Summer in the Field: Evaluating the Cost-Effectiveness of Equity-Based Incentives in Performance-Based Financing (PBF) for Improved Maternal and Child Health Outcomes in Rwanda
During my 2025 Summer in the Field Fellowship, I had the opportunity to pursue a research project exploring the effectiveness of equity-based incentives within the performance-based financing (PBF) model to enhance maternal and child health (MCH) outcomes in Rwanda. Partnering with the Ministry of Health, my goal was to understand how these incentives could address the persistent health disparities faced by underserved populations.
PBF marks a significant shift in Rwanda’s healthcare delivery model, where financial incentives are awarded to healthcare providers by the Ministry of Health based on specific health outcomes rather than the volume of services delivered. Initially launched as a pilot in 2001 and scaled up in 2008, PBF ties financial rewards to key indicators like vaccination rates and prenatal care visits. This innovative approach not only incentivizes healthcare providers but also fosters accountability in service delivery.
During my fieldwork, I gathered PBF data and engaged with Ministry of Health officials and healthcare providers. I observed providers’ strong motivation to meet performance targets, which directly correlated with the care quality received by mothers and children. For instance, clinics that achieve prenatal care goals often reward their healthcare workers with bonuses. This incentivization creates a positive feedback loop, leading to improved health outcomes for the community. The combination of these mixed methods helped establish a theory of change, illustrating how PBF translates into positive impacts, laying a foundational framework for my research and testing the new, enhanced equity-based PBF model.
Equity-based incentives are crucial for ensuring that all Rwandans, particularly marginalized groups, benefit from healthcare services. My central argument is that integrating equity-focused incentives into PBF is vital for maximizing cost-effectiveness and bridging service gaps. Women in remote areas often face significant barriers to healthcare, such as transportation challenges and a lack of awareness about available services. Equity-based incentives can motivate healthcare providers to effectively engage and treat underserved populations. For example, a healthcare center that implemented a mobile clinic initiative saw a substantial increase in prenatal visits from women in hard-to-reach areas, thanks to additional incentives for providers.
Focusing on underserved groups with equity-based incentives is essential for enhancing the overall impact of PBF. Investing in these populations not only improves health outcomes but also underscores the necessity of tailored interventions. Having been a healthcare provider and implemented PBF before, I can confirm from my own experiences that when healthcare providers prioritize vulnerable communities, service utilization increases significantly. Women are more likely to seek prenatal care when they know their specific needs are being addressed.
However, the sustainability of these equity-based incentives remains uncertain. Rwanda’s multi-source healthcare funding model, which includes government and international support, is promising, but continuous advocacy for stable funding is essential. During discussions with local health officials, concerns arose regarding the reliance on fluctuating donor funding and its implications for the viability of critical programs. Establishing a dedicated health fund for maternal and child health could provide greater financial security.
Despite advancements, several challenges persist. The complexity of the PBF framework and its performance indicators can confuse healthcare providers, which may detract from the quality of care. Simplifying this framework and providing more explicit guidance could alleviate these issues. Health workers have also expressed frustrations about the burdensome paperwork and reporting requirements associated with PBF, suggesting that streamlining these processes would allow them to concentrate more on patient care.
Effective monitoring and evaluation are paramount. My experience revealed that inadequate data management systems hinder our ability to assess the actual impact of PBF initiatives. Investing in robust data systems and training personnel is crucial for practical program evaluation. Discrepancies in reporting can undermine confidence in program success and create challenges in securing necessary funding.
To tackle these challenges, I propose an enhanced equity-focused PBF model that incorporates real-time health management information systems. By integrating AI technologies, we can better identify disparities in service delivery and enable healthcare managers to make timely adjustments. While the use of AI would be timely and cost-effective, concerns about its use on health information would need more careful consideration. Additionally, adjusting financial incentives to target underserved populations specifically can ensure that rewards align with efforts to reduce health disparities. For instance, offering higher bonuses for outreach in remote areas or for increasing prenatal visits among low-income families could substantially boost service delivery.
Defining specific indicators that can be adjusted for improved health service delivery is also vital. Understanding which metrics effectively drive positive changes in provider behavior will help maintain focus on measurable improvements in maternal and child health.
Reflecting on my experiences, the findings of my research suggest that placing equity at the center of Rwanda’s PBF system is the most effective path toward enhancing maternal and child health outcomes. A focused approach on equity-based incentives for vulnerable groups not only leads to better health outcomes but also promotes social justice, ensuring that no one is left behind. By committing to this equitable framework, we can cultivate a healthcare system that effectively serves all Rwandans.
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Learn more about the Summer in the Field Fellowship Program.