 Firstly, when developing a plan, it is important for the donors and those implementing the project to look to success stories to see what can be learned.  There are plenty of cases of successful projects, perhaps most notably the development of community-based health insurance into the national healthcare financing plan in Rwanda.  
	The Rwanda example also illustrates the importance of involving the government, both at a country-wide level and the community level, at an early stage and getting commitment from them before implementation of any rural insurance scheme.  With government backing, one might be able to get additional funding, or at least a “safety net” that may be willing to help the insurance organization should it experience funding problems in the future.
	Thirdly, it is important that the rural insurance scheme be developed to provide at the very least a basic set of services that can be paid for.  In other words, the insurance scheme will need to ensure from the start that catastrophic costs are not going to cause the entire scheme to fold.  As undesirable as it may be, that may mean that services will need to be excluded from coverage (for example, paying for outpatient services at clinics but not paying for hospital services).  Related to this is the consideration mentioned earlier about a waiting period before services can be utilized.  Another benefit of such a setup would be additional revenue from people unable to use funds yet, helping the insurance scheme stay afloat.
	Rural health insurance can work, and there are certainly examples of that.  The important part is that before implementation an experienced staff is put together to develop a financially stable, realistic system.  Restriction of services, waiting periods, and whether or not to subsidize premiums for the poor to expand equity are all issues that need to be considered and planned for in developing any new insurance scheme.



Pay for performance is being utilized by more health systems these days for good reason.  In many ways, this payment structure, when used in an intelligent manner, can increase health outcomes and increase health access.  When performance incentives are set up to measure outcomes, say the percentage of HIV-positive patients put on anti-retroviral therapy, increased health status should be a clear outcome.  This also adds to efficiency, as performance targets can be set to reward providers who provide low-cost, high effectiveness treatments and interventions.  Preventative care and screening, say HIV testing during regular checkups, can also add to efficiency, as HIV testing and screening has been shown to be a cost-effective intervention by the CDC.  In addition, for performance-based measures, physicians often have incentives to provide certain services to as much of the population as possible. Incentivizing the number of clients upon which HIV tests are performed for example, leads to increasing access for patients to HIV screening, and should result in physicians offering these services to patients they would not have offered this service to otherwise. 