Table 1. Comparison of contractual arrangements before and after initiation of the performance initiative.

	Initial institutional configuration	Performance initiative configuration
Physical resource contracts
Drugs	The health centre buys them from authorised suppliers (mainly the health district medical store) with its cash income.	No change.
Vaccines and vertical programme items	They are supplied for free by the national programme.	No change.
Cash	The health centre charges users for (i) drugs (with a mark-up), and (ii) for curative consultations and acts.	(i) and (ii) no change. A third-party payer (a “steering committee”) pays a fee-for-services for a limited list of curative and preventive services (see Box 1); the scheme is established by a contract that sets clear obligations upon the health centre; an independent agency checks the reality of reported figures.
Equipment	Accessed mainly through donation, free utilization by the health centre.	No change.
Building	Owned by the government, a congregation or the parish; free utilization.	No change.
Other	Bought on the market by the health centre with its cash income.	No change.
Governance and employment contracts
Ownership and constrains on the owners	A health centre is a combination of multiple owners. The land and the building are owned by the main owner (the government, a congregation or the parish). Equipment, drugs and financial assets are owned by the “health committee” (a community body). All health centres are run as non-profit organisations. The Rwandan Ministry of Health oversees all of them.	There has been no formal change of this set-up. Yet, a new “management committee” has been established. It empowers the staff and put them in a position to take and enforce decisions to boost health centre performance.
Management	(i) The health centre is headed by a head nurse. (ii) He is expected to implement policies made by the Rwandan Ministry of Health.	(i) The same, but higher involvement of staff (see above). (ii) The health district authorities leave more discretion to the health centre team for initiatives.
Labour	(i) Salaries of some qualified staff are paid by the government. (ii) Salaries of some qualified and all non-qualified staff are paid by the health centre with its cash income. (iii) Fixed bonuses are paid to most of the staff by the NGO.	(i) and (ii) no change. (iii) The NGOa does not pay a fixed bonus. The (variable) monthly revenue collected from the performance initiative scheme is shared among the staff. An individual share is fixed by a grid that takes into account qualification, responsibility and presence at work. Bonus cuts can be used as a disciplinary measure.

NGO, non-governmental organization.