Background The Government of Rwanda has nationally implemented performance-based financing (PBF) to improve the satisfaction and motivation of health workers, as well as access and quality of HIV/AIDS services in the context of scaling-up services. The scheme pays for 10 HIV/AIDS indicators (two related to HIV testing and counselling (HTC), which is believed to be a core strategy for decreasing HIV incidence and improving prevention and care). We present the effect of Rwanda's PBF program on individual and couple/partner testing as an entry point to other HIV services and in the context of scale up.
Methods Taking advantage of a prospective quasi-experimental design, an impact evaluation was conducted during phase-in of the Rwanda's PBF program in 2006 and 2008. Individual HTC was measured by whether or not the individual has ever been tested for HIV (371 treatment individuals (61.1% female), 378 control (56.6% female)), and partner testing was assessed by whether or not the sexual partners they had in the 12 months prior to the survey had ever been tested for HIV (208 treatment individuals (57.2% female), 202 control (52.0% females)). To evaluate the outcomes, a difference-in-difference fixed effects model was used with SEs clustered by district*year.
Results PBF increased HTC at the individual level by 9.45% from baseline (p=0.07). This effect was mainly found among married individuals (10.87% increase, p=0.02), specifically males (15.75% increase, p=0.06). PBF also increased testing among couples by an estimated 16.14% (p=0.034) increase from baseline, as reported by one of two partners.
Conclusion Our work provides evidence that PBF might be a useful tool to increase access to HTC for both individuals and couples. This is a remarkable result since couple testing has previously been difficult to encourage.