Collections > Electronic Theses and Dissertations > An Equity Analysis of Performance-Based Financing in Rwanda

Maternal and child health services favor the wealthiest in lower and middle income countries. Debate about the potential of performance-based financing (PBF) to address these disparities continues. As PBF is adopted by other countries, it is critical to understand the equity effects for primary health care services. The aim of this dissertation is to evaluate the effects of PBF on equity in maternal and child health service use when no specific provisions target the poorest in the population. In Rwanda, PBF was designed to increase health service use and improve quality of services provided. Paired districts were randomly assigned to intervention and control for PBF implementation. Using Rwanda's Demographic Health Survey data from 2005 (pre-intervention) and 2007-08 (post-intervention), cluster-level panel datasets of 7,899 women 15-49 years of age and 5,781 children 0-59 months living in intervention and control districts were created. A difference-in-differences estimation strategy was used to evaluate the program impact of PBF on select primary maternal and child health service outcomes. Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among women and children from poorer households. Health service use for women and children increased for intervention and control populations and across all wealth quintiles from 2005 to 2007. The probability of a facility delivery, the most incentivized service, was significantly higher in PBF districts, while no effect of PBF was found for ANC visits, contraceptive use, or care-seeking for childhood illness. No evidence that PBF was a pro-poor or a pro-rich strategy for increasing access was found. Treatment received for childhood illnesses, however, significantly improved for children in PBF districts, and data suggests that poorer children benefited more. These results indicate that PBF may be an effective strategy for increasing access when use is uniformly low and a service is well incentivized; but PBF will do little to alleviate disparities in service use. The larger effect of PBF on quality of services, which remains within the control of the facility and provider, suggests that PBF does positively impact health care quality and may narrow the equity gap.