Rwanda Performance-Based Financing for Health

Summary

Rwanda's health performance-based financing experiment was one of the first rigorous RCTs of pay-for-performance in a low-income country health system. The cluster randomized design, with equivalent funding in control facilities, cleanly isolated the effect of the incentive structure rather than the level of spending. The 23% increase in institutional deliveries — a high-value outcome that reduces maternal and infant mortality — was accompanied by measurable improvements in care quality. The findings influenced a wave of PBF programs globally, though subsequent evaluations in other countries have found more mixed results, suggesting context matters for whether incentive structures change health worker behavior.

Research question

"Do payments to health facilities based on quantity and quality of services improve health outcomes relative to equivalent unconditional funding?"

Methodology

Result

Positive

Institutional deliveries: +23%; complete child vaccination: +5 pp; quality index: +0.10 SD; staff effort and record quality improved

Evidence strength

Strong

Randomized controlled trial with large sample.

Replication status

Partially replicated