title: Impact of implementing performance-based financing on childhood malnutrition in Rwanda.
abstract: BACKGROUND
  Malnutrition remains a serious concern in Rwanda, particularly among children under-5 years. Performance-based financing (PBF), an innovative health systems financing strategy, has been implemented at the national level since 2008. This study aimed to assess the impact of PBF and other factors associated with the prevalence of three classifications of malnutrition (stunting, wasting and underweight) in children under-5 years in Rwanda.
  
  
  METHODS
  The study is a cross-sectional study comprising of 713 children under five years old from 557 households, whose anthropometric measurements (height, weight and age) had been obtained as part of the 2008 Rwanda General Health and HIV household survey. Z-scores for height-for-age, weight-for-age, weight-for-height, and body mass index-for-age were analyzed according to the World Health Organization 2006 Child Growth Standards. Random intercept logistic regression models were used to regress each anthropometric measure (WAZ, HAZ and WHZ) against child, maternal and household characteristics.
  
  
  RESULTS
  Child participants ranged in age from 0 to 60 months, 20.2% of children were under 12 months and 5.1% were HIV positive. The prevalence of wasting was 8.8%; of stunting was 58.4%; and of underweight status was 20.7%. Maternal emotional and social wellbeing was protective of wasting in children under-5 years of age. Living in districts implementing PBF was protective of wasting (Adjusted Odds Ratio: 0.43; 95% confidence interval: 0.19-0.97). Living in a district with PBF was not found to be associated with either stunting or underweight status among children under-5.
  
  
  CONCLUSIONS
  PBF may have a protective association with particular forms of malnutrition among children under-5 years in Rwanda. These findings warrant further investigation in relation to the impact of implementing innovative financing schemes on health outcomes.
authors.forename: Agnes
authors.initials: A
authors.lastname: Binagwaho
authors.affiliation: University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda. jcondo@nursph.org.
authors.forename: Jeanine
authors.initials: J
authors.lastname: Condo
authors.forename: Claire
authors.initials: C
authors.lastname: Wagner
authors.forename: Fidele
authors.initials: F
authors.lastname: Ngabo
authors.forename: Corine
authors.initials: C
authors.lastname: Karema
authors.forename: Steve
authors.initials: S
authors.lastname: Kanters
authors.forename: Jamie I
authors.initials: JI
authors.lastname: Forrest
authors.forename: Jean de Dieu
authors.initials: Jde D
authors.lastname: Bizimana
mesh_terms: D002648:Child; D002662:Child Health Services / Q000191:economics; D002675:Child, Preschool; D003153:Community Health Services / Q000191:economics*; D003430:Cross-Sectional Studies; D005260:Female; D061889:Healthcare Financing; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D044342:Malnutrition / Q000453:epidemiology* / Q000517:prevention & control; D009752:Nutritional Status; D011785:Quality Assurance, Health Care; D012432:Rwanda / Q000453:epidemiology