P4P on the use and quality of
prenatal, institutional delivery, and child preventive care
using data produced from a prospective quasi-experimental
evaluation nested into the national rollout of P4P in
Rwanda. Treatment facilities were enrolled in the P4P scheme
in 2006 and comparison facilities were enrolled two years
later. The incentive effect is isolated from the resource
effect by increasing comparison facilities' input-based
budgets by the average P4P payments to the treatment
facilities. The data were collected from 166 facilities and
a random sample of 2158 households. P4P had a large and
significant positive impact on institutional deliveries and
preventive care visits by young children, and improved
quality of prenatal care. The authors find no effect on the
number of prenatal care visits or on immunization rates. P4P
had the greatest effect on those services that had the
highest payment rates and needed the lowest provider effort.
P4P financial performance incentives can improve both the
use of and the quality of health services. Because the
analysis isolates the incentive effect from the resource
effect in P4P, the results indicate that an equal amount of
financial resources without the incentives would not have
achieved the same gain in outcomes.