Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda.
Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda.
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DOI：
10.3402/gha.v9.32943
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发表时间：
2016
影响因子：
2.6
通讯作者：
Hirschhorn LR
中科院分区：
文献类型：
--
作者：
Nahimana E;McBain R;Manzi A;Iyer H;Uwingabiye A;Gupta N;Muzungu G;Drobac P;Hirschhorn LR
绩效筹资(PBF)在改善低收入和中等收入国家的健康结果方面取得了一系列成功和失败。有证据表明，PBF的成功在很大程度上取决于所选择的模式，与各种背景因素有关。健康合作伙伴|InShuti Mu Buzima旨在评估卢旺达基雷赫区卫生中心与PBF新的能力建设模式相关的健康结果。基热河区的13家医疗中心为30多万人口提供医疗保健，它们同意参与一项PBF倡议计划，该计划整合了数据反馈、质量改进指导、点对点学习和区级优先事项设置。卫生中心在18个月内每6个月评估一次集体商定的特定地点健康目标的进展情况。只有当卫生中心达到卫生中心集体商定的所有三个优先事项的目标时，才会授予奖励：社区医疗保险覆盖率90%，避孕普及率70%，急性严重营养不良病例为零。所有四个时间点和设施的改善使用混合效应线性回归来衡量。在6个月的随访中，13个健康中心中有4个达到了1个目标。在12个月的随访中，7个中心达到了1个目标，18个月的随访中，6个中心达到了2个目标，2个中心达到了全部3个目标。在所有三个目标上，该地区卫生中心的平均业绩都有显著改善：平均保险覆盖率从基线的68%增加到93%(p<；0.001)；在过去6个月中，每个机构的平均急性营养不良病例数量从24例下降到5例(p<；0.001)；避孕普及率从42%上升到59%(p<；0.001)。确定了一些创新的改进举措。尽管资源有限，但PBF、地区参与/支助和对等学习的结合带来了重大改进，目前正被视为卢旺达其他地区扩大规模的典范。
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. 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. 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. 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. 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.