PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
This is a new activity/mechanism in FY 2009.
Performance-based financing (PBF) is an innovative approach to financing health services that is focused
on output and enhances quality of services leading to greater efficiency and sustainability. 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 proportionally reduced payment of HIV/AIDS
indicators is determined by the quality of general health services as measured by the score obtained using
the standardized national Quality Supervision tool. Financial incentives provided by PBF to motivate health
facilities to improve performance through investments in training, equipment, personnel and payment
systems that better link individual pay to individual performance. PBF is directly applied to HIV/AIDS
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 PBF for all health services. PEPFAR, in partnership with the World
Bank, BTC and other donors, is supporting national implementation of PBF and health services.
In FY 2007, MSH/PBF supported the GOR in collaboration with key donors to implement a national
strategy, policy, and model of PBF that applies to all health facilities. Consistent with the principles of linking
performance to incentives, MSH provided output-based financing to health facilities in six districts through
sub-contracts with health centers and district hospitals for HIV/AIDS indicators. PEPFAR adopted a strategy
in FY 2007 that combines both input and output financing to motivate health facilities for higher performance
while providing necessary resources and tools to meet the established targets. In Rwanda, though
performance has increased with PBF, TA and basic input support is still needed, especially in the current
context of rapid decentralization and accelerated national PBF roll-out. At the health center level, PEPFAR
partners purchase a quantity of the 14 key HIV/AIDS indicators. Performance on these indicators is
measured during monthly control activities jointly conducted by the MSH/PBF district coordinator, clinical
partners, and the district's Family Health Unit. The quality of services is evaluated through the existing
national supervisory and quality assurance mechanisms. The quantity and quality scores are then merged
during the quarterly District PBF Steering Committee meetings and the final payments are approved. At the
health center level, MSH/PBF uses 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, and children born to HIV-positive mothers tested for HIV.
MSH/PBF also has sub-contracts at the district hospital level for a slightly different purpose and scope than
with health centers. The focus of the contracts with district hospitals is on increasing quality service outputs,
quality assurance, self-evaluation, and review by peers, similar to an accreditation scheme. There is
payment for indicators from the National District Hospital PBF Scheme, which reinforces the supervisory
role that hospitals play in district health networks.
In FY 2008, MSH/PBF continues supporting the MOH PBF department and the national PBF TWG. In
addition, MSH/PBF provides TA to DHTs and implementing partners in 23 PEPFAR districts to effectively
shift some of their input financing to output-based financing for HIV/AIDS indicators in accordance with
national policy. MSH/PBF also provides intensive TA to districts that introduced PBF in FY 2008. At the
district level, MSH/PBF continues supporting the national model by 1) placing a district coordinator within
the Family Health Unit to work with the 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. PEPFAR
support to the district is critical for the proper functioning of the national PBF model. Monthly invoices
approved by the health center PBF management committee (COGE) and MSH are then presented to the
district steering committee for merging with the quality index and for final approval before payments are
made.
In FY 2009, the MSH PBF mechanism is coming to an end. However, performance based financing has
been successful in Rwanda and a priority of the GOR as it is linked to improved quality of HIV and other
health services. Consequently, PEPFAR is in the process of designing a new mechanism that would build
on the success of the MSH PBF project and potentially expand performance-based financing to the
community level. In FY 2009, there will be additional need to support the GOR with technical assistance as
sites continue to be graduated and as the PBF system is expanded into a community setting with the goal of
increasing the quality and standardization of care at all entry points to the health system. As a result, the
follow on mechanism will continue to purchase indicators in PMTCT. The follow on mechanism will also
continue to provide technical assistance to build the capacity of staff at both the central level health
institutions and the DHTs with the goal of improving the quality of PMTCT services.
PBF of HIV/AIDS services has been 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 PEPFAR five-year strategy for increasing institutional
capacity for a district managed network model of HIV clinical treatment and care services.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Estimated amount of funding that is planned for Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY UNCHANGED FROM FY 2008:
Performance-based financing (PBF) has been an innovative approach to financing health services based on
output that aims to enhance quality of services and lead to greater efficiency and sustainability. Output
financing involves the purchase of a certain quantity of high-quality health services with a performance
incentive for the production of more than agreed upon quantities of services. The quality of these health
services is ensured through the use of a score obtained using the standardized national Quality Supervision
tool. This score determines whether payment for HIV/AIDS indicators is full (high quality services) or
proportionally reduced (quality needs to be improved). (Note: The definition of "quality" used in PBF is
different from the definition used in other national quality improvement (QI) initiatives, including HealthQual).
