This activity relates to MTCT (7179, 7181, 8185, 8698), HBHC (7220), HVTB (7221), HVCT (7217), HTXS (7222), HVSI (8743).

Performance-based financing is an innovative approach to financing of health services that enhances quality of services and leads to greater efficiency and sustainability. Financial incentives provided by performance-based funding motivate health facilities to improve performance through investments in training, equipment, personnel and payment systems that better link individual pay to individual performance. PBF financing is directly applied to PMTCT and other HIV indicators at the facility level. As a result of successful pilots implemented by CordAID, GTZ and BTC, the MOH has endorsed national scale-up of performance-based financing for all health services. The USG, in partnership with the World Bank, BTC and other donors, is supporting national implementation of performance-based financing of health services.

In FY 2006, MSH/PBF supported the GOR in collaboration with key donors to develop a national strategy, policy, and implementation model of performance-based financing that applies to all health assistance. The initial strategy for EP-supported PBF activities was to transfer USG site support from a traditional inputs-based model to a purely output purchases model as sites achieved a certain level of technical competence. However, the implementation of COP06 activities brought a change in the USG team's thinking about this approach. Few, if any USG supported sites were found to be ready for complete graduation to an exclusively PBF model. While PBF clearly increases performance, technical assistance and basic input support is still needed, especially in the current context of rapid decentralization and accelerated national roll-out of the PBF model by the GOR. Therefore, an adjusted strategy has been developed that provides a combination of both input and output financing to all EP-supported sites. The combination of financing modalities will properly motivate health facilities for higher performance while providing necessary resources and tools to meet the established targets.

In FY 2007, MSH/PBF will continue to provide support to the MOH Performance Based Financing department and the national PBF TWG. In addition, MSH/PBF will provide TA to DHTs in all PEPFAR districts and to USG implementing partners to effectively shift some of their input financing to output-based financing for TB and other indicators in accordance with national policy. MSH/PBF will also provide output financing to health facilities in 6 districts (where other clinical partners will only provide input financing) through direct performance sub-contracts with health centers and district hospitals for PMTCT and other indicators. Output financing involves the purchase of a certain quantity of indicators with a performance incentive for the production of more than agreed upon quantities of services. Full or partially reduced payment of TB and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

At the health center level, MSH/PBF will use a ‘fixed price plus award fee' contract model to purchase a quantity of PMTCT and other HIV indicators with a performance incentive. Examples of PMTCT indicators include number of pregnant women tested for HIV, number of couples and partners tested for HIV, mother and child pair treated according to national protocol, children born to HIV-positive mothers tested for HIV, number of HIV-positive women who are using FP. Performance on these indicators will be measured during monthly control activities jointly conducted by the MSH/PBF district coordinator and the district's Family Health Unit and quality of services will be evaluated through the existing national supervisory and quality assurance mechanisms. The quantity and quality scores will be merged during the quarterly District PBF Steering Committee meetings and the final payments will be approved.

At the district hospital level, MSH/PBF will have sub-contracts with slightly different purpose and scope from that of health centers. In addition to the focus on increasing better quality service outputs, there is an emphasis on quality assurance, self-evaluation, and review by peers similar to an accreditation scheme. There will be payment for indicators from the National District Hospital PBF Scheme which reinforces the supervisory role hospitals play in district health networks.

At the district level, MSH/PBF will support the national model by 1) placing a district coordinator within the Family Health Unit to work with national family health steering

committee during data collection/entry and control of indicators, 2) facilitating the quantity control function by providing TA and paying associated costs, and 3) support secretarial functions for the Family Health Unit at the district level. Support to the district is critical for the proper functioning of the national PBF model since monthly HIV/AIDS invoice approved by the health center PBF management committee (COGE) and MSH are presented to the district steering committee for merging with quality index and final approval before payments are made.

PBF of PMTCT and other HIV services is a critical step to achieving the goal of sustainable, well-managed, high quality, and cost-effective PMTCT service delivery in a comprehensive HIV/AIDS treatment network. This financing modality supports the Rwanda EP five-year strategy for increasing institutional capacity for a district-managed network model of HIV clinical treatment and care services.

n/a

Table 3.3.01:

This activity relates to HBHC (8144, 7165, 7177, 7160, 7163), MTCT (7219), HVTB (7221), HVCT (7217), HTXS (7222), HVSI (8741).

