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Impact of Provider Performance Incentives on HIV/AIDS Services

Development Challenge

For the estimated 35.3 million people worldwide living with HIV/AIDS, antiretroviral therapy (ART) is the only treatment effective in improving and extending their quality of life. However, even when ART is available, continuity of care and compliance problems decrease the effectiveness of the treatment. Previous research has examined the role of incentives for patients to attend regular care visits and adhere to their treatment regimes, but compliance also depends on the quality of the provider. One approach to incentivize providers is via a pay for performance (P4P) scheme, where providers receive financial incentives to improve their behavior and treatment of patients. There has been little research on the effect of such financial incentives on patient outcomes in the HIV/AIDS context. 


Within Rwanda, HIV/AIDS impacts approximately three percent of the country’s population aged 15 to 49. The Government of Rwanda (GoR) has scaled up its investments in the health outcomes of people living with HIV/AIDS over the past decade; access to ART is now universal and free. Nevertheless, its effectiveness remains dependent on the continuity of care by healthcare providers, and the corresponding patient adherence to ART regimes. In 2006, to encourage improved patient care and attendance of visits, the GoR started rolling out the use of P4P incentives for medical providers managing the care of HIV positive patients. The goal is to promote the timeliness and quantity of patient visits in order to increase diagnostic and assessment tests, weight measurements, and formal diagnoses. 

Evaluation Strategy

Researchers exploit the rollout of the P4P program to evaluate its impacts on quality of care and patient outcomes. In 2004, the GoR rolled out the P4P program, phasing-in at the district level in pilot districts, and expanding to remaining districts in a random order. By 2008 all 450 clinics that offered ART services had implemented the program. Researchers assess patient outcomes in pilot districts, or the “treatment group,” in comparison to the districts that adopted the P4P program later. The study uses data from all individuals receiving ART treatment in Rwanda between 2002 and 2008, or approximately 100,000 patients at 450 health facilities.

Data will be collected from clinical medical records for each patient. When the GoR initiated its national HIV/AIDS program in 2002, they simultaneously initiated the collection of common format medical records associated with the treatment of people living with HIV/AIDS. Data will be analyzed using a difference-in-difference estimation by comparing pre-program trends and outcomes with post program trends. The researchers will evaluate quality of care and patient adherence to treatment regimes via the number of on-time visits, the CD4 count (T-cells) and weight of individual, and whether patients transferred into or out of facilities with P4P. The results of this study will inform how provider incentive programs can impact the health outcomes of patients.

Results and Policy Implications


Photo Credit: Bill and Melinda Gates Foundation. Alexandre receives his monthly antiretroviral therapy medication from Dr. Amri Jean de Dieu at Kivumu Health Centre, Rwanda.