Publication:
Effects of Performance Incentives for Community Health Worker Cooperatives in Rwanda

Loading...
Thumbnail Image
Files in English
English PDF (733.85 KB)
621 downloads
English Text (89.14 KB)
40 downloads
Published
2017-05
ISSN
Date
2017-05-24
Author(s)
Kalisa, Ina
Condo, Jeanine
Humuza, James
Mugeni, Cathy
Nkunda, Denis
Walldorf, Jeanette
Editor(s)
Abstract
This paper presents the results of a randomized controlled trial set to evaluate the effects of a pay-for-performance scheme that rewarded community health worker cooperatives for the utilization of five targeted maternal and child health services by their communities. The experiment took place in 19 districts in Rwanda between 2010 and 2014. The analysis finds no impact of the performance payments on coverage of the targeted services, attitudes and behaviors of community health workers, or outcomes at the cooperative level. No synergies are found between the scheme and a demand-side, in-kind transfer intervention that was independently effective in increasing coverage rates of targeted services.
Link to Data Set
Citation
Kalisa, Ina; Shapira, Gil; Condo, Jeanine; Humuza, James; Mugeni, Cathy; Nkunda, Denis; Walldorf, Jeanette. 2017. Effects of Performance Incentives for Community Health Worker Cooperatives in Rwanda. Policy Research Working Paper;No. 8059. © World Bank. http://hdl.handle.net/10986/26752 License: CC BY 3.0 IGO.
Associated URLs
Associated content
Report Series
Report Series
Other publications in this report series
  • Publication
    Climate and Social Sustainability in Fragility, Conflict, and Violence Contexts
    (Washington, DC: World Bank, 2026-01-07) Cuesta Leiva, Jose Antonio; Huff, Connor
    Climate change is widely recognized as a driver of violent conflict, but its broader social effects remain less understood. Ignoring these dimensions risks a vicious cycle where climate policies might undermine socially just adaptation. Evidence is still limited on how climate shocks influence political participation, trust, or migration. This paper helps fill that gap by examining links between climate change, conflict, and social sustainability, with a focus on inclusion, resilience, cohesion, and legitimacy. Using secondary data from 2019–24, the study applies simple correlation-based methods to test three hypotheses on the nature, severity, and composition of these associations. The analysis combines multiple climate impact measures, new conflict classifications, recent social sustainability frameworks, and controls for population and geography. The results reveal strong correlations—not causation—between climate events and contexts of fragility, conflict, and violence. Climate impacts are most pronounced in both national and subnational conflict settings. The study also finds robust links between fragility, conflict, and violence and low levels of social sustainability, reflecting its role as both a driver and consequence of conflict. Some dimensions—such as violent events and insecurity—appear weaker in areas most affected by climate shocks. Two of the hypotheses are supported, and one remains inconclusive.
  • Publication
    The Macroeconomic Implications of Climate Change Impacts and Adaptation Options
    (Washington, DC: World Bank, 2025-05-29) Abalo, Kodzovi; Boehlert, Brent; Bui, Thanh; Burns, Andrew; Castillo, Diego; Chewpreecha, Unnada; Haider, Alexander; Hallegatte, Stephane; Jooste, Charl; McIsaac, Florent; Ruberl, Heather; Smet, Kim; Strzepek, Ken
    Estimating the macroeconomic implications of climate change impacts and adaptation options is a topic of intense research. This paper presents a framework in the World Bank's macrostructural model to assess climate-related damages. This approach has been used in many Country Climate and Development Reports, a World Bank diagnostic that identifies priorities to ensure continued development in spite of climate change and climate policy objectives. The methodology captures a set of impact channels through which climate change affects the economy by (1) connecting a set of biophysical models to the macroeconomic model and (2) exploring a set of development and climate scenarios. The paper summarizes the results for five countries, highlighting the sources and magnitudes of their vulnerability --- with estimated gross domestic product losses in 2050 exceeding 10 percent of gross domestic product in some countries and scenarios, although only a small set of impact channels is included. The paper also presents estimates of the macroeconomic gains from sector-level adaptation interventions, considering their upfront costs and avoided climate impacts and finding significant net gross domestic product gains from adaptation opportunities identified in the Country Climate and Development Reports. Finally, the paper discusses the limits of current modeling approaches, and their complementarity with empirical approaches based on historical data series. The integrated modeling approach proposed in this paper can inform policymakers as they make proactive decisions on climate change adaptation and resilience.