Financial incentives provided by PBF motivate health facilities to improve both the quantity and the quality
of their performance through investments in training, equipment, personnel and payment systems that
better link individual pay to individual performance. PBF is directly applied to HIV/AIDS 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 PBF for all health services. PEPFAR, in partnership with the World Bank,
BTC and other donors, is supporting national implementation of PBF for health services.
strategy, policy, and model of PBF that applies to all health assistance. MSH/PBF undertook output-based
financing to health centers and district hospitals in six districts through direct performance sub-contracts
with these facilities for HIV/AIDS indicators. PEPFAR adopted a strategy in FY 2007 to combine both input
and output financing to properly motivate health facilities for higher performance while providing necessary
resources and tools to meet the established targets. While PBF clearly increases performance, basic input
support - such as training, materials, equipment and TA - is still needed, especially in the current context of
rapid decentralization and accelerated national roll-out of the PBF model by the GOR. At the health center
level, EP partners purchase a quantity of indicators with a performance incentive. Examples of basic health
care indicators include the number of HIV-infected clients who tested their CD4 levels six-monthly, number
of HIV-infected clients treated with cotrimoxazole each month, number of HIV infected women who are
using family planning, and number of HIV-infected clients who have been screened for STIs. Performance
on these indicators is measured during monthly control activities jointly conducted by the MSH/PBF district
coordinator, clinical partners, and the district's Family Health Unit. Quality of services is evaluated through
the existing national supervisory and quality assurance mechanisms. The quantity and quality scores are
merged during the quarterly district PBF steering committee meetings and the final payment is 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 quality service outputs, there is an emphasis on
quality assurance, self-evaluation, and review by peers (similar to an accreditation scheme). The National
District Hospital PBF Scheme also supports the payment for indicators which reinforces the supervisory role
of hospitals in district health networks.
In FY 2008, MSH/PBF continued providing support to the MOH PBF department and the national PBF
TWG. In addition, MSH/PBF provided TA to district health teams (DHTs) in all PEPFAR-supported districts
and implementing partners to effectively shift some of their input financing to output-based financing for
HIV/AIDS indicators in accordance with national policy. MSH/PBF also provided intensive technical
assistance to districts that will be introducing PBF in FY 2008. At the District level, MSH/PBF continued to
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.
In FY 2009, the MSH PBF mechanism is coming to an end. However, scale-up of performance based
financing has been successful in Rwanda and is a priority of the GOR as it is considered linked to improved
quality of HIV and other health services. Consequently, PEPFAR is in the process of designing a new
mechanism that would build on the success of the MSH PBF project and potentially expand into
performance-based financing at a community level. In FY 2009, there will be additional need to support the
GOR with technical assistance as sites continue to be graduated and as the PBF system is expanded into a
community setting with the goal of increasing the quality and standardization of care at all entry points to the
health system. As a result, the follow on mechanism will continue to purchase health indicators and to
provide technical assistance to build the capacity of staff at both the central level health institutions and the
DHTs. The follow-on to MSH PBF will continue to purchase indicators for basic care and support and also
continue to build the capacity of health facilities to improve the quality of their services. The MSH PBF follow
-on mechanism will also support the roll out of community PBF in PEPFAR supported districts and work with
the TBD mechanism that will provide community services.
capacity for a district-managed network model of HIV clinical treatment and care services.
Table 3.3.08:
THIS IS A CONTINUING ACTIVITY FROM FY 2008, ALREADY APPROVED
Table 3.3.09:
ACTIVITY UNCHANGED FROM FY 2008, BUT A NEW AWARD WILL BE MADE IN FY 09:
different from the definition used in other national quality improvement (QI) initiatives, including HealthQual,
which is based on the HIVQual model). Financial incentives provided by PBF motivate health facilities to
improve both the quantity and the quality of their performance through investments in training, equipment,
personnel and payment systems that better link individual pay to individual performance. PBF is directly
applied to HIV/AIDS indicators at the facility level and will be used to ensure that pediatric services are
prioritized. As a result of successful pilots implemented by CordAID (a Dutch organization that initiated PBF
in Rwanda), GTZ (German Cooperation) and Belgian Technical Cooperation (BTC), the MOH has endorsed
national scale-up of PBF for all health services. PEPFAR, in partnership with the World Bank, BTC and
other donors, is supporting national implementation of PBF for health services.
level, PEPFAR partners purchase a quantity of indicators with a performance incentive. Examples of
pediatric health care indicators include number of infants born to HIV+ mothers tested for HIV, and the
number of new pediatric patients under ART. Performance on these indicators is measured during monthly
control activities jointly conducted by the MSH/PBF district coordinator, clinical partners, and the district's
Family Health Unit. Quality of services is evaluated through the existing national supervisory and quality
assurance mechanisms. The quantity and quality scores are merged during the quarterly district PBF
steering committee meetings and the final payment is 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 quality service outputs, there is an emphasis on quality assurance, self-evaluation, and
review by peers (similar to an accreditation scheme). The National District Hospital PBF Scheme also
supports the payment for indicators which reinforces the supervisory role of hospitals in district health
networks.
