PBF in Rwanda: what happened after the BTC-experience?

Dear Sirs, Rusa et al. (2009a) accurately described the program that the Belgian Technical Cooperation (BTC) implemented on behalf of the Rwandan Ministry of Health (MOH) between 2005 and 2007 in Performance-based financing for better quality of services in Rwandan health centers: 3year experience . However, while it is limited to analysis of the BTC experience, the article gives the impression that the study concerns the national performance-based financing (PBF) program now being implemented in all the health centers (some 400) in the country. Performance-based financing is one of several strategies introduced to strengthen what WHO (2000) considered one of the weakest health care systems in the world. New financing schemes were introduced (Eichler et al. 2001; Soeters & Griffiths 2003) as pilot projects. The third pilot, introduced by BTC in 2003 in Rutongo District, began to be scaled up in 2005, as Rusa et al. describe. In the same year, the MOH adopted PBF as national policy. From 2005 to 2008, existing pilot programs continued as part of the nationwide effort. The US Agency for International Development (USAID), through Management Sciences for Health, supported 10 health districts. The article omits three major points: (i) it does not adequately reflect the role of the MOH in leading the decision-making about the national model; (ii) it is silent on the continuing work of other development agencies in PBF in Rwanda, notably the World Bank, USAID, and organizations based in the Netherlands, in making the national expansion of PBF possible; and (iii) it does not make clear that many of the elements of the BTC program have not been incorporated into the national approach. We encourage others who may wish to replicate the Rwanda experience (see MOH 2008) to consider that