  • Publication
    Institutional Capacity for Policy Implementation: An Analytical Framework
    (Washington, DC: World Bank, 2026-01-07) Kim, Galileu; Kumar, Tanu; Ramalho, Rita; Russell, Stuart
    State capacity is an important prerequisite for policy implementation, yet at the country level it is difficult to measure, assess, and reform. This paper proposes a focus on institutional capacity: the ability of public institutions to implement the specific policy mandates for which they are responsible. Based on a review of existing literature, the paper defines the different dimensions that compose institutional capacity and groups them into two cross-cutting categories: organizational dimensions (personnel, financial resources, information systems, and management practices) and governance dimensions (transparency, independence, and accountability). The paper proposes measures for organizational and governance dimensions using existing data, shows intra-institutional variation of these measures within countries, and discusses how new data could be collected for better measurement of these concepts. Finally, the paper illustrates how the framework can be used to diagnose the sources of common problems related to weak policy implementation.
  • Publication
    South Africa’s Fragmented Cities: The Unequal Burden of Labor Market Frictions
    (Washington, DC: World Bank, 2026-01-08) Baez, Javier E.; Kshirsagar, Varun
    Using high-resolution administrative, census, and satellite data, this paper shows that South African cities are characterized by spatial mismatches between where people live and where jobs are located, relative to 20 global peers. Areas within 5 kilometers of commercial centers have 9,300 fewer residents per square kilometer than expected, which is 60 percent below the global median. Poor, dense neighborhoods are most affected. In Johannesburg, a 10-percentile increase in distance from the nearest business hub corresponds to a 3.7-percentile drop in asset wealth (a proxy of household wellbeing) and 4.9-percentile drop in employment. In Cape Town, the declines are 4.0 and 3.7 percentiles, respectively. Employment is 87 percent lower in the poorest decile than the richest in Johannesburg and 61 percent lower in Cape Town. These findings suggest that South Africa’s spatial organization of people and economic activity constrains agglomeration and reinforces inequality. This methodology provides a scalable and standardized data-driven framework to analyze spatial accessibility and agglomeration frictions in complex, data-constrained urban systems.
  • Publication
    Investment in Emerging and Developing Economies
    (Washington, DC: World Bank, 2026-01-07) Adarov, Amat; Kose, M. Ayhan; Vorisek, Dana
    The world faces a pressing challenge to meet key development objectives amid slowing growth and rising macroeconomic and geopolitical risks. With the number of job seekers rising rapidly, infrastructure shortfalls continuing to be large, and climate costs mounting, the case for a significant investment push has never been stronger. Yet the capacity to respond in many emerging markets and developing economies has eroded. Since the global financial crisis, investment growth has slowed to about half its pace in the 2000s, with both public and private investment weakening. Foreign direct investment inflows—a critical source of capital, technology, and managerial know-how—have also fallen sharply and become increasingly concentrated, leaving low-income countries with only a marginal share. The risks of further retrenchment are significant, as trade tensions, policy uncertainty, and elevated debt levels continue to weigh on investment. Reigniting momentum will require ambitious domestic reforms to strengthen institutions, rebuild macro-fiscal stability, and deepen trade and investment integration—the foundations of a supportive business climate. At the same time, international cooperation is indispensable. A renewed commitment to a predictable system of cross-border trade and investment flows, combined with scaled-up financial support and sustained technical assistance, is essential to help emerging markets and developing economies—especially low-income countries and economies in fragile and conflict situations—bridge financing gaps and implement the domestic reforms needed to restore investment as an engine of growth, jobs, and development.
Journal
Journal Volume
Journal Issue