Performance-based financing is an innovative approach to financing of health services that enhances quality of services and leads to greater efficiency and sustainability. Financial incentives provided by performance-based funding motivate health facilities to improve performance through investments in training, equipment, personnel and payment systems that better link individual pay to individual performance. PBF financing is directly applied to basic health care and other HIV indicators at the facility level. As a result of successful pilots implemented by CordAID, GTZ and BTC, the MOH has endorsed national scale-up of performance-based financing for all health services. The USG, in partnership with the World Bank, BTC and other donors, is supporting national implementation of performance-based financing of health services.

In FY 2006, MSH/PBF supported the GOR in collaboration with key donors to develop a national strategy, policy, and implementation model of performance-based financing that applies to all health assistance. The initial strategy for EP-supported PBF activities was to transfer USG site support from a traditional inputs-based model to a purely output purchases model as sites achieved a certain level of technical competence. However, the implementation of COP06 activities brought a change in the USG team's thinking about this approach. Few, if any USG supported sites were found to be ready for complete graduation to an exclusively PBF model. While PBF clearly increases performance, technical assistance and basic input support is still needed, especially in the current context of rapid decentralization and accelerated national roll-out of the PBF model by the GOR. Therefore, an adjusted strategy has been developed that provides a combination of both input and output financing to all EP-supported sites. The combination of financing modalities will properly motivate health facilities for higher performance while providing necessary resources and tools to meet the established targets.

In FY 2007, MSH/PBF will continue to provide support to the MOH Performance Based Financing department and the national PBF TWG. In addition, MSH/PBF will provide TA to DHTs in all PEPFAR districts and to USG implementing partners to effectively shift some of their input financing to output-based financing for basic health care and other indicators in accordance with national policy. MSH/PBF will also provide output financing to health facilities in 6 districts (where other clinical partners will only provide input financing) through direct performance sub-contracts with health centers and district hospitals for basic health care and other indicators. Output financing involves the purchase of a certain quantity of indicators with a performance incentive for the production of more than agreed upon quantities of services. Full or partially reduced payment of basic health care and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

At the health center level, MSH/PBF will use a ‘fixed price plus award fee' contract model to purchase a quantity of basic health care and other HIV indicators with a performance incentive. Examples of basic health care indicators include the number of HIV+ clients who tested their CD4 levels six-monthly, number of HIV+ clients treated with CTX each month, number of HIV+ women who are using FP, number of HIV+ clients who have been screened for STDs. Performance on these indicators will be measured during monthly control activities jointly conducted by the MSH/PBF district coordinator and the district's Family Health Unit and quality of services will be evaluated through the existing national supervisory and quality assurance mechanisms. The quantity and quality scores will be merged during the quarterly District PBF Steering Committee meetings and the final payments will be approved.

At the district hospital level, MSH/PBF will have sub-contracts with slightly different purpose and scope from that of health centers. In addition to the focus on increasing better quality service outputs, there is an emphasis on quality assurance, self-evaluation, and review by peers similar to an accreditation scheme. There will be payment for indicators from the National District Hospital PBF Scheme which reinforces the supervisory role hospitals play in district health networks.

At the District level, MSH/PBF will support the national model by 1) placing a district coordinator within the Family Health Unit to work with national family health steering

committee during data collection/entry and control of indicators, 2) facilitating the quantity control function by providing TA and paying associated costs, and 3) support secretarial functions for the Family Health Unit at the District level. Support to the District is critical for the proper functioning of the national PBF model since monthly HIV/AIDS invoice approved by the health center PBF management committee (COGE) and MSH are presented to the district steering committee for merging with quality index and final approval before payments are made.

Performance-Based financing of basic health care and other HIV services is a critical step to achieving the goal of sustainable, well-managed, high quality, and cost-effective basic health care service delivery in a comprehensive HIV/AIDS treatment network. This financing modality supports the Rwanda EP five-year strategy for increasing institutional capacity for a district managed network model of HIV clinical treatment and care services.

This activity relates activities in HVTB (7162, 7169, 8147, and 8664).