TWG. In addition, MSH/PBF provided TA to district health teams (DHTs) in all PEPFAR districts and to
PEPFAR implementing partners to effectively shift some of their input financing to output-based financing
for HIV/AIDS indicators in accordance with national policy. MSH/PBF also provided intensive technical
financing has been successful in Rwanda and is a priority of the GOR, as it is considered linked to improved
community setting with the goal of increasing the quality and standardization of care at all entry points in the
health system. As a result, the follow-on mechanism will continue to purchase health indicators and to
-on mechanism will also support the roll-out of community PBF in PEPFAR supported districts and work
with the TBD mechanism that will provide community services.
quality, and cost-effective, basic health care service delivery in a comprehensive HIV/AIDS treatment
Table 3.3.10:
This is a continuing activity from FY 2008. No narrative required.
Table 3.3.11:
ACTIVITY UNCHANGED FROM FY 2008. THERE WILL BE A NEW MECHANISM IN FY 2009.
output that enhances quality of services and leads to greater efficiency and sustainability. Output financing
involves the purchase of a certain quantity of indicators with a performance incentive for the production of
indicators is based on the quality and quantity of scores of general health services as measured by the
score obtained using the standardized national Quality Supervision tool. Financial incentives provided by
PBF to motivate health facilities to improve performance through investments in training, equipment,
applied to HIV/AIDS 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 PBF for all health services. PEPFAR, in
partnership with the World Bank, BTC and other donors, is supporting national implementation of PBF and
health services.
Since FY 2007, MSH/PBF supported the GOR in collaboration with key donors to implement a national
strategy, policy, and model of PBF that applies to all health assistance and provided out-based financing to
health facilities in six districts through direct performance sub-contracts with health centers and district
hospitals for HIV/AIDS indicators. PEPFAR adopted a strategy in FY 2007 to combine both input and output
financing to properly motivate health facilities for higher performance while providing necessary resources
and tools to meet the established targets. 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. At the health center level, PEPFAR partners
purchase a quantity of indicators with a performance incentive. Examples of indicators include correctly
filling stock control cards in X-ray departments, the percentage of TB lab exams that are corroborated
during quarterly controls, and the number of complete series of AFBs (Acid Fast Bacilli) correctly done.
Performance on these indicators are measured during monthly control activities jointly conducted by the
MSH/PBF district coordinator, clinical partners, and the district's Family Health Unit and quality of services
is evaluated through the existing national supervisory and quality assurance mechanisms. The quantity and
quality scores are merged during the quarterly District PBF Steering Committee meetings and the final
payments are approved. At the district hospital level, MSH/PBF will have sub-contracts with slightly different
purposes 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 is payment for indicators from the National District Hospital PBF Scheme
which reinforces the supervisory role hospitals play in district health networks.
TWG. In addition, MSH/PBF provided TA to DHTs in all PEPFAR districts and to implementing partners to
effectively shift some of their input financing to output-based financing for HIV/AIDS indicators in
accordance with national policy. MSH/PBF also provided intensive technical assistance to districts that will
be introducing PBF in FY 2008. At the District level, MSH/PBF continued supporting 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 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.
health services. Consequently, the EP is in the process of designing a new mechanism that would build on
the success of the MSH PBF project and potentially expand performance-based financing to the community
level. In FY 2009, there will be additional need to support the GOR with technical assistance as sites
continue to be graduated and as the PBF system is expanded into a community setting with the goal of
follow on mechanism will continue to purchase indicators in TB and to provide technical assistance to build
the capacity of staff at both the central level health institutions and the DHTs (District Health Team) .