Related items

Showing items related by metadata.

  • Publication
    The Effects of In-Kind Demand-Side Conditional Transfers for Improving Uptake of Maternal and Child Health Services in Rwanda
    (World Bank, Washington, DC, 2017-05) Kalisa, Ina; Shapira, Gil; Condo, Jeanine; Humuza, James; Mugeni, Cathy; Walldorf, Jeanette
    To diagnose and treat preventable threats to maternal and neonatal health in Sub-Saharan Africa, a policy focus has been put on increasing coverage rates of targeted health services. Exploiting an experimental design, this study evaluates the impacts of an in-kind conditional transfer intervention in Rwanda that endowed women with gifts for receiving timely antenatal and postnatal care, as well as for delivering in health facilities. The analysis finds that although health centers experienced frequent stock outs of the gifts, the rate of women who initiated antenatal care within the first four months of their pregnancy increased by 7.7 percent, and that of women who received postnatal care in the 10 days following delivery increased by 8.6 percent. No impact was found on the rate of in-facility deliveries, which independently sharply increased during the years of the implementation of the program.
  • Publication
    Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda
    (World Bank, Washington, DC, 2013-02) Bautista-Arredondo, Sergio; de Walque, Damien; Kwan, Ada; Gertler, Paul J.; de Dieu Bizimana, Jean; Binagwaho, Agnès; Vermeersch, Christel; Condo, Jeanine
    Paying for performance provides financial rewards to medical care providers for improvements in performance measured by specific utilization and quality of care indicators. In 2006, Rwanda began a paying for performance scheme to improve health services delivery, including HIV/AIDS services. This study examines the scheme's impact on individual and couples HIV testing and counseling and using data from a prospective quasi-experimental design. The study finds a positive impact of paying for performance with an increase of 6.1 percentage points in the probability of individuals having ever been tested. This positive impact is stronger for married individuals: 10.2 percentage points. The results also indicate larger impacts of paying for performance on the likelihood that the respondent reports both partners have ever been tested, especially among discordant couples (14.7 percentage point increase) in which only one of the partners is HIV positive.
  • Publication
    Impact of Implementing Performance-Based Financing on Childhood Malnutrition in Rwanda
    (BioMed Central, 2014-11-04) Binagwaho, Agnes; Condo, Jeanine; Wagner, Claire; Ngabo, Fidele; Karema, Corine; Kanters, Steve; Forrest, Jamie I.; de Dieu Bizimana, Jean
    Malnutrition remains a serious concern in Rwanda, particularly among children under-5 years. Performance-based financing (PBF), an innovative health systems financing strategy, has been implemented at the national level since 2008. This study aimed to assess the impact of PBF and other factors associated with the prevalence of three classifications of malnutrition (stunting, wasting and underweight) in children under-5 years in Rwanda. The study is a cross-sectional study comprising of 713 children under five years old from 557 households, whose anthropometric measurements (height, weight and age) had been obtained as part of the 2008 Rwanda General Health and HIV household survey. Z-scores for height-for-age, weight-for-age, weight-for-height, and body mass index-for-age were analyzed according to the World Health Organization 2006 Child Growth Standards. Random intercept logistic regression models were used to regress each anthropometric measure (WAZ, HAZ and WHZ) against child, maternal and household characteristics.
  • Publication
    Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda
    (Elsevier, 2014-12-12) Bautista-Arredondo, Sergio; de Walque, Damien; Kwan, Ada; Gertler, Paul J.; de Dieu Bizimana, Jean; Binagwaho, Agnès; Vermeersch, Christel; Condo, Jeanine
    Paying for performance provides financial rewards to medical care providers for improvements in performance measured by utilization and quality of care indicators. In 2006, Rwanda began a pay for performance scheme to improve health services delivery, including HIV/AIDS services. Using a prospective quasi-experimental design, this study examines the scheme's impact on individual and couples HIV testing. We find a positive impact of pay for performance on HIV testing among married individuals (10.2 percentage points increase). Paying for performance also increased testing by both partners by 14.7 percentage point among discordant couples in which only one of the partners is an AIDS patient.
  • Publication
    Evaluating the Impact of Results-Based Financing on Health Worker Performance
    (World Bank, Washington, DC, 2013-01) Torsvik, Gaute; Lemiere, Christophe; Maestad, Ottar; Leonard, Kenneth L.; Herbst, Christopher H.
    In order to advance our understanding of why Results Based Financing (RBF) works or not, it is crucial that evaluations not only measure the impact of such an arrangement on final outcomes (population health), but also assess the changes in variables in the causal chain between intervention and final outcomes. Health worker performance is a key variable in this chain; it is only by changing health workers’ behaviors—their performance—that RBF can influence health outcomes. Careful assessment of impacts on health worker performance is therefore a natural and important element of any RBF impact evaluations. This paper discusses various approaches to evaluating the impact of RBF on health worker performance. The first part is a discussion of possible ways in which RBF may affect health worker behavior, based on economic theory and empirical evidence. The second part is a more practical discussion of how health worker performance and other relevant variables can be measured and how impacts can be estimated. This is followed by some practical steps that can be taken to ensure that the evaluation leads to actions that can be implemented; a brief conclusion completes the paper.

Users also downloaded

Showing related downloaded files