Performance-based financing is an innovative approach to financing of health services that enhances quality of services and leads to greater efficiency and sustainability. Financial incentives provided by performance-based funding motivate health facilities to improve performance through investments in training, equipment, personnel and payment systems that better link individual pay to individual performance. PBF financing is directly applied to TB and other HIV indicators at the facility level. As a result of successful pilots implemented by CordAID, GTZ and BTC, the MOH has endorsed national scale-up of performance-based financing for all health services. The USG, in partnership with the World Bank, BTC and other donors, is supporting national implementation of performance-based financing of health services.

In FY 2006, MSH/PBF supported the GOR in collaboration with key donors to develop a national strategy, policy, and implementation model of performance-based financing that applies to all health assistance. The initial strategy for EP-supported PBF activities was to transfer USG site support from a traditional inputs-based model to a purely output purchases model as sites achieved a certain level of technical competence. However, the implementation of COP06 activities brought a change in the USG team's thinking about this approach. Few, if any USG supported sites were found to be ready for complete graduation to an exclusively PBF model. While PBF clearly increases performance, technical assistance and basic input support is still needed, especially in the current context of rapid decentralization and accelerated national roll-out of the PBF model by the GOR. Therefore, an adjusted strategy has been developed that provides a combination of both input and output financing to all EP-supported sites. The combination of financing modalities will properly motivate health facilities for higher performance while providing necessary resources and tools to meet the established targets.

In FY 2007, MSH/PBF will continue to provide support to the MOH Performance Based Financing department and the national PBF TWG. In addition, MSH/PBF will provide TA to DHTs in all PEPFAR districts and to USG implementing partners to effectively shift some of their input financing to output-based financing for TB and other indicators in accordance with national policy. MSH/PBF will also provide output financing to health facilities in 8 districts (where other clinical partners will only provide input financing) through direct performance sub-contracts with health centers and district hospitals for TB and other indicators. Output financing involves the purchase of a certain quantity of indicators with a performance incentive for the production of more than agreed upon quantities of services. Full or partially reduced payment of TB and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

At the health center level, MSH/PBF will use a ‘fixed price plus award fee' contract model to purchase a quantity of TB and other HIV indicators (such as the number of HIV+ clients who have been screened for TB) with a performance incentive. Performance on these indicators will be measured during monthly control activities jointly conducted by the MSH/PBF district coordinator and the district's Family Health Unit and quality of services will be evaluated through the existing national supervisory and quality assurance mechanisms. Examples of quality indicators for TB include correctly filling stock control cards in X-ray departments, the percentage of TB lab exams that are corroborated during quarterly controls, the number of X-rays of good quality with correct diagnosis and report in patient file, and the number of complete series of AFBs correctly done. The quantity and quality scores will be merged during the quarterly District PBF Steering Committee meetings and the final payments will be approved.

At the district hospital level, MSH/PBF will have sub-contracts with slightly different purpose and scope from that of health centers. In addition to the focus on increasing better quality service outputs, there is an emphasis on quality assurance, self-evaluation, and review by peers similar to an accreditation scheme. There will be payment for indicators from the National District Hospital PBF Scheme which reinforces the supervisory role hospitals play in district health networks.

At the District level, MSH/PBF will support the national model by 1) placing a district coordinator within the Family Health Unit to work with national family health steering

committee during data collection/entry and control of indicators, 2) facilitating the quantity control function by providing TA and paying associated costs, and 3) support secretarial functions for the Family Health Unit at the District level. Support to the District is critical for the proper functioning of the national PBF model since monthly HIV/AIDS invoice approved by the health center PBF management committee (COGE) and MSH are presented to the district steering committee for merging with quality index and final approval before payments are made.

n/a

Table 3.3.07:

This activity is related to activities in HVCT (7178, 7182, 8164, 8168), MTCT (7219), HBHC (7220), HVTB (7221), HTXS (7222), HVSI (8743).

Performance-based financing is an innovative approach to financing of health services that enhances quality of services and leads to greater efficiency and sustainability. Financial incentives provided by performance-based funding motivate health facilities to improve performance through investments in training, equipment, personnel and payment systems that better link individual pay to individual performance. PBF financing is directly applied to VCT and other HIV indicators at the facility level. As a result of successful pilots implemented by CordAID, GTZ and BTC, the MOH has endorsed national scale-up of performance-based financing for all health services. The USG, in partnership with the World Bank, BTC and other donors, is supporting national implementation of performance-based financing of health services.