Table 3.3.12:
strategy, policy, and model of PBF that applies to all health assistance. Consistent with the principles of
linking performance to incentives, MSH provided output-based financing to health facilities in six districts
through sub-contracts with health centers and district hospitals for HIV/AIDS indicators. PEPFAR adopted a
strategy in FY 2007 to combine both input and output financing to properly motivate health facilities for
higher performance while providing necessary resources and tools to meet the established targets. In
Rwanda, though performance has increased with PBF, TA and basic input support is still needed, especially
in the current context of rapid decentralization and accelerated national PBF roll-out. At the health center
level, PEPFAR partners purchase a quantity of the 14 key HIV/AIDS indicators. Performance on these
indicators is measured during monthly control activities jointly conducted by the MSH/PBF district
coordinator, clinical partners, and the district's Family Health Unit. The quality of services is evaluated
through the existing national supervisory and quality assurance mechanisms. The quantity and quality
scores are then merged during the quarterly District PBF Steering Committee meetings and the final
payments are approved. Examples of TC indicators include the number of persons tested for HIV and
number of couples and partners tested for HIV. MSH/PBF also has sub-contracts at the district hospital
level for a slightly different purpose and scope than with health centers. The focus of these contracts with
district hospitals is on increasing quality service outputs, quality assurance, self-evaluation, and review by
peers similar to an accreditation scheme. There is payment for indicators from the National District Hospital
PBF Scheme, which reinforces the supervisory role that hospitals play in district health networks.
In FY 2008, MSH/PBF continued supporting the MOH PBF department and the national PBF TWG. In
addition, MSH/PBF provided TA to DHTs and implementing partners in 23 PEPFAR districts to effectively
national policy. MSH/PBF also provided intensive TA to districts that will introduce PBF in FY 2008. At the
district level, MSH/PBF continued supporting the national model by 1) placing a district coordinator within
district steering committee for merging with quality index and final approval before payments are made.
follow on mechanism will continue to purchase indicators in HVCT. The follow on mechanism will also
institutions and the DHTs with the goal of improving the quality of counseling and testing services.
Gender
* Increasing gender equity in HIV/AIDS programs
Workplace Programs
Table 3.3.14:
This activity is being amended to shift the costs ($120,000) associated with hiring five district coordinators
for PBF M&E from this TBD International TA partner (previously MSH) to the Ministry of Health.
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS
-The design of a mechanism that would support the expansion of PBF to the community and tertiary
hospital levels.
-Harmonization of the various data collection tools in use by the Ministry of Health
proportionally reduced (quality needs to be improved). Financial incentives provided by PBF motivate
health facilities to improve both the quantity and the quality of their performance through investments in
training, equipment, personnel and payment systems that better link individual pay to individual
performance. PBF is directly applied to HIV/AIDS 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 PBF for all
health services. PEPFAR, in partnership with the World Bank, BTC and other donors, is supporting national
implementation of PBF for health services.
At the health center level, PEPFAR partners purchase key HIV/AIDS indicators. Performance on these
indicators is measured during monthly control activities jointly conducted by the Management Sciences for
Health (MSH)/PBF district coordinator, clinical partners, and the district's Family Health Unit. The quality of
services is evaluated through the existing national supervisory and quality assurance mechanisms. The
quantity and quality scores are then merged during the quarterly District PBF Steering Committee meetings
and the final payments are approved. Because payment is made based on this information, reports from
health centers are complete and submitted on time and quality supervision visits are conducted regularly.
All data is stored in a web-based database that can be accessed by health facilities to review past
performance, track trends and make decisions about improving quality of services. The PBF approach
generates a significant amount of quality information that could be used by the GOR for decision making.
In FY 2009, the MSH PBF funding mechanism is coming to an end. However, performance based financing
has been successful in Rwanda and a priority of the GOR as it is linked to both improved quantity and
funding mechanism that would continue to provide support to the MOH for the successful implementation of
PBF at the health center and district hospital levels and also for the expansion of PBF to the community and
tertiary hospital levels. This follow-on will address the need to harmonize the various data collection tools
and databases in use by the MOH and will explore how the PBF approach can be used to ensure the
quality, availability and use of routine user information in health facilities.
Table 3.3.17:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
pilots implemented by the Dutch Development Organization (CordAID), the German Society for Technical
Cooporation (GTZ) and the Belgian Technical Cooperation (BTC), the MOH has endorsed national scale-up
of PBF for all health services. PEPFAR in partnership with the World Bank, BTC and other donors, is
supporting national implementation of PBF for health services.
In FY 2009, the MSH PBF mechanism is coming to an end. However, performance-based financing has
been successful in Rwanda and a priority of the GOR as it is linked to both improved quantity and quality of
HIV and other health services. Consequently, PEPFAR is in the process of designing a new mechanism
that would continue to support the successful implementation of PBF at the health center and district
hospital levels and also support the expansion of PBF to the community and tertiary hospital levels. In FY
2008, MSH PBF supported one technical assistance position under OHSS. In FY 2009, there will be
additional need to support the GOR with technical assistance as the PBF system is further refined and
expanded into the community and tertiary hospital settings with the goal of increasing the quantity and
quality of care at all levels of the health system. The support for this technical position will be continued
through the follow-on mechanism for MSH PBF.
Table 3.3.18:
