Performance-based financing in Rwanda: a qualitative analysis of healthcare provider perspectives

Abstract

Results-based healthcare financing policies have been adopted in countries worldwide, including those with limited resources. We conducted a retrospective, semistructured interview study to evaluate healthcare providers’ experiences with Rwanda’s performance-based financing (PBF) policy and the factors influencing its implementation. Guided by the health policy evaluation model—context, content, process, and actors—as a deductive framework supplemented by inductive coding, we analysed data from 21 participants (doctors, n = 13; nurses, n = 5; midwives, n = 3). Providers described PBF as a key motivator, supplementing incomes, increasing accountability, and fostering teamwork to meet performance targets. PBF was credited with improving patient outcomes, particularly in incentivized services; however, concerns arose regarding disparities in service prioritization. Key facilitators of and barriers to the implementation of PBF were identified, providing insights into its operational dynamics. Strong political commitment and integration into national strategies, such as Imihigo, along with decentralization through district steering committees, were key contextual enablers, enhancing the program’s flexibility and alignment with local priorities. The content factors centred on a two-tiered contracting system, combining national accreditation processes with individual performance incentives. Process factors supporting PBF were characterized by decentralized evaluations, audits, and multilevel communication, which collectively bolstered accountability mechanisms. The engagement and capacity of stakeholders were highlighted as crucial to the success of PBF. Nonetheless, significant barriers, such as payment delays, manual documentation, untimely evaluations, insufficient training, limited provider participation in decision-making, and the exclusion of patients as stakeholders, were identified. These findings offer practical recommendations for policymakers aiming to improve or adapt provider payment mechanisms in similar contexts.

Background

Healthcare provider payment methods are essential to strategic purchasing, a key health financing approach aimed at achieving universal health coverage (UHC), especially in resource-limited countries [1]. In Africa, this approach has been incorporated into major health plans and financing strategies [1, 2]. In 2001, the governments of the African Union signed the Abuja Declaration, urging countries to allocate 15% of their budgets to health [3]. Later declarations, such as the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa, emphasized the need for renewed health financing policies [4]. These commitments have driven important reforms in health financing. Many countries have adopted results-based financing policies, also known as performance-based financing (PBF), as key tools for achieving UHC [5,6,7]. PBF is a health financing approach designed to offer financial rewards to healthcare providers when they meet predefined quantitative and/or qualitative performance targets [1].

Rwanda adopted PBF early, starting a pilot in 2001 and scaling it up nationwide by 2006 [8, 9]. Since then, the government has made PBF a national priority, integrating it into key policies such as the Health Sector Strategic Plan 2009–2012 (HSSP-II), aligned with the Millennium Development Goals (MDGs) by 2015 and the Vision 2020 [9,10,11,12], the Economic Development and Poverty Reduction Strategy (EDPRS) (2008–2021) [10, 11], and the Health Financing Strategic Plan (2018–2024) [11, 12]. HSSP-II set objectives and outputs to create an enabling environment for service delivery to be optimally effective and efficient, with the PBF scheme serving as a crucial instrument to reward health facilities and staff for good performance (increased utilization and quality of services, focusing on output financing models rather than input financing) [10]. The EDPRS II (2013–2018) highlighted PBF’s role in advancing health sector goals by focusing on improving healthcare service quality, including facility management, while expanding both geographical and financial access. PBF was seen as a tool to foster healthy competition among facilities, encouraging healthcare providers to innovate, enhance service quality, and advocate for increased service utilization, ultimately increasing both income and personal incentives [12]. These efforts have standardized PBF models across the country as part of Rwanda’s strategic purchasing initiatives [13]. The program was primarily implemented in public and government-assisted facilities, which constitute most of the health sector [2]. In 2010, PBF was extended from health facilities to the community level to provide financial incentives to community health workers (CHWs) [13, 14].

A major reform in 2014 integrated the PBF program with the hospital accreditation system at the provincial and district levels. The linkage aimed to avoid duplication of efforts in implementing the two programs and, as such, promote and achieve greater efficiency [12, 13, 15]. Both programs share complementary goals of improving health facility performance by addressing intrinsic and extrinsic motivational factors among healthcare providers and managers. They also rely on third-party verification to assess performance against defined standards or targets. To ensure transparency and effective implementation, the Ministry of Health (MoH) developed a detailed PBF Procedures Manual for Health Facilities, covering both hospitals and health centers [12].