In FY 2006, MSH/PBF supported the GOR in collaboration with key donors to develop a national strategy, policy, and implementation model of performance-based financing that applies to all health assistance. The initial strategy for EP-supported PBF activities was to transfer USG site support from a traditional inputs-based model to a purely output purchases model as sites achieved a certain level of technical competence. However, the implementation of COP06 activities brought a change in the USG team's thinking about this approach. Few, if any USG supported sites were found to be ready for complete graduation to an exclusively PBF model. While PBF clearly increases performance, technical assistance and basic input support is still needed, especially in the current context of rapid decentralization and accelerated national roll-out of the PBF model by the GOR. Therefore, an adjusted strategy has been developed that provides a combination of both input and output financing to all EP-supported sites. The combination of financing modalities will properly motivate health facilities for higher performance while providing necessary resources and tools to meet the established targets.

In FY 2007, MSH/PBF will continue to provide support to the MOH Performance Based Financing department and the national PBF TWG. In addition, MSH/PBF will provide TA to DHTs in all PEPFAR districts and to USG implementing partners to effectively shift some of their input financing to output-based financing for CT and other indicators in accordance with national policy. MSH/PBF will also provide output financing to health facilities in 6 districts (where other clinical partners will only provide input financing) through direct performance sub-contracts with health centers and district hospitals for CT and other indicators. Output financing involves the purchase of a certain quantity of indicators with a performance incentive for the production of more than agreed upon quantities of services. Full or partially reduced payment of CT and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

At the health center level, MSH/PBF will use a ‘fixed price plus award fee' contract model to purchase a quantity of CT and other HIV indicators with a performance incentive. Examples of CT indicators include the number of persons tested for HIV and number of couples and partners tested for HIV. Performance on these indicators will be measured during monthly control activities jointly conducted by the MSH/PBF district coordinator and the district's Family Health Unit and quality of services will be evaluated through the existing national supervisory and quality assurance mechanisms. The quantity and quality scores will be merged during the quarterly District PBF Steering Committee meetings and the final payments will be approved.

At the district hospital level, MSH/PBF will have sub-contracts with slightly different purpose and scope from that of health centers. In addition to the focus on increasing better quality service outputs, there is an emphasis on quality assurance, self-evaluation, and review by peers similar to an accreditation scheme. There will be payment for indicators from the National District Hospital PBF Scheme which reinforces the supervisory role hospitals play in district health networks.

At the district level, MSH/PBF will support the national model by 1) placing a district coordinator within the Family Health Unit to work with national family health steering committee during data collection/entry and control of indicators, 2) facilitating the quantity control function by providing TA and paying associated costs, and 3) support secretarial

functions for the Family Health Unit at the district level. Support to the district is critical for the proper functioning of the national PBF model since monthly HIV/AIDS invoices are approved by the health center PBF management committee and MSH and are presented to the district steering committee for merging with a quality index and final approval before payments are made.

Performance-Based Financing of CT and other HIV services is a critical step to achieving the goal of sustainable, well-managed, high quality, and cost-effective VCT service delivery in a comprehensive HIV/AIDS treatment network. This financing modality supports the Rwanda EP five-year strategy for increasing institutional capacity for a district managed network model of HIV clinical treatment and care services.

This activity relates to HTXS (7161, 7176, 7185, 7213, 7246, 8172), MTCT (7219), HBHC (7220), HVTB (7221), and HVCT (7217).

Performance-based financing is an innovative approach to financing of health services that enhances quality of services and leads to greater efficiency and sustainability. Financial incentives provided by performance-based funding motivate health facilities to improve performance through investments in training, equipment, personnel and payment systems that better link individual pay to individual performance. PBF financing is directly applied to ART and other HIV indicators at the facility level. As a result of successful pilots implemented by CordAID, GTZ and BTC, the MOH has endorsed national scale-up of performance-based financing for all health services. The USG, in partnership with the World Bank, BTC and other donors, is supporting national implementation of performance-based financing of health services.

