protection programs in Latin America that included incentives for preventative health services (e.g. Gertler and Boyce 2001; Fernald Gertler and Neufeld 2008; Barham 2011; Barham and Maluccio 2011). Overall, these programs are found to be effective in increasing coverage of preventative health services and some studies even found positive impacts on the health status of beneficiaries.

This study contributes to this literature by evaluating a large-scale government-implemented program in Sub-Saharan Africa that endowed conditional in-kind transfers. Unlike the programs in Latin America, the policy intervention was not part of a bigger social protection program and was primarily implemented by health centers that procured and distributed the gifts. Unlike the experiments studied by Thornton (2008), which also took place in Sub-Saharan Africa, and Banerjee, Duflo et al. (2010), which also provided in-kind transfers, the CPBF scheme is a large-scale multi-year program. Evaluating the impacts of a program run by the government on a large scale, rather than by a research team or an NGO, is of value by itself as it might be implemented differently. For example, health centers experienced frequent stock outs of the gifts. That might have not occurred under a more controlled small-scale implementation of such a program.

# Background and the Intervention

Since the devastating 1994 genocide, Rwanda has experienced impressive improvements in health outcomes and utilization rates of health services. According to the Rwanda Demographic and Health Surveys, the infant mortality rate has decreased from 107 to 32 per 1,000 live births between 2000 and 2015 (NISR, MOH and ICF International 2012; 2015). Under-five mortality has decreased from 196 to 50 per 1,000 live births during the same period. The increase of in the share of births occurring in health facilities from 27 percent to 91 percent illustrates the increase in utilization of health services.

During the past two decades, the health sector in the country went through major reforms such as decentralization and the scaling up of the community-based health insurance program. One of the policy interventions that has been shown to contribute to improvements in maternal and child health indicators is the national Performance-Based Financing (PBF) scheme. In this pay-for-performance scheme, health facilities receive financial incentives for the use and quality of selected health services. evaluations of the program have concluded that it has significantly increased the health outcomes of children, quality of prenatal care and coverage of health services such as institutional deliveries, preventative care visits by children and voluntary counseling and testing for HIV by couples (Basinga, Gertler et al. 2012, Gertler and Vermeersch 2012 and de Walque, Gertler et al. 2015).

The CPBF program was designed with the objective of further expanding coverage of maternal and child health services and improving the quality of monitoring data collected at the village level. The program tries to achieve these objectives through expansion of performance-based payments to additional agents in the health system. A focus has been put on services whose coverage was not impacted by the PBF at the health facility level. The primary component of the program is performance payments to cooperatives of community health workers. The payments were given for timely completion and submission of reports on health indicators at the community level and for utilization of targeted health services by the communities the cooperatives serve.

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