Currently, PBF remains a key mechanism for incentivizing healthcare providers in Rwanda. The scheme seeks to increase both the quantity and quality of healthcare services. The purchasers within the PBF scheme (the Ministry of Finance and Economic Planning (MINECOFIN) and its partners), in collaboration with the regulator, the MOH, pay healthcare providers on the basis of a set of quantitative indicators adjusted for the overall quality of services delivered at the health facility [12, 13]. Performance indicators can be categorized into two groups: visit and outreach indicators (e.g., curative care visits, prenatal visits, contraceptive visits, facility deliveries, and child growth monitoring) and content of care indicators (e.g., timely vaccinations, malaria prophylaxis, and appropriate emergency referrals) [13, 16]. Quantitative indicators are evaluated monthly under the leadership of the District Steering Committee, with monitoring and supervision of health facilities reinforced through peer reviews, while quality assessments are conducted quarterly [12]. Since 2014, assessments of qualitative indicators at the district and provincial hospital levels have been integrated with accreditation assessments. Internal hospital self-assessments are conducted biannually by hospital staff, and certified accreditation surveyors carry out external assessments annually [12, 15].

The value of financial incentives varies across indicators, with the MoH and the Rwanda Biomedical Centre (RBC) determining payments on the basis of specific criteria. Key factors influencing these decisions include current coverage levels of each indicator—those indicators with lower achievement rates may receive higher funding to encourage improvement—and government priorities (referred to as “imihigo”), where indicators that have already achieved significant progress may receive reduced funding [12]. At the facility level, individual contracts are established between facility management and employees (e.g., individual providers), specifying bonuses for meeting agreed-upon goals. These contracts include both basic indicators and strategic intervention measures aligned with the facility’s action plan [12, 13].

Previous reports claim that Rwanda’s PBF policy has increased the utilization of health services and quality [2, 8, 9, 11,12,13, 16, 17], with most studies focused primarily on quantitative analyses [2, 8, 9, 16, 17]. For example, Gertler and Vermeersch reported a 20% increase in productivity and notable advancements in child health [16], whereas Basinga et al. reported a 23% increase in institutional deliveries and higher rates of preventive care visits for young children [17]. While these findings underscore PBF’s measurable benefits, quantitative research often falls short of explaining why policies succeed or fail, leaving critical gaps in understanding the lived experiences and challenges of those directly impacted [18]. Healthcare providers, as the primary beneficiaries of PBF, play a pivotal role in its implementation; however, their perspectives remain underexplored.

To address this gap, the present study examines healthcare providers’ views on PBF through in-depth interviews guided by an established health policy framework [19]. By emphasizing the factors that drive PBF success and identifying its challenges, the findings offer actionable insights for policymakers and stakeholders in other contexts seeking to implement or refine similar provider payment mechanisms.

Methods

Design and setting

We conducted a retrospective, semistructured interview study to gain detailed insights into healthcare providers’ perspectives and experiences regarding the implementation of PBF. Given that PBF has been widely implemented across Rwanda’s health system, we did not restrict the study to a specific geographic location or type of provider. Ethical approval for conducting this research was granted by the National Council for Science and Technology (NCST) of Rwanda (Research Permit No. NCST/482/0124/2024) and the Research Ethics Committee of Jagiellonian University Medical College (No. 118.0043.1.10.2024). Study procedures and methods were conducted in accordance with the Declaration of Helsinki guidelines. Written and verbal informed consent was obtained from all study participants.

Participants

We randomly sampled 25 healthcare providers (i.e., individuals directly involved in delivering health services) from various healthcare facilities across the four provinces of the country and Kigali city, inviting them to self-nominate for participation. To further expand the participant pool, we sent official request letters to two prominent professional associations in Rwanda: the Rwanda Medical and Dental Council (RMDC) and the National Council of Nurses and Midwives (NCNM). Additionally, we employed a snowball sampling method by asking interviewed participants to recommend other eligible candidates.

The enrolment process began with an email invitation sent to potential participants, providing a brief overview of the study’s objectives and procedures. Participants were assured of confidentiality and anonymity throughout the study. Interested individuals received detailed information about the study, including its purpose, potential risks, benefits, and rights as participants. Informed consent was obtained from all participants prior to conducting the interviews.

The eligibility criteria required participants to be healthcare providers with direct experience working in facilities implementing PBF schemes. Proficiency in Kinyarwanda and/or English was also mandatory to ensure effective communication during data collection (respondents could choose their preferred language for the interview).

