Since June 2006, Rwanda has implemented a national supply-side performance-based financing (PBF) program in hospitals and health centers. This 'first generation' PBF program provided financial rewards to health facilities in order to promote maternal, child, and HIV/AIDS healthcare. A prospective, rigorous impact evaluation (IE) was developed with the commitment of the Government of Rwanda (GOR) to assess the impacts of PBF on health outcomes and determine the possibility of scaling-up the PBF initiative nationwide. The IE showed significant positive impacts on quality of prenatal care, as well as increased utilization of institutional delivery and child preventive care services. However, it highlighted the limited effect of the supply-side intervention on other services, such as the demand for timely prenatal care and family planning. In 2010 the 'second generation' of PBF in Rwanda, the Community Performance-Based Financing (CPBF) program, was initiated to tackle the remaining issue of low utilization of health services by mothers and their children. The Community PBF implemented the following three interventions: (i) demand-side in-kind incentives for women, (ii) financial rewards for community health worker (CHW) cooperatives, and (iii) combined demand-side and CHW rewards. The three CPBF interventions were introduced in October 2010 in randomly selected sectors. The CPBF program is evaluated by a prospective, randomized impact evaluation (IE). The IE evaluates the causal effect of the CPBF interventions on maternal and child health outputs and outcomes.Analysis of the IE data that assessed the program impact compares outcomes in sectors implementing the three different interventions and a comparison group of sectors not implementing any of the interventions. The IE relies on baseline (Q1-Q2 2010) and follow up (Q4 2013-Q2 2014) data collection, consisting of household, CHW and CHW cooperative surveys. A health facility assessment was conducted at the follow up survey. The endline survey for the impact evaluation was fielded from November 2013 to June 2014. The University of Rwanda College of Medicine and Health Sciences School of Public Health (UR-CMHS-SPH) managed all activities related to data collection and entry. The baseline survey questionnaires were adapted to account for the modification to the sample described in the previous chapter. In addition, modules asking about the experience with the CPBF program have been added. Because the baseline survey did not include the health facility assessment, the relevant questionnaires were created by adapting the Health Results Innovation Trust Fund (HRITF) samples. Apart from the health facility assessment that was conducted in French, all other interviews were conducted in Kinyarwanda. Interviews with the CHWs and presidents of the cooperatives were conducted at the health centers and conducted jointly with the health facility assessment. The in-charge of each health center and the center's head of community health were informed two weeks prior to the visit. The CHWs in charge of MNH in the sample villages were asked to be present at the health center at the day of the visit. The head of community health was in charge of contacting the CHWs. Each survey team was composed of 3 enumerators led by a team leader. During a one-day visit, a team fielded the health facility questionnaire with the in-charge of the health center or the deputy, the CHW cooperative questionnaire with the cooperative's president in addition to interviews with providers, patients and CHWs. 2220 CHWs were successfully interviewed in endline out of the target of 2376. This is a response rate of 93%. A response analysis was performed to test whether assignment to a specific treatment arm affected the propensity to comply with the endline survey. The results indicate that response is not significantly correlated with the introduced interventions. The endline survey also included a health facility assessment for health centers containing interviews of facility in-charges and health providers as well as exit interviews with patients visiting the health center.