In FY 2006, MSH/PBF supported the GOR in collaboration with key donors to develop a national strategy, policy, and implementation model of performance-based financing that applies to all health assistance. The initial strategy for EP-supported PBF activities was to transfer USG site support from a traditional inputs-based model to a purely output purchases model as sites achieved a certain level of technical competence. However, the implementation of FY 2006 activities brought a change in the USG team's thinking about this approach. Few, if any USG supported sites were found to be ready for complete graduation to an exclusively PBF model. While PBF clearly increases performance, technical assistance and basic input support is still needed, especially in the current context of rapid decentralization and accelerated national roll-out of the PBF model by the GOR. Therefore, an adjusted strategy has been developed that provides a combination of both input and output financing to all EP-supported sites. The combination of financing modalities will properly motivate health facilities for higher performance while providing necessary resources and tools to meet the established targets.

In FY 2007, MSH/PBF will continue to provide support to the MOH Performance Based Financing department and the national PBF TWG. In addition, MSH/PBF will provide TA to DHTs in all PEPFAR districts and to USG implementing partners to effectively shift some of their input financing to output-based financing for ART and other indicators in accordance with national policy. MSH/PBF will also provide output financing to health facilities in six districts (where other clinical partners will only provide input financing) through direct performance sub-contracts with health centers and district hospitals for ART and other indicators. Output financing involves the purchase of a certain quantity of indicators with a performance incentive for the production of more than agreed upon quantities of services. Full or partially reduced payment of ART and other indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national quality supervision tool.

At the health center level, MSH/PBF will use a ‘fixed price plus award fee' contract model to purchase a quantity of ART and other HIV indicators with a performance incentive. Examples of ART indicators include the number of new adult ART patients, number of new pediatric ART patients, number of patients under ART seen after one month of starting treatment, and number of ART clients who have been seen six monthly. Performance on these indicators will be measured during monthly control activities jointly conducted by the MSH/PBF district coordinator and the district's Family Health Unit and quality of services will be evaluated through the existing national supervisory and quality assurance mechanisms. The quantity and quality scores will be merged during the quarterly District PBF Steering Committee meetings and the final payments will be approved.

At the district hospital level, MSH/PBF will have sub-contracts with slightly different purpose and scope from that of health centers. In addition to the focus on increasing better quality service outputs, there is an emphasis on quality assurance, self-evaluation, and review by peers similar to an accreditation scheme. There will be payment for indicators from the national district hospital PBF scheme which reinforces the supervisory role hospitals play in district health networks.

At the district level, MSH/PBF will support the national model by 1) placing a district coordinator within the Family Health Unit to work with national family health steering committee during data collection/entry and control of indicators, 2) facilitating the quantity

control function by providing TA and paying associated costs, and 3) supporting secretarial functions for the Family Health Unit at the district level. Support to the district is critical for the proper functioning of the national PBF model since monthly HIV/AIDS invoices approved by the health center PBF management committee and MSH are presented to the district steering committee for merging with quality index and final approval before payments are made.

Performance-based financing of ART and other HIV services is a critical step to achieving the goal of sustainable, well-managed, high quality, and cost-effective ART/HIV service delivery in a comprehensive HIV/AIDS treatment network. This financing modality supports the Rwanda EP five-year strategy for increasing institutional capacity for a district managed network model of HIV clinical treatment and care services.

n/a

Table 3.3.11:

This activity relates to MTCT (7219), HBHC (7220), HVTB (7221), HVCT (7217), HTXS (7222).

Performance-based financing is an innovative approach to financing of health services that enhances quality of services and leads to greater efficiency and sustainability. Financial incentives provided by performance-based funding motivate health facilities to improve performance through investments in training, equipment, personnel and payment systems that better link individual pay to individual performance. PBF financing is directly applied to 14 key HIV indicators at the facility level. As a result of successful pilots implemented by CordAID, GTZ and BTC, the MOH has endorsed national scale-up of performance-based financing for all health services. The USG, in partnership with the World Bank, BTC and other donors, is supporting national implementation of performance-based financing of health services.

In FY 2006, MSH/PBF supported the GOR in collaboration with key donors to develop a national strategy, policy, and implementation model of performance-based financing that applies to all health assistance. The initial strategy for EP-supported PBF activities was to transfer USG site support from a traditional inputs-based model to a purely output purchases model as sites achieved a certain level of technical competence. However, the implementation of FY 2006 activities brought a change in the USG team's thinking about this approach. Few, if any USG supported sites were found to be ready for complete graduation to an exclusively PBF model. While PBF clearly increases performance, technical assistance and basic input support is still needed, especially in the current context of rapid decentralization and accelerated national roll-out of the PBF model by the GOR. Therefore, an adjusted strategy has been developed that provides a combination of both input and output financing to all EP-supported sites. The combination of financing modalities will properly motivate health facilities for higher performance while providing necessary resources and tools to meet the established targets.

In FY 2007, MSH/PBF will continue to provide support to the MOH Performance Based Financing department and the national PBF TWG. In addition, MSH/PBF will provide TA to DHTs in all PEPFAR districts and to USG implementing partners to effectively shift some of their input financing to output-based financing for the 14 key HIV indicators in accordance with national policy. MSH/PBF will also provide output financing to health facilities in 6 districts (where other clinical partners will only provide input financing) through direct performance sub-contracts with health centers and district hospitals for the 14 key HIV indicators. Output financing involves the purchase of a certain quantity of indicators with a performance incentive for the production of more than agreed upon quantities of services. Full or partially reduced payment of indicators is contingent upon the quality of general health services as measured by the score obtained using the standardized national Quality Supervision tool.

At the health center level, MSH/PBF will use a ‘fixed price plus award fee' contract model to purchase a quantity of each of the 14 key HIV indicators with a performance incentive. Performance on these indicators will be measured during monthly control activities jointly conducted by the MSH/PBF district coordinator and the district's Family Health Unit and quality of services will be evaluated through the existing national supervisory and quality assurance mechanisms. The quantity and quality scores will be merged during the quarterly District PBF Steering Committee meetings and the final payments will be approved.

At the district hospital level, MSH/PBF will have sub-contracts with slightly different purpose and scope from that of health centers. In addition to the focus on increasing better quality service outputs, there is an emphasis on quality assurance, self-evaluation, and review by peers similar to an accreditation scheme. There will be payment for indicators from the National District Hospital PBF Scheme which reinforces the supervisory role hospitals play in district health networks.

At the District level, MSH/PBF will support the national model by 1) placing a district coordinator within the Family Health Unit to work with national family health steering committee during data collection/entry and control of indicators, 2) facilitating the quantity control function by providing TA and paying associated costs, and 3) support secretarial functions for the Family Health Unit at the District level. Support to the District is critical

for the proper functioning of the national PBF model since monthly HIV/AIDS invoice approved by the health center PBF management committee (COGE) and MSH are presented to the district steering committee for merging with quality index and final approval before payments are made.

Performance-Based financing of HIV services is a critical step to achieving the goal of sustainable, well-managed, high quality, and cost-effective HIV service delivery in a comprehensive health network. This financing modality supports the Rwanda EP five-year strategy for increasing institutional capacity for a district managed network model of HIV clinical treatment and care services.

[CONTINUING ACTIVITY FROM FY 2006 -- NO NEW FUNDING IN FY 2007] See related Activities: HVCT (2812), MTCT (2814), HBHC (2815), HTXS (2798, 4003), HVTB (4001), 4771, 4972. In coordination with the World Bank, the Belgian Government, Global Fund and other donors, the PBF of HIV/AIDS services will support the GOR and the MOH to develop and implement an HIV/AIDS component within a national system of PBF for primary care. Other donors have worked successfully in Rwanda to pilot PBF of primary health care. The GOR wishes to extend this system nationally and has other donor support to do so for non-HIV health services. The WB, EP and Global Fund will support integration of HIV/AIDS PBF into the larger performance-based health financing program while the Belgian Government, GTZ and others will support financing of non-HIV/AIDS primary health care services. PBF will provide direct health financing expertise to develop a system of performance-based contracting for indicators tied to EP targets. The PBF will sub-contract with USS to develop a national implementation and coordination plan on Quality Assurance, building on experience to date with the "Collaborative Approach".