Data collection

After providing consent, face-to-face interviews were conducted at locations chosen by the participants—usually their workplaces—or virtually between July 2024 and October 2024. The interviews were conducted by the principal investigator (CN), a PhD researcher with three years of training and research experience in healthcare provider payment reforms at the Faculty of Health Sciences, Department of Health Economics and Social Security at Jagiellonian University. While the principal investigator is a medical doctor (MD) with prior knowledge of the Rwandan healthcare system, he had no direct relationship with participants before the study commenced.

The interview guide consisted of seven key questions (see the Supplementary Material). Each interview began with introductory questions to provide an overview of the discussion and create a comfortable environment for participants. These initial questions focused on healthcare providers’ professional backgrounds, a brief description of their roles at their respective health facilities, and their general understanding of the PBF policy. Subsequently, specific questions and probes were used to examine their perceptions of the PBF scheme’s impact, including its benefits, risks, and unintended consequences for provider work and patient care. The participants were also asked to discuss the factors—both challenges and facilitators—that contributed to the success or failure of PBF implementation. The interviews concluded with an opportunity for participants to offer recommendations or suggestions for potential improvements to the PBF system and highlight areas that needed attention.

Seventeen of the 25 initially invited participants agreed to participate in the study, but one later declined due to unavailability. Nine additional participants were identified through snowball sampling, but after interviews with five participants, recruitment stopped as no new ideas or codes emerged. In total, 21 healthcare providers were included in the study. Twelve interviews were conducted in person (usually at participants’ work offices), two by phone, and seven via WhatsApp. The average interview time was 37 min. All the interviews were conducted in Kinyarwanda, except for two in English.

Data analysis

The interviews were recorded and transcribed verbatim (by CN). The interviews conducted in Kinyarwanda were then translated into English (by CN). The transcripts were subsequently anonymized and checked for accuracy (by RN). To protect participant anonymity and the confidentiality of their institutions, detailed sociodemographic information was excluded. The names and locations of health facilities were also omitted, as most Rwandan districts have only one hospital, making it easier to identify specific institutions or participants. Moreover, participants in prominent roles, such as clinical directors, could be easily recognized if facility names were disclosed. QDA MINER software (v3.0.6) was used to manage the interview data, and a thematic approach was employed for the analysis. Initial coding was deductive, on the basis of predefined themes from the interview guide (Supplementary Material), with additional codes generated inductively through a six-step process: (1) familiarizing with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the manuscript/report [20]. Codes were grouped into overarching themes and refined iteratively throughout the analysis. Recruitment and interviews continued until no new codes emerged.

The factors affecting PBF were classified using an existing health policy framework [21,22,23], which was previously used to analyse barriers to and facilitators of payment reforms [19]. This framework describes four dimensions of the health policy spectrum. The first dimension, Context, addresses systemic factors that can influence reforms, such as political commitment and regulatory frameworks affecting PBF. The second dimension, content, describes the specific elements of the reform, such as clearly defined performance indicators, the use of clinical guidelines, the suitability of the PBF payment system for providers, and tariff valuation. The third dimension, Process, relates to how the reform was developed, communicated, implemented, and evaluated, including pilot studies, coordination of implementation systems, availability of funds, IT systems, provider training, and management of the reform. The final dimension, Actors, includes all individuals involved in the policy-making process, with a focus on stakeholder engagement and capacity [19].

Results

Respondent background

All the participants confirmed having direct experience with PBF while working at public health facilities. Of the 21 participants, 12 were male and 9 were female. The majority were doctors (n = 13), followed by nurses (n = 5) and midwives (n = 3). Many participants were healthcare providers without managerial roles (n = 16), whereas five also held managerial roles, including clinical directors (n = 4) and a chief nurse (n = 1). The participants worked in diverse healthcare settings, including both urban and rural facilities. The majority of participants reported PBF experience across multiple facilities due to frequent rotations, part-time roles, or transitions to teaching hospitals for specialization.

PBF effects

Influence on provider work/practice

All the participants agreed that PBF significantly influenced their work. A majority of respondents reported increased accountability and documentation requirements, driven by the system’s emphasis on linking individual and facility performance to financial incentives. Many participants highlighted that PBF motivated them to work harder, knowing that their performance directly affected their income. Additionally, PBF was reported to encourage teamwork and communication among staff, as meeting hospital-wide targets required collective effort. The participants emphasized that the program played a critical role in sustaining performance. However, delays or the absence of PBF payments were associated with reduced morale and diminished service quality.

