The race to the top initiative: towards excellence in health-care service delivery

Background: Since 2006, Rwanda has adopted performance-based incentives to boost the motivation of health-care workers and improve Millennium Development Goal (MDG) health indicators. However, performance-based incentives will often create a focus on final outcomes rather than the improvement of processes. Furthermore, national evaluation of district health facilities uses the same indicators irrespective of district-level differences in burden of disease and health priorities. In 2013, Partners In Health, in collaboration with the Rwandan Ministry of Health, launched the “race to the top” initiative (RTT), a new district-based approach to performance incentives, which strengthens process and outcomes through engagement of community and health-care workers, the setting of priority targets, and peer-to-peer learning to speed up changes in the way care is delivered. Ongoing technical support is provided throughout RTT's action periods to foster local innovations and make the most of local resources, and support data-driven quality improvement. Here, we describe results from a health district in rural Rwanda, 18 months after implementation of the RTT initiative. Methods: We did a baseline assessment of population health indicators at 13 health centres in the Kirehe district hospital catchment area between January, 2013, and June, 2014. We set ambitious targets and success required a coordinated effort by health centres, local leaders, and community. We measured progress towards targets and gave feedback to health centres 6 months, 12 months, and 18 months after implementation. Health centres were given monetary rewards (to be invested in quality improvement) on the attainment of three pre-set goals: a minimum 90% coverage of community-based health insurance (CBHI); a 70% contraceptive prevalence rate; and complete elimination of severe acute malnutrition cases. Findings: At 6 months' follow up, four of 13 health centres had met one target. At 12 months, seven had met one target, and by 18 months, six centres had met two targets and two centres had achieved all three indicators. At 18 months, average performance had improved significantly across the district for all three targets. The mean CBHI coverage across facilities increased by 35% from 68% at baseline to 92%. The mean number of malnutrition cases per facility per 6 month period identified at the health centres fell by 78% from 24 at baseline to 5·2 at 18 months. Finally, the contraceptive prevalence rate increased by 55% from 42% to 65%. RTT also provided opportunity for health centres to develop innovative strategies to address identified performance gaps. Interpretation: The strength of the RTT intervention resides in its combination of the performance-based incentive and provision of technical support. RTT is being implemented in a neighbouring district and ongoing efforts including site visits and district level meetings are being implemented in Kirehe to understand the challenges that these health centres are facing. Funding: RTT was jointly funded by Partners In Health through Doris Duke foundation and Kirehe district.