title: Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda.
abstract: BACKGROUND
  Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors.
  
  
  OBJECTIVE
  Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda.
  
  
  METHODS
  Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers' progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression.
  
  
  RESULTS
  At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p<0.001); mean number of acute malnutrition cases in the previous 6 months declined from 24 to 5 per facility (p<0.001); and contraceptive prevalence increased from 42 to 59% (p<0.001). A number of innovative improvement initiatives were identified.
  
  
  CONCLUSIONS
  The combining of PBF, district engagement/support, and peer-to-peer learning resulted in significant improvements despite resource constraints and is now being considered as a model for scale-up in other districts of Rwanda.
authors.affiliation: Partners In Health | Inshuti Mu Buzima, Kigali, Rwanda.|Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; evnahimana@gmail.com.
authors.forename: Evrard
authors.initials: E
authors.lastname: Nahimana
authors.affiliation: Partners In Health, Boston, MA, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: McBain
authors.affiliation: Partners In Health, Boston, MA, USA.
authors.forename: Anatole
authors.initials: A
authors.lastname: Manzi
authors.affiliation: Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
authors.forename: Hari
authors.initials: H
authors.lastname: Iyer
authors.affiliation: Partners In Health | Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Alice
authors.initials: A
authors.lastname: Uwingabiye
authors.affiliation: Partners In Health | Inshuti Mu Buzima, Kigali, Rwanda.|Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Neil
authors.initials: N
authors.lastname: Gupta
authors.affiliation: Ministry of Local Affairs, Kigali, Rwanda.
authors.forename: Gerald
authors.initials: G
authors.lastname: Muzungu
authors.affiliation: Partners In Health | Inshuti Mu Buzima, Kigali, Rwanda.|Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Drobac
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.|Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Hirschhorn
keywords: Rwanda; capacity building; competition; priority setting; results-based financing