“PBF is essentially about motivating us to achieve better outcomes. It makes us think about quality more deliberately.” (Participant 8, Doctor)

“Yes, it definitely impacts the work. For example, when employees do not receive PBF on time—or sometimes not at all, as happens in some hospitals where staff can go a year without it—it leads to negative consequences. Employees become demotivated, and the quality of services declines. However, in hospitals that provide PBF regularly, employees work with greater commitment and effort. [Those] hospitals generate more revenue and deliver better services, which leaves patients well cared for.” (Participant 3, Clinical Director)

Influence on patient care/outcomes

The participants generally agreed that PBF contributed to improved patient outcomes, citing increased vaccination rates and greater utilization of maternal health services as examples. Timely PBF payments were widely regarded as enhancing patient care and satisfaction. However, participants also noted potential downsides, such as disparities in attention given to services on the basis of their associated incentives. Some services received less focus because they provided little or no financial reward.

“We’ve seen an increase in women seeking prenatal care since this hospital implemented the PBF program, which I believe is directly related to the incentives provided to healthcare providers. The PBF amount here is relatively high and fairly consistent compared with what my colleagues at other hospitals receive.” (Participant 15, Chief of Nursing)

Additionally, some participants reported that PBF indirectly influenced the volume of services provided, including the number of diagnostic tests ordered and the number of medications prescribed.

“The PBF system encourages us to be more thorough with patient care, which can sometimes mean ordering more lab exams or routinely offering various services, even if they aren’t of high importance for every patient. It’s a balance, though, as I always try to ensure it aligns with my patients’ needs. But [it] is important because this hospital benefits from PBF through more billing.” (Participant 21, Doctor)

While this ‘more billing’ often resulted in increased PBF payments to health facilities, it also raised concerns about the potential overutilization of resources and unnecessary services offered to patients. Nevertheless, some participants mentioned that facilities cannot exceed a specific ceiling on PBF payments, citing this restriction in connection with the MoH guidelines. However, the exact limit was neither clearly defined nor consistently reported by participants.

Perceptions of success/failure factors

Respondents indicated diversity of factors that influenced the PBF success. They were assigned to the four dimension of the health policy triangle (Fig. 1).

Fig. 1

Facilitators and barriers to performance-based financing in Rwanda

Context

Political willingness was consistently cited as a key driver of Rwanda’s success in implementing and scaling up PBF. The participants emphasized the government’s strong commitment to improving health system performance, reflected in policy prioritization, resource allocation, and the institutionalization of PBF within the national health strategy.

“The government’s leadership was instrumental. They recognized early on that PBF could address some problems in the health system and were willing to support it, both politically and financially.” (Participant 6, Clinical Director)

The participants highlighted that Rwanda’s postgenocide governance reforms created an enabling environment for innovative approaches such as PBF. The government’s emphasis on results-oriented policies ensured that PBF received high-level support from the MoH and local governments. The integration of PBF into broader Imihigo performance programs at the district level further demonstrated the political commitment to achieving health targets. This alignment reinforced accountability and helped sustain political momentum for PBF.

“The country’s leadership showed remarkable foresight by adopting PBF as a national policy. It wasn’t just about healthcare but about building accountability into service delivery.” (Participant 19, Clinical Director)

“The fact that PBF targets are part of the government’s performance programs ‘Imihigo’ with district leaders shows how serious they are about this program.” (Participant 3, Clinical Director)

The participants confirmed that the government has established robust frameworks to support PBF implementation. This included incorporating PBF into the National Health Strategic Plan and standardizing its operational tools and performance indicators. The establishment of a clear institutional framework was cited as a critical factor in ensuring accountability and coordination across all levels of the health system.

“The Ministry of Health played a vital role in developing policies and guidelines for PBF implementation, which made it easier for everyone to understand their responsibilities.” (Participant 3, Clinical Director)

Additionally, participants noted the government’s efforts to decentralize PBF management, allowing district health units (known as district steering committees) to oversee performance monitoring, data validation, and financial disbursements. This decentralization was viewed as a key enabler of flexibility and responsiveness in addressing local health priorities.

“The district health office plays a central role in managing PBF, but we also have the flexibility at the facility level to determine how funds are distributed based on our performance.” (Participant 19, Clinical Director)

“The decentralization of PBF has been a game changer. District health teams can adapt the program to fit local contexts, which has improved its impact on the ground.” (Participant 6, Clinical Director)

Content

The content dimension revealed diverse opinions among participants. While the majority admitted that they were not fully aware of the specific indicators used to determine their PBF payments, they readily identified activities they performed that were excluded from the payment scheme. Health education sessions were frequently mentioned as essential but not incentivized under PBF, and certain indicators were noted to qualify for PBF only for specific patient groups.

