Paying for Performance When Health Care Production is Multi-Dimensional: The Impact of Rwanda's National Program on Rewarded Services, Multitasking and Health Outcome

Performance-based contracting is particularly challenging in settings such as health care, where joint production, multiple agents, and market failures compound the critical contracting concern of multitasking. We analyze impacts of Rwanda’s national pay-for-performance (P4P) program using two waves of data from the Rwanda Demographic and Health Surveys collected before and after the randomized roll-out. We find that P4P improved some rewarded and unrewarded services, but had no impact on health outcomes. We find no evidence of multitasking, and find mixed effects of the program by baseline levels of facility quality, with most improvements seen in the middle quality tier.