PBF will support, through sub-contracts, health districts to develop governance systems for performance contracts to increase both quality and productivity of HIV/AIDS care. Health districts will develop "performance plans" that define specific indicators and their incentive payments for each health facility that signs a "performance-contract". The PBF, with USS, will develop performance contracts for DHTs based on incentives for effective supervision and implementation of HC performance contracts. The PBF will support districts to develop quality, productivity and financial audit systems to verify the performance of health facilities. The PBF will support the GOR to develop legal and financial systems to transfer funds from the GOR and from donors to health providers, based upon performance contracts, consistent with GOR policy and donor requirements. Until such systems are developed, donors will directly transfer funds to providers in accordance with donor requirements based upon collaboratively developed performance contracts. The PBF will balance timely achievements of EP targets and health system strengthening. The anticipated role of the health district in managing performance contracts is well aligned with the recent national district reorganization and with other EP support to DHTs (Activity 4771, 2798).

Activities in 2006 will include: collaborative work with the MOH Health Sector Working Group to finalize national policy on PBF, identification of districts and facilities for initiation of performance-based contracts for HIV/AIDS service delivery, baseline and semi-annual surveys of these sites' performance, capacity building of the USS and DHTs to manage performance-based contracting, development of health district and health facility quality assurance and financial management systems, definition and agreement of specific indicators for performance-based contracting, preparation of sites for launch, development and signing of contracts with health facilities, regular monitoring of performance by DHT supervisors, and subsequent reimbursement based upon performance. The PBF will undergo an independent audit in month 18 to determine if PBF is achieving the sustainability and performance-improvement goals of the GOR and the EP. (See Activity 4972)

The PBF project will provide managerial training, including planning, budgeting, and human resources to health facilities and DHTs. PBF will support DHTs to develop systems to monitor provider performance as the basis for reimbursement.

Quality indicators will include adherence to clinical standards (PMTCT, CT, BHC, and ARV), patient satisfaction and patient safety indicators. PBF will train DHTs and HCs to involve the community and patients in their governance, using the established PAQ model successfully implemented to date. PBF will work with USS and DHTs to continue and support national implementation of the successful "Collaborative Approach" for continuing quality improvement. PBF will expand these two established Rwandan quality improvement activities as well as introduce other performance-improving methods to DHTs and to providers with performance-based contracts.

The PBF project will strengthen the HIV/AIDS network model by reimbursing indicators reflective of network or system performance as well as individual site and provider performance. For example, reimbursable "network" indicators could include use of referral forms, numbers of patients jointly cared for by community and HCs or number of patients

treated by satellite ARV services with district hospital physician support. For shared indicators, reimbursement would be shared among all participants based upon their level of effort. Such shared indictors require greater effort to manage, but are necessary to minimize patient hoarding. Similarly, the District Health Team will be reimbursed based on indicators of overall performance of the entire health district, from the community to the district hospital.

Sustainability of quality health provider performance in delivering HIV/AIDS services is part of the Rwanda EP five-year EP strategy as well as the GOR long term strategy for improved health care system performance. ****PLUS-UP**** $600,000 - PBF will develop performance contracts with district supervisors to integrate HIV/AIDS indicators into their site visits to assure quality and efficiency of HIV/AIDS care. PBF will define and field test 10 indicators related to quality of HIV care for use in performance based contracting. PBF will develop national materials to guide districts in implementation of collaborative approach to achieve performance targets. These funds will be used to support national and district activities to integrate quality indicators into Performance-based contracting of HIV/AIDS services. Examples of quality indictors for possible use in PBC include: score > 70% on check lists from random medical record review for compliance with national protocols for: new PMTCT regimen, ARV prescribing, counseling for patients with positive HIV tests; score for percent of patients diagnosed with HIV from PIT, and score > 70% of checklist for adherence to supervision protocols. Rwanda has developed a national policy for quality improvement to serve as a basis for performance-based contracting. Continuing quality assurance through national implementation of the PBF is a top GOR priority and key activity to achieve sustainability in the Rwanda EP five-year strategy. Targeted DHTs will receive additional skill enhancement in monitoring the performance of health centers and hospitals in their districts to provide high quality, cost effective HIV services.