“Screening HIV for a male patient does not qualify for PBF at our facility. Regardless of how many you screen, even several hundred, you do not receive any payment for this. However, for female counterparts, this indicator is part of the quantitative criteria for the award of PBF.” (Participant 20, Midwife)

The participants holding nonmanagerial roles, such as nurses and doctors, were generally more familiar with their individual performance scoring metrics in their personal performance contracts (Imihigo)—agreements between providers and their respective health facilities specifying the required individual achievements. Nevertheless, they consistently identified the facility’s accreditation score as the primary determinant of PBF payments. They acknowledged that facility financing depended on accreditation levels, which directly influenced PBF payments from the government. However, the majority of these participants admitted that they had limited knowledge of the broader facility-level contracting rules and the specific metrics outlined in the facility agreements with the MoH.

“PBF is awarded to facilities on the basis of their accreditation levels I, II, and III, with level I receiving the lowest amount and level III receiving the highest. For individual providers, PBF is distributed on the basis of their performance contract achievements ‘Imihigo’, graded out of 100%: those achieving more than 90% receive full payment; those scoring between 70% and 90% receive reduced payments accordingly; and those scoring below 70% do not receive any payment.” (Participant 8, Doctor)

“I know that my PBF payment depends largely on the hospital’s accreditation score, but I don’t truly know how the score is calculated or what the process involves.” (Participant 2, Doctor)

In contrast, participants in managerial roles demonstrated a better understanding of PBF content beyond the individual provider level. They emphasized the alignment of PBF contracting with the country’s Imihigo performance contracts, which involve agreements with both administrative districts and health facilities. Nonetheless, these participants also highlighted the strong linkages between PBF and hospital accreditation performance scoring.

“The way hospital accreditation is linked to PBF is a powerful driver for change. It’s a key factor that shapes how our facility prioritizes and implements PBF, ensuring that quality is consistently measured.” (Participant 3, Clinical Director)

On the other hand, the participants appreciated the structured implementation of the PBF system but highlighted the need for greater transparency and inclusiveness in selecting and weighting performance indicators. Some participants suggested that actively involving providers in these processes could better align the PBF program with on-the-ground realities, enhance providers’ sense of ownership, and improve its overall effectiveness.

“The PBF system is well structured, but there needs to be more transparency and inclusiveness in how performance indicators are selected and how their importance is determined for financial rewards. If we were more involved in this process, it would align the program better with what’s actually happening on the ground, give us a sense of ownership, and ultimately make the system more successful.” (Participant 10, Doctor)

Providers expressed mixed feelings about the motivational impact of PBF. While most viewed it as a strong motivator owing to the financial incentives it provided alongside their regular salaries, dissatisfaction stemmed from the irregularity of payments and significant variations in the amounts received among providers and across health facilities. As one participant remarked,

“PBF payments are not consistent, and what we receive can vary a lot, even when we’re doing the same work. This makes it hard to rely on the money.” (Participant 12, Nurse)

Some providers felt that the payment system did not fully reflect the workload or complexity of the services they provided. Irregularities in the amounts received—largely influenced by the overall facility accreditation score—contributed to a sense of inequity in how the PBF system rewarded their efforts. Managerial participants noted that while defined performance indicators and unit costs exist, the valuation of specific indicators did not always capture the effort needed. This sentiment extended to preventive and community-based services, which were viewed as undervalued despite their significance for patient outcomes.

“Some indicators are undervalued compared with the effort they require. This discourages providers from prioritizing these services, even when they are important” (Participant 16, Doctor)

Process

The process dimension encompassed frequent themes related to how PBF was implemented, communicated, and monitored within healthcare facilities. Only one participant elaborated on the piloting of PBF, noting that its initial implementation in selected districts—including their hospital—was critical in refining the system before national rollout. This participant explained that the pilot phase allowed for the identification of potential challenges, adaptation of performance indicators, and development of standardized processes. However, providers who joined the health system after the national implementation of PBF expressed limited knowledge about the pilot phase.

Leadership within health facilities emerged as a critical factor in the PBF implementation process. The participants working under proactive and supportive leaders reported better teamwork, greater motivation, and more consistent performance outcomes.

“Our success with PBF is largely due to our leadership. They motivate us and ensure that we work together as a team to achieve our goals.” (Participant 2, Doctor)

Evaluation mechanisms were widely discussed, with participants describing a bottom-up approach for individual assessments. Monthly evaluations were conducted by first-line managers, such as unit heads or service directors, who assigned scores to individual providers. These scores were reviewed by the comité de gestion (COGE) and approved by the hospital’s director general. The participants emphasized the importance of integrating PBF evaluations with hospital accreditation systems.

“The PBF evaluation process begins with a monthly evaluation by your first-line manager (service director), such as the nursing service manager for nurses, who assigns the score. The score is then reviewed by the director of nursing and midwives before being submitted to the hospital’s director general for final approval. The individual provider’s score, along with the facility’s score on the basis of its level of accreditation, determines the amount awarded to the provider.” (Participant 3, Clinical Director)

At higher levels, PBF monitoring was decentralized, with districts playing a key role in aligning PBF plans with national health priorities and broader government objectives such as Imihigo. Providers noted that district health units oversaw performance monitoring through field visits, peer reviews, and compliance checks.

“The district health office ensures that we are meeting our targets and evaluates our hospital performance. They conduct field visits and audits to verify compliance, but sometimes their limited capacity affects how effectively they oversee the process.” (Participant 15, Chief Nurse)

However, the participants highlighted three key challenges associated with linking PBF with accreditation evaluations. The first challenge was the potential manipulation of evaluations, particularly concerning accreditation. Since accreditation assessments are infrequent and predictable, some facilities focus on meeting requirements only when the accreditation cycle approaches, which may not accurately reflect the facility’s true quality or operational reality. The participants suggested more frequent external independent evaluations to ensure that facilities consistently work toward agreed-upon targets rather than only during the accreditation cycle.

The second challenge was the potential aggravation of inequitable financing among facilities. Facilities were assessed via uniform accreditation criteria that did not account for significant differences among hospitals. Most participants emphasized that different hospitals cover large patient populations, serve broader geographical areas, or have limited resources, such as fewer hospital beds and workforce. While such disparities influenced how facilities performed in meeting accreditation targets, these differences were not considered. Yet hospital financing was based on accreditation outcomes without adjusting for such variations.

“Linking PBF with accreditation was a good idea, but we see unintended consequences. Hospitals with high accreditation scores receive substantial funding—not necessarily through PBF but also from other financing sources. These are often not the hospitals that need money because they serve smaller populations, cover smaller geographic areas, or have many beds and equipment that help them generate more revenue. Moreover, hospitals that are overburdened with large patient loads and limited resources receive less funding. We see this a lot in urban hospitals, especially in Kigali.” (Participant 8, Doctor)

The third challenge, closely related to the second challenge, was inequitable financial rewards for individual providers working in hospitals with low accreditation scores. Some participants expressed frustration that their PBF payments were significantly reduced due to the overall hospital accreditation score, despite their personal efforts. They cited external factors, such as high patient loads and understaffed facilities, as reasons for poor hospital performance, which they felt were beyond their control.

“Can you imagine working harder—much harder—than your colleagues in other hospitals, yet receiving half their PBF payments because your hospital scored low during accreditation? I left my first hospital because the workload was overwhelming due to the high number of patients we served. Despite our efforts, our accreditation score was low, and our PBF payments were much lower than where I work now.” (Participant 10, Doctor)

The availability of resources, including IT systems and tools, was another frequently discussed area. Many participants expressed concerns about the reliance on manual processes in their facilities, which increased workloads, delayed performance evaluations, and reduced time for patient care. They emphasized the need for digital tools to streamline documentation and improve timeliness.

“Digital tools would make an enormous difference. Right now, we spend too much time on paperwork, which takes away from patient care.” (Participant 18, Nurse)

“If we had more digital tools, it would simplify the process and make evaluations more timely and accurate.” (Participant 20, Midwife)

The participants also commented on the consistency and timeliness of PBF payments. Delays in payments were a common grievance, with some attributing delays to facility-level inefficiencies and others pointing to external factors such as funding gaps. Providers noted differing causes for these delays. Nonmanagement staff attributed delays to facility leaders not processing documentation promptly, whereas managers cited external factors, such as late payments from health insurance partners. Additionally, facilities often used PBF funds for both operational costs/utilities and provider incentives, leading to potential delays or reductions in payments when operational expenses exceeded available funds.

“Health facilities receive PBF payments quarterly, which are used to provide performance-based incentives to healthcare providers and/or cover health facility operational costs.” (Participant 6, Clinical Director)

Notably, PBF is provided in most, but not all, public health facilities. Additionally, two participants reported having worked in facilities receiving PBF funds from multiple sources, including donor-funded programs, but still perceived these funding sources as unreliable. Four participants (doctors, participants 16, 2, and 4, and nurses, Participant 9) also expressed reluctance to work at hospitals that did not offer PBF incentives. Participant 4, Doctor, believed that this worsened the quality of care in such institutions:

“Hospitals without PBF funding struggle to attract and retain skilled providers, which can exacerbate inequities in the Rwandan healthcare system.” (Participant 4, Doctor)

The majority of participants recommended three key ideas on this issue. First, they emphasized that PBF should be extended to all public hospitals. Second, they suggested linking PBF directly and fully to government funding and incorporating it into regular salaries rather than depending on monthly facility revenues. Finally, a few participants proposed that extending PBF incentives to all hospitals would help address workforce shortages in facilities that are unable to attract providers due to the inconsistency or absence of PBF incentives.

“To increase the effectiveness and sustainability of the PBF system, it is essential to link disbursements directly to government revenues and ensure timely funding. This will stabilize hospital finances and ensure consistent payment for healthcare providers, regardless of fluctuations in hospital-generated incomes.” (Participant 3, Clinical Director)

Training emerged as another key area of concern among participants. Many providers reported insufficient training on PBF processes, leading to confusion about expectations. Even those who attended training noted that it was infrequent and often focused more on hospital accreditation than on PBF specifics.

“We did not receive much training on how PBF works in practice. It felt like we were learning on the job, which led to a lot of confusion initially.” (Participant 1, Doctor)

Actors

The engagement and capacity of stakeholders were identified as crucial to the success of PBF. Most participants emphasized the importance of involving key actors—providers, facility managers, and policymakers. They particularly commended policymakers for their foresight and consistent efforts to improve the PBF system at both the central and local levels through decentralized policies. A commonly cited example was the role of district health units. These units were highlighted as essential for ensuring accountability and consistency in the implementation and evaluation of PBF. They also facilitated the integration of community perspectives by establishing community health committees, which provided oversight for public health facilities. Furthermore, quality improvement committees at the hospital level were created to coordinate quality improvement activities in collaboration with the MOH. These efforts reinforced accountability, aligned PBF activities with national priorities, and strengthened the representation of users’ voices in health services.

However, many noted that the limited engagement of providers in decision-making processes posed a significant barrier to PBF effectiveness. While providers played a strong role in delivering services to meet PBF targets, they often felt excluded from influencing PBF decisions.

“Providers need to be part of the PBF decision-making process. When we’re excluded, it feels like [such] policies do not reflect our realities.” (Participant 11, Doctor)

The participants also raised concerns about the exclusion of patients as key actors, despite their central role as beneficiaries. They highlighted the potential benefits of engaging patients in the design and implementation of PBF to better address their needs and improve the program’s effectiveness.

“Patients are not included in any decisions regarding PBF, yet these decisions affect them the most. Engaging patients could help us understand their needs better and improve the PBF program.” (Participant 17, midwife)

Building the capacity of stakeholders was also emphasized as a critical determinant of PBF success. The participants highlighted the need for targeted training and resource allocation to strengthen both the technical and the operational capacity of all involved actors.

“The success of PBF depends on how well-equipped the stakeholders are to manage it. Training and resources are key to ensuring this.” (Participant 6, Clinical Director)

Discussion

This study provides new insights into healthcare providers’ perceptions of PBF implementation in Rwanda, shedding light on its successes and challenges. Using a structured framework, the findings offer a comprehensive understanding of PBF’s role in incentivizing providers. The participants highlighted how linking financial incentives to performance metrics fosters accountability, motivation, and adherence to service delivery standards as well as improved provider attraction and retention. These findings align with prior research in Rwanda and other low-resource settings, where PBF has been notably linked to improved provider engagement, performance, and service efficiency [7, 16, 17, 24, 25].

One of the notable strengths of Rwanda’s PBF system is its integration into national health strategies, such as Imihigo, which aligns health sector goals with broader government priorities. This integration underscores the strong political commitment to accountability and results-based management, a feature frequently highlighted in comparative studies of PBF programs in sub-Saharan Africa [1]. The participants in this study attributed much of PBF’s success to structural and policy-level support, emphasizing their role in reinforcing sustainability and ensuring alignment with national priorities.

On the other hand, delayed payments emerged as a significant barrier, undermining provider morale and service delivery. The respondents largely attributed these delays to the manual processing of PBF documentation and, in some cases, to slow reimbursements from health insurance providers. Similar challenges have been documented in other PBF implementations, where inefficiencies in financial flows disrupt program effectiveness [6, 7]. Streamlining payment mechanisms through the adoption of digital tools could address these delays by improving the speed and accuracy of reimbursements. Research on digital technologies for health financing (DTHF) in low- and middle-income countries suggests that these tools offer promising solutions to such challenges [26, 27]. While specific digital (pilot) programs in Rwanda and other low- and middle-income countries are not well-documented, most countries use them for revenue raising and pooling, with few applying them for purchasing or provider payment. For example, the Philippines uses machine learning (ML) for fraud detection in claims, North Macedonia uses digital tools for claims management and e-contracting, and Estonia uses digital solutions for multiple purchasing purposes, including digital claims management, automated claims reviews, ML for claims evaluation, and cost-sharing aggregation [27]. Digitalization could also improve PBF evaluations by addressing the infrequency and irregularity of assessments reported by participants, ensuring more consistent and timely feedback. Previous research on healthcare digitalization and pay-for-performance incentives in financing (smart) hospitals revealed that such a move towards digitalization created an enhanced information feedback mechanism that could move healthcare delivery towards results-based practice and help make more efficient use of scarce resources [28].

Another potential challenge pertains to equity. Reliance on facility accreditation scores to determine payments disproportionately disadvantaged providers in resource-limited, low-graded facilities. This aligns with critiques emphasizing inequitable resource distribution in standardized PBF frameworks [5]. For example, a study in Rwanda reported that PBF improved efficiency but not equity in most health services [29]. Linking PBF to facility accreditation scores effectively creates a ‘Group Incentive Plan,’ which ties rewards to collective performance and fosters collaboration. However, this approach weakens the connection between individual effort and rewards, undermining perceptions of fairness [24, 30, 31]. Employees often struggle to see how their efforts influence group performance metrics, leading to perceived inequities, particularly compared with individual incentive plans [25]. Individual-level measures are seen as more achievable since they are within direct control, making individual PBFs preferred by providers [24, 25, 30, 31]. Providers tend to resist accountability for factors beyond their control, as shown in prior research [32].

The participants also raised concerns about limited involvement in the design and refinement of performance indicators. This exclusion may hinder the program’s adaptability and alignment with ground-level realities. Similar critiques have been made in other settings, where greater stakeholder engagement has been recommended to enhance PBF relevance and provider buy-in [33]. Expanding participatory mechanisms, such as regular structured feedback and provider representation in decision-making, as well as piloting changes under ‘real-life’ conditions prior to broader implementation, could improve the program’s effectiveness and acceptance among providers [34]. Similarly, this study revealed minimal emphasis on patient involvement in PBF design and evaluation, a gap that contrasts with global calls for more inclusive health system reforms [32, 35]. Engaging patients as active stakeholders could improve the program’s responsiveness, aligning it more closely with community health needs [35, 36]. These aspects fall under a broader need for participatory consensus building in health policy design, implementation, and evaluation [37,38,39].

Study strengths and limitations

This study is the first in-depth qualitative analysis of healthcare providers’ perspectives on PBF in Rwanda, offering valuable insights into the program’s strengths and challenges. By focusing on providers—the key implementers—it highlights their experiences, operational realities, and recommendations. The use of in-depth interviews allowed us to capture nuanced views and experiences of PBF in daily practice. The respondent group included diverse types of healthcare providers, enabling a comprehensive overview. The findings provide a solid foundation for policy improvements and cross-country learning in similar settings, particularly for countries developing or refining PBF frameworks.

However, the exclusion of other stakeholder groups represents a significant study limitation. Future research could incorporate perspectives from policymakers, CHWs, and patient representatives. For example, examining the informal health sector, where CHWs play a crucial role, could reveal opportunities and challenges for integrating PBF across all levels of care.

Conclusions

By linking financial incentives to performance metrics, PBF has motivated providers, enhanced accountability, and improved provider attraction and retention. Its successful implementation in Rwanda is largely attributed to strong political will, integration into national strategies, and decentralized management structures. However, addressing systemic barriers (e.g., payment delays) and contextual disparities among facilities and fostering greater stakeholder engagement are critical to maximizing the program’s impact. These findings offer valuable lessons for policymakers in Rwanda and other contexts looking to implement or refine PBF systems, emphasizing the need to balance financial incentives with equity and inclusivity in healthcare reform.